Surgical outcome of graded Harada-Ito procedure in the treatment of torsional diplopia ‒ a retrospective case study with long-term results.

To review and evaluate the surgical outcomes of the Fells-modified Harada-Ito procedure using a dosage scale approach with long-term follow up in patients with torsional diplopia. The records of patients who underwent the modified Harada-Ito procedure by the same surgeon during 2012-2019 were retrospectively reviewed regarding pre- and post-operative data and individual dose-scale used for the surgery. The modified Harada-Ito procedure involved advancing the anterior half of the superior oblique tendon toward the inferior edge of the lateral rectus muscle by a distance determined using a five-graded scale. A total of 27 patients (mean age 57.6 years, range, 22-81 years; 10 female) were included. Evaluating surgical outcome showed a significant difference in pre- to post-operative cyclodeviation (p = <0.001). Pre-operative mean extorsion was -10.4° and mean torsional correction achieved was 7.7°. The dose-effect relationship showed a wide spread effect, yet yielded a high success rate. All but two patients were symptom free from their torsional diplopia at the last post-operative evaluation, on average 24 months after surgery. Post-operative results and the dose-effect of the modified Harada-Ito corresponded with the aimed-for correction of torsional diplopia.. Fusion evaluation and individually based pre-operative assessments proved essential in determining individual doses for successful surgical outcomes.

Measuring health-related quality of life in individuals with cyclodeviation using the Adult Strabismus 20 (AS-20) questionnaire.

PURPOSE: To assess health-related quality of life (HRQoL) in patients diagnosed with cyclodeviation and to evaluate subjective change following surgical treatment using the Adult Strabismus-20 (AS-20) questionnaire. METHODS: A prospective cohort study was performed from 2014 to 2019 on 29 adult patients with cyclodeviation and cyclodiplopia who were due to undergo corrective strabismus surgery by the same surgeon. The group was divided into two subgroups, according to the type of surgery required for fusion. All scores were analyzed for the whole sample and subgroups. Preoperative scores were compared with those of control patients. RESULTS: Pre- and postoperative QoL scores were successfully collected from 26 patients (mean age, 56 years; 8 female) using the AS-20 questionnaire. Scores were significantly higher for control subjects than for patients in the cyclodeviation group (P = 0.0001). Postoperative scores for all 20 questionnaire questions were significantly improved for all patients (P = 0.002). There was a significant improvement in the functional subscale score (P = 0.001), but not in the psychosocial subscale score (P = 0.23). Results were enhanced by Rasch analysis. CONCLUSIONS: Cyclodeviation patients demonstrated significantly lower scores than controls. The functional scores were significantly lower than the psychosocial scores, in contrast to other forms of strabismus. Strabismus surgery had a significant effect on quality-of-life scores in this group of adults.

Clinical measurements of normative subjective cyclotorsion and cyclofusion in a healthy adult population.

PURPOSE: To investigate normative subjective cyclotorsion values and cyclofusion ranges in a healthy adult population. METHODS: A cross-sectional investigation was performed in 120 healthy, non-strabismic adults, 60 men and 60 women in the age range of 18-69 years. All subjects were assessed for cyclotorsion using the synoptophore and the single Maddox rod (SMR) methods. Cyclofusion was investigated with the synoptophore in 60 of the subjects. RESULTS: All age groups showed low values of subjective torsion, mainly excyclotorsion with mean values of -1 degree for both methods. Reference ranges of cyclotorsion were between -0.7 and -1.5 degrees for the SMR method and between -0.7 and -1.4 degrees using the synoptophore method. There were no significant differences between gender (p = 0.48), but the effect of age was significant for both methods (p = 0.026) demonstrating a slight increase in excyclotorsion with age. Cyclofusion showed a total mean amplitude of 16 degrees, the fusion range was +7 degrees of incyclotorsion to -9 degrees of excyclotorsion. CONCLUSIONS: Subjective reference ranges for cyclotorsion and cyclofusion reveal that low values of torsion are to be expected upon clinical investigation in non-strabismic adult individuals. Values outside of the reference range may be indicators of possible binocular abnormalities or physiological variations. The cyclotorsional measurements and prevalence in this adult population group can be regarded as normative data in clinical settings.

Ophthalmological findings in children with encephalitis.

PURPOSE: To evaluate ophthalmological abnormalities in children with acute encephalitis. METHODS: Thirty-six children included in a hospital-based prospectively and consecutively collected cohort of children with acute encephalitis were investigated for ophthalmological abnormalities. The investigation included clinical ophthalmological examination, fundus photography, neuro-ophthalmological examinations as well as visual and stereo acuity. Results on laboratory examinations, clinical findings, neuroimaging and electroencephalography registrations were recorded for all children. RESULTS: The median age was 4.0 years (Interquartile Range 1.9-9.8). The aetiology was identified in 74% of cases. Three of 36 patients were found to have abnormal ophthalmological findings related to the encephalitis. Transient sixth nerve palsy was seen in a 15-year-old child and transient visual impairment was seen in a 3.5-year-old child. Bilateral miosis and ptosis, i.e. autonomic nerve system symptoms, were seen in an 11-month-old child, with herpes simplex 1 and N-methyl-d-aspartate receptor antibody encephalitis. All three children recovered and improved their ophthalmological function with time. CONCLUSION: Only 3 of 36 children were found to have ophthalmological abnormalities due to encephalitis and they all improved with time. Thus, ophthalmological consultation does not seem to fit in a screening programme for childhood encephalitis but should be considered in selected cases.

Screening for Dyslexia Using Eye Tracking during Reading.

Dyslexia is a neurodevelopmental reading disability estimated to affect 5-10% of the population. While there is yet no full understanding of the cause of dyslexia, or agreement on its precise definition, it is certain that many individuals suffer persistent problems in learning to read for no apparent reason. Although it is generally agreed that early intervention is the best form of support for children with dyslexia, there is still a lack of efficient and objective means to help identify those at risk during the early years of school. Here we show that it is possible to identify 9-10 year old individuals at risk of persistent reading difficulties by using eye tracking during reading to probe the processes that underlie reading ability. In contrast to current screening methods, which rely on oral or written tests, eye tracking does not depend on the subject to produce some overt verbal response and thus provides a natural means to objectively assess the reading process as it unfolds in real-time. Our study is based on a sample of 97 high-risk subjects with early identified word decoding difficulties and a control group of 88 low-risk subjects. These subjects were selected from a larger population of 2165 school children attending second grade. Using predictive modeling and statistical resampling techniques, we develop classification models from eye tracking records less than one minute in duration and show that the models are able to differentiate high-risk subjects from low-risk subjects with high accuracy. Although dyslexia is fundamentally a language-based learning disability, our results suggest that eye movements in reading can be highly predictive of individual reading ability and that eye tracking can be an efficient means to identify children at risk of long-term reading difficulties.

Ocular Motor Score (OMS): a clinical tool to evaluating ocular motor functions in children. Intrarater and inter-rater agreement.

PURPOSE: Ocular motor score (OMS) is a new clinical test protocol for evaluating ocular motor functions in children and young adults. OMS is a set of 15 important and relevant non-invasive ocular motor function parameters derived from clinical practice. The aim of the study was to evaluate OMS according to intrarater and inter-rater agreement. METHODS: Forty children aged 4-10 years, 23 girls median age 6.5 (range 4.3-9.3) and 17 boys median age 5.8 (range 4.1-9.8) were included. The ocular motor functions were assessed and scored according to the OMS protocol. The examinations were videotaped. To obtain the intrarater agreement, the first author examined and scored the children twice, first in the clinic and 2 weeks later by watching the videotape. To obtain the inter-rater agreement, three other raters independently scored the ocular motor function of the children by watching the videotapes. RESULTS: The overall observed intrarater agreement was 88%, and the observed inter-rater agreement between the three raters was 80%. For none of the subtests was there an observed intrarater agreement lower than 65%. Three of the subtests had an observed inter-rater agreement of 65% or below. CONCLUSION: Overall there was high observed intra- and inter-rater agreement for the OMS test protocol. Subtests such as saccades and smooth pursuit were more difficult for raters to score similarly according the clinical OMS test protocol.

Ophthalmological findings in 10-year-old full-term children--a population-based study.

PURPOSE: To determine different ophthalmological parameters in 10-year-old, healthy, full-term children in Stockholm County, Sweden. METHODS: Two hundred and seventeen children were included in the study. Best-corrected distance and near visual acuities (VA) were measured using logMAR charts. Cycloplegic retinoscopy was performed, and spherical equivalent and astigmatism were determined. Examination of ocular movement and cover test for distance and near were performed. Stereopsis was assessed with the TNO test, and contrast sensitivity with the Vistech test. The Royal Air Force rule was used for assessing accommodation, and near point of convergence was measured with the Lang fixation stick. Ophthalmoscopy was performed through dilated pupils. RESULTS: Eighty-two per cent of the children had a distance VA of -0.1 logMAR (1.3 Snellen acuity) or better. None of the children were visually impaired [VA>0.6 logMAR (<0.3 Snellen acuity)]. Ninety-three per cent had a near VA of -0.1 logMAR (1.25 Snellen acuity) or better. Mean spherical equivalent was 0.6 D. Eight (3.6%) children had hypermetropia (≥+2 D), and 17 (7.8%) were myopic (≤-0.5 D). Nine (4.1%) children had an astigmatism≥1 D, and two (0.9%) had anisometropia of ≥1 D. Manifest strabismus was found in seven (3.2%) children, five of whom had exotropia. Heterophoria for distance and/or near was found in 80.2% of the children. In children without manifest strabismus, stereopsis>60 seconds of arc was found in five (2.4%). Three (1.4%) of 215 children had contrast sensitivity below normal limits. Binocular median near point of accommodation was 14 D, and median near point of convergence 6 cm. CONCLUSION: Knowledge of various visual functions in normally developing children is crucial to be able to draw conclusions from ophthalmological examinations in children with eye diseases. This population-based study describes different ophthalmological parameters in full-term ten-year-old children. The material can be used as a control when examining children of similar ages with various ophthalmological conditions, such as groups of children with specific neurological or retinal diseases, and syndromes.

Ocular motor score a novel clinical approach to evaluating ocular motor function in children.

PURPOSE: Ocular motility disturbances are common in a number of neuropaediatric and neurometabolic disorders. Assessment of ocular motor function can be a source of information for diagnosis and follow-up of these patients. AIM: To evaluate a new clinical ocular motor function test: ocular motor score (OMS) and provide reference values in children and young adults without known ocular or neurological disorders. MATERIAL AND METHODS: A total of 233 children and young adults, 103 males and 130 females between the ages of 6 months and 19 years, were assessed according to a specific OMS protocol. They were divided into four different age groups: 0.5-3, 4-6, 7-10 and 11-19 years. The OMS protocol consists of 15 different subtests evaluating ocular motor function, and a total score of minimum 0 up to max 15 can be obtained: the minimum score, 0, is considered normal while 1 represents an abnormal function. RESULTS: The median OMS in the whole reference group was 0.3 (range 0-4.8). The median OMS in the different age groups, starting with the youngest, was: 0.9 (range 0.3-4.8), 0.3 (range 0-3.4), 0.3 (range 0-2.3) and 0 (range 0-3.5), respectively. The youngest subjects, aged 0.5-3, showed a significantly higher total OMS compared with the other age groups (p < 0.001). CONCLUSION: This study provides reference values for the OMS test in a population aged 0.5-19 years. The test may be valuable as a screening tool for identification and follow-up of ocular motor dysfunction in children and young adults.

Accommodation and convergence in 10-year-old prematurely born and full-term children: a population-based study.

PURPOSE: To examine the accommodative amplitude and convergence in 10-year-old prematurely born children previously screened for retinopathy of prematurity (ROP) and to compare with full-term controls of the same age. METHODS: Two-hundred and thirteen prematurely born and 217 children born at term were included. Accommodative amplitude and near-point convergence were assessed, together with best-corrected visual acuity (VA). A questionnaire was answered regarding possible problems at school. RESULTS: Binocular accommodation (P = 0.03) and convergence (P = 0.003) were significantly poorer in prematurely born children. Accommodation was correlated to neurological findings in the preterm group, but not to the degree of prematurity or stage of ROP. Regarding convergence there were no correlations to neurology, stage of ROP, or degree of prematurity. For neither accommodation nor convergence were any correlations with distance and near VA found. Preterm children had a higher prevalence of school problems, and there was an association with poor accommodation. CONCLUSIONS: Prematurely born children had poorer accommodation and convergence than full-term children, but no association with near VA was found. The reduction of accommodative amplitude and convergence was small and was probably of little clinical significance. However, it may have additional effects on other ophthalmological problems and school problems in the preterm group.

Changes of saccadic eye movements in thyroid-associated ophthalmopathy.

PURPOSE: To establish whether or not the dynamics of saccadic eye movements are significantly changed in patients with different stages of thyroid-associated ophthalmopathy (TAO) and, subsequently, if analysis of saccades could serve as an additional diagnostic tool for early detection of inflammatory activity in TAO. METHODS: Thirty-seven patients with TAO and 10 age- and gender-matched control subjects were investigated. The patients were divided into four groups according to the stage of the disease: (i) early mild disease (n = 10), (ii) early severe disease (n = 11), (iii) long-standing restrictive disease (n = 10) and (iv) proven auto-immune hyperthyroidism without any signs of TAO (n = 6). Horizontal and vertical saccades with amplitudes of 10°, 20°, 30° and 40° were recorded binocularly using the induction scleral search coil technique. The two main sequence constants V(max) and C were calculated for each eye. Repeated measurement analysis of variance was carried out to test for differences between different gaze directions, eyes and groups. RESULTS: In horizontal saccades, significant differences were found between groups but not between abduction and adduction. In vertical saccades, differences between groups and the interaction between groups and up- and down-gaze saccades were significant. Compared with the control group, analysis of the main sequence curves revealed larger differences in patients of group 3 and 4 than in those of group 1 and 2. Whereas in the control group down-gaze saccades were faster than up-gaze saccades, the opposite behaviour was found in all patient groups. The largest differences were detected among those patients who had no signs of TAO (group 4). CONCLUSIONS: In this study, significant saccade differences were detected in all patients with TAO. In contrast to our earlier studies where evaluation of multiple individual saccade parameters did not reveal significant differences, analysis of the main sequence constants and mathematical reconstruction of the main sequence curves turned out to be a sensitive technique for reliable detection of subtle ocular motility changes. Significant differences were detected even in patients with auto-immune thyroiditis where no clinical signs of TAO were apparent.

Visual field function in school-aged children with spastic unilateral cerebral palsy related to different patterns of brain damage.

AIM: To relate visual field function to brain morphology in children with unilateral cerebral palsy (CP). METHOD: Visual field function was assessed using the confrontation technique and Goldmann perimetry in 29 children (15 males, 14 females; age range 7-17y, median age 11y) with unilateral CP classified at Gross Motor Function Classification System (GMFCS) level I and Manual Ability Classification System levels I to III. The type and extent of brain lesions were determined using cerebral imaging. RESULTS: Eighteen children had subnormal visual field function. The visual fields were severely restricted in six. The underlying brain lesions were malformation (n=7), white matter damage of immaturity (WMDI; n=13), and cortical-subcortical lesions (n=9). Visual field function could be correlated with the pattern of brain damage in children with cortical-subcortical lesions or extensive lesions caused by malformation or WMDI. Total homonymous hemianopia was common in the cortical-subcortical group but rare in children with malformation or WMDI. Five children had normal visual field function despite having malformation or WMDI involving parts of the brain usually encompassing the visual system. INTERPRETATION: Visual field function may be preserved by plasticity of the immature brain in children with malformation and WMDI. Severely restricted visual fields were more often associated with lesions occurring later in the developing brain. All children with severely restricted visual fields were identified by the confrontation technique. Goldmann perimetry was a suitable method to identify relative visual field defects.

Orthoptic findings and asthenopia in a population of Swedish schoolchildren aged 6 to 16 years.

PURPOSE: To determine the prevalence of refractive errors and binocular disorders in relation to asthenopia in a representative population of Swedish schoolchildren. METHODS: The study population included 216 schoolchildren, 60 in grade 1 (age 6-7 years), 96 in grade 4 (10-12 years) and 60 in grade 8 (14-16 years). Asthenopia was evaluated by questionnaire. Visual acuity was tested for distance and near, uncorrected and with the best subjective refraction. Refraction in cycloplegia and an orthoptic assessment was performed. RESULTS: Asthenopia was reported in 23.1% of schoolchildren; all but two of these schoolchildren had an abnormal eye examination. Asthenopia was related to uncorrected visual acuity < or = 0.65 (13.9%*) and myopia (8.8%*). No significant correlation could be found to accommodative or convergence insufficiency. CONCLUSION: Asthenopia was significantly associated with uncorrected visual acuity < or = 0.65 and with myopia (spherical equivalent -0.50 D or less) among Swedish schoolchildren.

The influence of accommodative insufficiency on reading.

BACKGROUND: It is not known how accommodative insufficiency influences reading performance. METHODS: Reading eye movements were recorded before and after treatment for accommodative insufficiency in 12 school children (eight to 16 years). During the eight-week treatment period all subjects wore a +1.00 D addition when reading. RESULTS: Large variations in reading patterns were found. Despite successful accommodative treatment (p < 0.001), no correlation was found to suggest improved reading velocity. DISCUSSION: Three case reports will be presented and the implications discussed.

Prevalence and development of strabismus in 10-year-old premature children: a population-based study.

PURPOSE: To evaluate the prevalence and development of strabismus, at 10 years, in children born prematurely. METHODS: This population-based study included 216 premature and 217 full-term children from the same geographic area. RESULTS: Strabismus was noted in 16.2% (35 of 216) premature and in 3.2% (7 of 217) full-term children. The most important risk factors for strabismus at 10 years were anisometropia at 6 months, spherical equivalent refractive errors (i.e., > +3 D or < -3 D) at 2.5 years, and various neurologic conditions. CONCLUSION: At 10 years, children born prematurely have a greater risk of strabismus than children born at term.

A population-based study on the visual outcome in 10-year-old preterm and full-term children.

OBJECTIVES: To report the visual outcome in prematurely born and full-term children at the age of 10 years and to evaluate the effects of prematurity per se, retinopathy of prematurity (ROP), and cryotreatment on visual acuity. METHODS: The study included 216 prematurely born children and 217 children born at term from the same geographical area and study period. Best-corrected distance and near visual acuities were assessed with linear letter logarithm of the minimum angle of resolution charts. Crowding was evaluated. RESULTS: Prematurely born children had reduced distance and near visual acuities compared with full-term children, even when children who had retinopathy of prematurity and neurologic disorders were excluded (P<.001). Children who had been treated with cryotherapy had the highest risk of a reduced visual acuity. Two percent of the prematurely born children were visually impaired (<20/60). CONCLUSIONS: Although we found an overall good visual outcome in the prematurely born cohort, the risk of reduced visual acuity was greater than in full-term children. Children who had been treated with cryotherapy had the highest risk, but prematurity per se was also associated with reduced visual acuity.

Asthenopia in schoolchildren, orthoptic and ophthalmological findings and treatment.

The aim of this study was to describe the orthoptic and ophthalmological findings in schoolchildren with asthenopia, to correlate them with asthenopic symptoms and to evaluate the effect of treatment. One hundred and twenty schoolchildren, aged 6-16 years, were included in the study. They were all referred by school nurses, for asthenopic symptoms. An orthoptic and ophthalmological assessment was performed. The main diagnoses were accommodative insufficiency, convergence insufficiency, refractive errors, and latent strabismus. Reading glasses could help 98% of the schoolchildren with reduced accommodation, and 94% of the children with refractive errors and heterophorias were helped with appropriate spherical, cylindrical and prism correction. Convergence exercise reduced the symptoms in all patients with convergence insufficiency. Ninety-three percent of all 120 schoolchildren were symptom free 3-6 month after treatment had started. By an orthoptic and ophthalmological examination abnormalities in schoolchildren with asthenopia related to visual problems can be identified. Most of the children were relieved from their symptoms by giving adequate glasses, convergence exercises and surgery.

A population-based study of the refractive outcome in 10-year-old preterm and full-term children.

OBJECTIVE: To evaluate the refractive outcome in 10-year-old prematurely born children and in full-term control children. METHODS: Retinoscopy during cycloplegia was performed in 213 prematurely born children from a previous population-based study on the incidence of retinopathy of prematurity and in 217 children born at term. The spherical equivalent, astigmatism, anisometropia, and significant refractive errors (defined as hypermetropia >3 diopters [D], myopia < or =-1 D, astigmatism > or =1 D in 1 or both eyes, and/or anisometropia > or =1 D) were analyzed. RESULTS: Significant refractive errors were found in 29.6% of the prematurely born and in 7.8% of the full-term children. Prematurely born children had higher prevalences of hypermetropia of more than 3 D, myopia of -1 D or less, astigmatism of 1 D or more, and anisometropia of 1 D or more than those born at term. In the preterm group, the cryotreated children had the greatest risk of refractive errors (16 [64%] of 25 children), with higher prevalences of myopia (<0, < or =-1, or <-3 D), astigmatism (> or =1 D), and anisometropia (> or =1 D). CONCLUSIONS: Significant refractive errors were 4 times more common in 10-year-old prematurely born children than in full-term controls. Cryotreated children had the highest risk, but prematurity per se was also associated with refractive errors. Ophthalmological follow-up of prematurely born children should, therefore, also include children without retinopathy of prematurity in the neonatal period.