Outcomes of pediatric accommodative esotropia with botulinum toxin A treatment in Thailand.

Accommodative esotropia is a condition commonly encountered by pediatric ophthalmologists. Patient with accommodative esotropia wear hyperopic glasses to decrease accommodation which occasionally provide them with good vision without glasses. Children are known to have limited compliance with glasses and patching. Their limited cooperation can also lead to variability in angle measurement across visits and defer surgery. To cope with these challenges, our team offered botulinum toxin injection to the medial rectus as an optional treatment while waiting for compliance and deferring the surgery. This is retrospective study including data from 114 accommodative esotropia patients who were injected with botulinum toxin into the medial rectus between 2010 and 2017. Of these, 102 patients met the inclusion criteria. Almost half of the patients were boys (47.06%). The average angle deviation before injection was 40 prism diopters (PD). The post-injection angle averaged at 11 PD at 2 weeks, 19 PD at 3 months, and 25 PD at 6 months. At 6 months, 51 patients (50.00%) had satisfactory results, 17 (16.67%) had excellent results (ortho to esotropia < 10 PD) and 34 (33.33%) had small angle esotropia (esotropia 11-20 PD). All complications including ptosis (37.25%), exotropia (11.76%), and hypertropia (4.9%) were reversible. Botulinum toxin injection into the medial rectus for pediatric esotropia showed satisfactory outcomes in 50% of patients with minimal complications. The study showed no significant association of good outcomes with age at onset, age during injection, status of development, status of amblyopia, refractive error, and angle of deviation as analyzed by the statistical package for social sciences.

Endoscopic Optic Nerve Sheath Fenestration for Treatment of Papilledema Secondary to Intracranial Venous Hypertension: Report of Two Cases.

Objective: To determine the safety and efficacy of endoscopic optic nerve sheath fenestration (ONSF) for the reversal of papilledema in intracranial venous hypertension. Material and Method: A retrospective chart review was performed on two consecutive patients who underwent endoscopic ONSF. Presenting symptoms, neuro-ophthalmological work-ups, including visual acuity (VA), visual field charting (VF), optical coherence tomography (OCT) and MRI as well as magnetic resonance venography (MRV) were recorded. Cerebrospinal fluid pressure was also measured preoperatively in both individuals. Visual improvement was assessed by comparing with preoperative ophthalmological findings. Results: This report is the first endoscopic ONSF study focusing on treatment of papilledema resulting from intracranial venous hypertension (tumor compressing transverse sigmoid junction in the first patient and venous sinus stenosis in the second patient). ONSF was performed on both sides of the first patient and on the right optic nerve of the second patient with showing reduction of papilledema on both eyes. Papilledema was improved in both individuals. Vision improved more in the first patient than in the second whom had pre-existing optic nerve atrophy. Conclusion: Endoscopic optic nerve sheath fenestration is an effective and safe procedure to revert visual loss or to stabilize vision in patients presenting with visual loss caused by intracranial venous hypertension.

Intracranial Hypertension in Unruptured Arteriovenous Malformation: Case Report.

A report of intracranial hypertension in unruptured cerebral arteriovenous malformation (AVMs) is presented. A 16-years-old obese female presented with a first episode of acute severe headache and papilledema. Non-contrasted computer tomography scan demonstrated no evidence of hemorrhage or hydrocephalus. The magnetic resonance imaging brain shows the unruptured AVMs at right temporal area. The AVMs was urgently embolized by glue. Headache completely disappeared within two weeks. The papilledemagradually improved within two weeks and completely recovered within six weeks. Patients with unruptured AVMs should undergo early intervention, either by means of surgical excision or embolization, so as to avoid the permanent deficits of optic nerve such as decreased visual acuity and impaired visual field and optic atrophy.

Isolated oculomotor nerve palsy in a white-eyed patient with dural carotid-cavernous sinus fistulas: a case report.

The study reported a woman with dural carotid-cavernous sinus fistulas (CCFs) who presented with a unilateral white-eyed appearance, and painful oculomotor nerve palsy with pupillary involvement. After cerebral angiography, which revealed posterior drainage of the fistulas, the dural CCFs closed, the oculomotor nerve palsy subsided spontaneously and no recurrence occurred throughout the 2-year follow-up. Dural CCFs should be kept in mind when patients present with painful oculomotor nerve palsy. Moreover, cerebral angiography remains the standard diagnostic method and fistulas may close spontaneously following this procedure.

The surgical outcome of inferior oblique recession on bilateral superior oblique palsy in children.

OBJECTIVE: To study the surgical effects of bilateral graded inferior oblique muscle (IO) recession on the reduction of the V pattern deviation and severity of inferior oblique muscle overaction (IOOA) in children who had bilateral superior oblique muscle palsies (SOP) with secondary inferior oblique muscle overaction. MATERIAL AND METHOD: Seven patients who presented with bilateral SOP with secondary IOOA were included. All patients had V pattern deviation and bilateral graded IO recession was done. The data of age, sex, deviation in primary position, V pattern and severity of IOOA was recorded both pre- and post -operatively. The comparison of pre-operative and post-operative amount of V pattern and IOOA was analyzed with nonparametric statistical analysis. RESULTS: Four females and three males had the average age of 5.7 +/- 1.8 years old. The mean pre-operative severity of IOOA was + 3 and the mean pre-operative deviation of the V pattern was 36 +/- 11.4 prism diopters (PD). The mean post-operative severity of IOOA was + 0.4 and of V pattern deviation was 10.7 +/- 4.4 PD. Comparing the pre-operative and post-operative severity of lOOA and V pattern deviation by non-parametric statistical analysis and the result was statistically significant. CONCLUSION: Bilateral graded IO recession is an effective surgical procedure to reduce the V pattern and the severity of IOOA in the children who are suffering from bilateral SOP with secondary IOOA.

Intracranial tumors affecting visual system: 5-year review in Prasat Neurological Institute.

OBJECTIVES: To study the types of intracranial tumors with histological confirmation that impair visual system and to determine the neuro-ophthalmic manifestations in patients with intracranial tumors. MATERIAL AND METHOD: Retrospective review of patients with intracranial tumors who were pre-operatively examined by ophthalmologists in the neuro-ophthalmology unit, Prasat Neurological Institute. All patients had tissue pathology confirmation, and the authors excluded the patients with recurrence or post-operative status of intracranial tumors. RESULTS: Male to female ratio was 1:2.5 of 149 patients. The age onset was highest in the 4th to 5th decade. The three most common types of intracranial tumors were meningioma (45%), pituitary adenoma (32.9%), tumors of neuroepithelial tissues (6.7%) and craniopharyngioma (6.7%).Common neuro-ophthalmological symptoms were visual blur (88.6%) and proptosis (12.1%). In addition, common signs were visual field defect (80.5%), abnormal optic discs (69.7%), and relatively afferent pupillary defect (43.6%). Ninety percent of the patients had the visual difficulty symptom for less than 12 months, before the diagnosis of intracranial tumors. Fifty-nine percent of the patients presented with visual acuity 20/200 or worse, and 15.4% of the patients presented with no light perception (NLP). CONCLUSION: From the study, meningioma is the most common tumor that impairs the visual pathway structures followed by pituitary adenoma. Furthermore, decreased visual acuity, visual field defects, abnormal optic discs, and relatively afferent pupillary defect are the common neuro-ophthalmic features that should be carefully examined to avoid late detection of intracranial tumors.