Occurrence of Dry Eye Disease in Patients With Concomitant Strabismus: A Preliminary Cross-sectional Analysis.

PURPOSE: To determine the effects of strabismus on dry eye parameters. METHODS: In this cross-sectional study, the preliminary assessment of ocular parameters related to dry eye disease was performed in patients with untreated concomitant strabismus. In total, 204 patients with concomitant strabismus and 125 volunteers without strabismus (4 to 30 years old, 170 male and 159 female) were enrolled. The Ocular Surface Disease Index questionnaire (OSDI) was administered, and ocular surface was examined using the Oculus Keratograph 5M (Oculus Optikgeräte GmbH) to collect data on tear film break-up time (TBUT), ocular redness index (based on bulbar conjunctival blood vessel engorgement), and meibomian gland atrophy. Subgroup analysis was performed based on strabismus type (concomitant exotropia, concomitant esotropia, and non-strabismus); age (juvenile versus adults age > 18 years); and 5- to 10-year and 10- to 20-year strabismus course, according to an age of 12 years. RESULTS: Concomitant exotropia and esotropia were reported in 134 and 70 patients, respectively. A total of 125 healthy volunteers were recruited. The three groups showed significant differences in the ocular redness index (right eye: P = .012, left eye: P = .018). In contrast, other parameters were not significantly different. Similarly, no statistical differences in ocular surface indicators were observed when patients were divided by age (P > .05 for all) and the 5- to 10-year and 10- to 20-year strabismus course. The meibomian gland showed varying degrees of atrophy in both the strabismus and non-strabismus groups. CONCLUSIONS: Strabismus does not affect tear film stability with age in this cohort with constant strabismus up to 30 years, indicating that strabismus may not increase the risk of dry eye disease. [J Pediatr Ophthalmol Strabismus. 2024;61(1):30-37.].

Acute bilateral hypotropia and esotropia complex as first manifestation of multiple sclerosis: a case report.

A 21-year-old Japanese woman presented with sudden eye movement disorders. An ophthalmic examination revealed bilateral hypotropia and esotropia complex. Brain magnetic resonance imaging revealed abnormal signals in the posterior and medial part of the lower pontine tegmentum (including periventricular and subcortical white matter) that were suggestive of demyelination. A cerebrospinal fluid test was positive for oligoclonal bands. She was subsequently diagnosed with multiple sclerosis and was administered intravenous methylprednisolone and oral dimethyl fumarate, with complete recovery from hypotropia and esotropia after two months. Bilateral hypotropia and esotropia are important clinical signs for the accurate diagnosis of multiple sclerosis.

Neurological pathologies in acute acquired comitant esotropia.

BACKGROUND: Acute acquired comitant esotropia (AACE) is an uncommon subtype of esotropia characterized by sudden and usually late onset of a relatively large angle of comitant esotropia with diplopia in older children and adults. METHODS: A literature survey regarding neurological pathologies in AACE was conducted using databases (PubMed, MEDLINE, EMBASE, BioMed Central, the Cochrane Library, and Web of Science) in order to collect data for a narrative review of published reports and available literature. RESULTS: The results of the literature survey were analyzed to provide an overview of the current knowledge of neurological pathologies in AACE. The results revealed that AACE with unclear etiologies can occur in many cases in both children and adults. Functional etiological factors for AACE were found to be due to many reasons, such as functional accommodative spasm, the excessive near work use of mobile phones/smartphones, and other digital screens. In addition, AACE was found to be associated with neurological disorders, such as astrocytoma of the corpus callosum, medulloblastoma, tumors of the brain stem or cerebellum, Arnold-Chiari malformation, cerebellar astrocytoma, Chiari 1 malformation, idiopathic intracranial hypertension, pontine glioma, cerebellar ataxia, thalamic lesions, myasthenia gravis, certain types of seizures, and hydrocephalus. CONCLUSIONS: Previously reported cases of AACE with unknown etiologies have been reported in both children and adults. However, AACE can be associated with neurological disorders that require neuroimaging probes. The author recommends that clinicians should perform comprehensive neurological assessments to rule out neurological pathologies in AACE, especially in the presence of nystagmus or abnormal ocular and neurological indications (e.g., headache, cerebellar imbalance, weakness, nystagmus, papilloedema, clumsiness, and poor motor coordination).

Modified Nishida's procedure for esotropia in Duane syndrome associated with Goldenhar syndrome.

Modified Nishida's procedure (no split, no tenotomy transposition) has been recently described as an effective surgery for monocular elevation deficiency and for traumatic rupture of the inferior rectus muscle. We report the modified Nishida's procedure combined with medial rectus muscle recession for the treatment of esotropia in unilateral Duane syndrome associated with Goldenhar syndrome. Following the surgery and over a 1-year follow-up period, the patient was orthophoric at distance and near, abduction improved, and the abnormal head position resolved.

A rare cause of acquired esotropia: Leprosy.

Leprosy is an infective chronic granulomatous disease involving the skin and peripheral nerves caused by Mycobacterium leprae. Complications such as lagophthalmos, corneal opacity and uveitis are common, but cranial nerve involvement is rarely seen. The fifth and seventh cranial nerves are most commonly involved. We report a case of acquired esotropia due to sixth nerve palsy following a rare cranial nerve involvement by leprosy.

The influence of refractive state and heterophorias on visual acuity and stereoacuity in healthy young adults.

PURPOSE: To evaluate associations of refractive error and heterophoria with best-corrected visual acuity and stereoacuity in a population of healthy young adults. METHODS: Data extracted from the Israeli Defense Forces Air Force candidates database was analyzed retrospectively. Myopia and hyperopia were defined as spherical equivalent of ≤ -0.50 D and ≥ +0.50 D. Cylinder of ≥0.75 D was considered astigmatism. Oblique astigmatism was defined as axis between 30°-60° and 120°-150°. Heterophoria of ≥8Δ for near was considered exo- or esophoria. RESULTS: The study population included 5,491 subjects (75.8% male), with a mean age of 17.6 ± 0.9 years: 2,355 (42.9%) had myopia, 640 (11.6%) had hyperopia, and the rest were emmetropic. Astigmatism was present in 2,006 participants (36.5%), and of those, 619 (30.9%) had oblique astigmatism. Emmetropia was correlated with better best-corrected visual acuity; astigmatism and high hyperopia, with poorer best-corrected visual acuity. A total of 331 subjects (6%) had heterophoria of ≥8Δ; of those, 300 (90.6%) had exophoria and 31 (9.4%) had esophoria. The prevalence of exophoria was higher in the myopic group, and exophoria was not associated with stereoacuity. Esophoria and anisometropia were associated with worse stereoacuity. The best stereopsis was achieved by emmetropic subjects with no astigmatism. CONCLUSIONS: Emmetropia is associated with better best-corrected visual acuity and stereoacuity. Astigmatism and high hyperopia are correlated with poorer best-corrected visual acuity. Exophoria does not interfere with stereopsis, but both esophoria and anisometropia do.

Unilateral Horizontal Rectus Muscle Recessions for Pediatric Comitant Strabismus.

INTRODUCTION: Compared to bilateral horizontal rectus muscle recessions (BHR), a unilateral horizontal rectus muscle recession (UHR) confers shorter operating time and anesthesia exposure, limits complication risks to one eye, and requires less recovery from the patient. METHODS: Retrospective chart review of pediatric patients who underwent unilateral medial rectus recession (UMR) for esotropia (ET), or unilateral lateral rectus recession (ULR) for exotropia (XT). Primary successes were defined as maximum distance deviation at post-operative month 3: -12 to +5 for ET, -5 to +12 for XT. Rates of postoperative horizontal incomitance (HI) >5 PD and success for small medium, and large (in mm, respectively, ET: <5, 5-6 mm, >6; XT: <8, 8-10, >10) recessions were analyzed. RESULTS: Seventeen ETs and 40 XTs were analyzed. Overall primary success was 71.9% (p = .02). Significantly, 80% (95% CI: 67.60,92.40) XTs succeeded. ETs were equally likely to succeed (53.9%) or fail (47.1%) (p = .22). For patients without significant preoperative HI, average postoperative HI was 3.90 PD (95% CI: 0.20, 7.60) for ETs; 5.48 PD (95% CI: 3.65, 7.32) for XTs. CONCLUSIONS: UHR was 71.9% successful in treating pediatric comitant strabismus. ULR for XT, particularly small to medium deviations, was most likely to succeed. In contrast to prior reports, large UMR and ULR were less likely to succeed and post-operative incomitance was frequent but rarely clinically significant.

Prisms in the treatment of diplopia with strabismus of various etiologies.

PURPOSE: We aimed to study the success of prism in regard to diplopia resolution score and associated factors in patients presenting with symptomatic diplopia arising from various etiologies. METHODS: In this descriptive, retrospective study diplopia resolution among 31 patients who were prescribed prism were analyzed. RESULTS: Fifty-four patients were evaluated for diplopia and 31 were included for the study done over 3 years. The mean follow-up was 15 months. Esotropia, exotropia, and hypertropia were seen in 39%, 51%, and 19.4% of patients, respectively. Furthermore, 71% received Fresnel prism and 29% were given ground glass prism. The mean prism power prescribed was 13.3 PD. 87% had complete resolution of diplopia; 96.8% continued usage of prism. High success rates were seen among patients with decompensated strabismus, sixth and fourth nerve palsy. Horizontal prism and oblique prism in the form of Fresnel prism yielded complete resolution of diplopia (P = 0.028). There was no association between the success of prism and etiology (P 0.058), history of trauma (P = 0.212), and type of deviation (P = 0.387). The study showed that oblique Fresnel prism can be considered for combined deviation. CONCLUSION: Our study showed prism to be effective in alleviating diplopia over a varied range of etiologies.

Strabismus, stereoacuity, accommodation and convergence in young adults born premature and screened for retinopathy of prematurity.

PURPOSE: The aim of the study was to evaluate strabismus, stereoacuity, accommodation and convergence in prematurely born young adults; screened for retinopathy of prematurity in the neonatal period and compare with term-born individuals of the same age. MATERIALS AND METHODS: The study participants included 59 prematurely born individuals with a birthweight of ≤1,500 grams and 44 term-born controls, all born during 1988-1990 in Stockholm County, Sweden. Ocular alignment was assessed with a cover test, stereoacuity with the TNO stereo test and the amplitude of accommodation and the near point of convergence with the Royal Air Force Rule. RESULTS: Seven of 59 (12%) preterms had manifest strabismus, 4/59 (7%) had esotropia and 3/59 (5%) exotropia. One of 44 (2%) controls had esotropia; no other controls had manifest strabismus. Stereoacuity was within normal limits in 38/59 (64%) preterms and 43/44 (98%) controls, p < 0.01; the difference remained after excluding those with strabismus. A neurological complication at 2.5 years of age was the strongest risk factor for subnormal stereoacuity within the preterm group after excluding those with strabismus. The mean amplitude of accommodation was poorer in the preterms than the controls in better (p < 0.05) and worse eyes (p < 0.05). The preterms were more likely to have an amplitude of accommodation below the minimum, according to Hofstetter's equation. There were no differences between the groups regarding the near point of convergence. CONCLUSION: Prematurely born young adults had a higher prevalence of strabismus, reduced stereoacuity and worse amplitude of accommodation than term-born controls.

Changes in refractive status of amblyopic patients with partially refractive esotropia.

PURPOSE: To investigate the changes in refractive status of amblyopic patients with partially refractive esotropia (PAET). MATERIALS AND METHODS: Amblyopic patients with PAET were enrolled. Non-amblyopic patients with full refractive accommodative esotropia (RAET) were included in the study as a control group. Preoperative and postoperative best-corrected visual acuity (BCVA), spherical equivalent (SE), astigmatism, stereoacuity, and deviations at near and distance were evaluated and statistically compared within the study group. Mean BCVA, SE, astigmatism were compared between the two groups. RESULTS: The patient and the control groups were composed of 58 eyes of 29 patients per group. There were statistically significant differences between pre- and postoperative mean astigmatism and SE between the patient and control groups. The mean astigmatism was higher in amblyopic eyes when compared with the eyes in the control group (P:0.009). During the follow-up period, changes in SE and astigmatism were not different between groups. CONCLUSION: The mean SE and astigmatism were changed in both amblyopic patients with PAET and non-amblyopic patients with RAET during the follow-up period. This suggested that neither amblyopia nor strabismus surgery has an effect on refractive status in patients with PAET.

Problems in Malaysian children with large angle infantile esotropia: Children and parents' perspectives.

INTRODUCTION: There is limited information regarding the problems faced by children with large angle infantile esotropia (LAIE). The aim of this study was to explore the problems that children with LAIE encounter from both their perspectives and those of their parents. METHODS: This study included children who had LAIE (with angle of 40 prism dioptres or greater), aged 5 and 17 years who had attended the Ophthalmology Clinic, Hospital Universiti Sains Malaysia from March to September 2016. The children and their parents or guardians were interviewed face-to-face using a validated semi-structured interview guide. Interviews were tape-recorded and transcribed verbatim. Content analysis was performed using the NVivo 12 software. RESULTS: A total of 30 children and 30 parents were interviewed. The most common problems identified by the children were social interactions (73.3%, 22 children), visual functions (60.0%, 18 children), emotions (60.0%, 18 children), physical issues (40.0%, 12 children) and difficulties regarding treatment options (26.7%, eight children). The parents reported that their children were more affected in terms of visual functions (100.0%, 30 parents), social interactions (56.7%, 17 parents), emotions (43.3%, 13 parents), physical issues (20.0%, six parents), and difficulties regarding treatment options (16.7%, five parents). CONCLUSION: The major problems that the children with LAIE identified were social interactions, while the parents observed that problems with visual functions was the most common issue encountered by their children. This suggests that the children affected have different perspectives from their parents and require support.

Risk factors for spontaneous consecutive exotropia in children with refractive and nonrefractive accommodative esotropia.

PURPOSE: To investigate the risk factors for development of spontaneous consecutive exotropia (ScXT) among patients with refractive and nonrefractive accommodative esotropia (AET). STUDY DESIGN: Retrospective. METHODS: Patients who were diagnosed with AET were reviewed from January, 2000 to December, 2016. The patients who developed ScXT after well corrected hyperopia were defined as exodeviation group (n = 51), and the patients who did not show exodeviation and were well controlled with eyeglasses were defined as the control group (n = 117). The changes in cycloplegic refraction, mean angle deviation at initial visit, time till the first correction of esodeviation, presence of amblyopia and accompanying strabismus were compared between the two groups. RESULTS: The mean interval from the first visit to correction of esodeviation under 8 PD in the exodeviation group was shorter than of the control group (P = 0.008). Patients in the exodeviation group showed more dissociated vertical deviation (DVD) (P = 0.015) and faster reduction in hyperopia per year (more hyperopic eye: P = 0.006; less hyperopic eye: P = 0.034) than the patients in the control group. Exodeviation was found mean 42.31 ± 41.13 months after hyperopia correction. There were no differences in angle deviation at initial visit, and presence of amblyopia. CONCLUSION: ScXT can be found in AET with faster reduction in hyperopia per year, accompanied by DVD, or in eyes with esodeviation corrected in relatively shorter time. It can be noted even in patients with good alignment over a long-term, so long-term follow-up is recommended.

Seasonality of births in horizontal strabismus: comparison with birth seasonality in schizophrenia and other disease conditions.

Recent work has implicated one type of horizontal strabismus (exotropia) as a risk factor for schizophrenia. This new insight raises questions about a potential common developmental origin of the two diseases. Seasonality of births is well established for schizophrenia. Seasonal factors such as light exposure affect eye growth and can cause vision abnormalities, but little is known about seasonality of births in strabismus. We examined birth seasonality in people with horizontal strabismus in a retrospective study in Washoe County, Nevada, and re-examined similar previously obtained data from Osaka, Japan. We then compared seasonal patterns of births between strabismus, refractive error, schizophrenia and congenital toxoplasmosis. Patients with esotropia had a significant seasonality of births, with a deficit in March, then increasing to an excess in September, while patients with exotropia had a distinctly different pattern, with an excess of births in July, gradually decreasing to a deficit in November. These seasonalities were statistically significant with either χ2 or Kolmogorov-Smirnov-type statistics. The birth seasonality of esotropia resembled that for hyperopia, with an increase in amplitude, while the seasonality for myopia involved a phase-shift. There was no correlation between seasonality of births between strabismus and congenital toxoplasmosis. The pattern of an excess of summer births for people with exotropia was remarkably similar to the well-established birth seasonality of one schizophrenia subtype, the deficit syndrome, but not schizophrenia as a whole. This suggests a testable hypothesis: that exotropia may be a risk factor primarily for the deficit type of schizophrenia.

Magnetic resonance imaging findings of age-related distance esotropia in Japanese patients with high myopia.

PURPOSE: This study aimed to investigate the characteristics of the extraocular muscles and the orbital connective tissue pulleys in Japanese patients with age-related distance esotropia (ARDE) and high myopia using magnetic resonance imaging (MRI). METHODS: This was a retrospective case-series study. High-resolution coronal MRI scans of 12 orbits were obtained in 6 patients with ARDE and high myopia (age range: 51-69 years). We analyzed the images to determine the positions of the rectus muscle pulleys relative to the center of the globe, the integrity of the lateral rectus-superior rectus muscle (LR-SR) band, and the LR angle (the angle between the major axis of the LR and the vertical plane). RESULTS: The distance esotropia ranged from 4 to 25∆, and 3 cases exhibited vertical deviations. The mean (±standard deviation (SD)) axial length was 28.5 (± 1.6) mm. The mean positions of the medial rectus muscle pulley and LR pulley were 1.3 mm inferior and 1.4 mm inferior, respectively, to those seen in the normal control group in our previous study (P = 0.002 and P = 0.05, respectively). All 12 orbits had abnormal elongated LR-SR bands, and 8 orbits (67%) displayed ruptured LR-SR bands. The LR angle (mean±SD; 18.8° ± 8.5°) increased significantly with the inferior displacement of the LR pulley (R2 = 0.77, P = 0.0002). CONCLUSIONS: Inferior displacement of the LR pulley and abnormal LR-SR bands were seen in Japanese ARDE patients with high myopia, as was found in ARDE patients without high myopia. The LR angle might be useful for judging the degree of LR pulley displacement.

An Interesting Case of Gradenigo Syndrome.

Gradenigo syndrome is a rare complication of acute otitis media infections, and early diagnosis and treatment of the condition are imperative. In this report, we present a case of a 22-month-old girl who developed acute, acquired esotropia associated with recurrent episodes of otitis media, which resolved after antibiotic treatment. To our knowledge, our patient is one of the youngest children reported in the literature to present with presumed Gradenigo syndrome and the only case of recurrent episodes of acquired esotropia and concurrent otitis media within the short time span of 1 month. We hope to add new information to the existing literature and to aid in the understanding of the pathophysiology and management of this condition.

Esodeviation without correction for tapering hyperopia in refractive accommodative esotropia.

OBJECTIVE: To investigate clinical features for prescription of tapered hyperopia in patients with refractive accommodative esotropia (RAET). METHODS: The clinical features in patients with RAET who began tapering of hyperopia were analyzed. Within a range that can sustain corrected visual acuity and stereoacuity, patients were prescribed for tapered hyperopic correction by 0.25-diopters (D) interval, up to a maximum of 1.0 D. At every visit, visual acuity and esodeviation with and without correction, amount of tapered hyperopia, and near stereoacuity were measured. RESULTS: One hundred and six patients were enrolled in this study. The follow-up period was 3.1 ± 0.2 years and frequency of visits was 6.3 ± 0.6. Tapering hyperopia was initiated at 6.1 ± 2.9 years, and baseline refraction was 7.6 ± 1.5 D. The esodeviation without correction was 24.3 ± 8.5 prism diopters (PD), and median near stereoacuity was 400 arc sec. The median amount of tapered hyperopia at visit was 0.5 D. At the final visit, there were no significant deteriorations in visual acuity, esodeviation with correction, or near stereoacuity (p > 0.05, all). The amount of tapered hyperopia was positively correlated with correction and the reduced esodeviation without correction (p = 0.03). CONCLUSIONS: Esodeviation without correction should be considered for tapering hyperopia for patients with RAET. Esodeviation without correction can be easily measured, and its decline may be used as a clinical indicator for tapering hyperopia.

The Value of Fusional Convergence Amplitudes in Esodeviation Surgery Without Adjustable Sutures.

PURPOSE: To explore the application of preoperative fusional convergence amplitudes in the selection of a target angle for non-adjustable suture strabismus surgery with deteriorated intermittent esotropia and diplopia. METHODS: Thirty-one consecutive cases of presumed acquired non-accommodative, deteriorated intermittent esotropia managed surgically between 2005 and 2016 were reviewed retrospectively. For each individual, a target angle (deviation angle for which surgery was based) was selected preoperatively after analysis of fusional convergence amplitudes. Outcomes in patients selected for overcorrection at 6 meters (target angle > angle in primary position at 6 meters) were compared to those who had planned surgery based on a target angle that did not exceed their measured angle (target angle ≤ angle in primary position) at 6 meters. RESULTS: All 31 patients achieved binocular single vision in primary position at both near and 6 meters without prisms, orthoptic therapy, or additional surgery at 4 to 6 months postoperatively. Greater mean correction in the target angle > angle in primary position group compared to the target angle ≤ angle in primary position group was observed, but this difference was not statistically significant (P = .57). CONCLUSIONS: Among this diagnostically specific cohort with intermittent esotropia with symptomatic diplopia and measurable binocular single vision preoperatively, targeted surgery based on an analysis of preexisting fusional convergence amplitudes had an outcome that compared favorably to that of documented adjustable suture strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2018;55(6):375-381.].

Improvement in Both Primary and Eccentric Ocular Alignment After Thyroid Eye Disease-Strabismus Surgery With Tenon's Recession.

PURPOSE: To evaluate the improvement in primary and eccentric gaze ocular alignment in thyroid eye disease (TED) patients undergoing horizontal strabismus surgery with Tenon's recession. METHODS: This is an Institutional Review Board-approved retrospective analysis of TED patients undergoing horizontal strabismus surgery for esotropia. The study included all patients from 2007 to 2016 operated on by a single surgeon at Columbia University Medical Center. Surgical success was defined as the ability to fuse at both near and distance either without prismatic correction or with less than 10 prism diopters (PD) of correction. Measurements of ocular alignment were also made in eccentric fields of gaze. This study was Health Insurance Portability and Accountability Act compliant with protection of individually identifiable information. RESULTS: Thirty-eight patients with TED and restrictive horizontal strabismus underwent unilateral or bilateral medial rectus recession to relieve diplopia. All patients underwent Tenon's recession with dissection of Tenon's from the overlying conjunctiva permitting it to retract into the orbit. Overall the success rate was 87% with a reoperation rate of 7.9%. The improvement in horizontal deviation in both primary and eccentric gaze was statistically significant (p < 0.001). The change in vertical deviation in the 5 cardinal positions of gaze was not statistically significant. The postoperative change in vertical deviation was not proportional to the preoperative horizontal deviation or the amount of horizontal recession. CONCLUSIONS: Due to the preoperative incomitance of ocular deviations in TED patients, persistent postoperative eccentric misalignment is expected. The addition of Tenon's recession to TED-horizontal strabismus surgery led to statistically significant improvement in ocular alignment in both primary and eccentric gaze. This is the first study of TED-strabismus surgery to analyze the postoperative results in positions outside of primary and reading gaze. The authors postulate that the release of scar tissue by the addition of Tenon's recession contributes to these improvements.