Age-related nonparalytic hypertropia: Clinical features.

PURPOSE: Age-related nonparalytic hypertropia (ARNH) is reported to be involved in sagging eye syndrome, where excyclotorsion is large and the lower eye is more extorted. The primary aim of this study was to describe the clinical profiles of patients with ARNH. The secondary aim was to compare cyclotorsion in patients with ARNH with that in normal individuals. METHODS: Inclusion criteria for ARNH were insidious onset of diplopia at distance after 50 years of age, nonparalytic hyperdeviation and follow-up >6 months. Objective cyclotorsion was measured as the disc-to-fovea angle (DFA) on fundus photographs obtained from two groups: 75 patients with ARNH (age, 74.1 ± 7.9 years) and 75 sex- and age-matched normal controls (73.9 ± 8.1 years). RESULTS: The hypertropia angle was 4.6 ± 2.8 prism dioptres. One patient also experienced diplopia at near-gaze. DFA in ARNH (right/left eye; 11.0 ± 4.8°/11.6 ± 3.9°) was larger than that of the control (6.6 ± 3.7°/9.2 ± 3.5°) (p < 0.0001). The DFA in the non-dominant eye (12.5 ± 4.1°) was larger than that in the dominant eye (10.2 ± 4.3°) (p = 0.0003). The lower eye did not have the larger DFA in 29 patients. CONCLUSION: The angle of hyperdeviation in patients with ARNH was small. The DFA in the ARNH group was larger than that in the normal group. The lower eye was not the eye with a larger DFA in 39% of ARNH, inconsistent with sagging eye syndrome. Decreased phoria adaptation (fusional ability) may trigger diplopia in patients with ARNH.

Transcriptomic alterations in hypertrophy of the ligamentum flavum: interactions of Rho GTPases, RTK, PIK3, and FGF.

PURPOSE: To analyze the differential transcriptome expression in hypertrophic ligaments flavum (HLF) compared to normal ligaments. METHODS: A case-control study was conducted that included 15 patients with hypertrophy of LF and 15 controls. Samples of LF were obtained through a lumbar laminectomy and analyzed by DNA microarrays and histology. The dysregulated biological processes, signaling pathways, and pathological markers in the HLF were identified using bioinformatics tools. RESULTS: The HLF had notable histological alterations, including hyalinosis, leukocyte infiltration, and disarrangement of collagen fibers. Transcriptomic analysis showed that up-regulated genes were associated with the signaling pathways of Rho GTPases, receptor tyrosine kinases (RTK), fibroblast growth factors (FGF), WNT, vascular endothelial growth factor, phosphoinositide 3-kinase (PIK3), mitogen-activated protein kinases, and immune system. The genes PIK3R1, RHOA, RPS27A, CDC42, VAV1, and FGF5, 9, 18, and 19 were highlighted as crucial markers in HLF. The down-expressed genes in the HLF had associations with the metabolism of RNA and proteins. CONCLUSION: Our results suggest that abnormal processes in hypertrophied LF are mediated by the interaction of the Rho GTPase, RTK, and PI3K pathways, which have not been previously described in the HLF, but for which there are currently therapeutic proposals. More studies are required to confirm the therapeutic potential of the pathways and mediators described in our results.

Transposición del vientre del oblicuo inferior sin desinserción en el tratamiento de la hipertropia en aducción / Transposition of the inferior oblique muscle belly without disinsertion for overshoot in adduction treatment

Propósito Analizar la eficacia y la seguridad de la transposición del oblicuo inferior con miopexia en pacientes con hiperfunción primaria o secundaria del oblicuo inferior leve-moderada, con o sin diplopía. Método Estudio observacional retrospectivo de 12 pacientes tratados con dicha técnica entre octubre de 2018 y septiembre de 2021. Se suturó el oblicuo inferior a esclera a 5mm posterior a la inserción temporal del recto inferior. Todos tenían desviación vertical de pequeño ángulo (media ±DE: 4,42±1,62) en posición primaria (≤6 dioptrías prismáticas [dp]), hipertropia en aducción leve-moderada y 10 tenían diplopía. Los diagnósticos fueron: paresia del IVnervio (9), DVD (1) e hipertropia en aducción unilateral (2). De los 12 casos, 7 presentaban tortícolis, 2 torsión subjetiva y 2 torsión objetiva. Resultados La edad media de la muestra fue 46,86±25,1 años (50% hombres). De los 10 casos con diplopía, en 9 se resolvió. La desviación vertical media final en mirada al frente fue: 1,5dp ±2,93 (p=0,001). De 7 casos con hipertropia en aducción leve, en 3 desapareció y 4 quedaron igual. De 5 casos con hipertropia en aducción moderada, 2 mejoraron a leves y en 3 desapareció. El tortícolis se resolvió en 5 casos, y en otros 2 mejoró. El tiempo de seguimiento medio fue de 14,08±8,05 meses. No se registraron hipercorrecciones. Conclusiones La transposición del oblicuo inferior con miopexia es una nueva técnica eficaz y segura en pacientes con leve-moderada hipertropia en aducción e hipertropia de pequeño ángulo, con o sin diplopía (AU)

Purpose To evaluate the efficacy and safety of inferior oblique muscle transposition and myopexy in patients with mild/moderate inferior oblique muscle overaction, with or without diplopia. Method We retrospectively analysed data for the 12 patients who underwent the technique. Data were collected from October 2018 to September 2021. Surgery was performed by suturing the inferior oblique belly to the sclera at 5mm posterior to the temporal end of the inferior rectus. All 12 patients had mild hypertropia (≤6 prism diopters [pd]) in primary position and mild/moderate inferior oblique overaction. Mean preoperative hypertropia was 4.42pd ±1.62. Diplopia was recorded in 10 cases. The diagnoses were fourth nerve paresis (9), unilateral primary inferior oblique overaction (2) and dissociated vertical deviation (1). Torticollis was observed in 7 cases, 2 had subjective torsion and 2 objective torsion. Results Mean age was 46.86±25.1 years (50%: men). Diplopia resolved in 9 of the 10 cases. The mean final vertical deviation was 1.5±2.93 (P=.001) pd in straight gaze. Of 7 mild overshoot in adduction, it disappeared in 3 and 4 remained the same. Of 5 moderate overshoot in adduction, 2 improved to mild and 3 disappeared. Torticollis was eliminated in 5 patients and improved in another 2. Mean time from surgery was 14.08±8.05 months. There were no overcorrections Conclusions Inferior oblique muscle transposition with myopexy is a safe and effective procedure in patients with mild-to-moderate inferior oblique muscle overaction and small-angle hypertropia, with or without diplopia (AU)

Muscle fenestration in vertical rectus muscle surgeries.

PURPOSE: To evaluate the outcome of fenestration of the vertical rectus muscles in correcting vertical deviations. MATERIAL AND METHODS: A retrospective chart review was conducted on patients who underwent fenestration surgery on the superior rectus (SR) or inferior rectus (IR) muscles. Ductions, versions, angle of deviations before and after surgery, and surgical details were analyzed. Success was defined as vertical alignment within 4 PD of orthophoria. RESULTS: Nineteen patients were identified. The mean age of the patients was 19.3 ± 13.1 (range; 4 to 48) years. The mean follow-up was 6.5 ± 2.7 (range, 3 to 12) months. Eleven patients presented with dissociated vertical deviation (DVD), 2 patients with sensory hypertropia, and 6 patients with sensory hypotropia. Fourteen patients had concomitant horizontal muscle surgery. The mean change of the angle of deviation was 13 ± 3 (range, 8 to 20) PD after SR fenestration. and 12 ± 2 (range; 10 to 15) PD after IR fenestration. There was a significant improvement in the post operative angle of deviation in both groups (P value <0.001). Success was achieved in 10 (77%) of patients who underwent SR fenestration and in all patients underwent ir fenestration. Only one patient in the IR group developed a 1-mm lower lid retraction. CONCLUSION: Fenestration of the vertical rectus muscles is an effective and safe method for correcting vertical deviations. We recommend increasing the amount of fenstration in DVD to further improve the outcome.

Transposition of the inferior oblique muscle belly without disinsertion for overshoot in adduction treatment.

PURPOSE: To evaluate the efficacy and safety of inferior oblique muscle transposition and myopexy in patients with mild/moderate inferior oblique muscle overaction, with or without diplopia. METHOD: We retrospectively analysed data for the 12 patients who underwent the technique. Data were collected from October 2018 to September 2021. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal end of the inferior rectus. All 12 patients had mild hypertropia (≤6 prism diopters [pd]) in primary position and mild/moderate inferior oblique overaction. Mean preoperative hypertropia was 4.42 pd ±â€¯1.62. Diplopia was recorded in 10 cases. The diagnoses were fourth nerve paresis (9), unilateral primary inferior oblique overaction (2) and dissociated vertical deviation (1). Torticollis was observed in 7 cases, 2 had subjective torsion and 2 objective torsion. RESULTS: Mean age was 46.86 ±â€¯25.1 years (50%: men). Diplopia resolved in 9 of the 10 cases. The mean final vertical deviation was 1.5 ±â€¯2.93 (p = 0.001) pd in straight gaze. Of 7 mild overshoot in adduction, it disappeared in 3 and 4 remained the same. Of 5 moderate overshoot in adduction, 2 improved to mild and 3 disappeared. Torticollis was eliminated in 5 patients and improved in another 2. Mean time from surgery was 14.08 ±â€¯8.05 months. There were no overcorrections. CONCLUSIONS: Inferior oblique muscle transposition with myopexy is a safe and effective procedure in patients with mild-to-moderate inferior oblique muscle overaction and small-angle hypertropia, with or without diplopia.

Congenital anomalies of inferior rectus and its surgical outcomes.

Congenital inferior rectus hypoplasia and aplasia is a rare abnormality of the extraocular muscles, and it is the second most common after superior oblique muscle aplasia. It has been reported either in isolation or with coexisting ocular or systemic associations. We describe here cases of inferior rectus hypoplasia/aplasia, their clinical features, and surgical approach to achieve satisfactory outcomes. We retrospectively reviewed medical records from January 2009 to December 2020 of patients with vertical strabismus due to inferior rectus hypoplasia/aplasia at a tertiary eye care center. Those who underwent surgical intervention with an adequate follow up postoperatively were included in the study. Three patients who presented with congenital hypertropia and diagnosed of inferior rectus aplasia/hypoplasia and who underwent strabismus surgery were identified. Diagnosis was based on clinical examination and orbital imaging. Coexisting horizontal deviation was present in two patients. None of the patients had any other ocular, cranial, or systemic anomalies. All patients had isolated inferior aplasia/hypoplasia with normal other extraocular muscles on orbital imaging. Intraoperatively, ipsilateral superior rectus was tight in all patients. All underwent ipsilateral superior rectus recession, whereas two patients with large vertical strabismus required additional inferior oblique anteronasal transposition in the same eye. Satisfactory outcomes were achieved in all three patients without the need for resurgery. Moderate to large vertical A pattern strabismus and limitation of infraduction are common clinical findings. Orbital imaging helps not only in diagnosis but also in surgical planning. Weakening of antagonist superior rectus with anteronasal transposition of inferior oblique not only gives good surgical outcomes but also avoids potential complications related to vertical transposition of either horizontal rectus muscle.

Bilateral congenital hypertropic strabismus fixus: A case report.

PURPOSE: To report an unusual and rare case of both eyes fixed in an extreme superomedial position. CASE REPORT: A case of 48-year-old woman presented with both eyes fixed in an extreme superomedial position; the microcorneas were covered almost completely by the upper eyelids even when she opened her eyes. A forced duction test was performed to confirm there were severe restrictions in all directions. She underwent disinsertion of the superior and medial rectus muscle, inferior oblique muscle belly transposition and sclera fixation. At the 1-year follow-up, there was improved ocular alignment. CONCLUSION: This case may be a special form of myopic strabismus fixus. The infratemporal fossa may be a bony landmark related to the etiology of global fixation.

The Role of Hypertropia in the Surgical Management of Bilateral Inferior Oblique Muscle Overaction.

PURPOSE: Inferior oblique muscle overaction (IOOA) is an ocular motility anomaly consisting of overelevation in adduction, often associated with ipsilateral hypertropia. The weakening procedure of IO muscle is the most widely used procedure in IOOA. Usually, surgical planning is based on the degree of overaction of the IO muscle. MATERIALS AND METHODS: We have retrospectively analyzed patients with bilateral IOOA with and without hypertropia in primary position, who underwent a bilateral IO weakening procedure. Both the amount of IOOA and the presence of a hypertropia in primary position were taken into consideration for the surgical plan. RESULTS: Nineteen patients met the entry criteria for this study. In 12 patients, a hypertropia in primary position was present at baseline, and it was significantly lower after the asymmetrical IO weakening: 11 had an asymmetric IOOA at baseline, and one had symmetric IOOA. None of the remaining seven patients had a vertical deviation in primary position before surgery, despite having asymmetric IOOA. None of them developed a hypertropia in primary position after symmetric IO weakening. CONCLUSIONS: Our findings outline the utility of considering both the presence of a vertical deviation in primary position and the magnitude of IOOA in this set of patients. Asymmetric inferior oblique weakening procedure is effective in treating a hypertropia in the primary position and bilateral IOOA.

Adjustable Sutures in the Treatment of Strabismus: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the scientific literature that evaluates the effectiveness of adjustable sutures in the management of strabismus for adult and pediatric patients. METHODS: Literature searches were performed in the PubMed database through April 2021 with no date limitations and were restricted to publications in English. The searches identified 551 relevant citations, of which 55 were reviewed in full text. Of these, 17 articles met the inclusion criteria and were assigned a level of evidence rating by the panel methodologist. The search included all randomized controlled studies regardless of study size and cohort studies of 100 or more patients comparing the adjustable versus nonadjustable suture technique, with a focus on motor alignment outcomes or reoperation rates. RESULTS: The literature search yielded no level I studies. Of the 17 articles that met the inclusion criteria, 11 were rated level II and 6 were rated level III. Among the 12 studies that focused on motor alignment outcomes, 4 small randomized clinical trials (RCTs) did not find a statistically significant difference between groups, although they were powered to detect only very large differences. Seven of 8 nonrandomized studies found a statistically significant difference in motor alignment success in favor of the adjustable suture technique, both overall and in certain subgroups of patients. Successful motor alignment was seen in both exotropia (in 3 studies that were not limited to children) and esotropia (in 1 study of adults and 2 of children). The majority of included studies that reported on reoperation rates found the rates to be lower in patients who underwent strabismus surgery with adjustable sutures, but this finding was not uniformly demonstrated. CONCLUSIONS: Although there are no level I studies evaluating the effectiveness of adjustable sutures for strabismus surgery, the majority of nonrandomized studies that met the inclusion criteria for this assessment reported an advantage of the adjustable suture technique over the nonadjustable technique with respect to motor alignment outcomes. This finding was not uniformly demonstrated among all studies reviewed and warrants further investigation in the development and analysis of adjustable suture techniques.

Botulinum Toxin Injection of the Inferior Oblique Muscles for V-Pattern Strabismus and Primary Position Hypertropia.

PURPOSE: To evaluate outcomes of botulinum toxin (BTX) injection of the inferior oblique (IO) muscle. DESIGN: Retrospective case series. METHODS: Setting: Single center, ophthalmology department at Boston Children's Hospital. STUDY POPULATION: All patients treated with IO muscle injection of BTX (onabotulinumtoxinA) between 2010 and 2020. OBSERVATION PROCEDURE: Sensorimotor evaluations at short-term (<2 months), medium-term (2-4 months), and long-term (≥4 months) intervals. OUTCOME MEASURE: Primary outcomes included median improvement in V-pattern strabismus and primary position hypertropia. Secondary outcomes included IO muscle overaction. Wilcoxon signed-rank tests were performed to identify differences before and after injection. RESULTS: Record review identified 20 patients with a median age of 4.5 (range, 1-69) years. Median BTX dose injected (31 IO muscles) was 5.0 (range, 3.0-7.0) units. Indications included V-pattern strabismus (N = 8), hypertropia (N = 7), or both (N = 5). Median long-term interval was 6.4 (range, 4.1-26.6) months. Injections were concurrent with treatment of horizontal strabismus in all but 3 cases. Median V-pattern magnitude changed from 10 prism diopters (PD) preoperatively to 0 PD short-term (P = .006) and 3.5 PD long-term (P = .34). Median hypertropia changed from 8.5 PD preoperatively to 1.5 PD short-term (P = .01) and 8 PD long-term (P = .87). Median IO muscle overaction grade improved significantly at short-term (P < .001) and long-term (P = .007) intervals. There were no complications associated with the IO muscle injections. CONCLUSIONS: BTX injection of the IO muscles can be a useful adjunct to the management of V-pattern strabismus. Intervention for primary position hypertropia may be helpful for short-term relief with no expectation of long-term benefit.

Inferior oblique belly transposition in the treatment of mild inferior oblique overaction with small angle vertical strabismus / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To observe the effect of inferior oblique belly transposition(IOBT)in unilateral mild inferior oblique overaction with small angle vertical stabismus.<p>METHODS: The data of patients who underwent IOBT in our hospital from September 2019 to August 2021 were analyzed retrospectively. Inclusion criteria targeted patients with mild inferior oblique overaction(2+ and below)and small angle incomitant vertical strabismus(4-9PD). The horizontal deviation and vertical deviation in both primary and lateral gazes were measured, and the degree of inferior oblique overaction and fovea-disc angle(FDA)were also evaluated preoperatively and postoperatively.<p>RESULTS: A total of 16 cases(16 eyes)were included, aged 4-39 years. One case was 5a postoperative congenital esotropia with secondary unilateral inferior oblique overaction by mild superior oblique palsy, whereas 15 patients had monocular primary inferior oblique overaction with horizontal strabismus. The follow-up was 3-6mo. The mean improvement of inferior oblique overaction was 2.00(1.25, 2.00)grade from +2.00(2.00, 2.00)preoperatively to 0.00(0.00, 0.00)postoperatively, the difference was statistically significant(<i>Z</i>=-3.70, <i>P</i><0.001). The horizontal strabismus decreased from 69.13±25.86PD preoperatively to 2.75±2.59PD postoperatively(<i>t</i>= 9.929, <i>P</i><0.001). The vertical strabismus in the primary position decreased from preoperative 7.44±1.32PD to 1.00±1.21PD postoperatively(<i>t</i>=22.335, <i>P</i><0.001), mean corrected hypertropia 6.44±1.15PD, and vertical strabismus in lateral gazes decreased from preoperative 12.44±2.73PD to 3.00±2.13PD postoperatively, mean corrected hypertropia 9.44±2.73PD, these differences were statistically significant(<i>t</i>=13.819, <i>P</i><0.001). The FDA decreased from -8.85°±6.53° preoperatively to -6.49°±7.01° postoperatively, the difference was statistically significant(<i>t</i>=-2.384, <i>P</i><0.001), with a mean reduction of 2.36°. No postoperative complications such as postoperative overcorrection or inferior oblique underaction were observed.<p>CONCLUSION:IOBT is safe and effective in correcting unilateral mild inferior oblique overaction with small angle vertical strabismus.

The Correlation between Hypertropia and Head Tilt in Congenital Unilateral Superior Oblique Muscle Palsy.

PURPOSE: To evaluate the correlation between the angle of deviation in different gazes and the amount of head tilt in patients with congenital unilateral superior oblique muscle palsy (SOP). METHODS: This case series study was performed on 20 consecutive SOP patients with head tilt. Based on the Bielschowsky three-step test, the angle of deviation was measured in different gazes. Furthermore, the hypertropia difference between the two lateral gazes (gaze difference) and the two head tilt sides (bilateral head tilt difference) was calculated. For measuring head tilt, close-up pictures from 40 cm with a habitual abnormal head position were captured and analyzed by the Corel Draw X7 software. RESULTS: The mean age of patients was 13 ± 9 years (range, 2.5-31 years). The mean angle of hypertropia in ipsilateral and contralateral head tilt was 24.5 Δ ± 7.1 Δ and 6.5 Δ ± 4.2 Δ, respectively (P < 0.001), and in ipsilateral and contralateral lateral gaze positions, it was 8.2 Δ ± 5.5 Δ and 22.5 Δ ± 6.1 Δ, respectively (P < 0.001). The mean of bilateral head tilt hypertropia difference was 18 Δ ± 5.3 Δ and gaze hypertropia difference was 14.3 Δ ± 6.16 Δ. There was a positive correlation between bilateral head tilt hypertropia difference and the amount of head tilt (R = 0.609, R 2 = 0.371, P = 0.004, the amount of head tilt = 0.39 × [Bilateral head tilt hypertropia difference] +1.77). The amount of head tilt also had a positive correlation with the gaze hypertropia difference (R = 0.492, R 2 = 0.242, P = 0.028, the amount of head tilt = 0.27 × [gaze hypertropia difference] +4.81). CONCLUSION: In SOP patients, the amount of head tilt had a positive correlation with bilateral head tilt hypertropia difference and also gaze hypertropia difference.

Inferior oblique muscle belly transposition and myopexy for diplopia.

To evaluate the outcomes of and review the indications for Inferior oblique muscle belly transposition in adults with diplopia and small-angle hypertropia associated with mild or moderate upshoot in adduction. We retrospectively analyzed data for the six patients who underwent the technique. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal pole of the inferior rectus. Data were collected from October 2018 to April 2020. All six patients had diplopia and mild hypertropia (≤6 prism diopters [pd]) in primary position. Mean preoperative hypertropia was 4.17 pd (range, 2-6 pd). Mean age was 51 ± 28.71 years. The diagnoses were fourth nerve paresis (5) and dissociated vertical deviation (1). All patients had mild/moderate upshoot in adduction. Torticollis was observed in four cases. Diplopia resolved in 5 of the 6 cases. The mean final vertical deviation was 2 pd in straight gaze. Torticollis was eliminated in 2 patients and improved in another 2. The upshoot in adduction was totally eliminated in the six patients. Transitory mild limitation of elevation in adduction was observed in two patients during the first week after surgery. No ocular torsion was diagnosed after surgery. Mean time from surgery was 11.5 months. No overcorrections were recorded. Inferior oblique muscle belly transposition with myopexy is a good alternative procedure in patients with diplopia associated with mild-to-moderate upshoot in adduction and small-angle hypertropia.

Recurrent Fevers and Neuro-ophthalmic Disorders in a Mathematical Genius.

Horner's syndrome coexisting with an ipsilateral fourth cranial nerve palsy is a rare occurrence and likely localises to pathology in the cavernous sinus. One such case may have occurred in the 18th century affecting the renowned mathematician Leonhard Euler. A review of his biographies, eulogies, and three finely detailed facial portraits suggest that these two neuro-ophthalmic conditions, along with visual loss and a decades-long intermittent febrile illness, may have been the result of an orbital cellulitis and septic cavernous sinus thrombosis, from an underlying chronic brucellosis infection.

Effect of unilateral vertical transposition of the horizontal rectus muscles on vertical strabismus.

PURPOSE: To study the effect of vertically transposing both horizontal eye muscles of one eye in the same direction on vertical strabismus. METHODS: Retrospective analysis of 33 patients in whom vertical transposition of the medial and lateral rectus muscles was combined with a recession/resection or recession/plication procedure. Preoperative ocular alignment was compared with that 1 day and 3 months postoperatively. RESULTS: Mean preoperative vertical deviation was 7.8 ± 4.3 (median 7.5, range 3-25) prism diopters (PD) at distance and 7.8 ± 4.1 (7, 0-18) PD at near. Vertical transposition of the horizontal rectus muscles averaged 5.6 ± 1.6 mm and reduced the vertical deviation to 3.4 ± 4.2 PD (2, 0-16) at distance and 2.9 ± 3.7 PD (2, 0-14) at near. Mean effect on the vertical deviation was 0.9 ± 0.7 (0.8, -0.8 to 2.13) PD/mm at distance and 0.9 ± 0.9 (0.83, -1 to 3) PD/mm at near, it was similar in patients operated on for esotropia and for exotropia. The surgical effect on the horizontal deviation was 2.1 ± 1.1 PD/mm (distance) and 2.6 ± 1 PD/mm (near). Both the vertical and horizontal surgical dose correlated with the effect in a linear way, but the variability was greater for the vertical transposition. CONCLUSIONS: Vertical transposition of the horizontal rectus muscles in the same direction allows for correction of vertical strabismus. This procedure may be performed during primarily horizontal strabismus surgery, without operating on an additional extraocular muscle. The transposition distance correlates with the surgical effect but predictability of the effect is limited.

Incidental Hamartoma in an elderly patient: a case report.

BACKGROUND: Neuromuscular hamartoma is a very rare tumor; with only five cases reported in the orbit. It often occurs in infants and young children and involves large peripheral nerves, but there has been only few reports of occurrence in the orbit and adults. CASE PRESENTATION: This paper describes a 70-year-old man with an incidental orbital mass detected by an imaging test and who later developed associated symptoms. The mass was diagnosed as neuromuscular hamartoma. Superior rectus muscle recession and inferior rectus muscle resection were performed in the right eye for hypertropia secondary to postoperative inferior rectus muscle palsy. Hypertropia in the right eye and diplopia improved after surgery, and regular follow-up is underway. CONCLUSION: This is the first case of an incidentally detected orbital mass diagnosed by histologic examination as a neuromuscular hamartoma in an older patient whose proptosis progressed after a long period of inactivity.

Assessment of Different Types of Strabismus Among Pediatric Patients in a Tertiary Hospital in Jeddah.

Background Strabismus, also known as squint, is an ocular disorder in which the eyes do not align properly with each other when looking at an object. The estimated global prevalence of strabismus among children is between 1.3% and 5.7%. This study aimed to assess the various types of strabismus among pediatric patients in Jeddah, in the western region of Saudi Arabia. Methods The medical records of 281 patients with strabismus aged ≤18 years, who presented to the pediatric ophthalmology clinic in King Abdulaziz University Hospital between 2010 and 2019, were retrospectively reviewed. Data were analyzed using the Statistical Package for Social Sciences (SPSS; IBM Corp., Armonk, NY, USA). A p-value of 0.05 or less was considered statistically significant. Results Out of the 281 patients, 141 were (50.2%) female. The average age of the patients was 9.50 ± 4.24 years. The most common type of strabismus was esotropia (177 [63%] patients), followed by exotropia (96 [34.2%] patients), hypertropia (10 [3.6%] patients), and dissociated vertical deviation (four [1.4%] patients). Two-hundred thirty-one (82.8%) patients had bilateral strabismus. A total of 178 patients (63.3%) had no associated conditions with strabismus, whereas 103 (36.7%) had an associated condition. A significant relationship was observed between esotropia and prematurity (p = 0.024). Conclusion Esotropia was the most common type of strabismus among the patients, followed by exotropia. The results of this study showed that males were equally affected as females. We also found a significant relationship between esotropia and prematurity. Implementation of a compulsory nationwide pediatric ophthalmic screening program for children aged one, three, and five years is recommended to enable timely diagnosis of strabismus and any other refractive errors.

Resection and Transposition of the Inferior Oblique for Hypertropia due to the Inferior Rectus Loss

PURPOSE: To report a case of resection and transposition of the inferior oblique muscle combined with superior rectus recession as treatment for large-angle hypertropia due to unilateral loss of the inferior rectus muscle. CASE SUMMARY: A 39-year-old man presented with a complaint of left hypertropia and vertical diplopia caused by blunt trauma 20 years previously. Left hypertropia of 70 prism diopters (PD) and exotropia of 16 PD in the primary gaze were noted; ocular movements of the left eye showed overactive supraduction (+4) and underactive infraduction (−5). On surgical exploration, neither the inferior rectus muscle nor capsule were present at the insertion site. The patient was diagnosed with loss of the inferior rectus muscle, thus, 7 mm of the inferior oblique muscle was resected and transposed at the original insertion site of the inferior rectus muscle; the superior rectus muscle was then recessed by 4.5 mm. After the surgery, vertical alignment was straight in the primary position, infraduction limitation was changed from −5 preoperative to −2 postoperative, and supraduction was changed from +4 preoperative to −2 postoperative. CONCLUSIONS: Extensive resection and transposition of the inferior oblique muscle combined with recession of the superior rectus may help in obtaining a successful surgical outcome in patients with inferior rectus muscle loss with a large angle of vertical deviation.

Role of a Standardized Prism Under Cover Test in the Assessment of Dissociated Vertical Deviation.

BACKGROUND: Dissociated vertical deviation (DVD) is commonly measured using a prism and alternate cover test (PACT), but some providers use a prism under cover test (PUCT). The aim of this study was to compare a standardized PUCT measurement with a PACT measurement, for assessing the magnitude of DVD. METHODS: Thirty-six patients with a clinical diagnosis of DVD underwent measurement of the angle of deviation with the PACT, fixing with the habitually fixing eye, and with PUCT, fixing both right and left eyes. The PUCT was standardized, using a 10-second cover for each prism magnitude, until the deviation was neutralized. The magnitude of hyperdeviation by PACT and PUCT was compared for the non-fixing eye, using paired non-parametric tests. The frequency of discrepancies more than 4 prism diopters (PD) between PACT and PUCT was calculated. RESULTS: The magnitude of hyperdeviation was greater when measured with PUCT (range 8PD hypodeviation to 20PD hyperdeviation) vs. PACT (18PD hypodeviation to 25PD hyperdeviation) with a median difference of 4.5PD (range -5PD to 21PD); P < 0.0001. Eighteen (50%) of 36 measurements elicited >4PD hyperdeviation (or >4PD less hypodeviation) by PUCT than by PACT. CONCLUSIONS: A standardized 10-second PUCT yields greater values than a prism and alternate cover test in the majority of patients with DVD, providing better quantification of the severity of DVD, which may be important for management decisions.

Surgical Management of Superior Oblique Muscle Palsy in Hypertropia 16 Prism Diopters or More

PURPOSE: Isolated inferior oblique weakening procedure is an effective treatment for patients with superior oblique muscle palsy who had up to 15 prism diopters (PD) of vertical deviation in the primary position, but 2-muscle surgery is needed for patients with larger deviations. Herein, we report the surgical results of simultaneous 2-extraocular muscle surgery for large primary position hypertropia 16 PD or more caused by superior oblique palsy. METHODS: This study was a retrospective review of the records of patients who presented with central gaze hypertropia 16 PD or more and underwent simultaneous 2-extraocular muscle surgery between January 2003 and June 2014 in Severance Hospital. The patients were divided into 3 groups: 43 patients who underwent inferior oblique (IO) myectomy and contralateral inferior rectus (IR) recession (Group 1), 10 patients who underwent IO myectomy and superior rectus (SR) recession (Group 2), and 8 patients who underwent SR recession and contralateral IR recession (Group 3). Criteria for success included correction of head posture and a primary position alignment within 5 PD of vertical deviation. RESULTS: Mean preoperative alignment at primary gaze was 25.5 ± 7.1 PD (range, 16-60 PD) compared to the postoperative value of -1.3 ± 6.8 PD (range, -20~25 PD) (p < 0.001). Surgery was successful in 49 (80%) patients. Nine (15%) patients were overcorrected and the other 3 (5%) patients were undercorrected. Success rate was the highest in subjects who underwent IO myectomy and contralateral IR recession. Among the 24 patients who did not receive combined horizontal muscle surgery, horizontal deviations decreased from 10.4 ± 2.7 PD to 1.5 ± 5.5 PD (p < 0.001) CONCLUSIONS: Two-muscle surgery can be effective in patients with large hypertropia 16 PD or more. Additionally, horizontal deviations are more likely to be resolved with vertical muscle surgery alone. However, IO myectomy combined with ipsilateral SR recession can cause overcorrection postoperatively, so surgical dose should be reduced when performing weakening procedure of two elevators in one eye.