Isolated Superior Rectus Muscle Hematoma Following Blunt Orbital Trauma.

Isolated ocular muscle hematoma due to blunt trauma is very rare. In this study, a 15-year-old patient presented with an isolated superior rectus hematoma due to an orbital hit from a cellular phone. He was treated with oral corticosteroids alone. Marked improvement in symptoms and eye movements was observed.

Evaluating distance stereoacuity in children 4-17 years of age with a novel digital application.

Distance stereoacuity measurement enables the evaluation and management of binocular vision disorders. Here, we compare the results obtained using standard tests for distance stereoacuity measurement with the novel STab test. We tested 87 children (4-17 years of age) using different tests for the quantification of stereopsis at distance: Distance Randot Stereotest (DRS), M&S random dots (M&S), and STab. A strong correlation was demonstrated between M&S-DRS (0.8), M&S-STab (0.81), DRS-STab (0.85) (all P < 0.0001). The limit of agreement between M&S and DRS was 0.45; between M&S and STab, 0.47; and between DRS and STab, 0.38. Our results suggest that all three methods can be used interchangeably.

Assessment of long-term visual outcomes in aphakic children wearing scleral contact lenses.

BACKGROUND: Timely management of aphakic children is critical for the rehabilitation of adequate visual gain. This study aims to evaluate the long-term efficacy of scleral contact lenses in terms of visual outcomes, complications, and compliance in aphakic children. METHODS: Retrospective data review of children with congenital or acquired cataract, or subluxated crystalline lenses, who underwent lensectomy from 2004 to 2018 and who used scleral contact lenses for refractive correction. Collected data from the follow up period included recorded aphakic refraction and visual acuity, complications following scleral contact lens wear documented in the clinic and ophthalmic emergency room and compliance to lens wear according to parental feedback on every visit in the clinic. RESULTS: 76% of cases, with final best corrected visual acuity (BCVA) of 20/40 or better achieved in seventeen eyes (34%). The rate of amblyopia was 50%. Strabismus developed in 56% of children, and those had less favourable visual outcomes (0.43 ± 0.4 LogMAR without strabismus and 0.8 ± 0.5 LogMAR with strabismus, p = 0.015). No corneal infections were documented during the follow up. Main adverse effect on the ocular surface was superficial punctate keratopathy (n = 16). Compliance was good in 48 children (96%)- except for two cases, the scleral lenses were tolerated well by all children. CONCLUSION: Scleral contact lenses are an effective means of visual rehabilitation in aphakic children after lensectomy and may be used long-term with good compliance of wear, excellent visual outcomes, and tolerable adverse events.

The dynamic optotype (Dyop): a novel visual acuity test for use in children.

PURPOSE: To evaluate the "dynamic optotype" (Dyop), a simple visual acuity test based on a dynamic target that requires minimal knowledge of symbols and letters. METHODS: A total of 160 consecutive, systemically healthy children, 4-17 years of age were prospectively recruited from the Pediatric Ophthalmology Unit of Meir Medical Center. Children were tested with the Dyop visual acuity test and the Early Treatment Diabetic Retinopathy Study (ETDRS) Lea numbers chart. The results of both tests were compared. The eye with the poorest acuity was tested with the new Dyop eye chart and the Lea numbers chart. The order of the testing was reversed between children. The logMAR visual acuity scores for each eye chart were compared. RESULTS: We found a strong linear correlation (r = 0.88) between visual acuity measures. The mean difference in visual acuity was -0.01 (95% CI, -0.02 to 0.01). The 95% limits of agreement were ±1.2 lines. The logMAR equivalent mean difference was about less than 1 letter. The Dyop test underestimated visual acuity relative to the Lea numbers chart. CONCLUSIONS: The results of this study support the Dyop eye chart as a valid measure of visual acuity in children 4-17 years of age, with visual acuity ranging from 20/16 to 20/200.

Nonsurgical management of congenital eyelid malpositions using hyaluronic Acid gel.

PURPOSE: To report our preliminary experience using hyaluronic acid gel fillers as a nonsurgical alternative in the management of congenital eyelid malpositions. METHODS: In this retrospective interventional case series, 5 patients (10 eyes) with congenital eyelid malpositions, including eyelid retraction, ectropion, euryblepharon, epiblepharon, and abnormalities associated with a shallow orbit, with resultant lagophthalmos and/or keratopathy and tearing were evaluated before and after injection with hyaluronic acid gel (Restylane) in the pretarsal and/or septal regions of the affected eyelid(s). Pretreatment, posttreatment, and follow-up photographs were analyzed for eyelid position and degree of eyelid closure and lagophthalmos, and slit-lamp evaluation of the degree of keratopathy. RESULTS: All 5 patients demonstrated significant improvement of eyelid position and degree of keratopathy. The mean improvement in lagophthalmos was 4.5 mm (range, 2-7 mm). The average volume of hyaluronic acid gel used was 0.5 ml per eyelid. Complications were minor, including transient edema and ecchymosis at the sites of injection. Of the 10 eyelids injected, only one had increased astigmatism after injection. CONCLUSIONS: Hyaluronic acid gel shows promise as a safe and effective nonsurgical treatment for the management of certain eyelid malpositions, disorders traditionally requiring surgical intervention if aggressive ocular lubrication fails. This treatment is particularly useful in such patients who are commonly premature with poor general health and serves as a temporizing measure by allowing the much needed tissue expansion to take effect over time.

Acute angle closure in an aphakic infant: Case report and review of the literature.

PURPOSE: Aphakic pupillary block glaucoma is a rare complication after congenital cataract surgery. We describe the case of an infant with acute angle closure in an aphakic eye following congenital cataract lensectomy with anterior vitrectomy nine months prior. Potential pathophysiology and therapeutic strategies are discussed. OBSERVATIONS: A one-year-old male infant presented to our emergency unit with right eye injection and pain. At the age of six weeks he had undergone right eye lensectomy with anterior vitrectomy for congenital cataract and was left aphakic with large anterior and posterior capsulorrhexis. Examination was significant for a shallow anterior chamber centrally and iridocorneal touch of the periphery for 360° with intraocular pressure (IOP) measured at 70 mmHg. The child was diagnosed with aphakic pupillary block leading to an acute angle closure event. He underwent emergent anterior vitrectomy with surgical peripheral iridotomy (PI) performed via pars plana approach. This resulted in immediate deepening of the anterior chamber, with resolution of the pupillary block and iridocorneal touch. Thereafter, his ocular exam was normal. CONCLUSIONS AND IMPORTANCE: This unusual case underscores the importance of vigilance in the postoperative management of children after congenital cataract extraction. Unexpected complications remain a threat despite the initial undertaking of preventative measures.

Diagnosis and Management Practice Patterns among Pediatric Ophthalmology Personnel in Israel.

PURPOSE: To investigate the diagnosis and management practice patterns of different aspects of pediatric ophthalmology among pediatric ophthalmologists and orthoptists in Israel. METHODS: A 21-question survey was delivered to all registered pediatric ophthalmologists and orthoptists in Israel. RESULTS: The response rate was 58.3%. Most pediatric ophthalmology personnel in Israel do not document intermittent exotropia (IXT) with a control scale, do not use modalities other than patching for amblyopia, and do not use distance stereoacuity tests. There was no consensus regarding patching and over minus treatments in IXT. In contrast to frequent use of prism adaptation test (PAT) for evaluating strabismus, most Israeli pediatric ophthalmology personnel do not use postoperation diplopia test (PODT). While most orthoptists use a questionnaire when diagnosing convergence insufficiency (CI), most pediatric ophthalmologists do not. CONCLUSION: This study highlights the current areas of consensus and disagreement regarding pediatric ophthalmology diagnosis and management practices in Israel. Adopting a uniform approach regarding diagnosing CI, including using a questionnaire by pediatric ophthalmologists and orthoptic exercises in the management of IXT, is warranted to enable unified treatment by pediatric ophthalmologist and orthoptists in Israel.

Incomitant esotropia following pterygium excision surgery.

OBJECTIVE: To report the clinical characteristics and treatment of subjects with incomitant esotropia following unilateral pterygium excision. METHODS: A retrospective review of 6 consecutive patients who developed incomitant esotropia, limited abduction, and diplopia following unilateral pterygium excision surgery. RESULTS: The mean preoperative deviation was 6 prism diopters (PD) (range, 0-25 PD) in the primary position and 13.8 PD (range, 6-25 PD) in the abducting field of the involved eye. Four patients underwent simultaneous surgery on the conjunctiva-perimuscular connective tissue complex and the medial rectus muscle. One subject had conjunctival-perimuscular connective tissue complex surgery alone. Postoperatively, all patients had orthotropia in the primary position and the deviation in the abducting field was improved to 5.2 PD (range, 0-14 PD). CONCLUSIONS: Incomitant esotropia is an uncommon but serious complication following pterygium excision surgery. Medial rectus muscle recession combined with scar tissue removal is required to eliminate diplopia in the primary position. Conjunctiva-perimuscular scar tissue removal may suffice to improve diplopia in the abduction gaze position.

Inferior oblique muscle fixation to the orbital wall: a profound weakening procedure.

INTRODUCTION: Recurrent or persistent inferior oblique overaction may occur after inferior oblique (IO) recession or anterior transposition. IO nasal and temporal myectomy and anterior-nasal transposition may result in undesirable IO palsy, exotropia, incyclotorsion, or limitation of elevation. Previous studies have shown that a rectus extraocular muscle may be profoundly weakened if the muscle insertion is reattached to adjacent orbital periosteum. We describe a reversible profound weakening surgical procedure of the IO muscle. METHODS: A total of 10 consecutive subjects with V-pattern strabismus and/or IO overaction underwent IO orbital fixation procedure by attaching its insertion to the periosteum of the lateral orbital wall. One subject was not included because short follow-up. Five subjects with persistent IO overaction after IO anterior transposition underwent bilateral IO orbital wall fixation. Four subjects with no previous IO surgery underwent unilateral IO orbital wall fixation; 3 of these 4 subjects had superior oblique palsy with a large vertical deviation in primary position and 1 had a V pattern with asymmetric IO overaction. RESULTS: V pattern significantly improved from 22(Delta) preoperatively to 7(Delta) postoperatively (p = 0.002). IO overaction improved from 2.5 (range, + 1.5 to + 4) to 0.1 (range, -2 to +3) postoperatively (p < 0.001). Six of 9 subjects had no residual overelevation in adduction postoperatively. Unilateral IO orbital fixation corrected 7(Delta) of vertical deviation in the primary position and 23(Delta) in adduction. Mean postoperative follow-up was 5 months. CONCLUSIONS: IO orbital fixation has a profound weakening effect on the IO muscle. Advantages of this procedure include reversibility and that it can be converted into another form of weakening procedure, if required.

Abducens nerve ocular neuromyotonia following non-sellar or parasellar tumors.

Ocular neuromyotonia is an uncommon disorder resulting from episodic involuntary discharge of ocular motor nerves producing sustained contraction of their respective ocular muscles. Ocular neuromyotonia manifests in brief spells of diplopia occurring spontaneously or after eccentric gaze holding. In most cases, ocular neuromyotonia follows months or years after radiotherapy to the sellar and parasellar region and involves the oculomotor nerve. We report two unusual cases of abducens nerve ocular neuromyotonia that followed radiation therapy of tumors in areas other than the sellar or parasellar region.

Do Intraocular Pressure Measurements Under Anesthesia Reflect the Awake Condition?

BACKGROUND: Anesthesia or sedation is needed when intraocular pressure (IOP) measurement is required in certain circumstances. The effect of different anesthetic regimens on the IOP is still debatable. We aimed to evaluate alterations in the IOP under anesthesia with either propofol or different end-tidal concentrations of sevoflurane, when compared with the awake state. METHODS: The IOP was measured in both eyes of 20 adult patients undergoing extraocular ophthalmic surgeries at 5 timepoints: before the induction of general anesthesia (under topical anesthesia), after the induction using propofol target-controlled infusion, and under 3 end-tidal concentrations of sevoflurane (0.5%, 2%, and 5%), either in a decreasing (group A) or an increasing (group B) concentration order. RESULTS: With either propofol or sevoflurane anesthesia, the IOP did not differ significantly from the measurement performed during the awake state (no anesthesia), regardless of the concentration of sevoflurane used (in the range of 0.5% to 5%) or the order of sevoflurane administration (from low to high concentration or vice versa). CONCLUSIONS: These data suggest that propofol and sevoflurane are valid anesthetic agents for the evaluation of IOP in adults when anesthesia is needed.

Maximum motor fusion combined with one-hour preoperative prism adaptation test in patients with acquired esotropia.

PURPOSE: Preoperative prism adaptation and the maximum motor fusion test reduce the risk of postoperative undercorrection, overcorrection, and bifocal requirements in acquired esotropia. The purpose of our study is to determine the efficacy of the maximum motor fusion test followed by a short prism adaptation test in patients with acquired esotropia undergoing bilateral medial rectus muscle recession. METHODS: We undertook a retrospective review of 29 subjects with acquired esotropia without history of amblyopia, previous strabismus surgery, use of bifocals, pattern anisotropia, dissociated vertical deviation, or oblique muscle dysfunction. All subjects underwent bilateral medial rectus muscle recessions based on the distance angle of deviation measured with the maximum motor fusion test followed by prism adaptation test. Alternate prism and cover testing was performed after 1 hour of prism adaptation to determine the angle of deviation for surgical correction. RESULTS: The age at surgery was 4.5 +/- 1 years. The preoperative angle of deviation at distance was 20.4 +/- 4.2(delta). It increased to 36.2 +/- 4.2(delta) after the maximum motor fusion test followed by 1 hour of prism adaptation testing. The final preoperative angle of deviation post motor fusion test-prism adaptation test was significantly larger than the initial angle of deviation (p < 0.0001). The final postoperative deviation at distance was 1.3 +/- 3.3(delta), and 5.2 +/- 1.5(delta) at near. Postoperative follow up was 18 +/- 2.6 months (range, 13-24 months). CONCLUSIONS: The combination of maximum motor fusion and preoperative prism adaptation allowed increased amounts of medial rectus muscle muscle recession, decreasing the risk of postoperative undercorrection without increasing the risk of overcorrection.

The efficacy of asymmetric bilateral medial rectus muscle recession surgery in unilateral, esotropic, type 1 Duane syndrome.

BACKGROUND: Many patients with esotropic, type 1 Duane syndrome adopt a head turn to gain binocular vision. Numerous surgical procedures have been performed to correct this condition, including asymmetric bilateral medial rectus muscle recession, first proposed by Jampolsky. However, few publications reported on the efficacy of this procedure. METHODS: The medical records of patients with unilateral, esotropic Duane syndrome who had asymmetric medial rectus muscle recession for correction of their abnormal head turn were retrospectively reviewed with attention to head turn, ductions, and motor alignment at near and distance fixation. Surgery was considered successful when preoperative head turn was completely eliminated. RESULTS: A total of 28 patients (18 females; mean age, 8 years) were included. In 24 patients (86%), the left eye was involved. Medial rectus recession averaged 4.7 mm (range, 3.25-6.0 mm) in the affected eye, with a recession larger by 1.0 mm in the unaffected eye. Average esotropia in the forced primary position improved from 32(Δ) preoperatively to 6(Δ) postoperatively, with a mean 22° improvement in head position (24°-2°). Twenty-four patients (86%) achieved complete resolution of their head turn postoperatively; the other 4 patients experienced partial improvement, with a residual head turn of 10°; a second re-recession of the medial rectus muscle in the affected eye of 1 patient resulted in complete resolution of head turn. CONCLUSIONS: Our study showed that asymmetric bilateral medial rectus recession eliminated the head turn in most of our patients with unilateral esotropic Duane syndrome.

Long-term results of the surgical management of intermittent exotropia.

PURPOSE: To examine long-term surgical success rates (>10 years) for patients with intermittent exotropia and the risk factors for failure of surgery in these patients. METHODS: An attempt was made to contact all patients who underwent surgical treatment for intermittent exotropia between the years of 1970 to 1998 with a minimum postoperative follow-up of 10 years. Each patient underwent a detailed sensory and motor examination, including measurements of near and distance stereoacuity, cover testing, and ocular rotations. Patients were classified as achieving an excellent, fair, or poor outcome on the basis of motor and sensory outcomes. Risk factor analysis was performed to evaluate associations with a poor outcome and reoperations. RESULTS: Of 197 patients identified, 50 were reevaluated. When combined motor/sensory criteria for surgical success were used, we found that 38% of patients achieved an excellent outcome, whereas 34% and 28% achieved a fair or poor outcome, respectively. When only the motor criteria were used, we found that 64% had an excellent outcome, whereas the remaining patients achieved either a fair (18%) or a poor (18%) outcome. During the follow-up period, 60% of patients required at least one reoperation. Multivariate risk factor analysis determined that anisometropia (p = 0.03) was associated with a poor outcome, whereas postoperative undercorrection (p = 0.04) and lateral incomitance (p = 0.06) were associated with reoperations. CONCLUSIONS: Long-term surgical results in intermittent exotropia are less encouraging when sensory status is added to the evaluation. Patients with anisometropia, lateral incomitance, and immediate postoperative undercorrection are at increased risk for poor outcomes and to require reoperations.

Binocular visual function in patients with Boston type I keratoprostheses.

PURPOSE: To report the postoperative binocular function of patients with Boston type I keratoprostheses implantation for unilateral visual impairment. METHODS: Seventeen patients who underwent implantation of a Boston type I keratoprosthesis and had a best-corrected visual acuity better than 20/50 in the contralateral eye before surgery were evaluated. All subjects prospectively underwent sensory testing of binocular function including Bagolini lenses, Worth-4-dot test, stereoacuity at distance and near, and double Maddox rods. In addition, an assessment of ocular rotations and alignment was performed on each subject. RESULTS: Twenty patients with best-corrected visual acuity better than 20/50 in the contralateral eye at the time of keratoprothesis surgery were identified. Seventeen of the 20 patients underwent binocular visual testing, with 16 of 17 (94%) demonstrating binocular function. Second-degree fusion at near was demonstrated via the Worth-4-dot test in 13 of 17 (76%) patients. Third-degree fusion at near was demonstrated in 7 of 17 (41%) patients. Patients with better postoperative sensory binocular function tended to be of younger age (P = 0.05) and have better postoperative visual acuity (P = 0.006). Five patients were found to have some degree of ocular misalignment. Overall, patients with strabismus had worse binocularity (P = 0.04). CONCLUSIONS: Implantation of the Boston type I keratoprosthesis in patients with good preoperative visual acuity in the fellow eye is associated with useful binocular function in greater than 90% of patients.

Surgical management of dissociated vertical deviation associated with A-pattern strabismus.

INTRODUCTION: Dissociated vertical deviation (DVD), pattern strabismus, and oblique muscle dysfunction frequently coexist, and the recognition of bilaterality, symmetry, and lateral incomitance is important in selecting appropriate surgical management. In this study, we compare 3 different surgical approaches in patients with DVD associated with A-pattern strabismus. METHODS: This was a retrospective review of 40 consecutive patients with DVD and A-pattern strabismus who underwent strabismus surgery. Bilateral superior rectus muscle recession was performed in 9 patients, bilateral superior rectus recession and superior oblique posterior tenectomy were performed in 14 patients, and bilateral superior oblique temporal tenotomy and inferior oblique recession were performed in 17 patients. RESULTS: Bilateral superior rectus muscle recession corrected 7(Delta) +/- 2(Delta) of A pattern, 10(Delta) +/- 3(Delta) of vertical deviation and 4(Delta) +/- 2(Delta) of DVD asymmetry. Bilateral superior rectus muscle recession combined with superior oblique posterior tenectomy corrected 17(Delta) +/- 3(Delta) of A pattern, 10(Delta) +/- 2(Delta) of vertical deviation, and 4(Delta) +/- 2(Delta) of asymmetry. Bilateral superior oblique muscle temporal tenotomy combined with inferior oblique recession corrected 30(Delta) +/- 4(Delta) of A pattern, 9(Delta) +/- 3(Delta) of vertical deviation, and 2(Delta) +/- 2(Delta) of asymmetry. CONCLUSIONS: In patients with DVD and A patterns, the size of the A pattern and the symmetry of the DVD are of major importance for surgeons determining appropriate procedures. Bilateral superior rectus muscle recession corrects small amounts of A pattern. Larger amounts of A pattern require additional superior oblique weakening or weakening of all four oblique muscles. superior rectus muscle recession is warranted if the asymmetry is larger than 5(Delta).

High-resolution magnetic resonance imaging demonstrates reduced inferior oblique muscle size in isolated inferior oblique palsy.

PURPOSE: The diagnosis of isolated inferior oblique muscle palsy is controversial for 2 reasons: first, clinical findings seem inconsistent with our current understanding of oculomotor neuroanatomy and, second, similar findings can occur with other causes. Because denervated extraocular muscles atrophy, we used high-resolution magnetic resonance imaging (MRI) to assess inferior oblique muscle size in patients with clinically suspected inferior oblique muscle palsy. METHODS: A diagnosis of inferior oblique muscle palsy in 6 patients (4 unilateral, 2 bilateral) was made clinically. High-resolution coronal and sagittal orbital MRI were obtained in subjects with clinical inferior oblique muscle palsy and in 30 age-matched control subjects. Cross sections of the inferior oblique, inferior rectus (IR), and medial rectus muscles were determined together because each is innervated by the common inferior division of the oculomotor nerve. No subject had pupillary abnormalities or other extraocular muscle weakness or restriction. RESULTS: Mean cross-sectional area of the affected inferior oblique muscle (n = 8) at the midpoint of the inferior rectus muscle was 10.2 +/- 1.05 mm(2), which was significantly smaller than the value of 18.8 +/- 3.6 mm(2) for control subjects (n = 58, p < 0.00001). Unilaterally affected inferior oblique muscles were significantly smaller than unaffected inferior oblique muscles (p < 0.05). Mean medial rectus muscle cross section (n = 8) ipsilateral to the affected inferior oblique muscle was 36.8 +/- 2.4 mm(2), which was not significantly different from the 35.1 +/- 3.7 mm(2) value for the medial rectus muscles of control subjects (n = 61, p > 0.1). Mean inferior rectus muscle cross section (n = 8) ipsilateral to the affected inferior oblique muscle was 32.5 +/- 2.3 mm(2), which was significantly greater than the 29.9 +/- 3.3 mm(2) measurement for the control subjects (n = 61, p < 0.01). CONCLUSIONS: We used MRI to demonstrate reduced inferior oblique muscle size in patients with clinically diagnosed inferior oblique muscle palsy, supporting the concept of isolated inferior oblique muscle weakness.

Surgical treatment of strabismus secondary to glaucoma drainage device.

OBJECTIVE: To describe surgical strategies in a series of patients with diplopia following implantation of a glaucoma drainage device. METHODS: Retrospective review of 9 consecutive patients who underwent strabismus surgery because of strabismus and diplopia after implantation of a glaucoma drainage device. RESULTS: Seven patients with marked limitation to ocular rotations and incomitant strabismus underwent surgery on the eye with the implant. Two patients with mild limitation to ocular rotations of the involved eye underwent surgery on the contralateral eye. All patients had a large fibrous capsule surrounding the implant plate, adjacent muscles, and sclera. Intraocular pressure was not elevated postoperatively. Postoperative diplopia in the primary position was eliminated in 5 patients and markedly improved in 3 patients. CONCLUSIONS: Strabismus following implantation of a glaucoma drainage device is an uncommon but serious complication. Restoration of ocular alignment is a complex undertaking requiring strabismus and glaucoma surgical expertise. Multiple surgical complications may occur. Surgical intervention may require complete removal of the fibrous capsule surrounding the implant and involved adjacent structures. Size reduction of the implant plate is helpful and did not interfere with postoperative intraocular pressure control in this study. Surgery on the contralateral eye is an option in patients with mild restriction.