[Acute Acquired Comitant Esotropia Type 2 - A Retrospective Analysis]. / Akut erworbene konkomitante Esotropie Typ 2 ­ eine retrospektive Analyse.

BACKGROUND: Acute acquired comitant esotropia (AACE) is an uncommon form of strabismus. The main characteristics of AACE Type 2 in childhood are: acute onset of strabismus around 3 years of age, large and comitant angle of strabismus, absence of accommodative component, hyperopia of not more than 3 dpt, and measurable stereopsis. Strabismus surgery is urgently indicated in AACE Type 2 in order to avoid maldevelopment or loss of stereopsis. Therefore, in order to better describe the characteristics of AACE Type 2, we performed a retrospective analysis of patients previously seen in our clinic. PATIENTS AND METHODS: Retrospective analysis of data from patients who underwent strabismus surgery between October 2011 and September 2019 due to suspected AACE Type 2 could be confirmed during postoperative visits by evaluating ocular alignment and stereopsis at our hospital. Analysed data included: age and symptoms at first visit, visual acuity, refractive status, correction by glasses, age at surgery, period of time between first symptoms and surgery, surgical procedure, stereopsis and angle of strabismus (before surgery and 1 day, 3 months, and 12 months after surgery). Ethical approval was obtained from the Cantonal Ethics Committee of Zurich. RESULTS: 18 patients (12 male, 6 female) with mean hyperopia of 1.4 ± 0.6 dpt were identified as meeting the inclusion criteria during the defined time period. Amblyopia was present at first assessment in two patients. Strabismus surgery was performed at 2.0 to 11.1 years of age and between 0.4 and 24.6 months after onset of symptoms. Surgery was performed within 6 months after onset of symptoms in 12/18 children. Before surgery, angle of strabismus at near was measured as 38 ± 10 prism diopters (PD) and was reduced after surgery to 3 ± 3 PD at 3 months and 2 ± 2 PD at 12 months. Stereopsis was confirmed in 5/18 patients one day after surgery and in 18/18 patients 12 months after surgery. CONCLUSION: Our analysis showed that our patients with diagnosis of AACE Type 2 had mild hyperopia and large comitant non-accommodative esotropia; prognosis for recovery of stereopsis is excellent. Preoperative amblyopia does not exclude the diagnosis of AACE Type 2. Therapeutic intervention is advisable within a short period of time after first symptoms and the diagnosis of AACE Type 2.

Long-term follow-up of an amblyopia treatment study: change in visual acuity 15 years after occlusion therapy.

PURPOSE: To determine change in visual acuity (VA) in the population of a previous amblyopia treatment study (Loudon 2006) and assess risk factors for VA decrease. METHODS: Subjects treated between 2001 and 2003 were contacted between December 2015 and July 2017. Orthoptic examination was conducted under controlled circumstances and included subjective refraction, best corrected VA, reading acuity, binocular vision, retinal fixation, cover-uncover and alternating cover test. As a measure for degree of amblyopia, InterOcular VA Difference (IOD) at the end of occlusion therapy was compared with IOD at the follow-up examination using Wilcoxon's signed-rank test. Regression analysis was conducted to determine the influence of clinical and socio-economic factors on changes in IOD. RESULTS: Out of 303 subjects from the original study, 208 were contacted successfully, 59 refused and 15 were excluded because of non-amblyopic cause of visual impairment. Mean IOD at end of therapy (mean age 6.4 years) was 0.11 ± 0.16 logMAR, and IOD at follow-up examination (mean age 18.3 years) was 0.09 ± 0.21 logMAR; this difference was not significant (p = 0.054). Degree of anisometropia (p = 0.008; univariable analysis), increasing anisometropia (p = 0.009; multivariable), eccentric fixation (p < 0.001; univariable and multivariable); large IOD (p < 0.001; univariable and multivariable) and non-compliance during therapy (p = 0.028; univariable) were associated with IOD increase. CONCLUSION: Long-term results of occlusion therapy were good. High or increasing anisometropia, eccentric fixation and non-compliance during occlusion therapy were associated with long-term VA decrease. Subjects with poor initial VA had a larger increase despite little patching, but often showed long-term VA decrease.

Refractive adaptation and efficacy of occlusion therapy in untreated amblyopic patients aged 12 to 40 years.

PURPOSE: Since neurophysiological and clinical trials have shown evidence for plasticity in the adult visual system, the upper age limit for amblyopia treatment is not rigid. The aim of this study was to investigate the efficacy of occlusion therapy and refractive adaptation in untreated amblyopic patients 12 to 40 years of age. METHODS: In a prospective study, all patients had full orthoptic and ophthalmic assessment including cycloplegic retinoscopy. Patients with a newly prescribed optical correction underwent an 18-week refractive adaptation. All patients were treated with occlusion for 3 h a day for 18 weeks. Acuity gain and responder rates (≥ 0.2 log units) were calculated. The rate of recurrence (visual acuity 9 months after end of the occlusion therapy; ≥ 0.2 log units) and the acuity gain after refractive adaptation were determined. Self-reported compliance to occlusion therapy was assessed. RESULTS: Median age of patients (n = 24) was 32.4 years (IQR 19.2). Best corrected visual acuity at start of occlusion therapy was 0.35 logMAR (IQR 0.5) and 0.30 (IQR 0.4) logMAR at the end of occlusion therapy, an acuity gain of 0.05 logMAR (P = 0.004). Six (25%) patients had an acuity gain of at least 0.2 logMAR units. Reading acuity was improved from 0.4 logMAR (IQR 0.4) to 0.3 logMAR (IQR 0.4) (P = 0.004). Visual acuity was stable 9 months after occlusion therapy. The acuity gain after 18 weeks of refractive adaptation was 0.05 logMAR (P = 0.238, n = 8). Acuity gain by correcting refractive errors was 0.25 logMAR (P = 0.006). Twenty-one (92%) of 24 patients achieved full recording in the calendar. Overall compliance was 17% (IQR 38). Only 5 out of 22 (23%) had acceptable compliance (≥ 50%) to occlusion therapy. Improvement of visual acuity was significantly better in patients with at least 50% compliance (P = 0.013). Compliance was worse in non-native patients than in native patients (P = 0.022). CONCLUSIONS: In adulthood, compliance to occlusion therapy is even more challenging than in children. Noncompliance is the main reason for treatment failure. Only a few patients with acceptable compliance to occlusion therapy had a small but significant improvement of visual acuity. The results suggest that some adults with amblyopia retain a degree of cortical plasticity. We found that untreated adult amblyopic patients did not wear optical correction on the amblyopic eye. The highest treatment benefit was achieved by correcting refractive errors prior to following period of refractive adaptation.

Comfort of wear and material properties of eye patches for amblyopia treatment and the influence on compliance.

BACKGROUND: Occlusion therapy for amblyopia has been the mainstay of treatment for centuries, however, acceptance of the patch is often lacking. This study evaluated comfort of wear of the eye patch and assessed the mechanical properties in order to achieve a more individualized prescription. METHODS: For 8 consecutive days, parents used each of the four main brands of patches for 2 consecutive days in a randomized fashion. After 2 days a 21-item questionnaire was completed to evaluate comfort of wear for each patch. Compliance was measured electronically using the Occlusion Dose Monitor (ODM). In addition, breathing capacity at 23°C and 33°C, resistance to water penetration, opacity, and strength of adhesion to the skin were measured. RESULTS: Twenty-four children participated. Overall, satisfaction was moderate: large differences in discomfort when removing the patch, skin reaction, and cosmetic appearance were found. In the material measurements large differences were found in opacity and strength of adhesion to the skin. In all brands breathing capability was minimal. Answers given by the parents matched the physical properties of the eye patch. There was no difference in electronically measured compliance between patches. CONCLUSIONS: We found large differences in comfort of wear and mechanical properties. Therefore, when prescribing a certain brand of patch, the wide variety needs to be taken into account. Further study into these properties seems warranted; especially breathing capability requires improvement since children often wear the patch for a longer period of time. This could contribute to increasing satisfaction and consequently may improve compliance.

Midbrain syndrome with eye movement disorder: dramatic improvement after cranioplasty.

BACKGROUND: Patients with skull defects sometimes develop neurological deficits, which have been grouped under "the syndrome of the trephined". The deficits are usually nonspecific or nonlocalizing, such as apathy or diffuse headaches. We report, to our knowledge, a first case of severe midbrain syndrome associated with a skull defect. Cranioplasty dramatically resolved the patient's symptoms. A midbrain syndrome represents the main manifestation of the syndrome of the trephined and can be corrected by cranioplasty. CLINICAL PRESENTATION: A 38-year-old man with head trauma and epidural hematoma initially had normal eye motility. He developed a skull defect after infection following cranioplasty. He presented with onset of neurological symptoms one year after head trauma with a skull defect, a small divergent and vertical strabismus, elevation deficit of both eyes, headaches and fatigue. Over several months he developed severe bilateral deficit of adduction, elevation, depression and convergence. He had neuropsychological deficits, fatigue, headaches and impaired coordination. Neuroimaging and lumbar puncture did not show evidence of increased intracranial pressure or hydrocephalus. INTERVENTION: Cranioplasty using Palacos was performed one-and-a-half years after trauma. Immediately after surgery, the patient noted remarkable improvement in his symptoms. Headaches and fatigue disappeared within two days. Two weeks after cranioplasty the patient had orthotropia and virtually normal ocular motility. Neurological symptoms completely disappeared. Recovery remained sustained for over 5 years after cranioplasty. CONCLUSION: To our knowledge, this represents the first case of the syndrome of the trephined in which the neurological deficits map primarily to the brainstem and show rapid improvement following cranioplasty. We show that cranioplasty in patients with large skull defects is indicated for more then cosmetic reasons and should be considered even after longer periods following a trauma.