Treatment of Infantile Esotropia - Comparison Between Botulinum Toxin A and Bilateral Medial Rectus Recession.

Objectives: The objective of the study is to evaluate the examination findings, treatment methods, and follow-up results of children diagnosed with infantile esotropia (IE) and to compare botulinum toxin A (BTA) and bilateral medial rectus (MR) recession surgery. Methods: We retrospectively reviewed the medical records of patients who were diagnosed with IE. The age of the patient and the angle of deviation were taken into account to determine the treatment. Patients who underwent bilateral MR recession surgery and BTA injection were analyzed and the BTA and surgical groups were compared. Successful correction was defined as orthotropia and a deviation of up to 10 prism diopters (PD) after one surgical procedure or 1-3 botulinum injections. Results: Two hundred and forty-six patients with esotropia were included in the study. Twelve were followed up with refractive correction only. BTA injection was administered to 110 patients, while 124 patients underwent bilateral MR recession. The age of the patients ranged from three to 39 months. Patients were followed for at least 6 months, with a mean follow-up of 24.3 months in the BTA group and 21.7 months in the surgical group (p=0.23). The mean pre-treatment angle deviation was 38.9 PD in the BTA group and 40.1 PD in the surgical group (p=0.62). The success rate for patients with more than 30 PD of deviation was 72% in the surgical group compared to 36% in the BTA group (p<0.001). No statistically significant difference in success rate was observed in patients with deviations <30 PD (surgery 62%, BTA 55%, p=0.26). Conclusion: Surgical treatment of IE was more successful than BTA injection in patients with large angle deviations (>30 PD). BTA injection can be considered as an alternative to surgery in cases of small to moderate angle deviations (<30 PD).

A Comparative Analysis of Surgical Outcomes for Infantile Esotropia With and Without Prior Botulinum Toxin a Injection.

PURPOSE: To compare the surgical outcomes in patients who had a failed botulinum toxin A injection before surgery versus those who had surgery as primary treatment (primary surgery) for infantile esotropia. METHODS: The files of patients who had strabismus surgery in the Strabismus Unit of Beyoglu Eye Training and Research Hospital between January 2012 and March 2022 were reviewed. This study included 104 eyes of 52 patients with infantile esotropia. The angle of deviation before and 1, 3, and 6 months after botulinum toxin A injection or surgery, complications, pattern deviations, family history, abnormal head position, history of prematurity, intensive care unit admission, and consanguineous marriage were noted. A successful outcome was defined as ocular alignment of 10 prism diopters (PD) or less. RESULTS: The study population consisted of 52 patients: 27 (52%) boys and 25 (48%) girls. In the botulinum toxin A group (n = 26), the mean age at admission was 14.0 ± 6.8 months, whereas the mean preoperative near and far angle of deviation were 41.92 ± 12.2 and 41.3 ± 13.0 PD, respectively. The mean age at the time of surgery was 40.6 ± 18.1 months. In the primary surgery group (n = 26), the mean age at admission was 34.0 ± 15.9 months. The mean preoperative near and far angle of deviation were 37.3 ± 8.0 and 35.3 ± 10.5 PD, respec tively. The mean age at the time of surgery was 48.1 ± 18.5 months. The success rates 6 months after treatment in the botulinum toxin A group and the primary surgery group were 76.9% and 88.5% in near (P > .05) and 80.8% and 88.5% in far (P > .05), respectively. Three patients had transient ptosis and one had consecutive exotropia after botulinum toxin A injection. CONCLUSIONS: In infantile esotropia treatment, strabismus surgery after failed botulinum toxin A injection compared to primary surgery has statistically comparable surgical success rates. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XXX-XXX.].

Effect of refractive errors on the results of botulinum neurotoxin administration in patients with infantile esotropia.

PURPOSE: To investigate the effect of refractive errors on the results of patients followed up with infantile esotropia (IE) and treated with botulinum neurotoxin (BNT) injection. METHODS: The files of patients with IE who presented to the ophthalmology pediatric ophthalmology unit and underwent BNT injection into both medial rectus muscles between 2019 and 2021 were reviewed retrospectively. Sixty eyes of 30 patients were included in the study. Patients with additional systemic or ocular diseases and those with a history of ocular surgery were excluded. Distance and near deviations were measured (with the prism cover test or Krimsky method) before and at the first, third, and sixth months after BNT injection. RESULTS: In Group 1 (n = 20) with a spherical equivalent of + 2.0 diopters (D) or less, the mean near and distance deviation value was both 36.8 ± 12.7 prism diopter (PD) before injection. In Group 2 (n = 10) with a spherical equivalent of above + 2.0 D, the near deviation was measured as 35.0 ± 7.1 PD and distance deviation as 31.8 ± 7.9. At six months after BNT injection, the near and distance deviation values were 20.6 ± 12.3 and 20.6 ± 11.6 PD, respectively in Group 1 and 10.1 ± 10.3 and 8.8 ± 10.8 PD, respectively in Group 2. The change in deviation did not statistically significantly differ between the groups (p > 0.05), but the distance and near deviation values were lower in Group 2 at sixth months after BNT injection. CONCLUSIONS: BNT injection is a preferred method in IE. Higher hypermetropic values seem to increase the success of BNT injection.

Pulled-in-two syndrome in strabismus surgery for congenital fibrosis of the extraocular muscles.

Purpose: The aim of this study is to present six cases of pulled-in-two syndrome (PITS) in strabismus surgeries and to discuss our prevention and management strategies. Methods: This is a retrospective study presenting cases of PITS during strabismus operations. The medical records of the subjects who underwent operation in the strabismus unit of Beyoglu Eye Training and Research Hospital were reviewed retrospectively, from January 2000 till March 2022. Detailed ophthalmological examination records and angle of deviation were noted. Results: A total of six cases (four males and two females) with a mean age of 37.2 ± 28.0 (min 9-max 71) years were included in this study. All of the cases had congenital fibrosis of extraocular muscles (CFEOM). The most commonly involved muscle was medial rectus (83%). Majority of cases (67%) were adults. In all cases, the muscle was found and reattached to the globe. No patients had diplopia after surgery. Conclusion: PITS is a rare complication that can be seen during strabismus surgeries, and CFEOM patients are in the risk group. Therefore, surgeons should be cautious and prepared in risky patients to be able to manage this complication.

Aberrant regeneration in an international registry of patients with 3rd-nerve palsy.

BACKGROUND/AIMS: To describe the patterns of pre-operative aberrant regeneration and motility outcomes reported in an international registry of patients with 3rd-nerve palsy treated with nasal transposition of the split lateral rectus muscle (NTSLR). METHODS: This cross-sectional study used data from an international, multicentre registry of patients with 3rd-nerve palsy treated with NTSLR. Patients with aberrant regeneration were identified, and patterns of innervation described. Demographics and postoperative success defined as horizontal alignment ≤15 PD were compared based on the presence, and type, of aberrant regeneration using Wilcoxon rank sum and Fisher's exact tests. RESULTS: Aberrant regeneration was reported in 16% (21/129) of patients. Age at diagnosis, sex, and aetiology of palsy were not significantly associated with aberrant regeneration. Abnormal movements were triggered by adduction in 52% (11/21), infraduction in 23% (5/21), and supraduction in 23% (5/21) of cases. Presentation patterns involved rectus muscle innervation in 29% (6/21) and levator muscle innervation in 71% (15/21) of cases. Although patients with aberrant regeneration had similar probability of success in comparison to those without following NTLSR (76% vs. 69%, p = 0.5), those with abnormal innervation of a rectus muscle had a lower success rate than those with abnormal innervation of the levator palpebrae superioris muscle (17% vs. 93%; p = 0.002). CONCLUSION: Successful treatment of a 3rd nerve palsy with NTSLR was not influenced by aberrant regeneration involving the levator muscle. Alternative surgical interventions should be considered when aberrant regeneration alters rectus muscle function given its adverse impact on motor outcomes with NTSLR.

Worldwide outcomes of nasal transposition of the split lateral rectus muscle for strabismus associated with 3rd-nerve palsy.

BACKGROUND/AIMS: To determine success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating strabismus from 3rd-nerve palsy. METHODS: An international, multicentre, registry of patients with unilateral 3rd-nerve palsy treated with NTSLR was created. Patients with concurrent surgery on the contralateral eye were excluded. Primary outcome was horizontal alignment within 15 prism dioptres (PD) of orthotropia. Incidence of technical difficulties and vision-threatening complications by 6 months post-procedure were reported. RESULTS: Ninety-eight patients met inclusion criteria. Median age was 33.5 years (IQR 10.75-46). Aetiologies included congenital (31%), neoplastic (16%) and traumatic (15%). Twenty-five per cent of patients had prior ipsilateral strabismus surgery. Median exotropia decreased from 70PD preoperatively (IQR 50-90) to 1PD postoperatively (IQR 0-15.5), with a success rate of 69%. Performing concurrent superior oblique muscle tenotomy (SOT) was independently associated with success (p=0.001). Technical challenges occurred in 30% of cases, independently associated with a history of ipsilateral strabismus surgery (p=0.01). Eleven per cent of patients had vision-threatening complications, independently associated with more posterior placement of the split lateral rectus (LR) muscle (p<0.001), and most commonly transient serous choroidal effusion. Surgical placement of the split LR muscle within 4.25 mm of the medial rectus (MR) muscle insertion reduced this risk. CONCLUSION: NTSLR significantly improved primary position alignment altered by 3rd-nerve palsy. Concurrent SOT and placement of the split LR muscle ≤4.25 mm posterior to the MR muscle insertion optimised outcomes. NTSLR proved technically challenging when prior ipsilateral strabismus surgery had been performed.

Extraocular muscle ductions following nasal transposition of the split lateral rectus muscle.

OBJECTIVE: To quantify changes in ductions following nasal transposition of the split lateral rectus muscle (NTSLR) for treating third nerve palsy. DESIGN: Retrospective cohort study. PARTICIPANTS: A single eye from each patient with third nerve palsy treated with NTSLR with ocular motility measurements. METHODS: Observation of changes in pre- and postoperative ductions. Outcome measures including patient demographic and surgical factors associated with the ability to adduct beyond the midline after NTSLR were evaluated using multivariable logistic regression. RESULTS: A total of 116 patients met the inclusion criteria for this study. The NTSLR significantly decreased abduction (median of 0 limitation [interquartile range (IQR), 0-0] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p < 0.001), with a corresponding improvement in adduction (median, -5 [IQR, -5 to -4] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p < 0.001). There was no change in median supraduction or infraduction after NTSLR (p > 0.05). The ability to adduct beyond the midline after NTSLR was demonstrated in 42% of patients. Although not statistically significant, a trend toward a postoperative ability to adduct beyond the midline was seen in patients who had concurrent superior oblique muscle tenotomy (odds ratio [OR] = 5.08; 95% CI, 0.91-40.9) or who were designated with partial rather than complete third nerve palsy (OR = 2.29; 95% CI, 0.82-6.70). CONCLUSIONS: NTSLR improves the horizontal midline positioning of eyes with third nerve palsy. Most eyes lose the ability to abduct, but some regain a modest ability to adduct while vertical ductions remain unchanged.

Treatment of convergence insufficiency type intermittent exotropia with bupivacaine injection to the medial rectus combined with lateral rectus recession.

PURPOSE: To evaluate the outcomes of combined bupivacaine HCL (BPX) injection in the medial rectus (MR) muscle with recession of the lateral rectus muscle in the treatment of convergence insufficiency-type intermittent exotropia (CI-IXT). METHODS: The medical records of patients who underwent combined injection-recession treatment from January 2019 to January 2020 for CI-IXT were reviewed retrospectively along with a group of age-matched controls with IXT without CI who underwent only unilateral LR recession during the same period. The following data were extracted from the record: age at surgery, average follow-up period, angle of deviation at distance and near and the difference between them before and after surgical procedure, correction of near and distance deviations, and recession dosage. Successful outcome was defined as a distance deviation in primary gaze between ≤10Δ of exophoria/tropia and ≤5Δ of esophoria/tropia. RESULTS: A total of 10 patients and 20 controls were included. Average follow-up was 13.9 ± 3.67 months in the BPX group and 15.9 ± 3.61 months in the control group (P = 0.17). Postoperative distance deviation measured 8.30Δ ± 5.88Δ in the BPX group and 14.67Δ ± 9.83Δ in the control group (P = 0.80). Distance-near differences were significantly reduced in the CI-IXT group receiving BPX, by a mean of 6.60Δ, from a preoperative mean of 10.50Δ ± 3.65Δ to 3.90Δ ± 3.26Δ (P < 0.01). CONCLUSIONS: BPX injection combined with unilateral lateral rectus recession yields outcomes comparable to bilateral lateral rectus recession for distance deviations, and results in reduction of the distance-near difference in the angle of exotropia.

Nasal Transposition of the Split Lateral Rectus Muscle for Strabismus Associated With Bilateral 3rd-Nerve Palsy.

PURPOSE: To determine the success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating bilateral 3rd-nerve palsy. DESIGN: Retrospective, interventional case series. METHODS: An international, multicenter registry was used for the study. The study population was all patients with bilateral 3rd-nerve palsy treated with NTSLR. Sensorimotor evaluations were conducted before and 6 months after unilateral or bilateral NTSLR. Outcome measures were postoperative horizontal alignment ≤15 prism diopters (PD), intraoperative technical difficulties, and vision-threatening complications. The association of patient demographics and surgical technique with each outcome was analyzed using multivariable logistic regression. RESULTS: A total of 34 patients were included, with a median age of 46 years (interquartile range [IQR] = 25-54 years) at surgery. The most common etiologies were ischemic (29%), neoplastic (15%), and congenital (12%). NTSLR performed unilaterally with alternative surgery on the opposite eye (65%) resulted in a median postoperative exotropia of 18 PD (IQR = 7-35 PD), and when performed bilaterally (35%) resulted in postoperative exotropia of 14 PD (IQR = 5-35 PD). Success was achieved in 50% of cases, intraoperative technical difficulties were reported in 18%, and vision-threatening complications occurred in 21%. Attachment of the lateral rectus muscle ≥10 mm posterior to the medial rectus insertion was associated with increased vision-threatening complications (odds ratio = 9.0; 95% CI = 1.3-99). CONCLUSIONS: NTSLR can address the large-angle exotropia associated with bilateral 3rd-nerve palsy. Surgeons should be aware that posterior placement of the lateral rectus muscle may increase the risk of vision-threatening complications, particularly serous choroidal effusion.

Combined Rectus Muscle Transposition With Posterior Fixation Sutures (Augmented Knapp Procedure) for the Surgical Treatment of Double Elevator Palsy.

PURPOSE: To evaluate the surgical results of full horizontal tendon rectus muscle transposition to the superior rectus muscle insertion, augmented by posterior fixation sutures, in patients with double elevator palsy. METHODS: In this retrospective comparative study, 17 patients treated by the augmented Knapp procedure (study group) were compared with 28 patients treated by the standard Knapp procedure (control group). Pre-operative and postoperative vertical deviation in primary position, ocular motility, binocular function, and rate of reoperation were evaluated. RESULTS: The mean preoperative near and distance deviations (hypotropia) decreased by 93% and 97% in the study group and 68% and 69% in the control group, respectively. The improvement in near and distance deviation was statistically more significant in the study group than the control group (P = .001 for each parameter). The mean preoperative elevation deficiency in abduction and adduction improved by 64% and 66% in the study group and 37% and 39% in the control group, respectively. The improvement in elevation deficiency in abduction and adduction was statistically significantly greater in the study group than the control group (P = .001 and .04, respectively). Reoperation was required in 15 patients (54%) in the control group and 2 (12%) in the study group during the follow-up period of 26 ± 4 months. CONCLUSIONS: The postoperative improvement in near and distance deviation and elevation deficiency in abduction and adduction was significantly better in the augmented Knapp procedure than the standard Knapp procedure. This procedure demonstrated a stronger effect in the treatment of double elevator palsy. [J Pediatr Ophthalmol Strabismus. 2022;59(1):17-23.].

Comparison of quantitative measurement of macular vessel density before and after inferior oblique muscle-weakening surgery: An optical coherence tomography angiography study.

PURPOSE: To investigate hemodynamic changes in retinal and choroidal vasculature after surgical inferior oblique (IO) weakening through optical coherence tomography angiography (OCTA). METHODS: The medical records of patients who underwent unilateral IO-weakening surgery at a single institution were retrospectively reviewed. Patients who had OCTA measurements before surgery and on postoperative days 7 and 30 were included. Vessel density was determined for the superficial capillary plexus (SCP), deep capillary plexus (DCP), the choriocapillaris (CCP) and the foveal avascular zone (FAZ). RESULTS: The study included 72 eyes of 36 patients. Fellow eyes were used as a control group. The preoperative and postoperative week 1 and month 1 mean central vessel densities of the SCP were 20.48% ± 3.52%, 20.68% ± 3.83%, and 23.56% ± 5.65%, respectively, in the operated eye; those of the DCP were 16.72% ± 3.33%, 16.08% ± 4.65%, and 20.85% ± 7.09%, respectively. The mean FAZ areas were 341.29 ± 88.04 µm2, 341.30 ± 98.25 µm2, and 316.02 ± 74.61 µm2, respectively. We detected no significant changes in SCP, DCP, and FAZ in the postoperative period. The mean central vessel density of the CCP increased significantly from the preoperative level of 54.06% ± 2.86% to 55.55% ± 2.63% at postoperative week 1, but there was no significant difference between baseline and postoperative month 1 (P = 0.001 and P = 0.515, resp.). CONCLUSIONS: IO muscle surgery does not seem to cause alterations in retinal hemodynamics, although it can transiently increase the central vessel density of the CCP during the early postoperative period.

Whole tendon disinsertion of superior oblique for the treatment of Brown syndrome: a comparative study with multiple techniques.

PURPOSE: To evaluate the results of a temporal whole superior oblique (SO) tendon disinsertion technique compared with other SO tendon-weakening procedures. METHODS: The medical records of patients who underwent an SO procedure at University of Health Sciences Beyoglu Eye Research and Training Hospital from January 2008 to January 2018 for treatment of Brown syndrome were reviewed retrospectively. Patients with follow-up of at least 12 months were included. The following data were included in our analysis: pre- and postoperative ocular ductions, versions, and vertical deviations; presence of abnormal head position (AHP); complications; and success rates of procedures. RESULTS: The record review identified 158 patients, of whom 52 patients had nasal tenotomy, 6 had nasal tenectomy, 48 had SO tendon elongation by suture spacer and 6 by silicone spacer, and 46 patients had temporal tendon disinsertion of the SO. The rate of AHP decreased from 91.3% to 4.3% postoperatively, and the preoperative mean limitation of elevation in adduction and hypotropia decreased from -3.60Δ ± 0.65Δ and -2.26Δ ± 4.28Δ to -0.47 ± 0.79 and -0.34 ± 2.67Δ postoperatively, respectively, in the temporal tendon disinsertion group. SO palsy was not observed after temporal disinsertion surgery, but undercorrection, overcorrection, and adhesion were seen in 8.7%, 8.7%, and 4.3% of patients, respectively, and a second surgery was needed for 17.4% of patients because of vertical deviations. The success rate of temporal tendon disinsertion technique was not significantly different from those of the other SO procedures (P = 0.91). CONCLUSIONS: Temporal disinsertion of the SO tendon may be as effective as other SO-weakening procedures.

Sliding shape extraocular muscle transposition with plication: Long-term results.

AIM: This study aims to evaluate the long-term results of sliding shape extraocular muscle transposition, which is a novel operation method of delivering both vascular protection and strengthening of the muscles and transposition of the muscles. METHODS: The patients' files were scanned retrospectively. All patients underwent a complete eye examination in addition to motility examination, both preoperatively and postoperatively. Patients were followed up for at least 1 year. Pre- and postoperative deviation measurement values and transposition effects were compared statistically. The two parameters were evaluated separately. RESULTS: In patients where 7-mm (or greater) resection was planned, the complete muscle widening transposition procedure was successful. Only two-thirds of transpositions could be achieved in patients who underwent less than 7 mm of strengthening. There was no anterior segment ischemia in the patients who underwent three rectus' muscle surgery in the same eye. Transposition effects were perfect in those whose vertical deviation was not due to monocular elevation deficiency. While resection effect was excellent in those MED (monocular elevation deficiency) and CEOMF (congenital extraocular muscle fibrosis) cases, transposition effects were limited but found at similar rates as with the standard resection and transposition procedures in CCDD (congenital cranial dis-innervation diseases) (R2-1). CONCLUSION: Even transposition effects were limited in CCDD. 'Sliding shape' design extraocular muscle plication was found to be a simple, safe, and effective procedure for patients who needed resection and transposition operation.

Evaluation of Diplopia Secondary to Seton Implantation Surgery: Ahmed Glaucoma Valve and Diplopia.

Objectives: To determine and evaluate the rate of diplopia after Ahmed glaucoma valve (AGV) implantation surgery. Materials and Methods: The records of patients who underwent AGV implantation in our hospital between the years of 2010 and 2017 were retrospectively reviewed. Patients who were referred to our strabismus department due to binocular diplopia after AGV implantation surgery were included. The details of postoperative day 1, day 7, day 15, and 1 month examinations were recorded. In the postoperative period, the onset time of diplopia complaints, diplopia type, and the presence of diplopia at distance and near fixation were noted. Ocular motility examination and deviation measurements were evaluated. Results: Ten (47%) of 211 patients who underwent AGV implantation in our hospital between 2010 and 2017 met the study inclusion criteria. Six of the 10 patients were men (60%) and 4 were women (40%). The mean age of the patients was 44.5 (34-63) years. Complaints of diplopia developed at a mean of 14.5±12.3 (1-30) days after AGV implantation. The prism measurements of the patients were found to be 8.4±1.4 prism diopters (PD) exotropia and 7.1±8.8 PD hypotropia. While 8 patients had diplopia only at near distance, 2 patients had diplopia at both distance and near. Three patients were treated with prismatic glasses, and their complaints of diplopia recovered spontaneously in 5.11±4.10 months. The other 7 patients were followed up without treatment, and their diplopia complaints resolved spontaneously in 6.11±4.40 months. Conclusion: Although most of the diplopia that develops after AGV implant surgery resolves without treatment, prismatic glasses might be considered as a treatment option in patients whose diplopia affects their daily lives.

Brown Syndrome: Features and Long-term Results of Management.

OBJECTIVES: The goal of this study was to evaluate surgical techniques and outcomes in patients with Brown's syndrome. METHODS: A retrospective review was conducted of patients who underwent surgery of the superior oblique (SO) muscle between 2003 and 2011 at a referral center. RESULTS: In all, 190 patients (111 female and 79 male) with an age range of 4-50 years were included in the study. The right eye was affected in 98 patients, and the left eye in 92 patients. Abnormal head posture (AHP), ocular movement (OM), and hypotropia were assessed. The greatest improvement of AHP was seen following an SO temporal tenotomy (91%). Patients with a -4 limitation achieved full OM after a SO temporal tenotomy. CONCLUSION: Temporal tenotomy provided the best improvement in limitation of elevation in adduction.

Effect of lateral rectus muscle resection on abduction in Duane retraction syndrome type 1.

PURPOSE: To assess the effect of lateral rectus muscle resection on abduction in Duane retraction syndrome (DRS) type 1. METHODS: The medical records of patients with DRS type 1 were reviewed retrospectively. Fifteen patients who underwent lateral rectus resection were included. Prism and cover test and the Krimsky test were used to detect deviations. Ocular ductions, abnormal head position (AHP), and globe retraction were recorded. RESULTS: Nine (60.0%) patients were female. The mean age was 13.1 ± 2.3 (range, 2-34) years. Left eyes were included in ten (66.7%) patients. Mean follow-up time was 37.6 ± 16.6 (range, 6-70) months. All patients had AHP, 13 patients had mild globe retraction, and 2 patients had no globe retraction preoperatively. Mean lateral rectus resection was 3.1 ± 0.7 (range, 2.0-4.5) mm, and the mean medial rectus recession was 4.4 ± 0.6 (range, 3.0-5.0) mm. The mean preoperative deviation decreased from 23.3 ± 6.9 (range, 14-35) prism diopters (pd) to 2.2 ± 4.1 (range, 0-10) pd at near, and from 23.6 ± 7.1 (range, 14-35) pd to 1.8 ± 3.5 (range, 0-10) pd at distance, at 6 months postoperatively (p = 0.01). The mean limitation in abduction decreased from - 3.2 ± 0.9 to - 1.3 ± 1.1 postoperatively (p < 0.001). AHP resolved in all patients. There was not a limitation in adduction or a worsening of globe retraction in any patient. CONCLUSION: Lateral rectus resection can be used to improve abduction in patients with DRS type 1 who have mild globe retraction. We assume that this procedure has no worsening effect on globe retraction in appropriate cases.

Muscle belly union surgery with or without medial rectus recession for the treatment of high myopic strabismus fixus.

PURPOSE: To evaluate the results of surgery involving the union of the superior rectus muscle and the lateral rectus muscle with or without medial rectus recession (MRc) for the treatment of high myopic strabismus fixus over a 20-year period. METHODS: The medical records of patients who underwent muscle belly union for the treatment of high myopic strabismus fixus were reviewed retrospectively. Patients were classified according to the timing of MRc. In group 1, MRc was performed before muscle union surgery; in group 2, MRc was performed concurrent with muscle union surgery; in group 3, MRc was not performed; in group 4, MRc was performed after muscle union surgery. RESULTS: A total of 50 eyes of 40 patients were included. Mean esotropia decreased from 57.27Δ ± 25.45Δ (range, 8Δ-100Δ) before surgery to 11.67Δ ± 13.85Δ (range, -18Δ to 45Δ) after (P < 0.001); mean hypotropia, from 6.05Δ ± 9.13Δ (range, 0Δ-13Δ) before to 1.20Δ ± 3.03Δ (range, 0Δ-10Δ) after (P < 0.001). Mean abduction improved from -2.82 ± 1.17 (range, -4 to 0) before to -0.75 ± 0.92 (range, -3 to 0) after (P < 0.001); mean elevation, from -1.62 ± 1.62 (range, -4 to 0) before to -0.57 ± 0.90 (range, -3 to 0) after (P < 0.001). Preoperative esotropia and postoperative limitation in abduction were significantly lower in group 3 (P = 0.03; P = 0.01). CONCLUSIONS: Muscle union surgery successfully corrected the restrictive esotropia and hypotropia. MRc in addition to muscle union surgery was not necessary for some patients, for whom preoperative esotropia was lower.

Assessment of Refractive Error Changes and Factors for Decompensation in Patients With Fully Accommodative Esotropia.

PURPOSE: To determine the factors affecting the risk of deterioration and evaluate the refractive error change in patients with fully accommodative esotropia. METHODS: Patients diagnosed as having fully accommodative esotropia (esotropic deviation that started before 7 years of age and less than 8 to 10 prism diopters [PD] of esotropia with full hyperopic correction and/or bifocals) were included in this retrospective population-based cohort study. Refractive error changes were recorded. For comparisons, patients were divided into two groups: nondecompensated fully accommodative esotropia group and decompen-sated fully accommodative esotropia group. RESULTS: Two hundred and twenty-three patients met the inclusion criteria. The mean follow-up time was 5.94 ± 0.31 years (range: 5 to 8 years). The changes in spherical equivalent in the younger than 7 years, 7 to 12 years, and 12 to 17 years groups were statistically significant (P < .001). The decrease of hypermetropia was 0.13 diopters/year between 7 and 12 years and 0.06 diopters/year between 12 and 17 years. Forty-one of 223 patients (18.4%) discontinued spectacle therapy during the follow-up period. Hyperopic error and presence of amblyopia were lower, whereas visual acuity level and presence of near-distance disparity were higher in the spectacle discontinuation group (P < .001, .007, .01, and 0.01, respectively). Deterioration of fully accommodative esotropia occurred in 30 of 223 patients (13.5%). Boys were more likely to require strabismus surgery (P = .32). The mean age at presentation, esotropia angle with and without refractive correction at both near and distance fixation, near distance disparity, and inferior oblique overaction were significantly higher in patients with decompensated fully accommodative esotropia. CONCLUSIONS: Hyperopic error increased from the initial level until 7 years of age, followed by a myopic shift thereafter. Few children had resolution of fully accommodative esotropia and could discontinue spectacle therapy. Children with male gender, higher esotropia angle, older age at presentation, near-distance disparity, and inferior oblique overaction experienced a greater deterioration of the fully accommodative esotropia. [J Pediatr Ophthalmol Strabismus. 2020;57(4):217-223.].

Refraction under general anesthesia in children, using cycloplegic refraction only as a reference.

PURPOSE: To compare the measurements of cycloplegic refraction and refraction (R1-1) under general anesthesia (GA) when using the same portable auto-refractometer (ARF) in pediatric patients. METHODS: 36Thirty-six to 60-month-old patients who underwent refraction measurements using a portable ARF (Retinomax® K plus 3, Righton, Japan), who did not receive prior cycloplegics under this GA and who had cycloplegic refraction using 1% cyclopentolate and the same Retinomax® device < 3 months prior this GA, between 2015 and 2018, were included in this study. The agreement (Bland-Altman analysis) and correlation (Pearson correlation) between the mean values of the measurements were analyzed. RESULTS: Two-hundred-twenty-two right eyes of 222 patients (114 male and 108 female) were included in this study. The mean age was 45.04 ± 11.24 months. The mean spherical refractions (R1-1, R2-1) under GA and cycloplegic refraction were 1.08 ± 3.50 diopter (D) (-8.00 to +8.00) and 2.58 ± 3.28 D (-6.50 to +9.25), respectively. A strong positive correlation was detected between the two measurements (r = 0.95). When comparing measurements, the mean measurement under GA was -1.49 D (95% confidence interval: lower limit, -3.63; upper limit, +0.63) more myopic than the mean cycloplegic refraction (R1-1) value (Bland-Altman analysis test). The differences between the measurements were within ± 1 D in 92 eyes (41.44%) and within ± 2 D in 180 eyes (81.01%). No significant difference was detected when comparing the cylindrical refractive error values (p > .05). CONCLUSION: Refractive measurements under GA were more myopic than cycloplegic refraction (R1-1) measurements. It is important to consider that complete cycloplegia is not achieved under GA.

Comparison of different tendon transposition techniques for the treatment of monocular elevation deficiency type 2.

PURPOSE: To compare results of three different tendon transposition techniques (Knapp procedure and two modified techniques) for the treatment of type 2 monocular elevation deficiency (MED) patients. METHODS: The medical records of patients with MED type 2 operated on at a single institution from 2000 to 2016 were reviewed retrospectively. Patients were divided into three vertical transposition groups: (1) full tendon width, (2) augmented surgery; and (3) partial tendon width. Surgical success was defined as no severe limitation of upgaze, hypotropia of <6Δ, and no hypertropia in primary position. Pre- and postoperative vertical deviations in the primary position and limitations in elevation levels were compared. RESULTS: A total of 39 patients were included. The pre- and postoperative deviations in the full-tendon group were 22.50Δ ± 4.17Δ and 3.50Δ ± 1.27Δ, respectively; in the augmented surgery group, 23.75Δ ± 4.78Δ and 1.75Δ ± 1.14Δ; and in the partial-tendon group, 20.50Δ ± 3.98Δ and 4.12Δ ± 2.78Δ. Corrected vertical deviations were 19Δ, 23Δ, and 16Δ, respectively. The pre- and postoperative limitation of elevations were -2.80 and -0.80 in the full-tendon group, -3.20 and -0.90 in the augmented surgery group, and -2.37 and -1.12 in the partial-tendon group. The pre- and postoperative vertical deviation improvements and limitations of elevation were statistically significant (P < 0.05) in all groups. Success was achieved in 29 patients (74%). CONCLUSIONS: In this study cohort, all three procedures were reasonably effective in improving vertical deviations and limitation of elevation.