The Effect of Preoperative Occlusion Therapy on Long-term Outcome after Surgery for Early-onset Exotropia.

PURPOSE: To investigate the effect of preoperative part-time occlusion therapy on long-term surgical success in early-onset exotropia. METHODS: The medical records of patients who underwent surgery for exotropia with onset before the first year of age and who were followed for ≥3 years were reviewed. Patients were divided into two groups according to the degree of compliance with part-time occlusion therapy: the good compliance group (>50% adherence rate) and the poor compliance group (≤50% adherence rate). Surgical success was defined as orthophoria to exodeviation less than 10 prism diopters both at distance and near. The level of postoperative stereopsis was compared between the two study groups among total enrolled patients and among those with constant exotropia. RESULTS: Of the 51 patients, 26 were assigned to the good compliance group and the remaining 25 patients to the poor compliance group. The surgical success rate was significantly higher in the good compliance group than in the poor compliance group (80.8% vs. 52.0%, p = 0.040). Among 24 constant exotropia patients (12 patients for each group), the success rate was insignificantly higher in the good compliance group than in the poor compliance group (75.0% vs. 58.3%, p = 0.448). The good compliance group had a better level of stereopsis than the poor compliance group (p = 0.045 for all 44 patients, p = 0.020 for 19 patients with constant exotropia). CONCLUSIONS: Preoperative part-time occlusion therapy was useful for improving the surgical outcome of early-onset exotropia and postoperative stereopsis.

Acquired Brown Syndrome Treated With Traction of Superior Oblique Tendon.

Brown syndrome is a rare strabismic disease characterized by a limited elevation in adduction of the eye. The lengthening/weakening of superior oblique muscle is the main way of surgical intervention for this disease. A 7-year-old boy was diagnosed as having acquired Brown syndrome in his right eye after injury in his face. We experienced successful release of this Brown syndrome through mere pulling outward of superior oblique tendon during surgical exploration. We briefly discuss why this manipulation of superior oblique tendon that we performed was successful.

Factors influencing the development and severity of dissociated vertical deviation in patients with infantile esotropia.

PURPOSE: To investigate the factors associated with the development and the severity of dissociated vertical deviation (DVD) in patients who underwent surgery for infantile esotropia. METHODS: The medical records of consecutive patients who underwent surgery from March 1998 to December 2011 for infantile esotropia were reviewed retrospectively. The development, severity, and onset of DVD were assessed. Patients were divided into three groups: spontaneous, latent, and no DVD. The age at the time of the initial surgery, the angle of deviation of esotropia, anisometropia, amblyopia, stereopsis measured at the final visit, and history of prematurity were compared. RESULTS: A total of 90 patients were included. DVD was detected in 52 (58%). Of these, 34 patients demonstrated spontaneous DVDs and 18 showed latent DVDs. In the spontaneous DVD group, 71% underwent surgery after 24 months and 50% had a large angle of esodeviation (>60(Δ)), compared to the latent DVD group, in which 22% underwent later surgery and 11% had large-angle esodeviations (P < 0.001 and P = 0.002, respectively), and the no DVD group, in which 16% underwent later surgery and 13% had large-angle esodeviations (P < 0.001 each). Multivariate logistic regression analysis between groups revealed that later surgery (OR = 8.23; P < 0.001) and large-angle esodeviation (OR = 6.32; P = 0.003) were associated that greater development of spontaneous DVD. CONCLUSIONS: Surgical correction for infantile esotropia prior to 24 months of age, especially in cases with a large amount of esodeviation, decreased the incidence of spontaneous DVD.

The impact of intermittent exotropia and surgery for intermittent exotropia on myopic progression among early school-aged children with myopia.

AIM: To investigate the relationship between myopic progression and intermittent exotropia, and the impact of surgery for exotropia on myopic progression in early school-aged children (from 7 years to 12 years of age). METHODS: Medical records of early school-aged patients with myopia were reviewed. Patients were divided into three groups; (A) Patients with intermittent exotropia and myopia at presentation and who underwent bilateral lateral rectus muscle recession for exotropia when 7-12 years old; (B) Patients with intermittent exotropia and myopia at presentation and who were merely observed for exotropia; and (C) Patients with myopia and straight ocular alignment. Main outcome measurements were the simple rate of myopic progression per year, the preoperative and postoperative rates of refractive growth with regards to the logarithmic age model in Group A, and the rate of high myopia development at the end of the early school period. RESULTS: The rates of myopic progression were -0.43±0.14 dioptre (D) per year in Group A, -0.49±0.17 D/year in Group B and -0.42±0.24 D/year in Group C. There was no significant difference in the rate of myopic progression among three groups. There was no significant intergroup difference in the preoperative and postoperative rates of refractive growth in Group A. There were no significant intergroup differences in the rates of high myopia development among three groups. CONCLUSIONS: Whether patients with intermittent exotropia underwent surgical correction for intermittent exotropia did not influence the rate of myopic progression. There was no significant difference in the rate of myopic progression between patients with accompanying intermittent exotropia and myopia and those with myopia alone.

Ocular torsion among patients with intermittent exotropia: relationships with disease severity factors.

OBJECTIVE: To investigate the distribution of ocular torsion in patients with intermittent exotropia and to determine possible correlation between the torsion and the severity of intermittent exotropia. DESIGN: Prospective, comparative study comprising 600 eyes of 300 children. METHODS: One hundred fifty patients with intermittent exotropia between 4 and 15 years of age and another 150 age-matched normal controls without strabismus were enrolled prospectively. Digital nonmydriatic fundus photographs were obtained from both eyes of each subject and the disc-foveal angle was calculated using digital image software. All photographs also were graded as normal, extorsion, or intorsion. We compared the size of the disc-foveal angle between the normal and intermittent exotropia group. We analyzed possible correlations between the disc-foveal angle and disease severity factors, including amount of exotropia, Titmus stereoacuity, and duration of strabismus. RESULTS: Mean disc-foveal angle of intermittent exotropia group was significantly larger than that of normal control group (6.13 and 5.13 degrees, respectively; P < .01). Ocular torsion (either extorsion or intorsion) was discovered in 45 (30%) patients among the intermittent exotropia group, whereas it was found in only 16 (11%) individuals among the normal control group (P < .01). The size of disc-foveal angle showed significant positive correlations with the amount of exotropia and the degree of stereoacuity (r = 0.45, P < .01, and r = 0.51, P < .01, respectively). CONCLUSIONS: Ocular torsion could be found not infrequently in patients with intermittent exotropia. Furthermore, the amount of torsion showed a significant relationship to the disease severity of intermittent exotropia. Assessment of ocular torsion could be used as a supplementary tool for evaluating fusion in patients with intermittent exotropia.

Comparison of intraoperative complications of phacoemulsification between sequential and combined procedures of pars plana vitrectomy and cataract surgery.

PURPOSE: To compare intraoperative complications during phacoemulsification between sequential and combined procedures of vitrectomy and cataract surgery. METHODS: We retrospectively reviewed the medical records of 54 patients who underwent cataract surgery in a previously vitrectomized eye (sequential group) and 311 patients who underwent combined vitrectomy and cataract surgery (combined group). Primary outcome measures were intraoperative complications during phacoemulsification. Secondary measures were preoperative and intraoperative cataract gradings. RESULTS: The most common complication during phacoemulsification was posterior capsule rupture. The rate of posterior capsule rupture was higher in the sequential group (6 eyes, 11.4%) than in the combined group (14 eyes 4.5%, P = 0.049). Preoperative lens density (nuclear color and posterior subcapsular scores) was higher in the sequential group (P < 0.001). Intraoperative nuclear grading was higher compared with the preoperative one in the sequential group, but the two gradings did not differ in the combined group. CONCLUSION: Phacoemulsification in a vitrectomized eye is associated with a higher rate of posterior capsule rupture than the one in combined vitrectomy. These results may have been caused by hard nucleus cataract in a vitrectomized eye.

Comparison of the outcomes of non-trapdoor-type blowout fracture repair according to the time of surgery.

PURPOSE: We classified the outcomes of non-trapdoor-type blowout fracture repair by surgical indications and then compared the outcomes according to the time of treatment. METHODS: The medical records of 591 patients with orbital fractures that were treated surgically within 30 days of trauma were included in the study. The enrolled patients were classified into 2 groups by the major surgical indications: 1 group included patients with diplopia or limited extraocular motion, and the other group of patients had significant enophthalmos (>2 mm) or a large fracture on computed tomography (>½). The clinical outcomes were compared between the patients who received surgical repair within 14 days of trauma (early) and those who received treatment from 15 to 30 days after the trauma (delayed) in each group. RESULTS: Two hundred thirty-three patients received surgical repair because of diplopia or limited extraocular motion. Both the early repaired group (n = 195) and the delayed repaired group (n = 38) showed significant improvement after surgeries. The degree of preoperative and postoperative diplopia and limited extraocular motion was not associated with differences between the 2 groups. Four hundred one patients received surgical repair because of enophthalmos (>2 mm) or a large fracture on computed tomography (>½). Both the early repaired group (n = 328) and the delayed repaired group (n = 73) showed significant improvement of the enophthalmos after surgeries. The degree of preoperative/postoperative enophthalmos did not show differences between the 2 groups. CONCLUSIONS: If the blowout fracture repairs were performed within a month, the surgical outcomes did not differ according to the time of surgery in the cases of nontrapdoor blowout fracture.

Vitrectomy, Laser Photocoagulation, and Intravitreal Triamcinolone for Combined Hamartoma of the Retina and Retinal Pigment Epithelium.

Combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) is a rare, benign tumor, but there are no established managements for CHRRPE. A patient with CHRRPE who is treated successfully by the new combination therapy was described. A 32-year-old man was diagnosed as having CHRRPE after evaluation with ophthalmoscopy, fluorescein angiography (FA), and optical coherence tomography (OCT). First performed intravitreal triamcinolone acetonide (IVTA) (4 mg/0.1 mL) and laser photocoagulation to treat the vascular component. There was a rapid and good response after that therapy, but a recurrence 3 months later. To relieve the glial component, we simultaneously combined vitrectomy with IVTA and laser photocoagulation. After the combination therapy, there were no recurrences or complications. A combination therapy of vitrectomy, laser photocoagulation, and intravitreal triamcinolone could be considered as a possible management for CHRRPE with the vascular and glial components.