Intraocular pressure changes at different gaze positions after superior rectus muscle-lateral rectus muscle loop myopexy in highly myopic strabismus.

PURPOSE: To evaluate changes in intraocular pressure (IOP) at different gaze positions before and after superior rectus muscle-lateral rectus muscle (SR-LR) loop myopexy in highly myopic strabismus (HMS). STUDY DESIGN: Nonrandomized clinical, prospective, interventional trial. METHODS: Fourteen patients with HMS (18 eyes) who underwent SR-LR loop myopexy were divided into 3 groups: < 100 prism diopters (PD) (mild esotropia [ET] group), > 100 PD (large ET group), and > 100 PD, and simultaneous recession of the medial rectus (MR) muscle was performed (large ET + MR group). Intraocular pressure was measured preoperatively and postoperatively at the primary, abduction, and adduction positions in each group. RESULTS: Intraocular pressure did not change after surgery in the mild ET group. Intraocular pressure significantly decreased in the abduction position (from 20.0 ± 2.1 to 16.0 ± 1.9 mmHg, P = 0.043) in the large ET group and in the abduction (from 22.2 ± 5.9 to 15.6 ± 4.3 mmHg, P = 0.048) and primary positions (from 15.8 ± 5.0 to 10.2 ± 2.8 mmHg, P = 0.043) in the large ET + MR group. The preoperative significant differences in IOP between the abduction and adduction positions in the large ET group (7.4 ± 3.4 mmHg) and the large ET + MR group (10.0 ± 5.5 mmHg) disappeared postoperatively (3.2 ± 2.8 mmHg and 3.6 ± 1.7 mmHg, respectively). The differences in IOP between abduction and adduction were similar in all the groups. CONCLUSION: SR-LR loop myopexy decreased IOP in patients with HMS in the abduction and primary positions.

Clinical presentations of acquired comitant esotropia in 5-35 years old Japanese and digital device usage: a multicenter registry data analysis study.

PURPOSE: To describe clinical presentations of acquired comitant esotropia and digital device use in children, adolescents, and young adults without neurological problems. STUDY DESIGN: Multicenter prospective observational study. METHODS: Patients with acquired comitant esotropia, without intracranial diseases aged 5-35 years at the time of visit, who were seen at pre-registered facilities within 1 year of onset were enrolled. The duration from the onset of symptoms and the time of digital device usage approximately 1 month before onset and their lifestyles were surveyed. Visual acuity, cycloplegic refraction, and strabismus angles were measured. Data were analyzed in three age groups (Child: 5-12 years, Adolescent: 13-18 years, and Young adult: 19-35 years). RESULTS: Between November 2019 and December 2021, 218 patients were enrolled from 55 facilities, and 194 patients (including 62 children, 69 adolescents, and 63 young adults) were analyzed. The child group spent the least amount of time using digital devices (children: 159; adolescents: 210; young adults: 267 min/work day, p < 0.05; (mean time in the same order below) 229, 338, 314 min/holiday, p < 0.05) and had the largest strabismus angle (mean strabismus angle at near: 30, 22, 18 PD, p < 0.01; at far: 28, 26, 21 PD, p<0.05). CONCLUSION: The clinical features of acquired comitant esotropia and hand-held digital device usage differed between children aged ≤ 12 years and older patients. This report gives the current clinical characteristics of young patients with acquired esotropia and digital device usage.

Recovery of stereoacuity after Yokoyama procedure in patients with highly myopic strabismus with good vision.

Purpose: To report stereopsis after bilateral Yokoyama procedure in patients with highly myopic strabismus and good visual acuity. Observations: Five patients aged between 34 and 81 years with best-corrected visual acuity of 20/25 or better were operated on. The preoperative strabismus angle ranged from esotropia of 35-113 prism diopters (PD) at distance and esotropia of 40-113 PD at near. One patient had left hypotropia of 4 PD and excyclotorsion of 15°, and the other had left hypotropia of 10 PD. Their axial lengths were 27.65-33.07 mm, and the posterior globe dislocation angles were between 123 and 148° on coronal magnetic resonance imaging (MRI). Limitations of abduction were between -1 and -2. All patients complained of diplopia, and none of them showed stereopsis. The Yokoyama procedure was performed on both eyes. Postoperative alternate cover testing showed from esotropia of 2 PD to exophoria of 8 PD at distance and from exotropia of 12 PD to esophoria of 10 PD at near.Three patients recovered stereopsis of 100, 50, and 140 sec, respectively. Two cases required unilateral inferior rectus muscle recessions, and their postoperative stereopsis was 25 and 50 sec. Conclusions and Importance: The Yokoyama procedure is effective not only in cases of heavy eye syndrome but also in cases of myopic esotropia associated with a globe dislocation angle of 120° or with little abduction restriction. If visual acuity is good, stereopsis may be restored with improvement in eye deviation.

Intraocular pressure at different gaze positions in patients with highly myopic strabismus.

PURPOSE: To evaluate intraocular pressure (IOP) at different gaze positions in patients with highly myopic strabismus (HMS). STUDY DESIGN: Nonrandomized, prospective, observational study. METHODS: This study included 18 eyes of 14 patients with HMS and 51 eyes of 51 age-matched controls without strabismus; these were further divided into two groups based on refractive errors: > -6.00 diopter (D) (n = 22 eyes) and ≤ -6.00 D (n = 29 eyes). IOP was measured in primary and side gazes and compared within and among groups. The relationships between IOPs and axial length, angle of globe dislocation measured on magnetic resonance imaging, strabismus angle, and degree of abduction deficit were studied. RESULTS: The HMS group showed higher IOP in abduction (19.3 ± 4.9 mmHg) than in the primary (12.5 ± 4.3 mmHg) and adducting positions (13.0 ± 3.3 mmHg), (p < 0.001). The IOP in the adducting position in the HMS group (13.0 ± 3.3 mmHg) was lower than in the control groups both with (17.6 ± 3.5 mmHg) and without (16.9 ± 4.1 mmHg) high myopia, ; (p < 0.001 and = 0.003). The difference in IOP between abduction and adduction was significantly larger in the HMS group (6.4 ± 4.6 mmHg) compared to others (p < 0.001) and positively correlated with the strabismus angle and the angle of globe dislocation and negatively with abduction deficit. CONCLUSION: The IOP of patients with HMS changes dramatically on side gazes, therefore, care should be taken while measuring IOP.

Exophthalmos associated with chronic progressive external ophthalmoplegia.

PURPOSE: Chronic progressive external ophthalmoplegia (CPEO) is a mitochondrial disease characterized by slowly progressive ptosis and limitations in ocular motility. Although exophthalmos is not considered to be a common feature of CPEO, this study focused on the incidence of exophthalmos in patients with CPEO. STUDY DESIGN: Retrospective observational case series METHODS: We reviewed the clinical charts of patients who received a diagnosis of CPEO sometime during the period between January 2010 and December 2018. CPEO was diagnosed on the basis of detection of a deletion of mitochondrial DNA (mtDNA) from saliva, buccal mucosa, or extraocular muscle specimens obtained during strabismus surgery. Horizontal MRI/CT images or Hertel ophthalmometry was used in determining exophthalmos. RESULTS: Seven patients (4 males) were identified. The mean age at diagnosis was 32.6 years (range 13-53 years). mtDNA deletion mutations were detected in the buccal mucous membrane DNA in 5 patients and in the saliva and extraocular muscle DNA in 2 patients. MRI/CT was recorded in 6 patients, four of whom showed exophthalmos (cases 1-4), and case 5 was determined as exophthalmos on the basis of a Hertel ophthalmometer reading. Exophthalmos was bilateral in 4 of the patients (cases 1, 2, 4, and 5) and unilateral in 1 patient (case 3). Exophthalmos was the chief concern of 2 of the patients; however, it was not clinically significant in the other patients. CONCLUSIONS: Although exophthalmos may not be recognized by either the patient or the clinician, it may be one of the common features of CPEO. A large multiethnic study should be performed.

Clinical findings of acute acquired comitant esotropia in young patients.

PURPOSE: This study aimed to identify the characteristics of acute acquired comitant esotropia (AACE) in young patients from a single institution; and clarify their relationship with the excess use of digital devices. STUDY DESIGN: Retrospective, observational. METHODS: We extracted the clinical charts of patients aged between 5 and 35 years who presented at the Hamamatsu University Hospital with AACE symptoms from January 1, 2015 to December 31, 2018. The age of onset, angle of deviation, refractive errors, history of near work, including excess smartphone use, and treatment modality were retrieved. Patients were divided into three groups: CHILD (aged 5-12 years), JUNIOR (aged 13-17 years), and ADULT (aged 18-35 years) and statistically analyzed with Kruskal-Wallis test. RESULTS: Forty-one patients were retrieved, with a mean age at onset of 15.8 (5-28) years; eight in the CHILD group, 23 in the JUNIOR group, and 10 in the ADULT group. Refractive errors and age of patients were correlated, but were not significantly different among groups. The mean angle of deviation at distance was 28.0 ± 12.8 prism diopters (PD) and 28.6 ± 17.2 PD at near. The CHILD group showed the largest near-distant dissociation. History of excessive near work was found in all groups. CONCLUSION: AACE was most commonly found in the JUNIOR group, especially those aged 15-16 years. AACE may encompass multiple diseases; using common diagnostic criteria and asking common questions regarding digital device usage is necessary to clarify the influence of digital device usage, and a multicenter prospective study is recommended.

Two cases of acquired bilateral trochlea nerve palsy treated by simultaneous inferior rectus muscle nasal transposition and inferior oblique muscle myectomy.

PURPOSE: To report two cases of acquired bilateral trochlea nerve palsy with large torsional deviation successfully treated by simultaneous bilateral inferior rectus muscle (IR) nasal transposition and inferior oblique muscle (IO) myectomy. OBSERVATIONS: Case 1 was of a 54-year-old man with torsional diplopia after a traffic accident. He showed 32° and 38° excyclotorsion in the primary and downward gazes, respectively. Case 2 was of a 56-year-old woman with torsional diplopia after a brain tumor operation. She showed 25° and 33° excyclotorsion in the primary and downward gazes, respectively. We simultaneously performed bilateral IR nasal transposition and IO myectomy in these two cases. Postoperatively, case 1 presented with improved excyclotorsion, with 2° and 7° excyclotorsion in the primary and downward gazes, respectively; case 2 similarly presented with improved excyclotorsion, with 4° and 12° excyclotorsion in the primary and downward gazes, respectively. CONCLUSIONS AND IMPORTANCE: Simultaneous bilateral IR nasal transposition and IO myectomy are effective for treating large-angle torsional deviations, especially in downward gaze, requiring only one operation. A new surgical approach is suggested for the successful treatment of large torsional deviations, requiring only one operation.

Effects of the Gaze Fixation Position on AS-OCT Measurements of the Limbus and Extraocular Muscle Insertion Site Distance.

PURPOSE: To investigate the effect of the gaze fixation position on measurement of the limbus and extraocular muscle (EOM) insertion site distance using anterior segment optical coherence tomography (AS-OCT). METHODS: Patients undergoing horizontal EOM surgeries were enrolled in this prospective experimental study. The distance between the angle recess and the muscle insertion site was measured using AS-OCT while patients fixed their gaze laterally or medially at inner or outer gaze fixation. The distance between the limbus and muscle insertion was intraoperatively measured using calipers. RESULTS: A total of 46 lateral rectus muscles and 36 medial rectus muscles of 44 patients were evaluated. Significant differences were observed between intra-operative measurements (6.3 ± 0.7 mm) and AS-OCT measurements (5.8 ± 0.7 mm) for the lateral rectus muscle at inner gaze fixation (P = .0017) and medial rectus muscle at outer gaze fixation (P = .0003); no difference was observed when the lateral rectus (6.4 ± 0.5 mm) and medial rectus (4.9 ± 0.6 mm) muscles were measured at outer and inner gaze fixation, respectively. Bland-Altman plots showed better consistency at outer gaze fixation than at inner gaze fixation for the lateral rectus muscle; the opposite was observed for the medial rectus muscle. More than 80% of the AS-OCT measurements were within 1 mm of the intraoperative measurements at outer gaze fixation for the lateral rectus muscle and inner gaze fixation for the medial rectus muscle. CONCLUSIONS: Gaze fixation at outer gaze fixation for the lateral rectus muscle and inner gaze fixation for the medial rectus muscle was an appropriate technique to assess limbus and EOM insertion using AS-OCT. [J Pediatr Ophthalmol Strabismus. 2021;58(1):28-33.].

Changes in conjunctival-scleral thickness after strabismus surgery measured with anterior segment optical coherence tomography.

PURPOSE: To evaluate changes in conjunctival-scleral thickness following strabismus surgery with anterior segment optical coherence tomography (AS-OCT). STUDY DESIGN: Prospective, observational, consecutive case series. METHODS: Distances between the conjunctival epithelium and inner scleral wall were measured with AS-OCT before and 3-5 months after strabismus surgery. The measurements were performed at 1.5 mm (limbus), 7.0 mm (insertion), and 8.0 mm (tendon) posterior to the scleral spur on the lateral rectus muscle (LR); and 1.5 mm (limbus), 4.0 mm (insertion), and 5.5 mm (tendon) posterior to the scleral spur on the medial rectus muscle (MR). Thirty-three extraocular muscles (20 LRs and 13 MRs) from 23 subjects were studied. RESULTS: Thicknesses were significantly less at the insertion (0.95-0.78 mm; p < 0.001) and tendon (0.99-0.78 mm; p < 0.001) after LR recession and at the tendon (1.21-0.92 mm; p = 0.02) after MR recession. Thicknesses were significantly greater at the insertion (0.82-1.07 mm; p = 0.01) and tendon (0.95-1.28 mm; p = 0.01) after MR resection or plication and at the limbus, insertion, and tendon (0.75-0.90 mm, 0.94-1.19 mm, 1.03-1.28 mm, respectively; all p = 0.04) after LR resection or plication. CONCLUSION: Conjunctival-scleral thicknesses showed various changes after recession and resection or plication. These findings may help detect previous surgical operations when conjunctival scarring and ciliary vessel changes are unclear.

Evaluation of Surgical Strategy Based on the Intraoperative Superior Oblique Tendon Traction Test.

PURPOSE: To clarify the efficacy of a surgical strategy based on the superior oblique tendon traction test. METHODS: A retrospective chart review was performed between January 2002 and June 2015. During that period, a single inferior oblique muscle (IO) myectomy and a combined IO myectomy and superior oblique muscle (SO) tuck procedure were performed based on SO tendon looseness as revealed by a traction test. The surgical effects of both procedures and the number of operations were analyzed. RESULTS: Sixty-five cases were retrieved. Seventy-four surgeries were required. The IO myectomy and simultaneous groups included 48 and 17 cases, respectively. Pre-operative vertical deviation was significantly lower in the IO myectomy (11.8 prism diopters) than in the simultaneous (27.2 prism diopters; Mann-Whitney U-test, P < 0.001) group. The mean induced changes were 9.4 prism diopters and 21.6 prism diopters in the IO myectomy and simultaneous groups, respectively, and the postoperative vertical deviation was not significantly different. On average, 1.13 and 1.18 surgeries per patient were performed in the IO myectomy and simultaneous groups, respectively. CONCLUSION: The simultaneous surgery of inferior oblique myectomy and superior oblique tuck is safe and effective for treating large angle of congenital/idiopathic superior oblique palsy with a lax superior oblique tendon, as determined by the traction test.