Augmented medial transposition of split lateral rectus in the management of synergistic divergence.

Synergistic divergence is a congenital disorder with abnormal ocular motility. Various management options have been described but with few satisfactory outcomes. We describe 3 cases of synergistic divergence a technique of medial transposition of split lateral rectus augmented with equatorial fixation sutures in 3 children. Postoperatively the synergistic divergence disappeared, and eyes were aligned in the straight-ahead gaze with improved adduction and convergence in all 3 cases.

Pulled into two syndrome (PITS) in a case of congenital fibrosis of the extraocular muscle.

A four-year-old child with a clinical diagnosis of unilateral congenital fibrosis of extraocular muscles (CFEOM) was planned for inferior and medial rectus muscle recession surgery, adjusted with the status of forced duction test. Due to pathological changes within the muscles subsequent to innervational abnormality, intraoperatively the inferior rectus muscle was pulled into two following the insertion of muscle hook. Moreover, the snapped muscle fibers could not be identified, thus further surgery was abandoned and an observation was commenced. At the end of 6 weeks, there was a significant reduction in the amount of hypotropia but clinically significant perverted convergence with esotropia necessitated further surgical intervention. A second surgical intervention consisting of medial rectus transposition to superior rectus with 3 mm recession was performed to achieve acceptable results in the primary gaze.

Assessment of macular vascular plexus density using optical coherence tomography angiography in cases of strabismic amblyopia.

PURPOSE: To evaluate the superficial retinal vascular plexus density using optical coherence tomography angiography (OCTA) in cases of strabismic amblyopia. METHODS: Ten eyes of 10 patients with purely strabismic amblyopia underwent detailed ocular evaluation followed by the assessment of the superficial retinal plexus vascular density using OCTA (Topcon DRI OCT Triton, Swept Source OCT, Topcon, Japan). Ten contralateral normal eyes of the same patients were considered as control. All these 20 eyes underwent a 4.5 × 4.5 mm cube scan OCTA centered at the fovea. Using the Topcon propriety software all 20 eyes were assessed for the capillary plexus density of the superficial retinal vascular plexus along the superior, inferior, nasal, and temporal quadrants centered at the fovea. The numerical values were statistically assessed using a paired t-test with respect to each quadrant between the normal and the pathological eyes. RESULTS: The average age of patients was 16 years and eight patients were males. The mean superficial retinal vascular plexus density along the superior, inferior, nasal, and temporal quadrants in normal and pathological eyes were 49.25 ± 30.34 and 48.93 ± 2.85, 47.22 ± 4.11 and 47.37 ± 4.8, 45.54 ± 1.55 and 43.81 ± 4.21, and 46.26 ± 4.63 and 46.38 ± 5.40, respectively. Similarly, the capillary densities along the central were 17.84 ± 3.49 and 17.24 ± 2.44 in normal and pathological eyes. The differences among all these four quadrants and central area were not statistically significant (P-values > 0.05 for all four quadrants and central area) as compared with the normal eyes. CONCLUSION: The superficial retinal vascular plexus density of a 4.5 × 4.5 mm cube centered at the fovea of eyes of cases of strabismic amblyopia is similar to that of normal eyes.

Bilateral hemorrhagic proptosis due to an uncommon cause in ocular emergency.

A 19-year-old male patient presented to the ocular emergency services with sudden onset of proptosis, pain, and bloody discharge. Further evaluation revealed bilateral visual acuity of finger counting close to face vision with an accurate projection of rays. Computed tomography scan of the head and orbit revealed diffuse orbital hemorrhage (mainly along the ocular coats) in the absence of any subperiosteal or intracranial hemorrhage. A complete hematological workup was done and it revealed decreased factor IX levels (9% of normal) consistent with hemophilia B (Christmas disease). The patient was managed medically with factor IX supplementation. At the end of 6 weeks, patient's visual acuity improved to 20/20 in both the eyes.

Observer variation in quantitative assessment of retinal shortening with ultrasound in patients of total rhegmatogenous retinal detachment.

Purpose: To evaluate the interobserver variation in the assessment of retinal length to choroidal length ratio (RCR) as a marker for proliferative vitreoretinopathy (PVR) in cases of rhegmatogenous retinal detachment (RRD). Methods: This was a double-masked, prospective study at a tertiary center. Ultrasound was used to calculate RCR in 50 eyes with total RRD by two observers. Both observers were trained after the first round of calculations, and all the calculations were repeated as before. Difference between the RCR values was stratified into four categories (<0.01, 0.01-0.05, 0.06-0.1, and >0.1) for descriptive analysis. A difference of 0.05 was set as the maximal limit for defining interobserver agreement. Correlation between RCR and interobserver difference was assessed. Results: The mean interobserver difference in RCR values was found to be 0.06 ± 0.0 (P = 0.41) and was reduced to 0.04 ± 0.02 (P = 0.81) following training. The interobserver difference was <0.1 in 82% of the cases before training and in 98% of cases after training. The worst interobserver agreement was noted in cases with RCR < 0.8, and there was a good negative correlation between RCR and interobserver difference (r = -0.6, P ≤ 0.001). Conclusion: There is good interobserver agreement in assessing RCR with ultrasound in eyes with RRD, which improves further with training. RCR needs careful assessment in eyes with very low RCR. This technique may be useful in prognostication of surgical outcomes in cases with advanced PVR.

Orbital cystic schwannoma masquerading as hydatid cyst.

Gradually increasing abaxial proptosis in a middle-aged female patient revealed a large well-defined cystic lesion behind the globe extending till the orbital apex. B scan ultrasound and CT findings were favouring a diagnosis of orbital hydatid cyst. Thus as a diagnostic/curative surgical protocol, the cystic lesion was removed in total. However, intraoperative gross specimen examination was not classical of hydatid cyst, thus a further histopathological evaluation was carried out, which confirmed the diagnosis of orbital schwannoma with extensive cystic degeneration. Postoperatively the clinical course was uneventful at the end of 1 year.

Acquired capillary haemangioma of the eyelid in a 10-year-old boy.

A 10-year-old boy presented with painless, gradually increasing mass in right upper lid without preceding trauma for the past 2 months. On examination, the mass was bluish red, soft to firm in consistency which bleeds on touch. Contrast-enhanced CT showed a well-defined heterogeneously enhancing mass lesion without any continuity with the underlying bone or the orbital cavity. Complete excision of the mass was performed under general anaesthesia, subsequent histopathological examination showed findings consistent with an acquired variant of capillary haemangioma. At the end of 1 year, patient is cosmetically fine without any recurrence/morbidity.