The Importance of Health Literacy in Addressing Eye Health and Eye Care Disparities.

Disparities in eye health and eye care frequently result from a lack of understanding of ocular diseases and limited use of ophthalmic health services by various populations. The purpose of this article is to describe the principle of health literacy and its central role in enhancing health, and how its absence can result in poorer health outcomes. The article evaluates the current status of health literacy in visual health and disparities that exist among populations. It also explores ways to improve health literacy as a means of reducing disparities in visual health and eye care. Advancing dissemination of health information and enhancing health literacy may help not only to reduce healthcare barriers in the underserved populations but also to lessen visual health disparities.

Titanium T-Plate as a Stabilizing Platform in the Management of Acquired Nystagmus and Oscillopsia Without a Null Zone.

The primary goal of nystagmus treatment is to improve visual function and quality of life. Current surgical interventions are limited by regression of effect, serious complications, and reliance on a null zone. Tse and colleagues in 2017 reported the use of a T-plate/suture fixation platform for globe stabilization to treat acquired nystagmus and oscillopsia without a null zone in a patient with bilateral internuclear ophthalmoplegia. However, the improvement in nystagmus was not objectively quantified. This case series reports 2 patients who underwent bilateral T-plate placement which resulted in immediate and sustained improvement of nystagmus objectively measured by videonystagmography.

Extraocular Muscle Injury in Zygomatic Implant Placement: A Case Report, Review of the Literature, and Simple Maneuver for Avoidance.

Zygomatic implants (ZIs) are used to support dental prostheses in patients with inadequate maxillary bone volume. Although the ZI success rates have been high, cases of inadvertent orbital entry during zygoma drilling have been reported, with varying severity of clinical sequelae. We report the second case treated at our institution of inadvertent orbital entry during zygoma drilling. The patient experienced partial lateral rectus muscle transection resulting in diplopia, and ultimately underwent strabismus surgery. Postoperatively, his diplopia resolved, and only a small angle esophoria persisted. A review of the literature revealed 3 other cases of extraocular muscle injury secondary to orbital entry during zygoma drilling, all of which required strabismus surgery to restore alignment. We propose placement of a metal shoehorn in the inferior fornix during zygoma drilling to protect the globe and intraorbital structures from injury in the event of orbital entry.

Zygomatic dental implant induced orbital fracture and inferior oblique trauma.

A 51-year-old female underwent four upper zygomatic dental implants (ZI) and one upper and four lower conventional implants. Immediately postoperatively, the patient had pain and diplopia upon manual elevation of the edematous eyelid. Panoramic x-ray showed a malpositioned right upper ZI, requiring removal of the right upper ZI the following day. The patient had delayed referral to ophthalmology one month later for persistent diplopia. Computed tomography scan and magnetic resonance imaging demonstrated a right inferolateral fracture with fibrosis surrounding the inferior oblique muscle. Clinical exam showed right lower eyelid retraction, right hypotropia, and inability to elevate in adduction, consistent with a right inferior oblique paresis. Surgical exploration revealed incarceration of lid and orbital tissue into the fracture. After repositioning of the prolapsed tissue, a high-density porous polyethylene implant was placed for fracture repair. The inferior fornix was reconstructed with amniotic membrane and 5-fluorouracil was injected into the scar tissue. Six months later, the patient underwent strabismus surgery with resolution of symptoms.

Systemic Amyloidosis and Extraocular Muscle Deposition.

Isolated amyloid deposition in an extraocular muscle is a rare event but can be a presenting feature of systemic amyloidosis. A 67-year-old woman with an acquired exotropia and hypertropia was found to have unilateral diffuse extraocular muscle enlargement on magnetic resonance imaging. Owing to the progressive nature of her strabismus and the negative laboratory testing for thyroid disease, she underwent an extraocular muscle biopsy that revealed amyloid deposition. Further workup demonstrated a monoclonal gammopathy consistent with systemic amyloidosis. This case demonstrates the need to consider amyloidosis in the differential diagnosis of patients presenting with an atypical acquired strabismus. We review other reports of isolated amyloid deposition in extraocular muscles and its association with systemic amyloidosis, emphasizing the importance of the ophthalmologist in the early recognition of this disease to prevent irreversible, life-threatening end organ damage.

Characteristics and Surgical Outcomes of Comitant Esotropia in an Adult Population Between 18 and 60 Years Old.

PURPOSE: To describe the clinical characteristics and surgical outcomes of adults with comitant non-accommodative esotropia. DESIGN: Retrospective case series METHODS: Retrospective review of medical records of patients 18 to 60 years old with comitant esotropia who underwent strabismus surgery at a tertiary eye care center between 2014 and 2023. The etiology of esotropia was categorized into three groups based on the disparity between near-distance angles of deviation: 1. basic esotropia (ETBA); 2. esotropia divergence insufficiency pattern (ETDI); or 3. esotropia convergence excess pattern (ETCE). The main outcome measures were strabismus characteristics and motor and sensory surgical outcomes. Surgical motor success was defined as a deviation that measured ≤ 10 prism diopters (PD). RESULTS: Of the 219 that met the inclusion criteria, most patients were female (140, 64%) and had a mean age of 36.7 ± 12.3 years (range 18-60 years). The majority were myopic (157, 72%) and reported diplopia (176/219, 80.3%). The ETCE group had the largest mean deviations at both distance (45.5 ± 11.5 PD) and near (64 ± 12.3 PD) while the ETBA group had the largest ranges at distance (31 ± 13.5 PD, range 3-90) and near (30 ± 15 PD, range 2- 85). Bilateral medial rectus recession (BMR) and unilateral recess-resect (R&R) procedures were performed with equal frequency (both 48%). Motor and sensory success were achieved more often with R&R than BMR, although only motor success was statistically significant (87.8% vs. 73.2%, p=0.0375 and 93.3% vs. 85.5%, p=0. 15 respectively). At the last encounter, 88.1% (119/135) of patients with pre-operative diplopia achieved single binocular vision. CONCLUSIONS: Regardless of the pattern of esotropia, strabismus surgery in adults with comitant non-accommodative esotropia resulted in good motor and sensory outcomes.

AAPOS Adult Strabismus Committee's Report on the Status of Adult Strabismus Telemedicine.

PURPOSE: To evaluate the utility of telemedicine in the treatment of adult patients with strabismus. METHODS: A 27-question online survey was sent to ophthalmologists of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) Adult Strabismus Committee. The questionnaire focused on the frequency of telemedicine utilization, the benefits in the diagnosis, follow-up, and treatment of adult strabismus, and barriers of current forms of remote patient visits. RESULTS: The survey was completed by 16 of 19 members of the committee. Most respondents (93.8%) reported 0 to 2 years of experience with telemedicine. Telemedicine was found to be useful for initial screening and follow-up of established patients with adult strabismus, mainly to reduce wait time for a subspecialist visit (46.7%). A successful telemedicine visit could be completed with a basic laptop (73.3%) or a camera (26.7%) or could be assisted by an orthoptist. Most participants agreed that common forms of adult strabismus (cranial nerve palsies, sagging eye syndrome, myogenic strabismus, and thyroid ophthalmopathy) could be examined via webcam. It was easier to analyze horizontal than vertical strabismus. Among the paralytic forms, sixth nerve palsy was the easiest one to assess. Latent forms of strabismus can be partially diagnosed and evaluated using telemedicine, but half of the respondents underlined the importance of in-person examinations in these cases. Sixty-nine percent believed that telemedicine could be a low-cost and time-efficient health service solution. CONCLUSIONS: Most members of the AAPOS Adult Strabismus Committee consider telemedicine to be a useful supplement to the current adult strabismus practice. [J Pediatr Ophthalmol Strabismus. 2023;60(6):386-389.].

Using the White Disk Test to Predict Fusional Potential.

INTRODUCTION: Fusional potential in patients experiencing binocular torsional diplopia may be challenging for the clinician to assess, particularly when accompanied by vertical and horizontal diplopia. OBJECTIVE: To demonstrate a clinical test that may help predict if binocular fusion can be achieved once cyclotorsion is alleviated. DESIGN: Video recording demonstrating how to perform the white disk test and retrospective chart review of patients tested with the white disk test. RESULTS: Twelve patients with binocular torsional diplopia were included. All subjects had excyclotorsion, 11 (91.7%) had combined vertical and horizontal strabismus and 1 patient (8.3%) had vertical strabismus. Eleven patients (91.7%) were able to achieve single binocular vision with the white disk test and 1 patient (8.3%) demonstrated brittle fusion. The white disk test successfully predicted postoperative fusion in 10 of 11 patients (90.9%). Eight patients (66.7%) demonstrated improved stereopsis after surgery. CONCLUSION: The white disk test was found to be very useful in predicting fusional potential in patients that experience binocular torsional diplopia.

A 2020 Update on 20/20 X 2: Diplopia after Glaucoma Surgery.

New-onset diplopia is an important complication that may occur following several types of ocular surgery, including glaucoma surgery. Surgeons should be aware of the possibility of ocular motility disturbances after glaucoma surgery, whereas strabismus experts must understand the mechanisms and the most appropriate management of these forms of strabismus. The incidence, mechanisms, characteristics and treatment of diplopia and strabismus after glaucoma surgery will be reviewed.

Characteristics of diplopia as the presenting symptom to an ocular emergency room.

The medical records of 350 patients (median age, 59 years) who presented emergently at Bascom Palmer Eye Institute from 2014 to 2019 for evaluation of diplopia were reviewed retrospectively. Diplopia was binocular in 305 cases (median duration, 5 days). Strabismus was present in 301 patients (horizontal in 49.2% of cases). The most common cause of binocular diplopia was cranial nerve palsy: of the 208 cases, 134 (64%) were microvascular. Nearly half of the neuroimaging scans obtained (102/205) were abnormal. Ten patients with abnormal scans required urgent neurosurgical evaluation.

Characteristics of diplopia in a pediatric population.

PURPOSE: To evaluate the characteristics of diplopia in children at a single tertiary eye care center. METHODS: The medical records of patients with diplopia onset at age 18 years or younger presenting during the period 2015-2018 were reviewed retrospectively. Demographic information, clinical characteristics, diagnoses, treatment, and outcome data were collected. The exact χ2 test was used to compare groups and select post hoc analyses were performed using the Fisher exact or exact χ2 tests. RESULTS: A total of 244 patients (average age, 12.2 years at presentation) were included. The most common clinical diagnoses were nonparalytic strabismus (49.2%), trauma (9.4%), and cranial nerve palsies (9%). There was no statistically significant difference in median age of diplopia onset in those with nonparalytic strabismus, cranial nerve palsies, and vision- or life-threatening conditions. There was a statistically significant difference in timing of onset of diplopia at presentation in vision- or life-threatening conditions compared to nonparalytic strabismus (P < 0.0001) and cranial nerve palsies (P = 0.01) and for neurologic symptoms in vision- or life- threatening conditions compared to nonparalytic strabismus (P = 0.032) and cranial nerve palsies (P = 0.0051). In patients with more than one neurologic symptom, the majority (58.3%) had a vision- or life-threatening condition. Initial interventions included observation (28.7%), prisms (18.4%), updating refractive correction (14.3%), and strabismus surgery (11.1%). In patients with follow-up data, 5.3% had resolution of diplopia prior to their clinic visit, and 46.6% had resolution after initial intervention. CONCLUSIONS: In our study cohort, most children who presented with diplopia had nonemergent conditions. In those with life-threatening conditions, diplopia tended to have an acute onset and associated neurologic signs and visual symptoms.

Ocular manifestations of Beckwith-Wiedemann syndrome.

Beckwith-Wiedemann syndrome (BWS; OMIM #130650) is a pediatric overgrowth disorder with few known ocular manifestations. We retrospectively reviewed the medical records of patients with BWS evaluated at Bascom Palmer Eye Institute over a 10-year period and identified 5 patients, of whom 4 presented with ocular misalignment and 1 with eye rubbing. Three patients were noted to have strabismus, and 1 patient manifested with significant astigmatism. No patients received surgical intervention.

Surgical treatment of strabismus in thyroid eye disease: characteristics, dose-response, and outcomes.

PURPOSE: To describe the surgical management, dose-response, and postoperative outcomes of strabismus surgery in patients with thyroid eye disease. METHODS: The medical records of patients operated on between 2014 and 2018 were reviewed retrospectively. Patient characteristics and surgical data were collected. Motor success was defined as vertical deviation of ≤5Δ and horizontal deviation of ≤10Δ; sensory success, as no diplopia in primary gaze. RESULTS: A total of 76 patients (mean age, 62.2 ± 12.9 years; 50 females) underwent 87 surgeries, most commonly unilateral inferior rectus recession (unilateral IR, 48%) and bilateral medial rectus recession (bilateral MR, 23%). Motor success was achieved in 69% and sensory success in 58%. For unilateral IR surgery, the dose-responses were 3.25Δ/mm (SE = 0.616; ß = 0.650; P < 0.001) at distance and 2.48Δ/mm (SE = 0.752; ß = 0.472; P = 0.002) at near; for bilateral MR surgery, 3.93Δ/mm (SE = 0.997; ß = 0.680; P = 0.001) at distance and 5.05Δ/mm (SE = 1.374; ß = 0.655; P = 0.002) at near. Median (Q1, Q3) postoperative drift was toward overcorrection for both procedures (unilateral IR, -2Δ [-8, 0] at distance and -2Δ [-7, 0] at near; bilateral MR, -2Δ [-8, 2] at distance and -2Δ [-10, 0] at near). Sex, age, duration of strabismus, prior orbital decompression, and concurrent vertical and horizontal procedures were not associated with dose-response or postoperative drift. CONCLUSIONS: Concurrent vertical and horizontal surgery did not affect the motor success rate, dose-response, or postoperative drift. Although unilateral IR surgery had a larger dose-response at distance, bilateral MR surgery had a larger dose-response at near. Most procedures tended to have a postoperative drift toward overcorrection.

Extraocular muscle insertion shift after disinsertion during strabismus surgery.

PURPOSE: To quantify the amount of insertion shift after disinsertion of the rectus muscles and identify factors that may influence the shift. METHODS: Patients who underwent rectus muscle surgery between November 2018 and April 2019 were included. During surgery, the limbal-insertion distance (LID) distance was measured in millimeters with calipers from the limbus to the center of the insertion at the anterior border of the rectus muscle prior to and after disinsertion. The primary outcome was the shift of the rectus muscle insertion after disinsertion. This was calculated by subtracting the LID after disinsertion from the LID before disinsertion. The secondary outcome was the identification of preoperative and intraoperative factors that influenced insertion shift. Randomization was performed to select one rectus muscle per patient. Patients with a history of prior scleral buckle procedure, glaucoma drainage device, orbital wall fracture and strabismus surgery in the same rectus muscle were excluded. RESULTS: 110 patients were included. The median (Q1, Q3) LID before disinsertion was shortest for the medial rectus muscle [5.0 (4.5, 6.0)], followed by lateral rectus muscle [6.0 (6.0, 7.0)] and inferior rectus muscle [6.0 (5.5, 7.0)]. The overall median (Q1, Q3) insertion shift was 1.0 (0.8, 1.0) mm (p < .001), which did not significantly differ between each rectus muscle subgroup (p = .158). Factors that influenced the amount of shift were moderate to severe restriction on forced duction testing (FDT) (B = 0.320, SE = 0.105, p = .003) and longer LID before disinsertion (B = 0.172, SE = 0.036, p < .001). CONCLUSIONS: We found a significant anterior insertion shift after disinsertion of rectus muscles. Moderate to severe restriction on FDT and longer LID before disinsertion can result in larger insertion shifts.

A novel test for predicting fusional potential in patients with torsional diplopia.

We introduce the novel "white disk" test to evaluate fusional potential in patients with torsional diplopia. In this test, a white disk is presented on a black background in a darkened room to eliminate perception of torsion. Horizontal and vertical misalignment is neutralized with prisms when necessary. The absence of diplopia on the white disk test is used to establish fusional ability. Nine patients with torsional diplopia were assessed using this test. All had excyclotorsion (mean, 9.9° ± 4.2°; range, 5°-15°) and could achieve single binocular vision on testing. Postoperatively, 9 patients reported no torsional diplopia in the preferred gaze position, with a mean excyclotorsion of 0.4° ± 2.8° (range, -5° to 4°). The test appeared to predict fusional potential in all patients.

X-Linked Retinoschisis and a Coats-Like Response in the Setting of Retinopathy of Prematurity.

PURPOSE: This case report describes a unique case of a young patient with retinopathy of prematurity (ROP), a unilateral Coats-like response, and X-linked retinoschisis (XLRS). METHODS: A 9-year-old boy with a history of regressed ROP presented with a unilateral Coats-like response, subretinal exudation, and XLRS. Examination and imaging findings demonstrated a highly unique combination of bilateral retinoschisis and a dramatic unilateral Coats-like response with a large schisis cavity. RESULTS: Treatment with laser photocoagulation and anti-VEGF therapy led to resolution of the subretinal exudative changes. CONCLUSIONS: This is the first published description to our knowledge of a patient with a Coats-like response, XLRS, and a history of regressed ROP with resolution after treatment.

Don't Miss This! Red Flags in the Pediatric Eye Exam: Blurred Disc Margins.

Evaluating a patient with blurred optic disc margins, particularly a child, and establishing a diagnosis can be a demanding task. We aim to review the differential diagnosis of blurred disc margins, identify the clinical characteristics of a swollen optic disc, discuss imaging modalities used in the evaluation of the optic nerve head as tools for formulating a diagnosis, and identify red flags that may indicate a serious disorder.