Current Status of Glaucoma-related Data Management and Efforts toward Data Standardization.

Purpose: To determine the normative value of the physiologic excyclotorsion angle of the eye using fundus photos (the angle between horizontal line and the line relating fovea and the center of the optic disc), and to analyze the aging effect on this angle. Methods: 45 and 65 year-old subjects who underwent group glaucoma checkup sponsored by Ohta city government during three years (2013 to 2015) were investigated. Only those without ocular diseases who had good-quality fundus photographs taken were included. Results: 212 photographs of 39 (45 year-old) and 67 (65 year-old) subjects were analyzed. Physiologic excyclotorsion angle (average±standard deviation) was 6.2±2.9/6.8±2.8 degrees in the right eye and 7.1±3.6/7.8±3.2 degrees in the left eye in the 45/65 year-old groups, respectively. There was no statistical difference between the two groups (t-test. right eye, p=0.27; left eye, p=0.24). The angle of the left eye was statistically larger than of the right eye when the data of both groups were combined (paired t-test, p=0.025). Conclusions: The angle of the physiologic excyclotorsion determined by fundus photos does not differ between 45 and 65 year-old subjects. The angle of the left eye is larger than the right eye.

[Long-Term Follow-up of Age-related Strabismus Patients 50 Years-old and Over].

PURPOSE: To characterize age-related strabismus by long term observation. METHODS: Clinical Characteristics were collected at two institutions from patients 50 years-old and over with age-related strabismus, who complained of diplopia and were followed up longer than 2 years without surgical intervention. RESULTS: The cohort consisted of one case of near exotropia (convergence insufficiency, exotropia angle at near was 11.3 degrees), eight cases of distance esotropia (divergence insufficiency, average esotropia angle at distance was 5.8 degrees), and 15 cases of hypertropia (average hypertropia angle at distance was 3.6 degrees). In 14 patients more than one year passed from the onset of diplopia to date of visiting one of the two clinics. The strabismus angle slowly increased (0.3 per year in average; Wicoxon signed-rank test, p < 0.01). 17 patients successfully used prism incorporated glasses. Diplopia was intermittent at first and became more frequent in most cases. Hypertropic patients often showed extorsion of the lower eye. CONCLUSION: Age-related strabismus eyes slowly develop diplopia and very slowly get worse in deviation angle. Prism incorporated glasses are useful in this condition.

Age-related nonparalytic hypertropia: Clinical features.

PURPOSE: Age-related nonparalytic hypertropia (ARNH) is reported to be involved in sagging eye syndrome, where excyclotorsion is large and the lower eye is more extorted. The primary aim of this study was to describe the clinical profiles of patients with ARNH. The secondary aim was to compare cyclotorsion in patients with ARNH with that in normal individuals. METHODS: Inclusion criteria for ARNH were insidious onset of diplopia at distance after 50 years of age, nonparalytic hyperdeviation and follow-up >6 months. Objective cyclotorsion was measured as the disc-to-fovea angle (DFA) on fundus photographs obtained from two groups: 75 patients with ARNH (age, 74.1 ± 7.9 years) and 75 sex- and age-matched normal controls (73.9 ± 8.1 years). RESULTS: The hypertropia angle was 4.6 ± 2.8 prism dioptres. One patient also experienced diplopia at near-gaze. DFA in ARNH (right/left eye; 11.0 ± 4.8°/11.6 ± 3.9°) was larger than that of the control (6.6 ± 3.7°/9.2 ± 3.5°) (p < 0.0001). The DFA in the non-dominant eye (12.5 ± 4.1°) was larger than that in the dominant eye (10.2 ± 4.3°) (p = 0.0003). The lower eye did not have the larger DFA in 29 patients. CONCLUSION: The angle of hyperdeviation in patients with ARNH was small. The DFA in the ARNH group was larger than that in the normal group. The lower eye was not the eye with a larger DFA in 39% of ARNH, inconsistent with sagging eye syndrome. Decreased phoria adaptation (fusional ability) may trigger diplopia in patients with ARNH.

[Clinico-pathological study of extraocular muscles: a case of chronic progressive external ophthalmoplegia and a case of myotonic dystrophy].

BACKGROUND: A small number of patients with ocular motility disorder suffer from myodystrophic disease. Clinico-pathological reports on the extraocular muscles of such patients are rare. CASE 1: A 23-year-old woman complained of a 40 prism diopter (PD) exotropia and slight ptosis palpebrae OD. Adduction was restricted bilaterally. Chronic progressive external ophthalmoplegia was suspected. The medial rectus muscle, which was resected as a part of strabismus surgery, was examined by light-microscopy. Muscle fibers were atrophic and many ragged-red-fibers were present. Eye alignment was 8 PD exophoric at 14 months after surgery. CASE 2: A 34-year-old man suffering from myotonic dystrophy presented with a 60 PD exotropia and bilateral ptosis palpebrae. Adduction was restricted bilaterally. Exotropia and ptosis OS were corrected surgically. Microscopic examination of the medial rectus muscle revealed increased adipose and collagen tissues. The muscle fibers were significantly reduced in diameter and contained multiple nuclei. The levator palpebrae muscle showed moderate atrophic change. The patient was 12 PD exophoric one month after surgery and 25 PD exotropic 8 months after surgery, and was satisfied with the results. CONCLUSION: Whenever properly indicated surgical correction is useful in treating and diagnosing strabismus due to myodystrophy when combined with pathological examinations.

Objective excyclotorsion in age-related distance esotropia.

Age-related distance esotropia (ARDE) is thought to be caused by sagging eye syndrome. Sagging of the lateral rectus derives from the naturally occurring aging process and induces excyclotorsion of the eye. To date, no study has compared the cyclodeviation in ARDE with that in the age-matched individuals without strabismus. This study aimed to measure the objective cyclotorsion on fundus photographs of ARDE patients and compare the findings with those for normal age-matched individuals. Objective cyclotorsion was measured by determining the disc-to-fovea angle (DFA) on fundus photographs, which were obtained from two groups: 38 consecutive patients with ARDE (age, 74.1 ± 7.9 years), 76 normal age-matched controls (age, 73.9 ± 8.1 years). DFA in ARDE patients was not different from that in the control group (Welch's t-test: ARDE vs Control, right eye; 7.7° ± 2.9° vs 6.8° ± 3.9°, p = .18. Left eye; 10.0° ± 4.5° vs 9.4° ± 3.6°, p = .54. Sum of both eyes; 17.6° ± 5.8° vs 16.2° ± 4.7°, p = .21). These findings suggest sagging of the lateral rectus is not the sole cause of ARDE. Another aging-related factor, such as decreased phoria adaptation, might also be responsible for ARDE.

Objective excyclotorsion increases with aging in adults.

INTRODUCTION: It has been reported that the disc-fovea angle (DFA), a measure of objective cyclotorsion, increases with age. DFA was measured in three age groups of adults and the effects of age, sex, and laterality on DFA is reported. METHODS AND SUBJECTS: A retrospective study was performed on patients who had a glaucoma checkup or who visited for suspected cataract, who underwent fundus photography between 2013 and 2021. Patients with visual acuity <0.7, axial length >27 mm, strabismus or ocular diseases affecting fusion were excluded. DFA was measured from digital fundus photographs obtained from 249 participants comprising three age groups (group I, 44.4 ± 0.5 years, n = 58; group II, 63.7 ± 3.6 years, n = 129; group III, 81.0 ± 3.8 years, n = 62). The sum of right- and left-eye DFAs is named as total DFA. RESULTS: Dunnett's post-hoc test after ANOVA showed that the left-eye DFA and total DFA of group III were significantly larger than those of group I (p = .01 and p < .01, respectively). Total DFA of female participant (15.6 ± 4.7°, n = 168) was significantly larger than that of male participant (13.9 ± 4.3°, n = 81) (p < .01). The DFA of the left eye (8.2 ± 3.5°, n = 249) was significantly larger than that of the right eye (6.8 ± 3.3°, n = 249) (p < .001). Group III was subdivided based on eye dominance (right eye dominance, n = 36; left eye dominance, n = 13; NA, n = 13). The DFA in the nondominant eye (9.7 ± 4.6°) was significantly larger than that in the dominant eye (7.4 ± 3.7°) (p < .01). DISCUSSION: This study found a slight increase of DFA with age. Furthermore, DFA in female or DFA in the left-eye was larger than DFA in male or in the right-eye.

Influence of eye dominance on objective and subjective excyclotorsion in unilateral superior oblique muscle palsy: objective cyclotorsion measured by fundus photography.

PURPOSE: To study the effect of eye dominance on excyclotorsion in unilateral superior oblique palsy (USOP). STUDY DESIGN: Retrospective clinical study METHODS: Objective excyclotorsion was measured as the disc-to-fovea angle by fundus photography OU. Subjective excyclotorsion was determined with a major amblyoscope based on the difference in the earth vertical and subjective visual vertical. Eye dominance was determined by the hole-in-the-card method. A p-value ≤ 0.05 was considered statistically significant. SUBJECTS: Data of 24 USOP patients were retrospectively collected. The diagnosis was mainly made by the Parks 3-step method, history and the presence of characteristic excyclotorsion. When possible, orbital magnetic resonance imaging findings were obtained. RESULTS: The median angle of objective excyclotorsion in the paretic eyes was significantly larger than in the nonparetic eyes. Both median angles of objective/subjective excyclotorsion in the dominant eye were significantly smaller than those of the non-dominant eye. Patients were subdivided into two groups: group A, those whose paretic eye was the dominant eye (n = 13); group B, those whose paretic eye was the non-dominant eye (n = 11). The objective/subjective excyclotorsional angles of the paretic eye were significantly larger than of the non-paretic eye only in group B. CONCLUSION: In USOP the angle of excyclotorsion in the dominant eye is smaller than in the non-dominant eye. This may imply that the vertical sense of visual space is mainly adapted to the dominant eye, keeping the subjective vertical close to the earth vertical.

[Case of traumatic chiasmal syndrome].

BACKGROUND: Traumatic neuropathy of the optic chiasm is a rare finding which occurs after severe blunt head trauma. It is often accompanied by dysfunction of the pituitary gland and hypothalamus and called traumatic chiasmal syndrome. We report a patient with traumatic chiasmal syndrome caused by a severe traffic accident. CASE: A 25 year-old woman was referred for bitemporal visual field defects caused by a traffic accident two months before. Corrected visual acuity was 0.05 in the right eye and 1.2 in the left eye. Bilateral optic atrophy and relative afferent pupillary defect in the right eye were found. Magnetic resonance imaging revealed an enlarged optic chiasm. Computed tomography disclosed many fractures in the skull including the back wall of the sphenoid sinuses. She also suffered from diabetes insipidus and anosmia. CONCLUSION: Traumatic optic neuropathy of the optic chiasm is a rare condition which can be differentiated from neuropathy in the optic canal by considering the patterns of visual field defects and their accompanying signs.

Antirecoverin antibody in the aqueous humor of a patient with cancer-associated retinopathy.

PURPOSE: To describe a patient with cancer-associated retinopathy (CAR) in whom antirecoverin antibody was found in the aqueous humor. DESIGN: Interventional case report. METHODS: A 65-year-old man underwent resection of adenocarcinoma of the lung in June 1991 and noted deterioration of vision 10 months later. Goldmann perimetry revealed a ring-like scotoma in each eye, and the electroretinogram was nonrecordable. Aqueous humor and peripheral venous blood were collected for Western blot analysis from this patient and three other patients during surgery for age-related cataract. RESULTS: We found antirecoverin antibody within the aqueous humor and serum in the patient with CAR. In contrast, such imunoreactivities were not observed in specimens from the control patients. CONCLUSION: These observations strongly suggest that antirecoverin antibody penetrates into the aqueous humor and vitreous cavity beyond the blood-retina barrier in CAR.

Near reflex substituting for acquired horizontal gaze palsy: a case report.

BACKGROUND: Some patients with acquired horizontal gaze palsy overcome the adduction palsy by utilizing convergence. This substitution phenomenon is very rare. We report a patient with horizontal gaze palsy who was able to use convergence to compensate for the lack of adduction in the left eye. CASE: The patient was a 31-year-old woman with an arteriovenous malformation in the fourth ventricle. She suffered right gaze palsy and right abducens palsy after tumor surgery and radiation therapy. OBSERVATIONS: Three years after the vascular accident, she was found to be able to adduct the left eye, in association with the adduction of the right eye. At the same time, constriction of both pupils and globe retraction of the left eye were observed. When she shifted the gaze direction of her left eye from left to right, an 11 and 8 diopter increase of myopia in the right and left eyes, respectively, was confirmed by objective refractometry. CONCLUSIONS: The existence of convergence substituting for adduction in this patient with horizontal gaze palsy was confirmed by refraction change in addition to pupillary change.

A case of congenital oblique retraction syndrome with upshoot in adduction.

We treated a 27-year-old man who suffered from a congenital eye movement abnormality. The patient could not adduct the left eye, and showed exotropia, hypertropia and excyclotropia of the left eye. The range of abduction was also limited. The left eye showed marked upshoot on right gaze and eye globe retraction on right down gaze under conditions of right-eye viewing. The superior rectus muscle of the left eye was recessed and transposed nasally. The insertion of the superior oblique muscle was found to be defective. The upshoot and face turn improved after surgery. The globe retraction on right down gaze was no longer evident. We believe that the superior rectus muscle was innervated by an anomalous branch of the oculomotor nerve, which was originally destined to innervate the medial rectus, and that simultaneous contraction of the superior and inferior rectus muscles caused the globe retraction on right down gaze. This case also suggests the possibility that some part of the upshoot in adduction in Duane's syndrome is due to the co-contraction of the superior and medial rectus muscles due to this innervation anomaly.

[A case of Tolosa-Hunt syndrome presenting ocular neuromyotonia].

A 27-year-old woman noticed diplopia when gazing left and paresthesia of the left face and headache of the left side for 8 months. Abduction and supraduction of the left eye were moderately restricted. Hypoesthesia of the face innervated by the ophthalmic branch of the left trigeminal nerve was detected. Visual disturbance due to optic neuropathy developed 5 months later. MRI with gadolinium revealed a mass lesion extending from the left cavernous sinus to the orbital apex. Ocular neuromyotonia and corresponding diplopia were induced by sustained right gaze. Such episodes occurred almost every day on awaking in the morning. Prednisolone (60 mg/day) was given and the headache and visual disturbance ameliorated in two days. The diplopia disappeared in 4 days. The patient remains free from these symptoms after 6 months. This is the first report of ocular neuromyotonia associated with Tolosa-Hunt syndrome.

Ocular neuromyotonia with spastic lid closure.

Ocular neuromyotonia is characterized by tonic spasms of extraocular muscles evoked by eccentric gaze that induces transient strabismus and diplopia. We report the case of a 70-year-old woman who initially presented with unilateral deficits in fifth and sixth cranial nerve functions attributed to a fifth cranial nerve schwannoma. After radiation treatment, she developed neuromyotonia and synkinesis of the ipsilateral third cranial nerve. During the attacks of neuromyotonia, the left eyelids were often spastically closed, a phenomenon not previously reported. The ocular neuromyotonia regressed spontaneously within 3 years, but components of the synkinesis persisted. Ephaptic transmission in a damaged third cranial nerve may be responsible for the neuromyotonia and synkinesis. Synkinesis is a more enduring manifestation.