Interventions for infantile esotropia.

BACKGROUND: Infantile esotropia (IE) is the inward deviation of the eye. Various aspects of the clinical management of IE are unclear; mainly, the most effective type of intervention and the age at intervention. OBJECTIVES: To examine the effectiveness and optimal timing of surgical and non-surgical treatment options for IE to improve ocular alignment and achieve or allow the development of binocular single vision. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers (November 2021). We did not use any date or language restrictions in the electronic searches for trials.  SELECTION CRITERIA: We included randomized trials and quasi-randomized trials comparing any surgical or non-surgical intervention for IE. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology and graded the certainty of the body of evidence for six outcomes using the GRADE classification. MAIN RESULTS: We included two studies with 234 children with IE. The first study enrolled 110 children (mean age 26.9 ± 14.5 months) with an onset of esotropia before six months of age, and large-angle IE defined as esotropia of ≥ 40 prism diopters. It was conducted between 2015 and 2018 in a tertiary care hospital in South Africa. It compared a maximum of three botulinum toxin injections with surgical intervention of bimedial rectus muscle recession, and children were followed for six months. There were limitations in study design and implementation; the risk of bias was high, or we had some concerns for most domains.  Surgery may increase the incidence of treatment success, defined as orthophoria or residual esotropia of ≤ 10 prism diopters, compared with botulinum toxin injections, but the evidence was very uncertain (risk ratio (RR) of treatment success 1.88, 95% confidence interval (CI) 1.27 to 2.77; 1 study, 101 participants; very low-certainty evidence). The results should be read with caution because 23 children with > 60 prism diopters at baseline in the surgery arm also received botulinum toxin at the time of surgery to augment the recessions. There was no evidence of an important difference between surgery and botulinum toxin injections for over-correction (> 10 prism diopters) of deviation (RR 0.29, 95% CI 0.06 to 1.37; 1 study, 101 participants; very low-certainty evidence), or additional interventions required (RR 0.66, 95% CI 0.36 to 1.19; 1 study, 101 participants; very low-certainty evidence). No major complications of surgery were observed in the surgery arm, while children experienced various complications in the botulinum toxin arm, including partial transient ptosis in 9 (16.7%) children, transient vertical deviation in 3 (5.6%) children, and consecutive exotropia in 13 (24.1%) children. No other outcome data for our prespecified outcomes were reported.  The second study enrolled 124 children with onset of esotropia before one year of age in 12 university hospitals in Germany and the Netherlands. It compared bilateral recession with unilateral recession surgeries, and followed children for three months postoperatively. Very low-certainty evidence suggested that there was no evidence of an important difference between bilateral and unilateral surgeries in the presence of binocular vision (numbers with event unclear, P = 0.35), and over-correction (RR of having exotropia 1.09, 95% CI 0.45 to 2.63; 1 study, 118 participants). Dissociated vertical deviation, latent nystagmus, or both were observed in 8% to 21% of participants. AUTHORS' CONCLUSIONS: Medial rectus recessions may increase the incidence of treatment success compared with botulinum toxin injections alone, but the evidence was very uncertain. No evidence of important difference was found between bilateral surgery and unilateral surgery.  Due to insufficient evidence, it was not possible to resolve the controversies regarding type of surgery, non-surgical intervention, or age of intervention in this review. There is clearly a need to conduct good quality trials in these areas to improve the evidence base for the management of IE.

Efficacy of part-time patching in preventing recurrence after bilateral lateral rectus recession in children with intermittent exotropia.

BACKGROUND: This study evaluate the efficacy of part-time patching in preventing recurrence after bilateral lateral rectus recession (BLR) in patients with intermittent exotropia (IXT). METHODS: A total of 190 children aged 3-13 years who experienced recurrence after BLR for IXT and received part-time patching were retrospectively reviewed. The patching was prescribed for 2 h per day for more than 6 months. Patients who had a recurrence of 18 PD or more underwent reoperation. Changes in exodeviation and reoperation ratio after part-time patching were analyzed. RESULTS: A total of 34 patients (17.9%) received reoperation after part-time patching, and the reoperation ratio after 2 years was 20.3% as per the Kaplan-Meier survival analysis. Patients with a recurrence of 7 to 10 PD showed a significantly better effect compared to those with a recurrence of more than 10 PD (p < 0.001), and the reoperation ratio was also lower in the survival analysis (p = 0.004). The factor associated with reoperation in patients with part-time patching was the duration between the operation and the initiation of part-time patching (hazard ratio [HR] = 1.006, p = 0.002). CONCLUSIONS: Part-time patching was effective in maintaining the efficacy of surgery and delaying the need of reoperation after BLR. This effect was better in patients with a recurrence of ≤ 10 PD.

Management of stretched scar- induced secondary strabismus.

BACKGROUND: To determine characteristics and management of consecutive or recurrent strabismus secondary to stretched scar. METHODS: This is a retrospective review of all patients diagnosed with late secondary consecutive or recurrent strabismus due to stretched scar from 2012 to 2017. The diagnosis of stretched scar was made in any case of late (≥ 1 month) consecutive or recurrent strabismus associated with underaction of the previously operated muscle. The diagnosis was confirmed intraoperatively by negative forced duction test and the characteristic appearance of the scar tissue. Surgical correction involved excision of the scar tissue with muscle re-attachment to the sclera using non-absorbable sutures. Study parameters include improvement in secondary deviations, degree of muscle underaction and diplopia. RESULTS: 21 consecutive and 6 recurrent cases of stretched scar -induced strabismus were identified and all cases were associated with variable degrees of limited ocular duction. After surgical correction of the stretched scar, consecutive deviations in the form of consecutive esotropia and exotropia were corrected by means of 26.1PD and 65.6PD while recurrent deviations in the form recurrent exotropia and recurrent hypertropia were corrected by means of 34.3PD and 11PD respectively with significant improvement of limited ocular ductions. 21 patients had diplopia at presentation and all were improved after surgery. CONCLUSION: management of stretched scar -induced secondary strabismus by excision of the stretched scar and muscle fixation to the sclera using non-absorbable sutures significantly corrects secondary deviations and improves limitation of ocular duction.

Nonvitreoretinal Eye Injuries in 2 Infants Due to Nonaccidental Trauma.

Intraocular findings are well known and well documented in child abuse cases. However, eye deviation on physical examination can also be just as important in evaluating a child for maltreatment. We present 2 cases of infants younger than 6 months who presented to the emergency department with new-onset abnormal eye deviation, and further evaluation revealed other findings consistent with nonaccidental trauma. These cases were ruled as abusive head trauma and demonstrate the importance of conducting a thorough evaluation for any acute-onset ophthalmological and neurological finding.

Bilateral Lateral Rectus Recession for the Treatment of Recurrent Exotropia after Bilateral Medial Rectus Resection.

PURPOSE: To evaluate the efficacy of bilateral lateral rectus muscle recession (BLR) to treat recurrent exotropia after bilateral medial rectus muscle resection (BMR). METHODS: Twenty-four patients who underwent BLR for recurrent exotropia and were followed up for more than 6 months were included in this retrospective study. All of them had prior BMR. The angle of deviation, success rates, near stereopsis, and surgical effect of BLR were evaluated. Surgical success was defined as postoperative deviations ≤10 prism diopters (PD). RESULTS: The overall mean follow-up time after reoperation for patients was 24.13 ± 15.01 months (range 6-60 months). The mean angle of deviation at distance was significantly reduced from -37.75 ± 14.93 PD to +1.50 ± 6.43 PD (p < 0.001). Twenty-two (91.6%) of 24 patients had successful outcomes, 1 (4.2%) had overcorrection, and 1 (4.2%) had undercorrection at the last follow-up. Improved stereopsis after reoperation was observed in 78.3% (18/23) of the patients. The mean surgical effect was 2.78 ± 0.71 PD/mm. CONCLUSION: Based on our results, BLR could be an effective and safe method for treating recurrent exotropia after a moderate to large amount of BMR.

Factors determining the outcome of paediatric exotropia surgery.

OBJECTIVE: To determine the socio-demographic and clinical profile of exotropia surgery outcomes amongst paediatric patients. METHODS: This is a descriptive, retrospective, clinical study of surgeries performed between 2014 and 2016 at the Sarawak Heart Centre, Malaysia. Medical records of patients with primary and secondary exotropia were reviewed. The following factors that affected the surgical outcomes were collected: onset age of squint, age at the time of surgery, the interval between diagnosis and surgery, the type of exotropia, visual acuity, presence of amblyopia, previous patching, anisometropia, refractive error, type of surgery, preoperative and postoperative deviation, pre-existing ocular comorbidity and systemic illness. RESULT: A total of 15 patients were studied with more than two thirds being females. Seven patients had primary exotropia while eight patients had secondary exotropia. Average interval between diagnosis and surgery was 1.3 years (±0.82) for primary exotropia and 1.2 years (±0.84) for secondary exotropia. Average pre-operative angle for primary exotropia was 50.57PD (±10.83) whereas secondary exotropia was 39.38PD (±8.63). Seven patients had successful surgical outcomes of within 10 prism dioptres, five for primary exotropia and two for secondary exotropia. The response to surgery was 3.0PD/mm (±0.59) for primary exotropia and 2.2PD/mm (±0.74) for secondary exotropia. CONCLUSION: In our study, primary exotropia had larger preoperative angle than secondary exotropia. The response to surgery was positively correlated with the preoperative angle of deviation. Primary exotropia showed better surgical outcome.

Lateral rectus muscle recession for intermittent exotropia with anomalous head position in type 1 Duane's retraction syndrome.

BACKGROUND: We questioned how to treat for intermittent exotropia in type 1 Duane's retraction syndrome (DRS). To avoid secondary abduction deficit and late overcorrection on the affected eye following ipsilateral lateral rectus (LR) recession, we performed less correction of the lateral rectus (LR) recession to correct exodeviation and anomalous head position (AHP). We report the surgical outcomes of LR recession in patients with unilateral type 1 DRS. METHODS: Four patients who underwent less correction of LR recession in the affected eye to correct intermittent exotropia and AHP to the contralateral side in type 1 DRS were enrolled. Data on preoperative and postoperative angle of exodeviation, degree of AHP, ocular motility, global retraction, palpebral fissure change, and complications were retrospectively obtained. Success was defined as postoperative deviation within 8 prism diopters (PD) and AHP < 5°. RESULTS: The preoperative angles of exodeviation and AHP were significantly improved after LR recession. The median grade of abduction limitation was improved from - 1.3 to - 0.8 postoperatively. Final median value of deviation was orthotropia in the primary position of the eye with the normal motility. All patients had successful outcomes without overcorrection or further abduction limitation in DRS eyes. CONCLUSIONS: Less correction of ipsilateral LR recession may be useful for correcting intermittent exotropia and AHP in patients with type 1 DRS.

Acute transient large-angle exotropia caused by traumatic orbital contusion.

We report an unusual case of acute large-angle left exotropia associated with blunt orbital trauma in a healthy 8-year-old boy. Examination revealed a large-angle left exotropia with limitation in adduction of the left eye. Microhyphema and commotio retinae of the left eye were also present. High-resolution orbital magnetic resonance imaging (MRI) demonstrated perimuscular and intramuscular edema mostly involving the left medial rectus muscle but also involving the left lateral rectus muscle. The extraocular muscle insertions were intact. Complete resolution of the strabismus and adduction limitation occurred within 24 hours of starting systemic steroid therapy. This case highlights the utility of high-resolution imaging to assess for injury to the extraocular muscles. If disinsertion, transection, or rupture of the muscle is not present on imaging, resolution may occur with systemic steroid therapy and surgical intervention is not needed.

[The causative diseases, common comorbidities and surgical procedures of 948 cases of horizontal sensory strabismus].

Objective: To investigate the common causes, onset age of vision impairment and complications of sensory strabismus, and to explore the effective surgical methods for sensory strabismus and associated complications. Methods: In this retrospective study, there were 948 cases of surgical treatment for sensory strabismus from 2005 to 2015 in Tianjin Eye Hospital, including 822 cases of sensory exotropia and 126 cases of sensory esotropia. Causative disease, onset age of vision impairment, eye movement, horizontal and vertical deviation and surgical methods were evaluated. Statistical methods included independent samples t test, Mann-Whitney U test and chi-squared test. Results: Congenital or traumatic cataract was the most common cause of sensory strabismus. Anisometropia, optic atrophy, corneal opacity and retinal detachment were also primary reasons. The mean onset age of vision impairment was (2.3±4.2) years in the sensory esotropia group and (8.8±9.0) years in the exotropia group, and a positive correlation was found between the two groups (t=-8.00, P<0.01). Sensory strabismus occurred with A- or V-pattern in 100 cases (10.5%), nystagmus in 42 cases (5.1%), DVD in 57 cases (6%) and oblique overaction in 134 cases (14.1%;including 54 cases with A- or V-pattern). No statistically significant difference existed between the relevance ratio of A- or V-pattern, oblique overaction and the type of strabismus (χ(2)=0.13, 0.04; P>0.05), but significance difference existed between the relevance ratio of nystagmus, DVD and the type of strabismus (χ(2)=48.33, 12.04; P<0.01). Conclusions: The leading cause of sensory strabismus was cataract. The onset age of vision impairment was earlier in the sensory esotropia group than the exotropia group. Patients were more likely to suffer from DVD and nystagmus in the sensory esotropia group than the exotropia group. Surgeons should make a comprehensive assessment before surgery to design a rational surgical procedure. (Chin J Ophthalmol, 2018, 54: 283-287).

Autogenous Fascia Lata Graft Fixation to Treat Exotropia Resulting From Iatrogenic Medial Rectus Transection.

PURPOSE: To describe autogenous fascia lata graft fixation as a novel method to treat exotropia related to medial rectus (MR) muscle injury following functional endoscopic sinus surgery. METHODS: Three consecutive patients with MR transection and exotropia after functional endoscopic sinus surgery were selected. Preoperative examination was performed; no MR function was noted for over 3 months after injury. CT and dynamic functional MRI were performed, where MR transection and medial wall breach were noted. An autogenous fascia lata graft was harvested and fixated from the remaining periosteum of the posterior-most extent of the medial orbital wall and attached to the globe at the MR insertion. In addition, an ipsilateral lateral rectus muscle recession was performed. RESULTS: Alignment of the eyes in primary gaze and downgaze was achieved and remained so at the 3-month postoperative examinations, with minimal head turn or prism correction (<5 prism diopters) necessary to control diplopia. Two patients required recession of the fascial graft for a minor overcorrection and have remained stable for over 6 months. CONCLUSIONS: Severe exotropia secondary to MR damage following functional endoscopic sinus surgery is a known complication historically difficult to treat. Traditional surgical methods, including vertical muscle transposition, commonly result in complete recurrence of exotropia and increase risk of anterior ocular ischemia. Unlike simple nonabsorbable suture fixation, fascial grafts are completely biointegratable, do not result in significant inflammation, and are unlikely to rupture. Fascia lata graft fixation of the MR to the posterior orbital medial wall is a new and successful method to eliminate exotropia after MR injury.

Pressureless Orbital Decompression for Myopic Proptosis.

Orbital decompression surgery increases the orbital volume. It has rarely been used for proptosis of the large highly myopic globe. However, external decompression surgery carries significant risks because of the large thin-walled globe. The authors report the first use of endoscopic medial wall orbital decompression surgery in this setting to obviate the risk of globe pressure.Endoscopic medial wall decompression brought about a 4 mm reduction of proptosis, correction of exotropia and elimination of retrobulbar ache providing good symmetry with the fellow eye.Endoscopic medial wall orbital decompression can be very effective for correcting the proptosis of high myopia and minimizes the risk of damage to the very large, thin-walled globe.

A Rare Orbital Complication of Eye Exodeviation With Limited Abduction During Monobloc Le Fort III Distraction Osteogenesis.

Monobloc Le Fort III distraction osteogenesis allows superior skeletal advancement in treating severe syndromic craniosynostosis. We report a rare orbital complication in a 3-year-old boy with Crouzon syndrome who developed right-eye exodeviation with limited abduction during the intradistraction period following this surgery. Images from a computed tomography scan confirmed direct impingement of the distracted right lateral orbital wall to the lateral rectus muscle. The impingement was surgically relieved via lateral orbital wall osteotomy. Ten months postdistraction, a review showed normal eye movement. A lateral orbital osteotomy cut for a monobloc Le Fort III distraction should be designed near the rim to prevent this complication.

Neurological Involvement and Hepatocellular Injury Caused by a Snake With Hematotoxin Envenomation.

Venomous snakes with hematotoxin-Russell's viper (Daboia spp), Malayan pit viper (Calloselasma rhodostoma), and green pit viper (Cryptelytrops albolabris and C macrops, previously named Trimeresurus spp) are commonly found in Thailand. Coagulation factor activation, thrombocytopenia, hyperfibrinolysis, and disseminated intravascular coagulation are the main mechanisms of hemorrhaging from these snake bites. The neurological involvement and hepatocellular injury after Russell's viper bites were reported in Sri Lanka, but there is no report from Southeast Asia. This case was a 12-year-old hill tribe boy who had ptosis and exotropia of the left eye, respiratory distress, and prolonged venous clotting time, prothrombin time, and activated partial thromboplastin time; low fibrinogen and platelet count; and transaminitis after being bitten by a darkish-colored snake. He did not respond to antivenom for cobra, Malayan pit viper, or Russell's viper. However, his neurological abnormalities, respiratory failure, and hepatocellular injury improved, and coagulopathy was finally corrected after receiving antivenom for green pit viper. The unidentified snake with hematotoxin was alleged for all manifestations in this patient.

Detection of central white matter injury underlying vestibulopathy after mild traumatic brain injury.

PURPOSE: To determine if central axonal injury underlies vestibulopathy and ocular convergence insufficiency after mild traumatic brain injury (TBI) by using tract-based spatial statistics (TBSS) analysis of diffusion-tensor imaging (DTI). MATERIALS AND METHODS: The institutional review board approved this study, and the requirement to obtain informed consent was waived. Diffusion-tensor images were retrospectively reviewed in 30 patients with mild TBI and vestibular symptoms and 25 patients with mild TBI and ocular convergence insufficiency. Control subjects consisted of 39 patients with mild TBI without vestibular abnormalities and 17 patients with mild TBI and normal ocular convergence. Fractional anisotropy (FA) maps were generated as a measure of white matter integrity and were analyzed with TBSS regression analysis by using a general linear model. DTI abnormalities were correlated with symptom severity, neurocognitive test scores, and time to recovery with the Pearson correlation coefficient. RESULTS: Compared with control subjects, patients with mild TBI and vestibular symptoms had decreased neurocognitive test scores (P < .05) and FA values in the cerebellum and fusiform gyri (P < .05). Patients with ocular convergence insufficiency had diminished neurocognitive test scores (P < .05) and FA values in the right anterior thalamic radiation and right geniculate nucleus optic tracts (P < .0001). Cerebellar injury showed an inverse correlation with recovery time (R = -0.410, P = .02). Anterior thalamic radiation injury showed correlation with decreased processing speed (R = 0.402, P < .05). CONCLUSION: DTI findings in patients with mild TBI and vestibulopathy support the hypothesis that posttraumatic vestibulopathy has a central axonal injury component. Peripheral vestibular structures were not assessed, and a superimposed peripheral contribution may exist. DTI evaluation of central vestibular structures may provide a diagnostic imaging tool in these patients and a quantitative biomarker to aid in prognosis.

Brainstem infarction with wall-eyed bilateral internuclear ophthalmoplegia syndrome and vertical one-and-a-half syndrome.

We describe a rare case in which both wall-eyed bilateral internuclear ophthalmoplegia syndrome and vertical one-and-a-half syndrome were observed in a 68-year-old man with acute ischemic stroke. Concurrent horizontal and vertical gaze palsies are rare because the corresponding gaze centers are anatomically separated. The complicated gaze palsies observed in this patient might have resulted from long, vertical lesions affecting oculomotor pathways for both sides of the brain stem.

[Convergence insufficiency with unilateral exophoria at near in schizophrenia and bipolar disorder - a preliminary study]. / Niewydolnosc konwergencji z jednostronna egzoforia do blizy w schizofrenii i chorobie afektywnej dwubiegunowej - badania wstepne.

OBJECTIVES: The study describes an abnormal convergence symptom, i.e. unilateral exophoria at near, in patients with schizophrenia (SZ) and bipolar disorder (BD). The aim of this paper is to present the symptom and discuss its possible explanations. METHODS: 29 patients with SZ, 15 patients with BD and 20 healthy controls (HC) took part in the study. The neurological assessment was done with International Co-operative Ataxia Rating Scale (ICARS) and Neurological Evaluation Scale (NES). RESULTS: The abnormal vergence pattern was observed in 12 patients with SZ, 1 patient with BD and 0 HC. Symptom appeared statistically more often in SZ patients than in BD patients and HC. SZ patients with vergence symptom performed significantly worst in oculomotor and dysarthia subscores of ICARS. CONCLUSIONS: The symptom can be linked to disruptions in cortico-ponto-cerebellar network and midbrain. It was the only neurological symptom that differed SZ and BD groups, thus it might be used in differential diagnosis. Further research is needed to obtain a full clinical description of the symptom.

Relationship between strabismus associated with Angelman syndrome and orbital anomaly.

PURPOSE: To investigate the relationship between the details of strabismus and orbital abnormalities determined by ocular motility tests and orbital imaging examinations in 9 cases with Angelman syndrome (AS). STUDY DESIGN: A retrospective, clinical report. METHODS: The 9 AS cases (mean age at initial visit: 4.6 ± 8.0 years) were confirmed by genetic diagnosis of the chromosome 15q11-13 region. In all cases, axial imaging of the orbit in the transverse plane of the horizontal extraocular muscles was obtained. The opening angle between both lateral walls of the orbit (greater wing of sphenoid) was measured as the biorbital angle, and compared with the 95% confidence interval of the orbital angle in normal children. RESULTS: All cases had exotropia with means of the distance and near of angle 32.2 prism diopters (Δ) ± 9.7Δ and 32.8Δ ± 8.3Δ. The mean of the biorbital angle was 107.7° ± 7.6°, greater than the biorbital angle of 94.3° ± 5.1° previously reported in 129 normal children (P < 0.0001, t-test). Except for one biorbital angle of 93° in the 25-year-old patient, all the biorbital angles in the 8 children were larger than the upper 95% confidence interval in normal children. Astigmatic and hyperopic ametropic amblyopia were detected in 3 cases and 1 case, respectively. CONCLUSIONS: The frequency of exotropia in AS is higher than previously reported, with our results strongly suggesting that the enlarged biorbital angle is related to the pathogenesis of exotropia in AS.

Traumatic lysis of the inferior rectus muscle.

BACKGROUND: The study aims to report a rare case of traumatic lysis of inferior rectus muscle after a traffic accident. METHODS: This is a case report wherein the clinical features, computed tomographic findings, and surgical treatment were presented. RESULTS: A 42-year-old woman complained of double vision and upward deviation of the left eye for 13 months after being involved in a traffic accident. The alternate prism and cover test both at distance and near testing showed an exotropia of 18 prism diopters (PD) and hypertropia of 50 PD of the left eye. The left eye had complete restriction of downward movement, and the forced duction test was negative. Computed tomography disclosed that the middle portion of the left inferior rectus muscle was absent. Diagnosis was traumatic lysis of left inferior rectus muscle. The deviation of the left eye was corrected by left superior rectus muscle recession and partial transposition of the medial and lateral rectus muscles. Six months after surgery, no deviation at the primary position both at distance and near testing was present; however, the left eye remained at a -3 restriction of downward movement. CONCLUSIONS: Paralysis of the inferior rectus muscle may have resulted from the traumatic lysis, a rare clinical feature that can be confirmed by computed tomography.

Double covering with amniotic membrane in restrictive strabismus.

A case of severe restrictive strabismus after a consecutive exotropia surgery is presented. We describe the exitous managment through a technique consist of wrapping with amniotic membrane (AM) the affected muscle where we add a second AM graft in the reconstruction of the ocular Surface.