Early-Onset Ocular Motor Cranial Neuropathy Is a Strong Predictor of Dementia: A Nationwide, Population-Based Cohort Study.

PURPOSE: To assess the risk of dementia in individuals with newly diagnosed ocular motor cranial neuropathy (OMCN). DESIGN: A nationwide, population-based cohort study using authenticated data from the Korean National Health Insurance Service (KNHIS). PARTICIPANTS: This study included 60 781 patients with OMCN who received a diagnosis between 2010 and 2017 and were followed up through 2018, with an average follow-up of 3.37 ± 2.21 years with a 1-year lag. After excluding patients with disease related to oculomotor dysfunction preceding the OMCN diagnosis, a total of 52 076 patients with OMCN were established. Of these, 23 642 patients who had participated in the National Health Screening Program (NHSP) within 2 years before the OMCN diagnosis were included. After applying the exclusion criteria, the final cohort comprised 19 243 patients and 96 215 age and sex-matched control participants without OMCN. METHODS: We identified patients with newly diagnosed OMCN in the KNHIS database and collected participant characteristics from the health checkup records of the NHSP. The study end point was determined by the first claim with a dementia diagnostic code and antidementia medications. The association of OMCN with dementia risk was examined using Cox proportional hazards regression analysis, adjusting for potential confounding factors. MAIN OUTCOME MEASURES: The main outcome measures were hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause dementia (ACD), Alzheimer's disease (AD), and vascular dementia (VaD) development in patients with OMCN relative to those without OMCN. RESULTS: Patients with newly diagnosed OMCN demonstrated higher metabolic comorbidities than those without OMCN. New OMCN was associated with an elevated risk of ACD (HR, 1.203; 95% CI, 1.113-1.300), AD (HR, 1.137; 95% CI, 1.041-1.243), and VaD (HR, 1.583; 95% CI, 1.286-1.948), independent of potential confounding factors. The younger age groups exhibited a stronger association between OMCN and ACD (HR, 8.690 [< 50 years] vs. 1.192 [≥ 50 years]; P = 0.0004; HR, 2.517 [< 65 years] vs. 1.099 [≥ 65 years]; P < 0.0001). CONCLUSIONS: This nationwide population-based study assessed the association between OMCN and dementia risk. Our results demonstrated a robust relationship between OMCN and the risk of dementia, particularly in the younger population. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Optical Coherence Tomography Parameters and Optimal Cut-off Values for Predicting Visual Prognosis in Ethambutol-Induced Optic Neuropathy.

BACKGROUND: The objective of this study was to evaluate the prognostic value of optical coherence tomography (OCT) parameters in patients with ethambutol-induced optic neuropathy (EON) and establish their optimal cut-off values for predicting visual acuity outcomes. METHODS: A retrospective cross-sectional study was conducted on 64 eyes of 32 patients with EON who underwent OCT. Peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (mGCIPL) thickness were measured using Cirrus high-definition OCT (HD-OCT) within 3 months after EON diagnosis. Visual acuity of patients was recorded and analyzed at the first visit, the 1-year visit, and the latest visit. Prognostic capacities of OCT parameters for visual prognosis were evaluated and their optimal cut-off values for predicting final visual acuity were established. RESULTS: Increased pRNFL thickness was significantly associated with better visual acuity at 1 year postdiagnosis and the latest visit. A significant association was established between increased pRNFL thickness and a higher rate of recovery to visual acuity >20/25 at 1 year postdiagnosis. Receiver-operating characteristic curves identified ideal cut-off values for OCT parameters as follows: pRNFL thickness of 83 µm (sensitivity 100%, specificity 48.3%) and mGCIPL thickness of 74 µm (sensitivity 100%, specificity 83.3%) for visual acuity >20/25 at 1 year, mGCIPL thickness of 61 µm (sensitivity 85.7%, specificity 71.4%) for visual acuity >20/40 at 1 year, with corresponding AUCs exceeding 0.7. CONCLUSIONS: Both pRNFL and mGCIPL thickness possess potential values for predicting visual outcomes in patients with EON. Future research should continue to explore the utility of OCT parameters in EON prognosis.

Cranial Nerve Palsy and Risk of Kidney Cancer: A Nationwide Population-Based Study.

Background and Objective: Understanding whether cranial nerve palsy (CNP) acts as an independent risk factor for kidney cancer could have important implications for patient care, early detection, and potentially the development of preventive strategies for this type of cancer in individuals with CNP. This study aimed to examine the risk of kidney cancer following the onset of ocular motor CNP and assess whether CNP could be considered an independent risk factor for kidney cancer. Materials and Methods: A population-based cohort study was conducted using data from the National Sample Cohort (NSC) database of Korea's National Health Insurance Service which was collected from 2010 to 2017. Follow-up was until kidney cancer development, death, or 31 December 2018. Cox proportional hazard regression analysis was performed to determine hazard ratios (HRs) for kidney cancer according to CNP status. Participants aged 20 years or more diagnosed with CNP from 2010 to 2017 were included. Exclusions comprised individuals with specific pre-existing conditions, inability to match a control group, and missing data, among others. CNP patients were age-sex matched in a 1:5 ratio with control cases. The primary outcome was incidence of kidney cancer during the follow-up period. Results: This study comprised 118,686 participants: 19,781 in the CNP group, and 98,905 in the control group. Compared to the control group, participants with CNP had a higher risk of kidney cancer (adjusted HR in model 4, 1.599 [95% CI, 1.116-2.29]). After a 3-year lag period, the CNP group had a significantly higher risk (adjusted HR in model 4, 1.987 [95% CI, 1.252-3.154]). Conclusions: Ocular motor CNP may be an independent risk factor for kidney cancer, as indicated by a higher incidence of kidney cancer in CNP patients. Further research is needed to elucidate the underlying mechanisms and explore potential preventive measures for kidney cancer in patients with ocular motor CNP.

Hormone Replacement Therapy and the Incidence of Nonarteritic Anterior Ischemic Optic Neuropathy: a Nationwide Population-Based Study (2009-2018).

PURPOSE: This study aimed to assess the association between hormone replacement therapy (HRT) and the prevalence of nonarteritic anterior ischemic optic neuropathy (NAION) in menopausal women using national data from the entire Korean population. METHODS: The health screening data of 1,381,605 women between 40 and 90 years of age collected by the National Health Insurance Service (NHIS) of Korea between January 1, 2009, and December 31, 2018, were retrospectively reviewed. Before data analysis, the potential cofounders were adjusted for among all participants. Based on HRT use and its duration (classified into four groups), the hazard ratio (HR) and 95% confidence interval (CI) of NAION development were calculated via a Cox proportional hazards regression analysis using the nonuser group as a reference. RESULTS: Overall, 7824 NAION diagnoses were made during the mean follow-up of 8.22 years (standard deviation: 1.09 years) in 1,381,605 post-menopausal women. NAION was more common in the HRT group than in the non-HRT group (HR [95% CI]: 1.268 [1.197-1.344]). Furthermore, the risk of NAION increased along with increased HRT duration (p < 0.0001). In the multivariate analysis, the adjusted HRs of the < 2-year HRT group, the 2-5-year HRT group, and the ≥ 5-year HRT group were 1.19 (95% CI: 1.10-1.28), 1.3 (95% CI: 1.17-1.45), and 1.473 (95% CI: 1.31-1.65), respectively. Compared to women younger than 65 years, the HR of HRT for NAION was significantly higher than that of women older than 65 years (p < 0.0001). CONCLUSION: Our population-based cohort study found that HRT was significantly associated with increased incidence of NAION. The incidence of NAION also increased with the duration of HRT.

Ocular motility disorders following coronavirus disease-19 vaccination.

PURPOSE: To describe clinical manifestations and short-term prognosis of ocular motility disorders following coronavirus disease-2019 (COVID-19) vaccination. METHODS: Ocular motility disorders were diagnosed by clinical assessment, high-resolution magnetic resonance imaging, and laboratory testing. Clinical manifestations, short-term prognosis, and rate of complete recovery were analyzed. RESULTS: Sixty-three patients (37 males, 26 females) with a mean age of 61.6 ± 13.3 years (range, 22-81 years) were included in this study. Among 61 applicable patients with sufficient information regarding medical histories, 38 (62.3%) had one or more significant underlying past medical histories including vasculopathic risk factors. The interval between initial symptoms and vaccination was 8.6 ± 8.2 (range, 0-28) days. Forty-two (66.7%), 14 (22.2%), and 7 (11.1%) patients developed symptoms after the first, second, and third vaccinations, respectively. One case of internuclear ophthalmoplegia, 52 cases of cranial nerve palsy, two cases of myasthenia gravis, six cases of orbital diseases (such as myositis, thyroid eye disease, and IgG-related orbital myopathy), and two cases of comitant vertical strabismus with acute onset diplopia were found. Among 42 patients with follow-up data (duration: 62.1 ± 40.3 days), complete improvement, partial improvement, no improvement, and exacerbation were shown in 20, 15, 3, and 4 patients, respectively. CONCLUSION: This study provided various clinical features of ocular motility disorders following COVID-19 vaccination. The majority of cases had a mild clinical course while some cases showed a progressive nature. Close follow-up and further studies are needed to elucidate the underlying mechanisms and long-term prognosis.

Dynamic Changes in Metabolic Status Are Associated With Risk of Ocular Motor Cranial Nerve Palsies.

BACKGROUND: To investigate whether recovery from or development of metabolic syndrome (MetS) in a population is associated with an altered risk for ocular motor cranial nerve palsy (CNP). METHODS: This cohort study included 4,233,273 adults without a history of ocular motor cranial nerve palsy (ocular motor CNP) who underwent 2 consecutive biennial health screenings provided by the Korean National Health Insurance System between 2009 and 2011. They were followed up until December 31, 2018. Participants were categorized into a MetS-free, MetS-developed, MetS-recovered, or MetS-chronic group. A multivariable Cox proportional hazard regression model was used. Model 3 was adjusted for age, sex, smoking status, alcohol consumption, and physical activity. RESULTS: Compared with the MetS-free group, the MetS-chronic group had the highest risk of ocular motor CNP (hazard ratio [HR]: 1.424; 95% confidential interval [CI]: 1.294-1.567, Model 3), followed by the MetS-developed group (HR: 1.198, 95% CI: 1.069-1.343), and the MetS-recovered group (HR: 1.168, 95% CI: 1.026-1.311) after adjusting for potential confounders. The hazard ratio of ocular motor CNP in men with chronic MetS was 1.566 (95% CI, 1.394-1.761) while that of women with chronic MetS was 1.191 (95% CI, 1.005-1.411). Among age groups, those in their 30s and 40s showed the highest association between dynamic MetS status and ocular motor CNP. CONCLUSIONS: In our study, recovering from MetS was associated with a reduced risk of ocular motor CNP compared with chronic MetS, suggesting that ocular motor CNP risk could be managed by changing MetS status.

Non-Arteritic Ischemic Optic Neuropathy Following COVID-19 Vaccination in Korea: A Case Series.

BACKGROUND: To report the clinical manifestations of non-arteritic anterior ischemic optic neuropathy (NAION) cases after coronavirus disease 2019 (COVID-19) vaccination in Korea. METHODS: This multicenter retrospective study included patients diagnosed with NAION within 42 days of COVID-19 vaccination. We collected data on vaccinations, demographic features, presence of vascular risk factors, ocular findings, and visual outcomes of patients with NAION. RESULTS: The study included 16 eyes of 14 patients (6 men, 8 women) with a mean age of 63.5 ± 9.1 (range, 43-77) years. The most common underlying disease was hypertension, accounting for 28.6% of patients with NAION. Seven patients (50.0%) had no vascular risk factors for NAION. The mean time from vaccination to onset was 13.8 ± 14.2 (range, 1-41) days. All 16 eyes had disc swelling at initial presentation, and 3 of them (18.8%) had peripapillary intraretinal and/or subretinal fluid with severe disc swelling. Peripapillary hemorrhage was found in 50% of the patients, and one (6.3%) patient had peripapillary cotton-wool spots. In eight fellow eyes for which we were able to review the fundus photographs, the horizontal cup/disc ratio was less than 0.25 in four eyes (50.0%). The mean visual acuity was logMAR 0.6 ± 0.7 at the initial presentation and logMAR 0.7 ± 0.8 at the final visit. CONCLUSION: Only 64% of patients with NAION after COVID-19 vaccination have known vascular and ocular risk factors relevant to ischemic optic neuropathy. This suggests that COVID-19 vaccination may increase the risk of NAION. However, overall clinical features and visual outcomes of the NAION patients after COVID-19 vaccination were similar to those of typical NAION.

Liver enzymes and risk of ocular motor cranial nerve palsy: a nationwide population-based study.

This study aimed to assess the associations between liver enzymes including γ-glutamyl transferase (GGT) and the development of ocular motor cranial nerve palsy (CNP) using the National Sample Cohort database from Korea's National Health Insurance Service. We analyzed data from 4,233,273 medical screening examinees aged 20 years or more in 2009. Study participants were followed up until December 31, 2018. A Cox proportional hazard regression analysis was performed for quartiles of liver enzymes to determine the linkage between each value and ocular motor CNP using quartile 1 as a reference after adjusting for potential confounders. A total of 5,807 (0.14%) patients developed ocular motor CNP during the follow-up period of 8.22 ± 0.94 years. The incidence of ocular motor CNP gradually increased as the GGT levels increased. The highest quartile of the GGT group had hazard ratio (HR) of 1.245 (95% confidence interval [CI], 1.136-1.365). Regarding alanine aminotransferase (ALT), the highest quartile of the ALT group had HR of 1.141 (95% CI, 1.049-1.241). However, the incidence of ocular motor CNP did not gradually increase as the ALT levels increased. The coexistence of the increased level of GGT, metabolic syndrome, and obesity showed a stronger association with ocular motor CNP development (HR, 1.331; 95% CI, 1.173, 1.511) compared to having a single factor or two factors. In conclusion, our population-based cohort study demonstrated a significant association between serum GGT level and the incidence of ocular motor CNP, suggesting that GGT could be a new clinical marker for predicting the occurrence of ocular motor CNP.

Association of mental disorders and strabismus among South Korean children and adolescents: a nationwide population-based study.

PURPOSE: The aim of this study is to determine the association between mental disorders and strabismus in South Korean children and adolescents. METHODS: Using data from the Korean National Health Claims Database from 2011 to 2017, the prevalence rates of mental illnesses and odds ratio were calculated. Children and adolescents (1-19 years) with strabismus and their randomly selected nonstrabismic age- and sex-matched controls (1:1) were enrolled. The odds ratios were adjusted for preterm birth, cerebral palsy, and mental retardation. Subgroup analysis was performed according to sex and the type of strabismus. RESULTS: A total of 327,076 subjects (male, 158,597; female, 168,479) identified as strabismus patients were enrolled. After adjusting for preterm birth, cerebral palsy, and mental retardation, the corrected odds ratio of overall mental illness was 1.10 (95% CI, 1.08-1.12) for the strabismus group compared to the controls: 1.7 (95% CI, 1.62-1.78) for developmental disorder, 1.36 (95% CI, 1.27-1.45) for pervasive developmental disorder (autism), 1.14 (95% CI, 1.10-1.17) for attention-deficit hyperactivity disorder (ADHD), 1.15 (95% CI, 1.05-1.27) for obsessive-compulsive disorder (OCD), 1.08 (95% CI, 1.05-1.11) for pediatric behavioral and emotional disorders, 0.93 (95% CI, 0.88-0.99) for post-traumatic stress disorder (PTSD), and 0.85 (95% CI, 0.82-0.89) for tic disorder. CONCLUSION: South Korean children and adolescents with strabismus had a higher relative risk for various types of mental disorders such as a developmental disorder, autism, ADHD, and OCD than the controls, whereas they had a relatively lower risk of tic disorder.

Population-based Incidence of Pediatric and Adult Optic Neuritis and the Risk of Multiple Sclerosis.

PURPOSE: To determine the age- and sex-specific prevalence and incidence of demyelinating optic neuritis and the risk of multiple sclerosis (MS) in pediatric and adult populations in South Korea. DESIGN: A nationwide, population-based, retrospective study using data from the Korean National Health Claims database from 2010 to 2016. PARTICIPANTS: The entire South Korean population aged 65 years of age or younger (n = 44 700 564). All patients with optic neuritis from the entire Korean population were included. METHODS: Patients aged 14 years of age or younger were classified as pediatric patients, and those aged 15 to 65 years were classified as adults. Each group was analyzed separately. Patients with optic neuritis had a subsequent diagnosis, including idiopathic, MS, neuromyelitis optica (NMO), and acute disseminated encephalomyelitis. Prevalence and incidence, conversion rate to MS, and treatment modalities (steroids, plasmapheresis, interferon-ß, and immunosuppressants) were estimated. MAIN OUTCOME MEASURES: Prevalence and incidence of optic neuritis, and conversion rate to MS. RESULTS: Among 44 700 564 individuals, 531 pediatric patients (50.7% female) and 7183 adults (53.3% female) were identified as having optic neuritis. Annual incidence was 1.04 (95% confidence interval [CI], 1.01-1.07) per 100 000 pediatric individuals and 3.29 (95% CI, 3.28-3.30) per 100 000 adults. Peak incidence was observed at 10 to 14 years in the pediatric population and at 30 to 34 years and 50 to 54 years in the adult population. Conversion rate to MS was 13.8% in the pediatric population and 11.4% in the adult population. Fourteen percent of all patients were treated with chronic immunosuppressants, 38% of patients with NMO underwent plasmapheresis, and 50% of patients with MS were treated with interferon-ß. CONCLUSIONS: This is a nationwide epidemiologic study of optic neuritis in individuals of all ages in South Korea. The incidence of optic neuritis and subsequent risk of MS in the pediatric population are comparable to those reported in western countries but are lower in the adult population than in western countries. The incidence rate in adults was 3.2-fold higher than in the pediatric population, and the overall MS conversion rate in the entire Korean population was estimated to be 10.6%.

Leber's hereditary optic neuropathy following unilateral painful optic neuritis: a case report.

BACKGROUND: Leber's hereditary optic neuropathy (LHON) is a maternally inherited mitochondrial disease, characterized by acute or subacute, painless, bilateral visual loss. LHON is often misdiagnosed as optic neuritis at an early stage because of the similarity of their clinical presentation. To date, there has been no reported case of actual optic neuritis and LHON in one patient. CASE PRESENTATION: A 40-year-old, healthy man was referred to our clinic with acute painful visual loss in the right eye for 2 weeks. In the right eye, visual acuity decreased to 20/40, and the Ishihara colour test score was 8/14 with a relative afferent pupillary defect. Optic disc swelling was found only in the right eye, and magnetic resonance imaging revealed enhancement of the the right optic nerve, consistent with optic neuritis. After receiving 1 g of intravenous methylprednisolone daily for three days, his ocular pain resolved, and visual acuity improved to 20/20 within 2 weeks. Seven months later, the patient developed acute painless visual loss in the right eye. Visual acuity decreased to 20/200 in the right eye. There was no response to the intravenous methylprednisolone therapy at that time. Eight months later, he developed subacute painless visual loss in the left eye. Genetic testing for LHON was performed and revealed the pathologic mtDNA 11778 point mutation. CONCLUSIONS: We report a case with painful unilateral optic neuritis preceding the onset of LHON. Even if a typical optic neuritis patient has completely recovered from steroid treatment once in the past, it is advisable to keep in mind the possibility of LHON if acute or subacute loss of vision subsequently or simultaneously occurs in both eyes and does not respond to steroids.

Computer-aided recognition of myopic tilted optic disc using deep learning algorithms in fundus photography.

BACKGROUND: It is necessary to consider myopic optic disc tilt as it seriously impacts normal ocular parameters. However, ophthalmologic measurements are within inter-observer variability and time-consuming to get. This study aimed to develop and evaluate deep learning models that automatically recognize a myopic tilted optic disc in fundus photography. METHODS: This study used 937 fundus photographs of patients with normal or myopic tilted disc, collected from Samsung Medical Center between April 2016 and December 2018. We developed an automated computer-aided recognition system for optic disc tilt on color fundus photographs via a deep learning algorithm. We preprocessed all images with two image resizing techniques. GoogleNet Inception-v3 architecture was implemented. The performances of the models were compared with the human examiner's results. Activation map visualization was qualitatively analyzed using the generalized visualization technique based on gradient-weighted class activation mapping (Grad-CAM++). RESULTS: Nine hundred thirty-seven fundus images were collected and annotated from 509 subjects. In total, 397 images from eyes with tilted optic discs and 540 images from eyes with non-tilted optic discs were analyzed. We included both eye data of most included patients and analyzed them separately in this study. For comparison, we conducted training using two aspect ratios: the simple resized dataset and the original aspect ratio (AR) preserving dataset, and the impacts of the augmentations for both datasets were evaluated. The constructed deep learning models for myopic optic disc tilt achieved the best results when simple image-resizing and augmentation were used. The results were associated with an area under the receiver operating characteristic curve (AUC) of 0.978 ± 0.008, an accuracy of 0.960 ± 0.010, sensitivity of 0.937 ± 0.023, and specificity of 0.963 ± 0.015. The heatmaps revealed that the model could effectively identify the locations of the optic discs, the superior retinal vascular arcades, and the retinal maculae. CONCLUSIONS: We developed an automated deep learning-based system to detect optic disc tilt. The model demonstrated excellent agreement with the previous clinical criteria, and the results are promising for developing future programs to adjust and identify the effect of optic disc tilt on ophthalmic measurements.

Incidence and timing of recurrence of optic neuritis.

PURPOSE: To describe the incidence and timing of recurrence in patients with optic neuritis (ON). METHODS: Medical documents of adult patients with ON were retrospectively reviewed. The incidence and timing of recurrence of an ON episode were analyzed. RESULTS: One hundred eleven patients with ON were included in this study. Their mean follow-up duration was 4.1 ± 3.1 years. Seven relapses occurred after intravenous methylprednisolone treatment. The estimated cumulative incidence of recurrence in either eye was 26% at 1 year, 33% at 3 years, 37% at 5 years, and 50% at 10 years after the first episode of ON. If there was no recurrence until 6 months after the first episode of ON, the next 5-year recurrence-free survival probability was 67%. If there was no recurrence until 1 year, the next 5-year survival probability was 72%. If there was no recurrence until 2 years, the next 5-year survival probability was 81%. Relapse within 1 month and the presence of neuromyelitis optica-immunoglobulin G were factors that increased the recurrence rate over time. CONCLUSIONS: We evaluated the incidence and timing of the recurrence in patients with ON after the first episode. Lower probability of recurrence was observed in patients with longer recurrence-free follow-up period. However, monitoring for recurrence is needed even in patients with a single episode of ON due to the increasing tendency of the estimated cumulative incidence of recurrence over many years.

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.

Clinical characteristics according to the laterality of ocular torsion in unilateral superior oblique palsy.

BACKGROUND: To compare clinical characteristics according to the laterality of objective ocular torsion in patients with unilateral superior oblique palsy (SOP). METHODS: This retrospective study included all patients with a diagnosis of unilateral SOP. They were classified into subgroups according to correspondence between the paretic eye and the extorted eye using fundus photography. Ocular alignment and muscle action were tested by the prism and alternate cover tests and 4-scale movement measure. Various clinical factors, including the amount of preoperative ocular torsion and change in ocular torsion postoperative, were compared between the accordance and disaccordance groups. RESULTS: A total of 70 Asian patients (140 eyes) were included and underwent fundus photography preoperatively. Excyclotorsion in the paretic eye was defined as accordance (45 patients), excyclotorsion in the nonparetic eye was defined as disaccordance (25 patients). The presence of horizontal strabismus was detected in 28 (62%) patients in the accordance group and only 8 (32%) patients in the disaccordance group (p = 0.024). All horizontal strabismus observed in the accordance group involved exodeviation. The proportion of horizontal strabismus surgery was also significantly larger in the accordance group than the disaccordance group (p = 0.039). Among those patients, there were 26 who underwent fundus photography postoperatively. There was significant reduction in ocular excyclotorsion postoperatively in the accordance group (p = 0.001), but no significant reduction postoperatively in the disaccordance group (p = 0.270). There was no significant correlation between the amount of torsional reduction and the amount of vertical deviation reduction (p = 0.979). CONCLUSIONS: In cases of preoperative excyclotorsion in paretic eyes, careful consideration of combined horizontal misalignment which may require surgical correction is helpful to manage unilateral SOP.

Superior rectus muscle insertion injury following cosmetic upper lid blepharoplasty: a case report.

BACKGROUND: Direct damage to the superior rectus (SR) muscle insertion following upper lid blepharoplasty has not been reported. We document a rare case of vertical diplopia due to direct damage to the SR muscle insertion following cosmetic upper lid blepharoplasty. CASE PRESENTATION: We describe a case of 24-year-old woman with Asian eyelid. The patient had already undergone multiple cosmetic upper lid surgeries and complained of vertical diplopia immediately after her most recent surgery (levator resection with skin approach). Preoperatively, large-angle right hypotropia and severe upgaze limitation were present and noticeable ptosis was observed in the right eye. Intraoperatively, the SR muscle fibers were observed to be detached at the insertion site and severe fibrosis and adhesion surrounding the muscle was noted. After strabismus surgery, vertical strabismus was improved. CONCLUSIONS: This case can provide valuable insight to surgeons performing ptosis surgery and blepharoplasty, particularly in cases of reoperation. Surgeons should be careful while manipulating the levator muscle or resecting deep tissues not to affect the SR muscle.

Increase in esodeviation under cycloplegia with 0.5% tropicamide and 0.5% phenylephrine mixed eye drops in patients with hyperopia and esotropia.

BACKGROUD: To evaluate the manifestations of increased esodeviation under cycloplegia with 0.5% tropicamide and 0.5% phenylephrine in children with hyperopia and esotropia. METHODS: We reviewed the medical record of 34 children with hyperopia and esotropia who underwent a prism alternate cover test before and after instillation of mixed eye drops containing 0.5% tropicamide and 0.5% phenylephrine between November 2014 and October 2015. Increased angle of deviation was defined as 10 prism diopters (PD) or greater deviation after cycloplegia. The factors related to increased angle of deviation were evaluated using univariable and multivariable logistic regression analysis. RESULTS: The median age was 5.0 years (interquartile range, 3.75 to 5.0) and 12 patients (35.3%) were male. The median manifested refractive (MR) was +2.13 diopters (D) (+0.92 to +4.47) and cycloplegic refractive (CR) was +3.50 D (+1.72 to +5.66). The median difference between MR and CR was +0.88 D (+0.50 to +1.28). Thirteen patients (38.2%) showed increased esodeviation under cycloplegia and all had accommodative esotropia. A larger difference between MR and CR was the only significant factor affecting increased esodeviation in both univariable (OR = 4.72, P = 0.029) and multivariable (OR = 5.22, P = 0.047) analyses. CONCLUSION: Children with hyperopia and esotropia often showed an increased angle of deviation after instillation of 0.5% tropicamide and 0.5% phenylephrine. This phenomenon reminded the clinicians that cycloplegics can have a different effect on esodeviation and suggested that increased angle of esodeviation may help to reveal the latent deviation in some patients with hyperopia and esotropia.