Successful prism treatment for cyclic esotropia: A case report.

Purpose: To report a case of cyclic esotropia successfully treated with prismatic correction. Observations: A 9-year-old girl presented with intermittent esotropia and diplopia occurring over the previous 4 months. The patient had 30 prism diopters (PD) of esotropia at both distance and near. Ocular motility testing, other ophthalmic examinations, and brain magnetic resonance imaging revealed no abnormalities. At the third visit, the patient had 6 PD of intermittent esotropia without diplopia, and the eye position diary demonstrated esotropia every other day, which led to a diagnosis of cyclic esotropia with a 48-h cycle. The cyclic pattern persisted for 9 months following the initial visit. However, during a subsequent regular visit, the patient reported a newfound ability to self-adjust from "esotropic" days to "straight" days by tightly closing the eyes immediately after waking up in the morning, particularly when wishing to avoid strabismus. To address the condition, we affixed a Fresnel membrane prism on the glasses to compensate for the latent deviation on a "straight" day. During the subsequent 18 months, the esotropia completely resolved, and the patient was followed up with gradual decreases in prism power. Conclusions and Importance: Correcting latent deviation using a prism lens is a simple approach without potential side effects. The present findings suggest that this approach is a viable treatment option for cyclic esotropia during its early and periodic stages.

Prism adaptation response and surgical outcomes of acquired nonaccommodative comitant esotropia.

PURPOSE: To investigate the clinical factors influencing the prism adaptation response of acquired non-accommodative comitant esotropia (ANAET) and evaluate the surgical outcomes. STUDY DESIGN: Retrospective observational study. METHODS: This study assessed patients with ANAET who underwent strabismus surgery based on the results of a short prism adaptation test (PAT). Patients wore Fresnel trial prisms based on alternate prism cover tests in outpatient clinics. The cover test was then performed after 15-20 minutes; if the deviation increased, the power of the prism was increased to neutralize the angle. The test was repeated until the angle was stable. Patients were classified as either prism builders (angle increased by ≥ 10 prism diopters [PD] compared with the entry angle) or prism non-builders (angle increased by < 10 PD). The following clinical characteristics were noted: age at onset, age at surgery, duration of esotropia, refractive error, angle of deviation, presence or absence of intermittent esotropia at near, and pre- and postoperative sensory status. RESULTS: A total of 41 patients (median age, 15.4 years) were evaluated. The mean (standard deviation) spherical equivalent refractions were -3.03 (3.33) diopters (D) and -3.05 (3.23) D in the right and left eyes, respectively. Twenty-seven (66%) patients were prism builders. The prism builders had greater myopia (builders vs. non- builders, right eye: -3.97 [2.97] vs. -1.22 [3.33] D, P = .01; left eye: -4.08 [2.78] vs. -1.07 [3.20] D; P = .003), lower angle of deviation at near (median [interquartile range] 30.0 [20.0, 35.0] vs. 42.5 [35.0, 49.4] PD; P = .009), much more preoperative intermittent esotropia or esophoria at near (44% vs. 7%, P = .03) and diplopia (96% vs. 64%, P = .01), and better postoperative stereoacuity (50 [40, 110] vs. 100 [60, 400] arcsec, P = .02) than the prism non-builders. The overall success rate was 83%, without a significant difference between the two groups (builders vs. non-builders, 89% vs. 71%, P = .21). CONCLUSION: In cases of myopic refractive error, a small entry angle with intermittency at near, and good binocularity, it is recommended that surgery is performed based on prism-adapted angle to prevent under-correction.

Macular Microvasculature and Associated Retinal Layer Thickness in Pediatric Amblyopia: Magnification-Corrected Analyses.

Purpose: The purpose of this study was to characterize macular microvasculature and structural retinal layers using magnification-corrected optical coherence tomography angiography (OCTA) images in children with amblyopia. Methods: This prospective cross-sectional study included 22 children with unilateral amblyopia (4-11 years of age) receiving spectral-domain OCTA. Vessel densities in foveal and parafoveal regions of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were measured in amblyopic and fellow eyes using a customized image analysis program correcting the scale of retinal image with axial length. Iowa Reference Algorithms (Iowa Institute for Biomedical Imaging) were used to measure mean thickness values of 10 intra-retinal layers rescaled for image size correction. Results: Foveal and parafoveal vessel densities in amblyopic eyes were lower than that of the fellow eyes in the SCP (fovea: P = 0.006 and parafovea: P = 0.003) and the DCP (P = 0.024 and P = 0.025, respectively). Amblyopic eyes had significantly smaller foveal avascular zone (FAZ) area than fellow eyes (P < 0.001). There were significant differences in retinal layer thickness between paired eyes, particularly in the inner retina in both foveal and parafoveal regions; retinal nerve fiber layer (RNFL) (P = 0.024 and P = 0.095, respectively), ganglion cell layer (P < 0.001 and P = 0.008), inner plexiform layer (IPL; P = 0.12 and P = 0.037), inner nuclear layer (P = 0.005 and P = 0.005), and outer plexiform layer (OPL; P = 0.02 and P = 0.057), except in the foveal IPL, the parafoveal RNFL, and OPL. Conclusions: Unilateral amblyopic eyes demonstrate reduced macular vessel density and thicker inner retinal layers compared with fellow eyes even after correcting for image magnification. Changes in macular microvasculature and structural layers may offer valuable insights in the development of amblyopia.

Primary isolated amyloidosis in the extraocular muscle as a rare cause of ophthalmoplegia: A case report and literature review.

PURPOSE: To report a case of external ophthalmoplegia due to an uncommon form of amyloidosis exclusively affecting the lateral rectus muscle, and to discuss the clinical manifestation, diagnostic challenges, and management pitfalls of isolated amyloidosis in the extraocular muscle. OBSERVATIONS: A 64-year-old woman presented with diplopia in her left gaze lasting for six months. She had orthophoria in the primary position and abduction limitation in the left eye. Routine laboratory examinations were unremarkable. Orbital magnetic resonance imaging showed fusiform enlargement of the left lateral rectus muscle, without tendon involvement. Extraocular muscle biopsy was recommended to make a diagnosis, which revealed amyloid deposition in the lateral rectus muscle. A systemic work-up showed no evidence of systemic amyloidosis. Therefore, a diagnosis of primary isolated amyloidosis was made. Orthophoria in the primary position and diplopia in the lateral gaze persisted at the six-month follow-up. CONCLUSIONS AND IMPORTANCE: Atypical extraocular muscle enlargement should alert clinicians to the need for tissue biopsy to identify uncommon etiologies, such as amyloidosis. There are no pathognomonic or radiological features to distinguish localized from systemic amyloidosis. Therefore, if amyloidosis of the extraocular muscles is diagnosed, a systemic work-up is needed to rule out systemic amyloidosis, which is potentially life-threatening.

Resection and anterior transposition of the inferior oblique muscle for treatment of inferior rectus muscle hypoplasia with esotropia.

PURPOSE: To report a case of inferior rectus muscle hypoplasia with esotropia, which was treated successfully by resection and anterior transposition of the inferior oblique muscle. OBSERVATIONS: A 1-year-old boy presented with esotropia. He had esotropia of 15-30° and intermittent left hypertropia. At the age of 3 years, the alternate prism cover test showed esotropia of 35Δ and left hypertropia of 25Δ. Magnetic resonance imaging of the orbit revealed left inferior rectus muscle dysgenesis. Strabismus surgery was performed and a hypoplastic left inferior rectus muscle was identified. We performed bilateral medial rectus muscle recession, and resection and anterior transposition of the left inferior oblique muscle. Nine months after the surgery, the patient had esotropia of 8Δ and left hypertropia of 6Δ. CONCLUSIONS AND IMPORTANCE: Resection and anterior transposition of the inferior oblique muscle is useful for hypoplasia of the inferior rectus muscle accompanied by horizontal strabismus.

Retinal and choroidal hyperreflective foci on spectral-domain optical coherence tomographic images in a patient with retinitis pigmentosa accompanied by diabetic retinopathy.

PURPOSE: To report the detailed macular morphology documented by spectral-domain optical coherence tomography (SD-OCT) in a patient with retinitis pigmentosa (RP) and diabetic retinopathy (DR). OBSERVATIONS: A 54-year-old man with a hemoglobin A1c level of 11.4% was referred for decreased visual acuity (VA) bilaterally (right eye, 20/100; left eye, 20/40). Funduscopy showed typical retinal findings of RP bilaterally. The macular area of both fundi showed retinal dot-and-blot hemorrhages, hard exudates. Time-domain OCT revealed macular edema in the right eye. The patient was diagnosed with RP accompanied by DR bilaterally. Five years after the first visit, the BCVAs remained 20/100 in the right eye and 20/40 in the left eye. SD-OCT showed that the retinas were thinner temporal to the maculas. The external limiting membrane line (ELM) and the ellipsoid zone of the photoreceptors line (EZ) was not visible in the foveal region in the right eye and temporal to the macula in both eyes. The image revealed the characteristic intraretinal and intrachoroidal hyrerreflective foci, the number of which increased corresponding to the extent of the disappearance of the ELM and EZ line with thinning of the outer nuclear layer (ONL). In addition, the image also showed a great number of the hyperreflective foci in the ONL and the choriocapillaris in the foveal region in the right eye compared with the left eye. CONCLUSIONS: In the current case, the SD-OCT findings suggested that the characteristic hyrerreflective foci clinically observed in the fundi of a patient with RP accompanied by DR are present in the retinal layers and the choroid. In addition, the foci in the retinal and choroidal layers in the foveal region may increase as vision declines corresponding to the disappearance of the ELM and EZ line.