Medial Rectus Disinsertion for the Management of Large-Angle Sensory Esotropia.

Background and Objectives: The aim of the report is to report the outcomes of the medial rectus (MR) disinsertion procedure for the management of large-angle esotropia (ET) patients. Materials and Methods: This is a retrospective case series of patients with large-angle ET who underwent an MR disinsertion procedure between March 2012 to April 2022. The procedure happened accidentally during muscle surgery. The demographic and clinical data, including sex, age, visual acuity, pre- and postoperative angle of strabismus, duction limitations, results of intraoperative forced duction tests, and follow-up duration were collected from medical records. Results: Five patients were enrolled in this study. The mean age was 62.2 ± 9.8 years, and the mean follow-up was 24.8 ± 8.7 months. The ET at the primary position of gaze was 92.0 ± 17.9 prism diopters (PD) before MR disinsertion and 38.0 ± 29.5 PD after MR disinsertion only. Abduction deficiency was -4 before after MR disinsertion, which improved to -1 at the last follow-up. Conclusions: The results of MR disinsertion were not as frustrating as anticipated. MR disinsertion may be considered in patients with large-angle sensory ET who refuse surgery on the opposite eye.

Congenital abnormalities of the retinal vasculature in neurofibromatosis type I.

The aim of this cross-sectional study was to investigate congenital abnormalities of the retinal vasculature (CARVs) in patients with neurofibromatosis type I (NF-1). Forty-eight patients (96 eyes) with NF-1 diagnosed according to the National Institutes of Health (NIH) criteria and 48 healthy controls were included in this study. Standard fundus photographs were obtained for each subject to evaluate the presence and frequency of CARVs. The sensitivity, specificity, and diagnostic accuracy of different cut-off numbers of CARVs were compared with those of the NIH criteria. Forty-four (91.7%) patients in the NF-1 group demonstrated either supranumeraty optic disc vessels or triple branching of the retinal vasculature, and 22 patients (45.8%) demonstrated both findings. The frequencies of these two CARVs were significantly different between the two groups (p < 0.00001). A cut-off value of either one for supranumerary optic disc vessels or triple branching showed the highest accuracy along with sensitivity and specificity of 91.7% and 87.5%. CARVs such as supranumerary optic disc vessels or triple branching were frequently observed in NF-1 patients, and their occurrence was unrelated to the age of patients. Thus, these CARVs could be added as new ophthalmologic manifestions for NF-1 and may potentially enable early diagnosis of NF-1.

Heimann-Bielschowsky phenomenon and hypotropic DVD in case of monocular vision loss: a case report.

BACKGROUND: The Heimann-Bielschowsky phenomenon (HBP) is an underrecognized condition characterized by slow, pendular, vertical oscillations of the eye accompanying monocular vision loss. Hypotropic dissociated vertical deviation (DVD) is another rare condition induced by asymmetric visual input. This report documents a rare case of HBP with hypotropic DVD. CASE PRESENTATION: This report describes a case of a 58-year-old woman with HBP and hypotropic DVD, having suffered monocular vision loss in the left eye due to blunt trauma at the age of 10. Preoperatively, she was orthophoric at near fixation and demonstrated an intermittent, slow hypotropia of the left eye upon distance fixation that never rose above the midline. She underwent a 7 mm recession of the inferior rectus muscle in the left eye. After surgery, intermittent, downward drifts became constant vertical oscillations at both distance and near fixation. CONCLUSIONS: This case describes the clinical manifestation of an eye movement disorder related to prolonged monocular vision loss.

Surgical Responses and Outcomes of Bilateral Medial Rectus Recession in Esotropia With Spinocerebellar Ataxia.

PURPOSE: To evaluate the surgical responses and outcomes of bilateral medial rectus (BMR) recession in esotropic patients with spinocerebellar ataxia (SCA) and to compare the results with normal controls. METHODS: The medical records of patients with SCA who underwent strabismus surgery for esotropia between 2006 and 2015 were reviewed retrospectively. Five esotropic patients with SCA (SCA group) and 10 esotropic patients without neurologic disorders (control group) who underwent BMR recession were included. Success rates, surgical responses, and the amount of preoperative and postoperative distance-near disparity were evaluated and compared between the groups. RESULTS: The mean preoperative esodeviation was not different between the SCA and control groups (20 vs 17.3 prism diopters [PD], P = .214). However, patients with SCA showed significant undercorrection compared with controls 1 week postoperatively (4.8 vs 1.0 PD, P = .048) and at the final follow-up (6.8 vs 1.8 PD, P = .032). The surgical success rates for the SCA and control groups were 40% and 80%, respectively (P = .095). Patients with SCA demonstrated a significantly reduced surgical response compared with controls (3.15 vs 3.87 PD/mm, P = .004), and a greater amount of postoperative distance-near disparity than controls (8.0 vs 1.1 PD, P = .001). CONCLUSIONS: A significant undercorrection was observed following BMR recession in esotropic patients with SCA. Accordingly, the authors recommend a slight overcorrection of 5 to 10 PD or adding a slanting procedure when planning strabismus surgery for this distinct group of patients. [J Pediatr Ophthalmol Strabismus. 2019;56(4):266-270.].

Vertical rectus muscle recession versus combined vertical and horizontal rectus muscle recession in patients with thyroid eye disease and hypotropia.

PURPOSE: To compare the postoperative vertical drift in patients with thyroid eye disease (TED) with hypotropia who underwent vertical rectus recession alone versus vertical rectus recession combined with horizontal rectus recession. METHODS: The medical records of patients with TED who underwent strabismus surgery for hypotropia between 2006 and 2015 were reviewed retrospectively. Patients were divided into two groups: group 1 underwent vertical rectus recession only; group 2 underwent vertical rectus recession plus horizontal rectus recession. Data collection included pre- and postoperative deviation measurements and amount of surgical recession performed. The amount of postoperative vertical drift between groups was compared. RESULTS: Of 67 patients who underwent surgery during the study period, 18 met inclusion criteria, 9 in each group. Mean postoperative hypotropia was 24.2Δ in group 1 and 24.5Δ in group 2 (P = 0.82). Mean vertical deviations were 0.3Δ and -2.2Δ (P = 0.134) on postoperative day 1; -0.9Δ and -8.0Δ (P = 0.043) at final follow-up for groups 1 and 2. Mean postoperative vertical drift toward hypertropia was 1.2Δ in group 1 and 6.8Δ in group 2 (P = 0.048). The surgical success rate for group 1 was superior to that for group 2 (89% vs 67% [P = 0.024]). CONCLUSIONS: There was a significantly larger postoperative vertical drift in TED patients with hypotropia who had combined vertical rectus and horizontal rectus recessions compared with those who underwent vertical rectus recession alone.

Cryopreserved rabbit amniotic membrane alleviated inflammatory response and fibrosis following experimental strabismus surgery in rabbits.

We evaluate the ability of cryopreserved rabbit amniotic membrane (AM) transplantation to reduce postoperative inflammation and the extent of fibrosis following experimental strabismus surgery. Ten white rabbits underwent bilateral superior rectus (SR) muscle resection. In the left eye, the resected SR muscle was wrapped with cryopreserved rabbit AM. The right eye underwent SR resection only and served as a control. The eyes were enucleated 4 weeks after strabismus surgery. The degree of postoperative inflammatory infiltration, the extent of fibrosis, and profile of the relative expression of inflammatory mediators in the SR muscle were evaluated and compared between the two groups by histological analysis and real-time polymerase chain reaction (PCR). There were statistically meaningful differences in the degree of postoperative inflammatory infiltration and extent of fibrosis between the eyes treated with cryopreserved rabbit AM after SR resection and those underwent SR resection only. A significant decrease in the expression of inflammatory cytokines [interleukin (IL)-12a, IL-12b, IL-17f, and tumor necrosis factor- alpha (TNF-α)], and a markedly increased expression of anti-inflammatory cytokines (transforming growth factor-beta-1(TGFß-1) and IL-10) were observed in the eyes treated with cryopreserved rabbit AM. In this study, we demonstrate that cryopreserved rabbit AM is effective in reducing postoperative inflammation and extent of fibrosis in a rabbit model of strabismus surgery. Our results imply that cryopreserved AM allograft has anti-inflammatory and anti-scarring properties that can prevent postoperative adhesions following strabismus surgery.

Clinical Analysis of Ocular Parameters Contributing to Intraoperative Pain during Standard Phacoemulsification.

Purpose. To study the correlation between ocular parameters and subjective pain that patients perceived during phacoemulsification. Methods. Medical records of 142 patients who underwent standard phacoemulsification under topical anesthesia between March and August 2016 were retrospectively reviewed. The pain during phacoemulsification and 1 h after surgery was assessed and compared using a visual analog scale. In addition, demographic data, preoperative biometric parameters, and intraoperative surgical parameters were recorded. Results. Mean age of patients was 67.49 ± 12.50 years. The mean pain score was 2.26 ± 0.85 during phacoemulsification and 0.40 ± 0.69 postoperatively. Intraoperative pain was significantly associated with higher preoperative intraocular pressure (ß = 0.220, P = 0.016), greater anterior chamber depth (ß = 0.210, P = 0.028), and greater axial length (ß = 0.181, P = 0.043). Conclusions. To reduce the subjective pain when patients have high preoperative intraocular pressure, large anterior chamber depth, or great axial length, supplementary procedures may be required.

Comparison of Astigmatism Induced by Combined Inferior Oblique Anterior Transposition Procedure and Lateral Rectus Recession Alone.

PURPOSE: The purpose of this study is to compare the magnitude and axis of astigmatism induced by a combined inferior oblique (IO) anterior transposition procedure with lateral rectus (LR) recession versus LR recession alone. METHODS: Forty-six patients were retrospectively analyzed. The subjects were divided into two groups: those having concurrent inferior oblique muscle overaction (IOOA) and intermittent exotropia (group 1, 20 patients) and those having only intermittent exotropia as a control (group 2, 26 patients). Group 1 underwent combined anterior transposition of IO with LR recession and group 2 underwent LR recession alone. Induced astigmatism was defined as the difference between preoperative and postoperative astigmatism using double-angle vector analysis. Cylinder power, axis of induced astigmatism, and spherical equivalent were analyzed at 1 week, 1 month, and 3 months after surgery. RESULTS: Larger changes in the axis of induced astigmatism were observed in group 1, with 4.5° incyclotorsion, than in group 2 at 1 week after surgery (axis, 84.5° vs. 91°; p < 0.001). However, there was no statistically significant inter-group difference thereafter. Relaxation and rapid regression in the incyclotorsion of induced astigmatism were observed over-time. Spherical equivalent significantly decreased postoperatively at 1 month in both groups, indicating a myopic shift (p = 0.011 for group 1 and p = 0.019 for group 2) but did not show significant differences at 3 months after surgery (p = 0.107 for group 1 and p = 0.760 for group 2). CONCLUSIONS: Combined IO anterior transposition procedures caused an increased change in the axis of induced astigmatism, including temporary incyclotorsion, during the first week after surgery. However, this significant difference was not maintained thereafter. Thus, combined IO surgery with LR recession does not seem to produce a sustained astigmatic change, which can be a potential risk factor of postoperative amblyopia or diplopia compared with LR recession alone.

Pathological Involvement of Astrocyte-Derived Lipocalin-2 in the Demyelinating Optic Neuritis.

PURPOSE: The current study was done to determine the role of lipocalin-2 (LCN2) in the pathogenesis of demyelinating optic neuritis using an experimental autoimmune optic neuritis (EAON) model. METHODS: The EAON was induced by subcutaneous immunization with an emulsified mixture of myelin oligodendrocyte glycoprotein (MOG35-55) peptide in mice. The LCN2 expression was examined in the optic nerve after MOG peptide injection. Degree of demyelination, inflammatory infiltration, glial activation, and expression profile of inflammatory mediators in the optic nerve were compared between LCN2 knockout (KO) animals and wild-type littermates by histological analysis and real-time PCR following EAON induction. Plasma levels of LCN2 in patients with optic neuritis were measured by ELISA. RESULTS: The expression of LCN2 was notably increased in the optic nerve after EAON induction. Expression of LCN2 was colocalized with reactive astrocytes. A significant reduction of demyelination, inflammatory infiltration, and gliosis was demonstrated in the optic nerve of LCN2 KO mice. The LCN2 KO mice also showed markedly reduced gene expression associated with the M1-polarized glia phenotype and toll-like receptor signaling in the optic nerve. The LCN2 levels in plasma were significantly higher in optic neuritis patients (71.6 ± 10.6 ng/mL) compared to healthy controls (37.4 ± 9.1 ng/mL, P = 0.0284). CONCLUSIONS: In this study, we demonstrated a significant induction of LCN2 expression in astrocytes of the optic nerve following EAON induction. Our results imply that astrocyte-derived LCN2 may have a pivotal role in the development of demyelinating optic neuritis, and LCN2 can be a therapeutic target to alleviate immune and inflammatory damage in the optic nerve.

Dried human amniotic membrane does not alleviate inflammation and fibrosis in experimental strabismus surgery.

Purpose. The purpose of this study was to evaluate the efficacy of dried human amniotic membrane (AM) in reducing the postoperative inflammatory response and scarring after strabismus surgery. Methods. The inflammatory response at the extraocular muscle reattachment site was analyzed after superior rectus (SR) resection in 12 rabbits. Dried human AM (Ambiodry2) was applied between the resected SR muscle plane and Tenon's capsule of the left eyes of rabbits. As a control, the right eyes of rabbits underwent SR resection only. The surgeon randomly ordered which eye gets operated first during the experiment. Two weeks later, enucleation was performed. Six sagittal sections were made for each eye at the insertion of the SR muscle. The grade of postoperative inflammation and the presence of fibrosis were evaluated in histological examinations. Results. There was no statistically significant difference in the intensity of inflammation and fibrous proliferation between the eyes treated with dried human AM after SR resection and those treated with SR resection only. Conclusions. The use of dried human AM was not effective in controlling the postoperative inflammation and scarring in rabbit eyes after extraocular muscle surgery. However, this may be due to the devitalized dry preparation of human AM (Ambiodry2), which may have lost the expected anti-inflammatory and anti-scarring properties, and further studies on humans may be necessary.

Superciliary keyhole surgery for unruptured posterior communicating artery aneurysms with oculomotor nerve palsy: maximizing symptomatic resolution and minimizing surgical invasiveness.

OBJECT: For oculomotor nerve palsy (ONP) induced by unruptured posterior communicating artery (PCoA) aneurysms, the authors performed surgical clipping via a superciliary keyhole approach as an optimal treatment modality with high efficiency and low invasiveness. In this study, they then evaluated the technical feasibility, safety, clinical outcomes, including recovery from ONP as well as cosmetic results, and durability of the procedure. METHODS: Thirteen patients presenting with complete (7 patients) or incomplete (6 patients) ONP underwent surgery via a superciliary approach. The operative video record was used to evaluate the technical feasibility, neurological examinations and CT were performed to analyze the safety of the treatment, and neuroophthalmological examinations and 3D CT angiography were undertaken to determine the effectiveness and durability of the treatment. RESULTS: In all cases, the aneurysms were successfully clipped using a 3.5-cm eyebrow incision and supraorbital minicraniotomy. The mean operative time was 108 ± 24 minutes. Twelve (92.3%) of the 13 patients showed complete resolution of the ONP. All 6 patients (100%) with incomplete ONP recovered completely within 1-2 months after surgery, whereas 6 (85.7%) of the 7 patients with complete ONP recovered completely within 1-6 months after surgery. Cosmetic results for the operative wounds were excellent without frontalis palsy. The durability of the treatment was ascertained based on 3D CT angiograms obtained 1 year after surgery. CONCLUSIONS: Surgical clipping via a superciliary keyhole approach can be an optimal treatment modality for PCoA aneurysms inducing ONP because it is effective, safe, and durable.

Comparison of magnitude of astigmatism induced by lateral rectus recession.

PURPOSE: To study the relationship between the amount of surgical recession with magnitude and axis of induced astigmatism. METHODS: From March 2003 to April 2007, 62 patients with intermittent exotropia who had undergone unilateral or bilateral lateral rectus recession were identified retrospectively. The subjects were divided into two groups: group 1 (34 eyes, 34 patients) with a lateral rectus recession < or = 9.5 mm and group 2 (56 eyes, 28 patients) with a recession < or = 8 mm. Induced astigmatism was defined as the difference between preoperative and postoperative astigmatism, which was calculated using double-angle vector analysis. Cylinder power and axis of induced astigmatism were analyzed at 1 week, 1 month, and 3 months after surgery. RESULTS: Larger changes in induced astigmatism were found in group 1 than in group 2 at 1 week after recession (0.8 D cylinder, axis 91 degrees vs. 0.3 D cylinder, axis 88 degrees, Student's t-test, p < 0.01). There was a statistically meaningful correlation between the amount of recession and the cylinder power of induced astigmatism at 1 week after recession (Pearson correlation coefficient r = 0.27, p < 0.01). However, this significant difference between the two groups was not maintained thereafter. Relaxation of astigmatism was observed toward the preoperative value over time in both groups; however, there was a statistically significant difference in the cylinder power of induced astigmatism compared with that of preoperative astigmatism in both groups until the 3-month follow-up (p < 0.01). CONCLUSIONS: The larger recessions had more induced astigmatism during the first week after surgery. However, there was no statistically significant difference in the magnitude of induced astigmatism thereafter between the two groups. Large lateral rectus recession does not seem to produce a sustained astigmatic change compared with moderate recession.

Comparison of the stability of postoperative alignment in sensory exotropia: adjustable versus non-adjustable surgery.

PURPOSE: To compare the success rates and stabilities of postoperative alignment between adjustable and the non-adjustable surgeries in the treatment of sensory exotropia. METHODS: A retrospective analysis was performed on all patients with sensory exotropia who had undergone unilateral lateral rectus recession and medial rectus resection (R&R) between January 1998 and August 2005. Thirty-four patients underwent conventional R&R, and 20 patients underwent R&R with adjustable suture of the lateral rectus. The surgical results between the two groups were analyzed with regard to the preoperative and post-operative deviation angles and the postoperative drift. The postoperative deviation angle was measured on postoperative day 1 as well as at two weeks, three months, six months and the final visit after surgery. RESULTS: There were no statistically significant differences in the mean preoperative and postoperative deviation angles between the two groups. In 30 (88%) patients in the non-adjustable group and 15 (75%) patients in the adjustable group, postoperative deviation was less than 15 prism diopters (PD) at the three month follow-up. There was no significant difference in the mean postoperative drift between the two groups. CONCLUSIONS: Strabismus surgery with adjustable sutures did not show a significantly better result than surgery without adjustable sutures in the treatment of sensory exotropia. Considering the amount of postoperative exodrift in both groups, we postulate that the immediate ocular alignment after surgery for sensory exotropia should be orthophoric or 5-6 PD of esodeviation.

The effect of unilateral medial rectus muscle resection in patients with recurrent exotropia.

PURPOSE: To investigate the effect of unilateral medial rectus muscle resection for recurrent exotropia after bilateral lateral rectus muscle recession for intermittent exotropia METHODS: A retrospective analysis was made of thirtypatients who underwent unilateral medial rectus resection for recurrent exotropia. All had prior bilateral lateral rectus recession for intermittent exotropia. Data were collected for age, the preoperative deviation, the postoperative deviation at 2 weeks, 3 months, 6 months and the last visit, and the amount of medial rectus resection performed. RESULTS: The average preoperative deviation was 27.0+/-3.6 PD. After unilateral medial rectus resection, average deviation at distance was 2.8 PD at postoperative 2 weeks, 4.5 PD at 3 months, 5.1 PD at 6 months and 5.8 PD at last visit. The average deviation corrected per millimeter of medial rectus resection was 3.53+/-0.17 PD/mm. CONCLUSIONS: Considering that deviation angles of recurrent exotropia is smaller than those of primary surgery and the possibility of saving the other medial rectus muscle, unilateral rectus muscle resection could be effective surgical method for recurrent exotropia.

Reduction of deviation angle during occlusion therapy: in partially accommodative esotropia with moderate amblyopia.

PURPOSE: To evaluate changes in ocular alignment in partially accommodative esotropic children age ranged from 3 to 8 years during occlusion therapy for amblyopia. METHODS: Angle measurements of twenty-two partially accommodative esotropic patients with moderate amblyopia were evaluated before and at 2 years after occlusion therapy. RESULTS: Mean deviation angle with glasses at the start of occlusion treatment was 19.45+/-5.97 PD and decreased to 12.14+/-12.96 PD at 2 years after occlusion therapy (p<0.01). After occlusion therapy, 9 (41%) cases were indications of surgery for residual deviation but if we had planned surgery before occlusion treatment, 18 (82%) of patients would have had surgery. There was a statistical relationship between increase of visual acuity ratio and decrease of deviation angle (r=-0.479, p=0.024). CONCLUSIONS: There was a significant reduction of deviation angle of partially accommodative esotropic patients at 2 years after occlusion therapy. Our results suggest that occlusion therapy has an influence on ocular alignment in partially accommodative esotropic patients with amblyopia.