Surgical Outcome of Inferior Oblique Myectomy versus Recession-Anteriorization in the Treatment of Inferior Oblique Overaction.

Purpose: This study aimed to compare the surgical outcome of inferior oblique myectomy, IOM versus inferior oblique recession-anteriorization, IORA in the treatment of inferior oblique overaction, IOOA. Patients and Methods: A retrospective chart review was performed over a 12-year period, from 2009 to 2021. Eighty-nine patients diagnosed with IOOA who underwent IOM or IORA were included. The primary outcome was postoperative residual IOOA (grade 0 to +4) and percentage favorable outcome, defined as IOOA grade ≤1+ at 6 months post operation, in each group. The outcomes were compared between the two surgical procedures (IOM and IORA). The secondary outcome was the percentage of postoperative anti-elevation syndrome cases for each surgical procedure. Results: The median age at the time of surgery was 10.50 years (interquartile range, IQR: 2.83 to 28.33) in the IOM group and 5.08 years (IQR: 2.75 to 29.42) in the IORA group. The favorable outcome at 6 months was 90.91% in the IOM group, which was lower than the 95.74% in the IORA group but the difference was not statistically significant (P-value = 0.390, 95% CI: 0.07-2.82). The only surgical complication, anti-elevation syndrome, was detected in 3.77% of IOM cases and 5.80% of IORA cases, with an odds ratio of 0.64 on comparing the IOM group to the IORA group (P-value = 0.611, 95% CI: 0.11-3.62). Conclusion: These two weakening procedures are effective for treating IOOA. Although IORA seemed slightly superior to IOM in terms of favorable outcomes, the difference was not statistically significant. Moreover, the myectomy procedure was easier, was less time-consuming, had a lower risk of globe perforation and presented fewer complications such as anti-elevation syndrome.

Optimal Duration of Monocular Occlusion to Eliminate Fusion Effect in Intermittent Exotropia.

Purpose: To determine the optimal duration of monocular occlusion in patients with intermittent exotropia. Patients and Methods: This prospective cohort study enrolled 40 patients with intermittent exotropia at Ramathibodi Hospital between May 2023 and September 2023. Angles of deviation at distance (6 m) and near fixation (0.33 m) were measured before and after monocular occlusion for 30, 60, and 90 minutes. All measurements were performed by a single ophthalmologist. The mean angle of deviation was calculated at each time point. Results: The mean age at presentation was 12.5 years (range, 5-33 years). The mean angles of deviation before monocular occlusion were 27.8 ± 15.1 prism diopters (PD) at distance and 26 ± 13.7 PD at near fixation. At distance, mean angles of deviation after monocular occlusion were 32.2 ± 14.6, 32.9 ± 15.0, and 32.6 ± 14.7 PD at 30, 60, and 90 minutes, respectively. At near fixation, mean angles of deviation after monocular occlusion were 37.4 ± 15.0, 39.8 ±14.3, and 39.5 ± 14.6 PD at 30, 60, and 90 minutes, respectively. All angles significantly differed from the pre-occlusion deviation (all P < 0.01). For deviation at distance, there was no statistically significant difference between 60 and 30 minutes of monocular occlusion (P = 0.48). For deviation at near fixation, there was a significant difference between 60 and 30 minutes of monocular occlusion (P = 0.048), but the difference of 2.5 PD was not clinically significant. There were no statistically significant differences between 90 and 60 minutes of monocular occlusion at distance or near fixation (both P = 0.82). Conclusion: Monocular occlusion is necessary to eliminate the fusion effect in patients with intermittent exotropia; 30 minutes of monocular occlusion is sufficient to achieve the maximum angle of deviation.

Age-Specific Outcomes of Conservative Approach and Probing for Congenital Nasolacrimal Duct Obstruction.

Purpose: To evaluate the resolution rate of lacrimal sac massage and the efficacy of primary probing among different age groups of patients with CNLDO in Thai population. Patients and Methods: Retrospectively reviewed the medical records of patients younger than 10 years of age who had been diagnosed with CNLDO, from January 1st, 2011, to October 31st, 2021. Patients were divided into two groups. The conservative treatment group comprised patients who had received Crigler's maneuver and topical antibiotic when indicated; the intervention group comprised patients who had received probing. Results: There were 469 patients in the conservative treatment group and 108 patients in the probing group. In the conservative treatment group; the patients were categorized into five groups according to age: 0 to <6 months, 6 to <12 months, 12 to <18 months, 18 to <24 months, and ≥24 months. The resolution rates for these age groups were 99.25%, 96.23%, 64.71%, 50%, and 62.07%, respectively. The rate of spontaneous resolution was significantly associated with patient age (p <0.01). In the intervention group; the patients were categorized into four age groups according to age: 0 to <12 months, 12 to <24 months, 24 to <36 months, and ≥36 months. The success rates of primary probing for these age groups were 92.86%, 89.29%, 85.71%, and 94.12%, respectively. The success rate of primary probing was not significantly associated with patient age (p >0.05). Conclusion: The Crigler's maneuver is a safe and highly effective procedure for the management of CNLDO in patients of multiple ages, particularly patients less than 12 months of age. According to the high spontaneous resolution rate and the low rate of complications, the clinicians may delay surgical intervention when desired.

Maximal Levator Resection Beyond Whitnall's Ligament in Severe Simple Congenital Ptosis with Poor Levator Function.

PURPOSE: To evaluate the functional and cosmetic outcomes, as well as factors that influence surgical success of maximal levator resection beyond Whitnall's ligament in patients with poor levator function (LF) and severe simple congenital ptosis. METHODS: This retrospective interventional study included patients with severe simple congenital ptosis and LF of ≤4 mm who had undergone maximal levator resection beyond Whitnall's ligament with a minimum of 12 months follow-up. Postoperative marginal reflex distance-1 (MRD1) was assessed for functional outcomes as excellent, good, fair and poor. Eyelid contour and the difference in MRD1 between eyes were assessed for symmetrical cosmetic outcomes as excellent, good and poor. Demographic data, factors influencing surgical success and postoperative complications were analyzed. RESULTS: A total of 38 ptotic eyelids in 31 patients were included. Successful surgical outcomes (at least good functional and cosmetic outcomes) were achieved in 26 patients (83.87%) with the mean MRD1 of +3.61 ± 0.27 mm and +3.51 ± 0.17 mm at 1 week and 12 months after surgery, respectively. There were no significant differences in demographic and preoperative data between the successful and unsuccessful surgical outcome groups, mean preoperative ptosis measurements were 4.19 ± 0.20 mm versus 4.72 ± 0.36 mm (p = 0.242) and mean pre-operative LF were 3.16 ± 0.15 mm versus 2.29 ± 0.61 mm (p = 0.561), respectively. The only factor that significantly influenced the surgical success rate was the length of the resected levator muscle. The mean lengths in successful and unsuccessful groups were 18.15 ± 0.44 mm and 14.29 ± 0.94 mm, respectively (p = 0.011). CONCLUSION: Maximal levator resection beyond Whitnall's ligament is an effective procedure for severe simple congenital ptosis with poor LF. Refinement of surgical techniques and careful assessment of the optimal resected length for the levator muscle grants successful surgical outcomes.

Isolated Sixth Nerve Palsy as a First Presentation of Nasopharyngeal Carcinoma: A Case Series.

PURPOSE: To describe isolated sixth nerve palsy as an uncommon presentation of nasopharyngeal carcinoma (NPC). PATIENTS AND METHODS: We analyzed the demographics, clinical presentation, neuroimaging findings, and pathological examination results of the nasopharyngeal masses of patients diagnosed with isolated sixth nerve palsy due to NPC. RESULTS: Isolated sixth nerve palsy as the first presenting sign of NPC was diagnosed in five patients. Two patients were aged <50 years and three were aged >50 years, and one of these three older patients had vascular risk factors. Most of the patients in our case study had an uncommon presentation of isolated sixth nerve palsy with diplopia, followed by typical NPC signs such as a neck lump (two patients), nasal obstruction (two patients), tinnitus (two patients), hearing loss (one patient), and epistaxis (one patient). Pathological examination revealed non-keratinizing NPC in all cases. Neuroimaging showed that the sites of tumor invasion were the clivus, Dorello's canal, and cavernous sinus, which explained the sixth nerve palsy. One patient whose NPC had progressed to the orbital apex later developed other cranial nerve palsies. Three patients underwent concurrent chemoradiotherapy (CCRT), and one patient underwent CCRT with adjuvant chemotherapy. The last patient was unfortunately lost to follow-up. The symptoms of four patients who underwent treatment improved. CONCLUSION: Isolated sixth nerve palsy can be the first presentation of NPC, especially in patients aged <50 years old without microvascular risk factors or even in patients aged >50 years old with microvascular risk factors. This case study emphasizes that a thorough clinical history and careful physical and neuroimaging examinations might be necessary to rule out life-threatening conditions in patients with isolated sixth nerve palsy.

The Outcome of One-to-Four Muscle Surgery by Intraoperative Relaxed Muscle Positioning with Adjustable Suture Technique in Thyroid Eye Disease.

PURPOSE: To identify the outcome of one-to-four muscle surgery by intraoperative relaxed muscle positioning with adjustable suture technique for the treatment of thyroid eye disease. METHODS: Ninety patients diagnosed with thyroid eye disease who underwent intraoperative relaxed muscle positioning with adjustable suture technique at Ramathibodi Hospital from January 1, 2015 through December 31, 2020 were included in this retrospective study. The patient demographic data were evaluated. Pre- and post-operative ocular alignment and diplopia status were measured after a follow-up period of at least 6 months. Successful outcomes were categorized into two parts: motor outcome and sensory outcome. Successful motor outcome was defined as vertical deviation equal to 4 prism diopters or less and horizontal deviation equal to 10 prism diopters or less in primary position. Successful sensory outcome was defined as the absence of diplopia in primary position. RESULTS: Ninety patients were included in this study, and the mean age of strabismic surgery was 56.6 ± 10.1 years old. Thirty-nine patients had a history of orbital decompression surgery. Mean follow-up time was 33.7 ± 11.8 months. The success of motor and sensory outcomes exhibited a decrease from one-to-four muscle surgery. Motor success decreased from one-muscle to four-muscle surgery (84.62%, 81.58%, 75.00%, and 64.29%) and sensory success similarly decreased (84.62%, 84.21%, 75.00%, and 78.57%). However, the comparative outcomes of motor success and sensory success were not statistically different among groups (p = 0.58 and 0.84). Lower lid retractions were found in 12 patients (13.33%). CONCLUSION: Intraoperative relaxed muscle positioning technique might be a successful option for the correction of thyroid eye disease-associated strabismus. This technique may be done with one-to-four muscle surgery, which yields success in both motor and sensory outcomes.

A Prospective Study of One-Muscle Surgery in 15-25 Prism Diopters Horizontal Comitant Strabismus in Adults.

PURPOSE: To prospectively evaluate the results of one-muscle surgery in 15-25 prism diopters (PD) horizontal comitant strabismus in adults. PATIENTS AND METHODS: 15-25 PD horizontal strabismus patients, comprising 25 exotropic (XT) patients and 11 esotropic (ET) patients, who underwent one-muscle recession by a single surgeon with a fixed surgical dosage were included in the study with a minimum follow-up of 3 months. The main outcome was a surgical success, which is defined as a residual deviation of <8 PD at the last examination. Other parameters include postoperative lateral incomitance and patient satisfaction. Postoperative lateral incomitance indicated a difference in deviation of >5 PD between the primary position and lateral gaze, or duction limitation at any visit. Patient satisfaction regarding cosmetic and functional outcomes was assessed by using a 5-point Likert scale. RESULTS: Successful alignment was obtained in 19 (76%) and 9 (81.81%) XT and ET patients (p = 1.00), with a median and interquartile range (IQR) of follow-up time of 3, 3-3 months and 3, 3-7 months, respectively. Postoperative lateral incomitance was observed in 8 (32%) XT patients and in 1 (9.09%) ET patient (p = 0.22). One XT patient and one ET patient who developed incomitance reported diplopia, which disappeared 3 months after surgery. One XT patient reported diplopia while gazing towards the operated eye whilst one ET patient reported diplopia occasionally which was unrelated to gaze direction. Patient satisfaction was based on Likert scale scores with 4.12 ± 0.97 in XT patients and 4.73 ± 0.65 in ET patients (p = 0.07). CONCLUSION: One-muscle recession with a fixed surgical dosage was effective for treating small angle horizontal strabismus with a high rate of surgical success and patient satisfaction. Although postoperative lateral incomitance occurred, only a few patients developed symptomatic diplopia, which completely resolved 3 months after surgery.

Acute Acquired Comitant Esotropia: Etiology, Clinical Course, and Management.

PURPOSE: To identify the etiologies, clinical course and management of acute acquired comitant esotropia in Ramathibodi Hospital, Thailand. METHODS: Thirty patients who were diagnosed with acute acquired comitant esotropia at Ramathibodi Hospital from January 1 2017 to December 31 2019 were identified using electronic medical records, from which demographic, etiology, clinical course and management, laboratory, and neuroimaging data were collected. RESULTS: The etiologies of acute acquired comitant esotropia were Swan (16.67%), Burian-Franceschetti (30.00%), Bielschowsky (36.67%), Arnold Chiari malformation (3.33%) and decompensated esophoria (13.33%). Mean age of onset was 19.8 ± 18.3 years. Mean angle of esodeviation was 28.4 ± 12.1 prism diopters for distance fixation and 29.3 ± 11.8 prism diopters for near fixation. Refraction differed between age groups: children under 10 years had mild hyperopia (median +0.63 diopters, first quartile +0.25 diopters, third quartile +0.75 diopters) and teenagers (10-18 years old) had emmetropia to mild myopia (median +0.25 diopters, first quartile -2.50 diopters, third quartile +0.75 diopters), whereas adults had mild to moderate myopia (median -0.75 diopters, first quartile -5.25 diopters, third quartile ±0.00 diopters). Twelve patients (40.00%) were prescribed spectacles and surgical intervention was performed in 26 patients (86.67%). All patients except one case of Arnold Chiari malformation (96.67%) maintained normal binocular function and alignment following strabismus surgery or spectacles correction. CONCLUSION: Bielschowsky was the most common etiology of acute acquired comitant esotropia in our study. We suggest that refraction should be performed in all patients with acute acquired comitant esotropia. Most etiologies were benign and might not require neuroimaging. However, neuroimaging is recommended in those with atypical presentations, such as nystagmus, headache, or cerebellar signs. Surgical intervention with a 0.5-1.0 mm increase in recession was effective for restoring ocular alignment and binocular function in our patients.

Evaluation of retinal structure in unilateral amblyopia using spectral domain optical coherence tomography.

PURPOSE: To investigate potential differences in the retinal nerve fiber layer (RNFL) thickness, macular thickness and foveal thickness between amblyopic eyes and normal fellow eyes on spectral domain optical coherence tomography (SD-OCT). METHODS: A cross-sectional study of patients ≥10 years of age with unilateral amblyopia resulting from an anisometropic, strabismic or deprivative cause. Comprehensive ophthalmic examination was completed and the retinal structures of both eyes were measured using SD-OCT. We compared the measurements obtained between the amblyopic eye and the fellow normal eye in each subject. RESULTS: Twenty-six unilateral amblyopia patients with a mean age of 29.92 ± 14.19 years old participated in the study, of which 17 (65.4%) were classified as anisometropic, 7 (26.9%) as strabismic, and 2 (7.7%) as deprivative. For the amblyopic eye and fellow normal eye, respectively, the mean RNFL thickness was 95.87 ± 14.56 µm and 97.87 ± 14.56 µm (P = 0.628), the mean macular thickness was 270.87 ± 14.43 µm and 275.60 ± 14.43 µm (P = 0.251) and the mean foveal thickness was 250.59 ± 27.82 µm and 242.91 ± 27.82 µm (P = 0.332). SD-OCT assessments revealed no statistically significant differences between both eyes. CONCLUSIONS: Using SD-OCT, there were no significant changes in the retinal structure of amblyopic eyes. Therefore, amblyopia does not seem to have a profound structural effect on the retinal nerve fiber layer, the macula, or the fovea.

Autoimmune retinopathy associated with systemic lupus erythematosus: A diagnostic dilemma.

Visual loss in systemic lupus erythematosus (SLE) due to autoimmune retinopathy (AIR) is rare and easily misdiagnosed as hydroxychloroquine retinopathy. We report the rare clinical presentation of severe visual loss in a patient with SLE due to nonparaneoplastic AIR as differentiated from hydroxychloroquine toxicity. A 70-year-old female diagnosed and treated for lupus for 17 years and had been taking hydroxychloroquine for 15 years. Over the past 2 years, she developed progressive peripheral visual loss oculus uterque which rapidly advanced in the latter 6 months. Hydroxychloroquine toxicity was initially suspected, but diagnostic testing revealed a retinal degeneration. Antiretinal autoantibody testing using Western blot analysis revealed autoantibodies against 44-kDa, 46-kDa (anti-enolase), and 68-kDa proteins. Visual acuity improved in the first 6 months of treatment with mycophenolate mofetil. Our case suggests that AIR should be considered in the differential diagnosis of rapid, severe visual loss in patients with hydroxychloroquine treatment.

Sector iris hemangioma in association with diffuse choroidal hemangioma.

Two patients referred for iris lesions were found to have sector hemangioma of the iris stroma in contiguity with diffuse choroidal hemangioma. Neither patient had other manifestations of Sturge-Weber syndrome.

Anirdia-like phenotype caused by 6p25 dosage aberrations.

Axenfeld-Rieger spectrum (ARS) includes the anterior segment abnormalities posterior embryotoxon, irido-corneal adhesions, corectopia, and other abnormalities of pupil size and shape. Glaucoma occurs in approximately 50% of affected children. It is often caused by mutations of FOXC1 or PITX2. Timing of expression and dosage of these transcription factors appear to be very critical in the development of the anterior segment. We report on one child with a deletion and another with a duplication involving 6p25, causing an anirdia-like phenotype. Classic anirdia is a pan-ophthalmic disorder caused by heterozygous mutations involving the paired homeobox gene PAX6 at 11p13. It is often associated with optic nerve hypoplasia, foveal hypoplasia, corneal pannus, nystagmus, and cataract. Microdeletion of 11p13 may be associated with life threatening Wilms tumor. Distinguishing these two syndromes has critical implications for prognosis and treatment. We demonstrate how chromosomal microarray can be instrumental in differentiating these phenotypes.

Lyonization in ophthalmology.

PURPOSE OF REVIEW: To describe the entity of Lyonization in ocular eye diseases, along with its clinical and counseling implications. RECENT FINDINGS: Several X-linked ocular diseases such as choroideremia, X-linked retinitis pigmentosa, and X-linked ocular albinism may have signs of Lyonization on ocular examination and diagnostic testing. These findings may aid in the proper diagnosis of ocular disease in both female carriers and their affected male relatives. SUMMARY: Manifestations of Lyonization in the eye may help in the diagnosis of X-linked ocular diseases which may lead to accurate diagnosis, appropriate molecular genetic testing and genetic counseling.