The distribution characteristics of strabismus surgery types in a tertiary hospital in the Central Plains region during the COVID-19 epidemic.

OBJECTIVE: This study aimed to analyze the distribution of different types of strabismus surgery in a tertiary hospital in Central China during the three-year period of the COVID-19 pandemic. METHODS: A retrospective analysis was conducted on the clinical data of strabismus patients who underwent surgery and were admitted to the Department of Strabismus and Pediatric Ophthalmology at the First Affiliated Hospital of Zhengzhou University between January 2020 and December 2022. RESULTS: A total of 3939 strabismus surgery patients were collected, including 1357 in 2020, 1451 in 2021, and 1131 in 2022. The number of surgeries decreased significantly in February 2020, August 2021, and November and December 2022. Patients aged 0-6 years accounted for 37% of the total number of strabismus surgery patientsr. The majority (60%) of all strabismus surgery patients were diagnosed with exotropia, with intermittent exotropia accounting for the highest proportion (53%). There was no statistically significant difference in the proportion of intermittent exotropia and constant exotropia during the three-year period (χ2 = 2.642, P = 0.267 and χ2 = 3.012, P = 0.221, respectively). Among patients with intermittent exotropia, insufficient convergence type was the most common form of strabismus (accounting for over 70%). Non-accommodative esotropia accounted for more than 50% of all internal strabismus cases. CONCLUSION: During the period from 2020 to 2022, the total number of strabismus surgeries in our hospital did not show significant fluctuations, but there was a noticeable decrease in the number of surgeries during months affected by the pandemic. Exotropia accounted for the highest proportion among strabismus surgery patients. Intermittent exotropia was the most common type among patients undergoing surgery for exotropia, and the most prevalent subtype was the insufficient convergence type. The age distribution of patients varied in different months, with a concentration of surgeries for strabismus patients in the 7-12 years old age group during the months of July and August each year.

[Change in the age spectrum in strabismus surgery]. / Änderung des Altersspektrums in der Strabismus-Chirurgie.

BACKGROUND: The proportion of children undergoing strabismus surgery in the total volume of eye muscle operations appears to have decreased. To verify this we analyzed the age of patients who underwent extraocular muscle (EOM) surgery. METHODS: The data of patients who underwent EOM surgery at the University Eye Hospital Giessen between 1991 and 2019 were reviewed and the numbers of operations in decadal age groups were compared to the German population in the respective period. In addition, the types of strabismus which led to surgery were evaluated. The data pool comprised > 25,000 surgeries involving > 60,000 muscles. RESULTS: In comparison to 1991, in 2019 the proportion of children aged ≤ 10 years decreased from 50.2% to 31.8%, corresponding to a relative decrease of more than one third. The proportion of patients aged > 50 years increased from 6.5% to 22.5%, i.e., by a factor > 3, while the population ≤ 10 years in 2019 was 13% smaller than in 1991 and the population aged > 50 years increased by 37%. The major reason for the decreasing proportion of children was a 53% reduction in surgery for esotropia. We found no apparent changes in the 2nd-5th decades of life. DISCUSSION AND CONCLUSION: The lower proportion of children undergoing EOM surgery appears to indicate an improvement in vision screening during the past 4 decades. The increasing proportion of older patients may result from better information on potential treatment and increased incidence of acquired strabismus with corresponding complaints. The demographic shift played a secondary role. Due to the population structure in Germany, a further increase in the demand for EOM surgery is to be expected.

The effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid ophthalmopathy.

PURPOSE: To evaluate the effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy. METHODS: This retrospective study enrolled 55 eyes of 33 patients treated in our hospital for restrictive strabismus caused by thyroid-associated ophthalmopathy. We performed muscle recession for the obviously restricted extraocular muscles, with 6 weeks of follow-up. Surgical outcomes were compared between the orbital decompression group (DG, n=15) and non-orbital decompression group (NDG, n=18). RESULTS: A total of 33 patients with Graves' ophthalmopathy who underwent rectus muscle recession surgery were included. Of these, 15 patients had undergone orbital decompression prior to strabismus surgery, and 18 had not. The two groups did not differ in terms of the preoperative horizontal or vertical ocular deviation, degree of restriction of eye movement, degree of diplopia, or mean number of muscles that underwent surgery (P>0.05). There was no significant difference in the preoperative horizontal or vertical ocular deviation, level of eye movement restriction, degree of diplopia and the success rate of the surgery (P>0.05). CONCLUSION: Rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy during the quiescent period could improve the ocular deviation and diplopia, and orbital decompression performed before strabismus surgery had no significant effect on surgical technique or outcomes of rectus muscle recession surgery.

Incidence, Risk Factors and Management of Postoperative Complications in Horizontal Strabismus Surgery.

OBJECTIVE: To report the incidence, risk factors and management of postoperative complications after horizontal strabismus surgery. DESIGN: Retrospective Cohort study. PARTICIPANTS: The study assessed 1,273 patients with 1,035 cases of exotropia and 238 cases of esotropia, with a minimum 18-month follow-up. METHODS: Retrospective review of strabismus operation patients' medical records included baseline demographics, age at surgery, pre/postoperative visual acuity, and deviation. Complications were categorized as surgical site (infection, scarring, cyst, granuloma, ischemia) and strabismus-related (recurrence, diplopia), with analysis of incidence, risk factors, and management. RESULTS: Among surgical site complications, the incidence of infection, pyogenic granuloma, and anterior segment ischemia were similar between the exotropia (0.3%, 0.3%, 0.2%) and esotropia (0.8%, 0%, 0.4%) groups (p = .221, 0.406, 0.515). In contrast, the esotropia group presented a higher risk of conjunctival inclusion cyst and conjunctival scar than the exotropia group, with incidences of 5.0% vs 2.2% and 6.3% vs 1.3%, respectively (p = .004, <0.001). Regarding strabismus complications, the incidence of early recurrence was not significant between the two groups, with 10.0% in the exotropia group and 10.5% in the esotropia group (p = .553). Older age and poor initial visual acuity were associated with early recurrence (p < .001). The esotropia group had a higher risk of persistent diplopia than the exotropia group, with incidences of 4.2% vs 2.0%, respectively (p = .003). CONCLUSION: Esotropia carries a higher risk of conjunctival inclusion cysts, conjunctival scarring, and persistent diplopia compared to the exotropia group, while both groups exhibit similar rates of early recurrence and other surgical site complications.

Frequency of Amblyopia in strabismus patients presenting to tertiary care hospital.

Objective: The rationale of study was to find the magnitude of amblyopia with reference to type of squint among the strabismus patients visiting Hayatabad Medical Complex Peshawar, Pakistan. Materials and Methods: After ethical approval, a cross sectional study was carried out in the Department of Ophthalmology, Hayatabad Medical Complex, Peshawar, Pakistan, from April 2022 to October 2022, the total number of patients included being 237. Results: Amblyopia was observed in 113 out of 160 (70.6%) cases of uniocular squint, while in alternating squint it was found to be 11 out of 77 (14.2%). Amblyopia in patients with esotropia was seen in 73.2% (107 out of 146), while 59.3% (54 out of 91) exotropia had associated amblyopia. Conclusion: Strabismus amblyopia leads to developmental arrest of vision in early critical years of life. Permanent visual loss can be avoided with comprehensive screening and detailed examination of strabismic patient.

Cataract surgery outcomes in pediatric patients with systemic comorbidities.

Purpose: The aim of the study was to evaluate the outcomes of cataract surgery in patients of the pediatric age group with systemic comorbidities. Methods: Medical records of 54 eyes (30 patients) of the pediatric age group with systemic comorbidities who had undergone cataract surgery in a tertiary-care center were reviewed. The following parameters were recorded: systemic comorbidity; toxoplasmosis, rubella, cytomegalovirus, herpes simplex, HIV (TORCH) profile, best spectacle-corrected visual acuity (BSCVA), strabismus, nystagmus, and cataract morphology. Results: Thirty patients with a mean age of 55 months (9 months-14 years) were included. On average, every child was seen by three physicians, and the mean duration between the first visit to a physician and presentation to our center was 2.23 ± 0.67 years. The various causes for delay in referral include multiple referrals due to a lack of general anesthesia services in 78% of cases, a long waiting list at the referral hospital in 35% of cases, and a lack of awareness at the primary-care physician level in 50% of cases. The mean BSCVA at presentation was 1.4 logMAR (0.3 to 3 logMAR). The most common cataract morphology was that of zonular cataract (31.48%; 17/54). Strabismus and abnormal eye movements were observed in 27.7% (15/54) and 33.3% (18/54) of eyes, respectively. Various systemic associations were periventricular leukomalacia (12/30), Down's syndrome (6/30), seizure disorder (6/30), cardiac valvular anomalies (6/30), Marfan's syndrome (4/30), hypothyroidism (4/30), rubella (3/20), cytomegalovirus (3/20), cerebral palsy (2/30), nephrotic syndrome (2/30), Type 1 diabetes mellitus (1/30), microcephaly (1/30), cryptogenic West syndrome (1/30), congenital rubella syndrome (1/30), and Tourette syndrome (1/30). The mean postoperative corrected distance visual acuity (CDVA) at 2-year follow-up improved to 1.0 logMAR (0 to 3 logMAR). No postoperative complications were reported at the final follow-up. Around 70% of the parents reported improvement in their child's psychomotor skills. Conclusion: Intellectually impaired pediatric patients with cataract should be operated upon whenever there is a presence of infrastructure, and unnecessary delay in surgery should be avoided by referring the patient to higher centers. Even though objective improvement in visual acuity was suboptimal, there was definitely an improvement in the psychomotor skills of the patients.

Strabismus and Nystagmus in Patients With Pediatric Cataracts: Study Using Insurance Claims Data.

PURPOSE: To describe the characteristics and prevalence of strabismus and nystagmus in children diagnosed with cataracts using a national insurance claims database. DESIGN: Population-based retrospective cohort study. METHODS: Patients aged <13 years diagnosed with cataracts (traumatic cataracts excluded) and enrolled continuously in their health care program for ≥5 years after their first cataract diagnosis were identified in a retrospective review of 66 million charts in Optum's de-identified Clinformatics Data Mart Database between 2003 and 2015. Patients were categorized based on age of their first diagnosed cataract, and if cataract surgery was performed. Clinical and demographic factors associated with the occurrence of strabismus and nystagmus were evaluated. RESULTS: Of 1636 children diagnosed with cataract, 434 (26.5%) and 109 (6.7%) were diagnosed with strabismus and nystagmus, respectively. Both strabismus and nystagmus were more common in those who underwent cataract surgery (P < .001) and in patients diagnosed with cataract at ≤12 months of age (P < .001). Survival analysis demonstrated that strabismus and nystagmus may be diagnosed 8 years after the initial cataract diagnosis. Cox proportional hazard regression analyses revealed strabismus was associated with cataract surgery, nystagmus, and the diagnosis with cataract at ≤12 months and cataract surgery at >12 months. CONCLUSIONS: As strabismus and nystagmus occur more frequently in children diagnosed with cataracts necessitating cataract surgery, regular long-term follow-up is crucial for these children to monitor for the development of strabismus and nystagmus.

The impact of the first peak of the COVID-19 pandemic on childhood myopia control practice patterns among ophthalmologists-an international pediatric ophthalmology and strabismus council global perspective.

BACKGROUND: The prevalence of myopia keeps increasing during the COVID-19 pandemic. We aimed to map the worldwide treatment preferences of ophthalmologists managing myopia control during the first wave of the pandemic. METHODS: An online questionnaire inquiring about pharmacological and optical treatment patterns during the first half of 2020 was sent to pediatric ophthalmology as well as general ophthalmology memberships worldwide. The results among pediatric ophthalmologists were compared to a previous study we performed before the pandemic. RESULTS: A total of 2269 respondents from 94 countries were included. Most respondents were pediatric ophthalmologists (64.6%), followed by ophthalmologists from other subspecialties (32.3%). The preferred modality for all geographical regions was a combination therapy of pharmacological and optical treatments. When evaluated independently, the pharmacological treatment was more popular than the optical treatment in most regions other than East Asia (P < 0.001). Compared to a pre-pandemic questionnaire, the participation of pediatric ophthalmologists affiliated with non-university hospitals increased. Additionally, the prevalence of respondents utilizing either any type of pharmacological treatment and those that using only evidence-based treatments increased globally. Although a decline in the use of optical treatment was evident worldwide, the use of evidence-based optical treatments increased. CONCLUSION: Ophthalmologists around the world preferred a combination therapy of pharmacological and optical treatments. More pediatric ophthalmologists treated myopia progression and preferred a better evidence-based approach to control myopia. These trends reflect a positive response and more awareness of the rising prevalence of myopia due to the increased burden of myopia imposed by the COVID-19 pandemic.

Early childhood eye diseases and perinatal risk factors: potential of record linkage between current information flows.

BACKGROUND: The aim of this study was to analyze the occurrence of specific maternal, obstetric or neonatal factors, by performing a comparison between children with refractive error, strabismus and/or amblyopia (cases) and unaffected children (controls) in the province of Trento (North-East Italy). METHODS: In 2012-2014, 14,346 children attending the second year of nursery school were assessed through the preschool orthoptic screening scheme (covering 91% of the preschool population). Record linkage was performed between the orthoptic screening database and birth records (birth confirmation certificate database) for the corresponding birth cohorts (2008-2010), to examine specific maternal factors (age, smoking, nationality/race), obstetric factors (type of delivery) and neonatal factors (gestational age, weight at birth, Apgar Score, congenital birth defects, hospitalization at birth). The correlations were investigated using univariate and multivariate analysis in accordance with the logistic regression method. RESULTS: During orthoptic screening, 6.4% of children were found to have at least one refractive error, with astigmatism being the most common condition (5.1%). 1.9% of children were found to have strabismus and 1.8% amblyopia. Multivariate logistic regression analysis showed that the risk of developing a refractive error is associated with: maternal age ≥45 years, foreign nationality, vacuum-assisted delivery and neonatal weight <1500 grams. An excessive risk of strabismus was observed in children whose mother had smoked during pregnancy (adjusted OR=1.64). CONCLUSIONS: Preschool orthoptic screening is a well-consolidated practice in the province of Trento, with adhesion values consistently over 90%. Studies of this type show the potential of record linkage between current information flows.

A longitudinal study of local stereoacuity and associated factors in schoolchildren: The Shahroud Schoolchildren Eye Cohort Study.

CLINICAL RELEVANCE: Impaired stereoacuity is seen in some children without amblyopia, strabismus, and clinically significant refractive errors. Therefore, there are probably other factors affecting stereoacuity. BACKGROUND: The aim of this work was to investigate the longitudinal changes of local stereoacuity and associated factors in schoolchildren. METHODS: The present report is a part of the Shahroud Schoolchildren Eye Cohort Study. The target population was children aged 6 to 12 years in Shahroud, Iran. The second phase of the study was conducted in 2018 by re-inviting all participants in the first phase (2015). After an initial interview, study participants underwent optometric examination and ocular biometry. Stereoacuity was evaluated using Stereo Fly Test. Exclusion criteria were functional amblyopia, strabismus, significant refractive errors, probable ocular pathology/organic amblyopia in either of the two study phases, a history of intraocular surgery or ocular trauma, and incomplete data. RESULTS: The data of 4666 children were analysed for this report, of which 53.7% were male. The mean age of the studied participants in the second phase was 12.37 ± 1.71 years. The mean stereoacuity was 42.31 (95% CI: 42.05 - 42.57) seconds of arc in the first phase, which reduced to 51.72 (95% CI: 50.79-52.65) seconds of arc in the second phase (P < 0.001). The prevalence of poor stereoacuity was 0.17% (95% CI: 0.06-0.29) in the first phase, which increased to 3.94% (95% CI: 3.34-4.54) in the second phase (P < 0.001). According to the multiple linear regression, older age in the first study phase (ß = 0.011, P < 0.001), urban residence (ß = -0.019, P = 0.006), increased spherical anisometropia (0.038, P = 0.013), and increased axial length (ß = 0.062, P = 0.003) were significantly associated with reduction of stereoacuity (in log scale) after three years. CONCLUSION: In addition to the known risk factors of amblyopia, strabismus, and significant refractive errors, other factors are also associated with stereoacuity changes in children.

Incidence of A pattern strabismus after inferior rectus recession in patients with Graves' orbitopathy: A retrospective multicentre study.

INTRODUCTION AND PURPOSE: Patients with Graves' orbitopathy (GO) may develop restricted elevation; this can lead to hypotropia, sometimes in combination with an abnormal head posture. Recession of one or both inferior rectus muscles is the first line surgery to restore eye motility in these patients. However, this may result in A pattern strabismus. This study was performed to determine the rate of occurrence of this type of incomitant strabismus and potential predictive factors. METHODS: All patients undergoing surgery on one or two inferior rectus muscles over a 10-year period were screened retrospectively for the A pattern, defined as a ≥5° difference in squint angle between the primary gaze and downgaze. The extraocular muscle thickness in patients with acquired A pattern was determined by computed tomography (CT) and compared with a control group consisting of patients randomly selected from the total cohort. RESULTS: In a total of 590 patients, surgery was performed on the inferior rectus muscle(s) during the study period; the A pattern was identified in 59 patients. Simultaneous surgery was performed on one or both medial rectus muscles in 32% of the patients. This group had significant incyclotorsion (p = 0.000) and less depression (p = 0.000) postoperatively. The mean amount of recession was 4.38 ± 1.53 mm in the A pattern group and 3.91 ± 1.37 mm in the control group (p = 0.032). The amount of depression was 50.2° ± 7.4° in the A pattern group and 57.3° ± 4.4° in the control group (p = 0.045). The inferior rectus muscle was significantly thicker in the A pattern than in the control group (p = 0.027), while there was no significant difference in the thickness of the superior oblique muscle between the two groups (p = 0.870). Of all patients with the A pattern, 47% required further surgery to achieve adequate binocular single vision. CONCLUSION: Increased preoperative inferior rectus muscle thickness and relatively limited depression could be predictors of postoperative A pattern inferior rectus recession in patients with GO. Step-by-step procedures are preferable in this surgically challenging group of patients.

Presence and development of strabismus in children with telecanthus, epicanthus and hypertelorism.

Purpose: To study the presence and development of strabismus in children with telecanthus, epicanthus, and hypertelorism. Methods: This is a prospective, longitudinal, and observational study. Sixty children aged between 6 months and 18 years with telecanthus, epicanthus, and hypertelorism in isolation or in combination were recruited. A detailed analysis of the history, determination of best corrected visual acuity, complete evaluation of strabismus, and ocular examination were carried out. The presence of telecanthus, epicanthus, and hypertelorism and associated strabismus, if any, was noted. All children were followed up for a minimum and maximum period of 12 and 18 months, respectively, to analyze the strabismus (previously present) and for detection of strabismus in those who did not have. The data were analyzed descriptively with mean and standard deviation. Chi square test and Fishers exact test were used to analyze the data between the groups. A P value less than 0.05 was considered to be statistically significant. Results: Telecanthus was the most common lid feature (55%). At baseline, ten (16.66%) children had strabismus (six: esotropia; four: exotropia). Two (3.33%) children underwent surgery. One child developed exotropia at the third follow-up (18 months). At the end of the study, 11 (18.33%) children had strabismus. No significant association was seen between lid characteristics and the type of strabismus. Conclusion: Children with telecanthus, epicanthus, and hypertelorism in isolation or in combination may or may not have associated strabismus. These features can pose difficulty in strabismus diagnosis, which mandates a careful examination, especially in younger age groups and small-angle strabismus. On the other hand, children without strabismus need longer follow-up to detect the development of strabismus and to initiate further management at the earliest.

Pattern Strabismus in a Tertiary Hospital in Southern China: A Retrospective Review.

Background and objectives: To analyze demographic and clinical features of pattern strabismus patients and assess the relationship among these clinical variables and risk factors. Materials and Methods: Medical records of pattern strabismus patients who had undergone strabismus surgery at our center between 2014 and 2019 were retrospectively reviewed. Data collected included gender, age at onset, age at surgery, refraction, Cobb angle, pre- and post-operative deviations in the primary position, up- and downgaze, angle of ocular torsion, type/amount of pattern, grade of oblique muscle function and presence/grade of binocular function. To verify the clinical significance of the Cobb angle, 666 patients who had undergone surgery within one week after ocular trauma between 2015 and 2021 were enrolled as controls. Results: Of the 8738 patients with horizontal strabismus, 905 (507 males and 398 females) had pattern strabismus, accounting for 10.36%. Among these 905 patients, 313 showed an A-pattern and 592 showed a V-pattern. The predominant subtype was V-exotropia, followed by A-exotropia, V-esotropia and A-esotropia. Over half of these patients (54.6%) manifested an A- or V-pattern in childhood. The overall mean ± SD Cobb angle was 5.03 ± 4.06° and the prevalence of thoracic scoliosis was 12.4%, both of which were higher than that observed in normal controls (4.26 ± 3.36° and 7.8%). Within A-pattern patients, 80.2% had SOOA and 81.5% an intorsion, while in V-pattern patients, 81.5% had IOOA and 73.4% an extorsion. Patients with binocular function showed decreases in all of these percent values. Only 126 (13.9%) had binocular function, while 11.8% of A-pattern and 15.1% of V-pattern patients still maintained binocular function. Pre-operative horizontal deviation was negatively correlated with binocular function (r = −0.223, p < 0.0001), while the grade of oblique muscle overaction was positively correlated with the amount of pattern (r = 0.768, p < 0.0001) and ocular torsion (r = 0.794, p < 0.0001). There were no significant correlations between the Cobb angle and any of the other clinical variables. There were 724 patients (80.0%) who had received an oblique muscle procedure and 181 (20.0%) who received horizontal rectus muscle surgery. The most commonly used procedure consisted of horizontal rectus surgery plus inferior oblique myectomy (n = 293, 32.4%), followed by isolated horizontal rectus surgery (n = 122, 13.4%). Reductions of pattern were 14.67 ± 6.93 PD in response to horizontal rectus surgery and 18.26 ± 7.49 PD following oblique muscle surgery. Post-operative deviations were less in V- versus A-pattern strabismus. Post-operative binocular function was obtained in 276 of these patients (30.5%), which represented a 16.6% increase over that of pre-operative levels. The number of patients with binocular function in V-pattern strabismus was greater than that of A-pattern strabismus (p = 0.048). Conclusions: Of patients receiving horizontal strabismus surgery, 10.36% showed pattern strabismus. In these patients, 54.6% manifested an A- or V-pattern in childhood, and V-exotropia was the most frequent subtype. Pattern strabismus patients showed a high risk for developing scoliosis. Cyclovertical muscle surgery was performed in 724 of these patients (80.0%), and horizontal rectus surgery was effective in correcting relatively small levels of patterns. Binocular function represented an important factor as being involved with affecting the occurrence and development of pattern strabismus.

Profile of infantile strabismus at a tertiary eye care center in India.

Purpose: To study the profile, risk factors, and management outcomes of infantile strabismus at a tertiary eye care center. Methods: We prospectively analyzed the data of infants (children less than 1 year of age) who presented at our institute from August 2018 to December 2019. We excluded infants who did not complete a minimum follow-up of 6 months. Detailed meticulous history based on a set of standardized questionnaires was obtained and a comprehensive ophthalmological examination of the child was performed. Data were collected regarding refractive error (astigmatism; myopia; hyperopia; anisometropia [<1.0 DS or >1.0 DS]; astigmatism [<1.0 DS or >1.0 DS]) and the type of strabismus. Results: During this period, we saw 4,773 infants, out of which 123 infants were diagnosed to have infantile-onset strabismus (hospital prevalence of 2.6%). Boys and girls were equally affected. Sixty-two patients had esotropia, 37 had exotropia, 2 had hypotropia, and 22 had pseudo strabismus. Prematurity, hypermetropia, and anisometropia had increased odds of developing esotropia, whereas delivery by cesarean section, delayed cry at birth, infantile seizures, parental consanguinity, delayed development of milestones, and myopia had increased odds of developing exotropia. Twenty-nine patients underwent a surgical correction. The mean deviation at the first visit was 42.59 ± 15.40 PD and 8.25 ± 12.70 PD at the last visit. For all patients who underwent a squint surgery, the change in ocular deviation was clinically and statistically significant (P-value <0.0001, paired t-test). Conclusion: The hospital prevalence of infantile strabismus in our cohort was found to be 2.6%. Our study suggests that esotropia is two-fold more common in our cohort as compared to exotropia. Further, our study highlights risk factors for the development of strabismus in infancy, which must be kept in mind and awareness must be created among pediatricians. Surgical correction should be considered early during the infantile period, because it may lead to promote the development of good binocular vision.

A retrospective study of strabismus surgery in a tertiary eye hospital in the Chaoshan area in China from 2014 to 2020.

BACKGROUND: To investigate the distribution pattern of strabismus surgery at an eye center in southern China. METHODS: The data of all patients who underwent strabismus surgery at the Joint Shantou International Eye Center of Shantou University /Chinese University of Hong Kong from 2014 to 2020 were retrospectively analyzed. The type of strabismus and its relationship with age and sex were analyzed, and the trend in the number of strabismus surgeries was observed. RESULTS: The data of 4640 patients included a total of 5,282 surgeries. Exotropia surgery was the most common, accounting for 54.0% of all strabismus surgeries, which tended to increase over time, but not significantly (P = 0.109). Constant exotropia was the most common exotropia, but its proportion decreased year by year. The next most common was intermittent exotropia. The percentage of surgeries for intermittent exotropia increased from 2016 to 2020. Surgery for esotropia accounted for 22.1% of all strabismus surgeries and became significantly less common from 2016 to 2020 (P < 0.01). Among patients with intermittent or constant exotropia, the proportion of patients younger than 12 years who underwent surgical intervention increased yearly, while this proportion amoung patients older 12 years old with constant exotropia decreased yearly. CONCLUSION: Among exotropia surgeries, surgery for constant exotropia was the most common but decreased in prevalence annually. Children under 12 years old were the most affected population.

Ophthalmic involvement in PHACES syndrome: prevalence, spectrum of anomalies, and outcomes.

PURPOSE: To highlight prevalence, spectrum of anomalies, and outcome of ophthalmic involvement in PHACES syndrome (posterior fossa malformations, infantile hemangiomas, arterial, cardiac, eye, and sternal anomalies). METHODS: A retrospective, noncomparative, single-institution observational case series of children with PHACES was conducted from 2000 to 2019. Data on ocular presentations, interventions and visual outcomes were collected. Primary outcome measures were the frequency and spectrum of ocular involvement. Secondary outcomes were final visual acuity, long-term ocular sequelae, and frequency of surgical interventions. RESULTS: A total of 43 infants had PHACES, of whom 29 (67%) had periocular infantile facial hemangiomas (IFH) and 6 (14%) had primary ocular anomalies that were always ipsilateral to the IFH. Five patients (12%) met ocular PHACES-specific diagnostic criteria, including optic nerve (3), retinal vascular (1) and lenticular (2) anomalies. Non-PHACES-specific abnormalities were Peters anomaly (1), persistent pupillary membranes (2), dysmorphic optic nerves (1), and iris/choroidal hemangiomas (2). IFH-related periocular abnormalities were frequent: ptosis (29), proptosis (9), strabismus (6). Surgery was required in 8 of the 29 children: (strabismus [6], entropion [2], ptosis [2], and optical iridectomy [1]), all of whom had orbital/conjunctival hemangioma (P = 0.03). Final visual acuity (follow-up, 8.7 years) ranged between 20/20 and 20/80 in 26 of 29 patients. All patients with visual acuity worse than 20/200 (3/29 [10%]) had structural anomalies. CONCLUSIONS: Two-thirds of infants with PHACES have periocular IFH causing vision compromising complications of amblyopia and strabismus. Structural ocular anomalies exist in 1 of 7 patients and are always ipsilateral to the IFH. Long-term ophthalmic monitoring and management is required, and the majority of patients obtain good visual outcomes.

Nationwide Incidence of Thyroid Eye Disease and Cumulative Incidence of Strabismus and Surgical Interventions in Denmark.

Importance: Thyroid eye disease (TED) is a serious condition that can cause proptosis and strabismus and, in rare cases, lead to blindness. Incidence data for TED and strabismus and surgical interventions after TED are sparce. Objective: To investigate the nationwide incidence of TED, strabismus, and surgical interventions associated with TED. Design, Setting, and Participants: A Danish nationwide registry-based cohort study between 2000, which marks the beginning of uniform coding for the decompression surgery nationwide, and 2018. The cohort consisted of a mean 4.3 million people aged 18 to 100 years with no prior TED diagnosis each year. Total observation time was 8.22 × 107 person-years (women, 4.18 × 107 person-years; men, 4.04 × 107 person-years). Main Outcome Measures: The annual numeric and age-standardized incidence of hospital-treated TED and cumulative incidence of strabismus, strabismus surgery, and orbital decompression surgery in patients with TED. The incidence was stratified by sex, thyroid diagnosis, and age. Results: A total of 4106 incident diagnoses of TED were identified during 19 years among 3344 women (81.4%) and 762 men (18.6%). The mean numeric annual nationwide incidence rate of TED was 5.0 per 100 000 person-years overall, 8.0 per 100 000 person-years in women, and 1.9 per 100 000 person-years in men, resulting in a 4:1 ratio of women to men with TED. The age-standardized incidence was similar. The mean (SD) age at onset was 51.3 (14.5) years. At the time of TED diagnosis, 611 patients (14.9%) were euthyroid, 477 (11.6%) were hypothyroid, and 3018 (73.5%) were hyperthyroid. In patients with TED who were euthyroid, the 4-year cumulative incidence was 41% for antithyroid medication and 13% for L-thyroxine. In patients with TED, the 4-year cumulative incidence for strabismus was 10%. The 4-year cumulative incidence of surgical interventions after TED was 8% for strabismus surgery and 5% for orbital decompression. At 4 years, strabismus surgery was more common in men (13.3%; 95% CI, 10.75-15.86) than in women (7.2%; 95% CI, 6.24-8.08), and the absolute difference was 6.1% (95% CI, 3.42-8.14; P < .001). Conclusions and Relevance: This study in Denmark provides nationwide empirical incidence of TED and strabismus and surgical interventions after TED that required inpatient or outpatient hospital treatment, and might be used for patient information and health care planning.

An epidemiologic analysis of the association between eyelid disorders and ocular motility disorders in pediatric age.

Aim of the study was to assess: (a) the prevalence and type of strabismus, ptosis and eyelid dynamic disorders features, (b) the prevalence of refractive errors, amblyopia and, (c) their association with ocular/systemic syndromes in a cohort of patients. This is a retrospective observational multicenter cohort study. Patients with coexisting ocular motility disorders, comitant and incomitant strabismus, ptosis and dynamic eyelid disorders who have never undergone surgery were enrolled throughout a 3-years a study period. 137 out of 19,089 patients were enrolled, of which 97 with uniocular and 40 with binocular disease. Isolated congenital ptosis was observed in 84 patients. A polymalformative syndrome was present in almost one third of cases, whilst among strabismus type, esotropia was slightly more prevalent. Most patients were hypermetropic. In monocular disease, myopia mainly affected older patients, who were characterized by a worse ptosis margin reflex distance and levator function, and significantly higher astigmatism. Amblyopia occurred in 67.4% of the study sub-population. Of note, in monocular disease this was mild in 25.8%, moderate in 24.2% and severe in 11.3% of cases, whilst in binocular disease it was mild in 25%, moderate in 41.7% and severe in 16.7%. All patients with coexisting eyelid and ocular motility dysfunctions in pediatric age need ophthalmologic and systemic evaluation to accurately assess amblyopia, refractive errors and systemic/ocular disorders.

Long-term ophthalmological outcomes in patients with anterior plagiocephaly managed with a fronto-orbital advancement procedure.

BACKGROUND: Anterior plagiocephaly results from early fusion of a unilateral coronal cranial suture, which affects 1/10,000 infants at birth and can be associated with ophthalmological complications. The study aimed to evaluate the frequency of oculomotor disorders and refractive errors in children with non-syndromic anterior plagiocephaly. METHODS: Patients with anterior plagiocephaly undergoing surgery using a fronto-orbital advancement technique were included in this retrospective study between 2011 and 2017. The following data were collected: cycloplegic refraction in diopters (D), best-corrected visual acuity, manifest strabismus in primary position, ocular motility, head tilt in primary position, slit-lamp and fundus examination. The refractive errors were determined by autorefraction after cycloplegia with cyclopentolate. RESULTS: Among the sixteen patients included, hyperopia >2.5D was found in 10 patients, astigmatism >1D in 10 patients and anisometropia >1D in 7 patients. Astigmatism was contralateral to the synostosis in 7 cases. In total, significant refractive errors were found in 92.9%. Amblyopia was found in 33.3% patients. Strabismus was found in 11 patients, most frequently combined horizontal and vertical, of which 4 required strabismus surgery. The most frequent vertical deviation was ipsilateral hypertropia in 54.5%. We found superior oblique muscle limitation in 3 patients. Optic disc pallor was found in 2 patients. CONCLUSION: In the years following fronto-orbital advancement for non-syndromic anterior plagiocephaly, refractive errors and oculomotor disorders are frequently encountered, mainly contralateral astigmatism and strabismus with both horizontal deviation and ispilateral hypertropia.

Prevalence of the Infantile Strabismus Complex in Premature Children With and Without Periventricular Leukomalacia.

PURPOSE: To determine whether rates of strabismus and associated visuomotor deficits differed among children with different severities of periventricular leukomalacia (PVL). DESIGN: Retrospective, case-control study. METHODS: Brain magnetic resonance images (MRI) obtained from 98 children aged ≥2 years were analyzed using a standardized scoring system: 67 of 98 had PVL (mean GA 31 weeks) and 31 of 98 did not have PVL (mean GA 29 weeks). Severity of PVL was scored as degree of damage to the posterior optic radiations and the splenium of the corpus callosum on MRI. Ophthalmologic examination data were collated to assess the prevalence of visuomotor deficits and the relationship to PVL severity (grades 1-3, mild to severe). RESULTS: Infantile strabismus was documented in 61% of children with mild, 74% with moderate, and 88% with severe PVL (esotropia: exotropia ratio 3.5:1). Associated ocular motor deficits also increased systematically with PVL severity: latent ("fusion maldevelopment") nystagmus (20%, 47%, and 40%, respectively), dissociated vertical deviation (13%, 28%, and 30%), and nasotemporal pursuit/optokinetic nystagmus asymmetry (23%, 38%, and 54%). Additionally, the prevalence of retrograde optic neuropathy increased with PVL severity (5%, 26%, and 38%). The prevalence of each of these signs was substantially lower in children who had no PVL. CONCLUSIONS: Children who suffer PVL are likely to develop the deficits of the infantile strabismus complex. The deficits tend to increase systematically as a function of PVL severity. These findings provide evidence that infantile strabismus is linked to perinatal damage to cerebral vergence and gaze pathways.