Ophthalmic Findings of Abusive Head Trauma in Korea from a Single-large Trauma Center, 2011-2022

Purpose@#To investigate the ophthalmic findings associated with abusive head trauma (AHT) at a major trauma center in Korea. @*Methods@#We retrospectively reviewed the medical records of 14 children with AHT referred for an ophthalmologic examination at a large regional trauma center from January 2011 to December 2022. We analyzed pertinent findings for AHT and its sequelae on brain computed tomography, skeletal surveys obtained using X-ray, external photographs, and fundus photographs taken with a portable fundus camera. @*Results@#Among 14 patients (mean age, 7.4 months) with subdural hematoma from AHT, nine (64.3%) had retinal hemorrhages. Eight of these patients (88.9%) required neurosurgery, while only one child (20.0%) among the five without retinal hemorrhages needed drainage for brain hemorrhages. All patients with retinal hemorrhages (mean age, 6.0 months) presented with numerous multilayered hemorrhages across the entire retina including dome-shaped hemorrhages (six patients), perimacular ridges (one patient), and retinal hemorrhages at different stages of healing (one patient). The retinal hemorrhages resolved within an average of 2.4 months without necessitating retinal surgery. In five patients followed for an average of 28.2 months, there were instances of optic disc pallor in three, cortical visual impairment in one, and fovea scarring in one. @*Conclusions@#More than half of the Korean children with AHT had extensive retinal hemorrhages leading to ophthalmic sequelae in the majority. These findings support the need for long-term active ophthalmic follow-up in AHT cases.

Effect of Low-dose Atropine on Myopia Control in Children Operated for Intermittent Exotropia

Purpose@#To evaluate the effect of low-dose atropine on myopia control in children with a history of surgery for intermittent exotropia (IXT). @*Methods@#We retrospectively reviewed the medical records of children who used 0.05% atropine for ≥ 1 year to control myopia progression. This group included 45 patients with a history of IXT surgery and 57 patients with no such history. The annual changes in spherical equivalent and axial length were compared 6 months before, 6 months after, and 1 year after atropine instillation between the IXT surgery group and myopia controls. In this comparison, the dominant eye was paired with the right eye and the non-dominant eye with the left eye. We also analyzed the difference between IXT surgery cases corrected within versus not within 10 prism diopters (PD) at the start of low-dose atropine treatment. @*Results@#A total of 102 patients had an average of -3.81 ± 1.53 diopters (D) and used low-dose atropine for an average of 16.8 months from a mean age of 8.2 years. On average, the IXT surgery group underwent muscle surgery for 28.1 PD of IXT at 7.8 years. A year after instillation, the myopia progression rate was -0.52 ± 0.89 D/year and 0.27 ± 0.40 mm/year in the IXT surgery group compared to -0.47 ± 0.83 D/year and 0.31 ± 0.24 mm/year in the myopia control group with no significant differences. However, after 6 months of instillation, the dominant eye in the IXT surgery group exhibited a significantly faster myopia progression rate than the right eye in the myopia control group (-0.84 ± 1.61 D/year vs. -0.56 ± 0.80 D/year, p = 0.04; 0.27 ± 0.33 mm/year vs. 0.22 ± 0.21 mm/year, p = 0.02). No difference was found in the myopia control effect between corrected and uncorrected cases in the IXT surgery group. @*Conclusions@#The effect of low-dose atropine on myopia control in children after IXT surgery was similar to that in myopia controls. However, it was less effective in the dominant eye during the early treatment period.

Profile of pediatric ophthalmic referrals in a single emergency department in Korea

Purpose@#This study was performed to examine a comprehensive profile of ophthalmic (OPH) referrals based on diagnosis in a single emergency department (ED) in Korea. @*Methods@#We analyzed the clinical profiles of children (< 18 years) who underwent immediate OPH referrals in a tertiary hospital ED, from March 2013 through December 2022. Exclusion criteria were a visit related to procedural complication and a discharge before thorough evaluation. We focused on a diagnosis-based high OPH severity requiring emergency surgery or hospitalization. The profiles were compared according to the severity and age group (0-3, 4-6, 7-12, and 13-17 years). @*Results@#A total of 1,939 children consisted of 1,281 (66.1%) with injury and 658 (33.9%) with non-injury. Top 3 injuries were orbital fracture, hyphema, and corneal abrasion whereas top 3 non-injuries were keratoconjunctivitis, cellulitis, and hordeolum. Children with high OPH severity (54.5%) had significantly lower proportions of girls (26.5% vs. 38.9%), visits on weekend/holiday (34.4% vs. 43.4%), and most non-injury chief complaints, and higher proportions of 13-17 years (41.1% vs. 23.6%), injury (87.7% vs. 40.1%), emergency surgery (4.9% vs. 0.1%), in-ED procedure (9.3% vs. 2.4%), hospitalization (4.0% vs. 0.8%), and most injury mechanisms. With increasing age, high OPH severity, orbital fracture, and hyphema increased in proportions, in contrast to a decreasing tendency in corneal abrasion, keratoconjunctivitis, cellulitis, and hordeolum (all Ps for trend ≤ 0.001). There were 610 (31.5%) children with low OPH severity or no OPH diagnosis. @*Conclusion@#True OPH emergencies may be more common in injured, older, or male children. This finding could be useful in focusing on emergencies while diverting less urgent cases to outpatient departments or outside ophthalmology clinics.

Ophthalmic Features 5 Years after Cranioplasty in Children with Unilateral Coronal Craniosynostosis

Purpose@#To investigate ocular asymmetry status 5 years after cranioplasty in children with unilateral coronal craniosynostosis. @*Methods@#The medical records of 41 children who underwent cranioplasty at a mean age of 11.7 months were retrospectively reviewed. The cranial vault asymmetry index (CVAI) and the amount of head tilt were measured on images obtained before cranioplasty. Presence of anisometropia, aniso-astigmatism, amblyopia, and strabismus was evaluated at a mean age of 6.8 years. Correlations among the CVAI, direction of synostotic suture and ocular asymmetries were analyzed. @*Results@#Before cranioplasty, the CVAI was 4.5%; 31 of 41 patients (75.6%) exhibited head tilting, which was contralateral to the synostotic suture site in 29 of these patients. At a mean of 5.6 years after cranioplasty, anisometropia of ≥ 1.00 diopters on the spherical equivalent was present in 9 patients (22.0%) and aniso-astigmatism of ≥ 1.00 diopters in 10 patients (24.4%). Amblyopia was in 15 patients (36.6%); the eye contralateral to the synostotic suture was more frequently affected, and anisometropic amblyopia was the most common subtype. Strabismus was present in 28 patients (68.3%); exodeviation and vertical deviation were the most common subtypes. The non-dominant eye was the eye ipsilateral to the synostotic suture in 12 of 13 patients (92.3%) with simulated superior oblique palsy and in 7 of 10 patients (70.0%) with dissociated vertical deviation. In children with CVAI of ≥ 5%, anisometropia was significantly more common than in other children (p = 0.04), but we found no relationship between any other type of ocular asymmetry and a high CVAI. @*Conclusions@#Ocular asymmetries including anisometropia, aniso-astigmatism, amblyopia, and strabismus were observed even 5 years after successful cranioplasty treatment for unilateral coronal craniosynostosis, emphasizing the need for continuous ophthalmic follow-up.

Non-Arteritic Ischemic Optic Neuropathy Following COVID-19 Vaccination in Korea: A Case Series

Background@#To report the clinical manifestations of non-arteritic anterior ischemic optic neuropathy (NAION) cases after coronavirus disease 2019 (COVID-19) vaccination in Korea. @*Methods@#This multicenter retrospective study included patients diagnosed with NAION within 42 days of COVID-19 vaccination. We collected data on vaccinations, demographic features, presence of vascular risk factors, ocular findings, and visual outcomes of patients with NAION. @*Results@#The study included 16 eyes of 14 patients (6 men, 8 women) with a mean age of 63.5 ± 9.1 (range, 43–77) years. The most common underlying disease was hypertension, accounting for 28.6% of patients with NAION. Seven patients (50.0%) had no vascular risk factors for NAION. The mean time from vaccination to onset was 13.8 ± 14.2 (range, 1–41) days. All 16 eyes had disc swelling at initial presentation, and 3 of them (18.8%) had peripapillary intraretinal and/or subretinal fluid with severe disc swelling. Peripapillary hemorrhage was found in 50% of the patients, and one (6.3%) patient had peripapillary cotton-wool spots. In eight fellow eyes for which we were able to review the fundus photographs, the horizontal cup/ disc ratio was less than 0.25 in four eyes (50.0%). The mean visual acuity was logMAR 0.6 ± 0.7 at the initial presentation and logMAR 0.7 ± 0.8 at the final visit. @*Conclusion@#Only 64% of patients with NAION after COVID-19 vaccination have known vascular and ocular risk factors relevant to ischemic optic neuropathy. This suggests that COVID-19 vaccination may increase the risk of NAION. However, overall clinical features and visual outcomes of the NAION patients after COVID-19 vaccination were similar to those of typical NAION.

Fibrous Band between Extraocular Muscles in Unilateral Coronal Synostosis

No abstract available.

Quantitative Forced Cyclorotation Testing Using a Smartphone

Purpose@#To evaluate the utility of a quantitative forced cyclorotation test using a smartphone in patients with unilateral superior oblique palsy. @*Methods@#Twenty-nine patients who underwent muscle surgery for superior oblique palsy were included. With patients under anesthesia prior to surgery, the 12 and 6 o’clock positions of the limbus were marked, the globe was maximally excyclorotated and incyclorotated, and photographs of the globe were taken in each position. The maximum angle of rotation was read by two masked observers using two different smartphone applications. Maximum excyclorotation and incyclorotation were compared between patients with superior oblique palsy alone and patients with both superior oblique palsy and intermittent exotropia; associations were evaluated regarding age at surgery, angle of hypertropia, and cyclotorsion on fundus photographs. @*Results@#The intraclass correlation coefficient between the two readers was 0.989. The maximum excyclorotation of affected eyes was significantly greater than that of the fellow eyes (46.1 ± 9.9° vs. 41.7 ± 7.6°; p = 0.040). Maximum incyclorotation did not differ between the two eyes. The maximum excyclorotation of affected eyes of 18 patients with unilateral superior oblique palsy alone was significantly greater than that of the fellow eyes (47.0 ± 9.5° vs. 39.4 ± 6.3°; p = 0.010). The maximum excyclorotation of affected eyes of 11 patients with both superior oblique palsy and intermittent exotropia was similar to that of the fellow eyes (44.5 ± 10.9° vs. 45.5 ± 8.3°). Maximum incyclorotation did not differ according to group or eye. Maximum excyclorotation did not differ according to age at surgery, angle of hypertropia, or cyclotorsion on fundus photographs. @*Conclusions@#New forced cyclorotation tests using a smartphone quantitatively assess the passive range of cyclorotation, and detect bilateral differences, particularly in patients with unilateral superior oblique palsy alone.

Acute Leukemia Relapse Presenting as Recurrent Involvement of the Optic Nerve

PURPOSE: To report two cases with recurrent involvement of the optic nerve as the initial sign of acute leukemic relapse.CASE SUMMARY: An 8-year-old male with acute lymphoblastic leukemia on the maintenance chemotherapy was referred for a decrease in visual acuity in the right eye. The visual acuity and optic disc swelling were completely resolved with high-dose steroid therapy. Two months after the initial presentation, the symptoms recurred and brain/orbit magnetic resonance imaging (MRI) showed high intensity along the right optic nerve from the retrobulbar area to the optic chiasm. The visual acuity was restored after high-dose steroid therapy. One month after the second attack, the symptoms recurred and the cerebrospinal fluid cytology was positive for lymphoblasts. Three weeks after the intrathecal chemotherapy, the visual acuity improved fully, but optic disc atrophy developed. A 45-year-old male, who received allogenic peripheral blood stem cell transplantation for acute myeloid leukemia, presented with a decrease in visual acuity in the left eye. The left optic disc swelling improved with high-dose steroid therapy, but the medication was restarted due to the recurrence of symptoms 3 weeks later. Brain MRI showed a mass lesion compressing the left optic nerve, presumed to be a myeloid sarcoma. One month after local irradiation, the visual acuity was no light perception in the left eye.CONCLUSIONS: In patients with a prior history of acute leukemia, the recurrent involvement of the optic nerve should be considered as a central nerve system relapse, regardless of improvement with steroid treatment.

Quantitative Forced Cyclorotation Testing Using a Smartphone

Purpose@#To evaluate the utility of a quantitative forced cyclorotation test using a smartphone in patients with unilateral superior oblique palsy. @*Methods@#Twenty-nine patients who underwent muscle surgery for superior oblique palsy were included. With patients under anesthesia prior to surgery, the 12 and 6 o’clock positions of the limbus were marked, the globe was maximally excyclorotated and incyclorotated, and photographs of the globe were taken in each position. The maximum angle of rotation was read by two masked observers using two different smartphone applications. Maximum excyclorotation and incyclorotation were compared between patients with superior oblique palsy alone and patients with both superior oblique palsy and intermittent exotropia; associations were evaluated regarding age at surgery, angle of hypertropia, and cyclotorsion on fundus photographs. @*Results@#The intraclass correlation coefficient between the two readers was 0.989. The maximum excyclorotation of affected eyes was significantly greater than that of the fellow eyes (46.1 ± 9.9° vs. 41.7 ± 7.6°; p = 0.040). Maximum incyclorotation did not differ between the two eyes. The maximum excyclorotation of affected eyes of 18 patients with unilateral superior oblique palsy alone was significantly greater than that of the fellow eyes (47.0 ± 9.5° vs. 39.4 ± 6.3°; p = 0.010). The maximum excyclorotation of affected eyes of 11 patients with both superior oblique palsy and intermittent exotropia was similar to that of the fellow eyes (44.5 ± 10.9° vs. 45.5 ± 8.3°). Maximum incyclorotation did not differ according to group or eye. Maximum excyclorotation did not differ according to age at surgery, angle of hypertropia, or cyclotorsion on fundus photographs. @*Conclusions@#New forced cyclorotation tests using a smartphone quantitatively assess the passive range of cyclorotation, and detect bilateral differences, particularly in patients with unilateral superior oblique palsy alone.

Clinical Features of Amblyopic Children with Myopic Anisometropia at a Tertiary Center

PURPOSE: To evaluate the clinical features of unilateral amblyopia with myopic anisometropia at a tertiary center. METHODS: The medical records of 102 children wearing spectacles due to myopic anisometropia with an interocular difference in spherical equivalent (SE) ≥ 1.00 diopters (D) with a follow-up ≥ 1 year were reviewed. Patients were classified into mild or severe groups according to an interocular SE difference ≥ 3.00D. The frequency of amblyopia (interocular difference ≥ two lines of visual acuity [VA]) and response to patching, the magnitude of anisometropia, and the frequency of combined ocular or systemic disorders except refractive errors were compared between the two groups. The VA and refractive errors were measured four months and one year after spectacle correction and at the last follow-up. RESULTS: In all, 61 patients with mild myopic anisometropia and 41 patients with severe myopic anisometropia started to wear spectacles at a mean age of 5.2 years old and were followed-up during a mean period of 34.6 months. The frequency of amblyopia decreased more prominently in the mild group: 82.0% in the mild group vs. 92.7% in the severe group four months after spectacle correction and 45.9% in the mild group vs. 87.8% in the severe group at the last follow-up. At baseline, the mild group had anisometropia of 1.42 ± 0.66D, while the severe group had anisometropia of 5.47 ± 2.09D. The magnitude of anisometropia tended to increase by 0.42D but not significantly: +0.78D in the mild group and −0.02D in the severe group. More than half of the patients had combined disorders: 57.4% in the mild group and 53.7% in the severe group. CONCLUSIONS: Severe myopic anisometropic amblyopia at a tertiary center showed little improvement and the magnitude of anisometropia did not change.

Bilateral Occipital Lobe Infarction Presenting as Bilateral Inferior Altitudinal Defects

PURPOSE: Horizontal visual field defects are generally caused by lesions before the optic chiasm, but we report a case with bilateral inferior altitudinal defects secondary to bilateral occipital lobe infarction. CASE SUMMARY: A 57-year-old male with a history of diabetes and hypertension presented with a month of blurring in the inferior visual field. His corrected visual acuity was 1.0 in the right eye and 0.63 in the left eye, and the intraocular pressure was normal in each eye. Pupillary response, ocular movement, and color vision tests were normal in both eyes. There was no specific finding of the optic disc and macula on fundus examination. Visual field examination revealed an inferior congruous homonymous hemianopia with horizontal meridian sparing and a left incongruous homonymous quadrantanopia. Optical coherence tomography for peripapillary retinal nerve fiber layer thickness revealed a mild decrease in the inferior disc of both eyes. Brain magnetic resonance imaging confirmed the presence of an acute infarction confined with upper medial calcarine fissures of bilateral occipital lobe and the right splenium of the corpus callosum, which were consistent with inferior altitudinal hemianopia and left superior incongruous quadrantanopia, respectively. Brain magnetic resonance angiography showed multiple stenosis of bilateral posterior cerebral arteries. CONCLUSIONS: The altitudinal visual field defects could be caused by the occipital lesion medial to the calcarine fissure, and unusual visual defects could be due to a combination of multiple lesions.

Clinical Features of Children with +4.00 Diopters or More Hyperopia Weaning with Age

PURPOSE: To evaluate the clinical features of children with high hyperopia weaning with age. METHODS: The medical records of 203 children wearing spectacles due to hyperopia of +4.00 diopters (D) or greater in at least one eye based on the cycloplegic refraction and with follow-up for 3 years or more were reviewed. The patients were divided into those who showed a decrease in the spherical equivalent (SE) of 1.50 D or greater and those who maintained. The age of wearing spectacles, the magnitude of hyperopia, the angle of deviation, the ratio of accommodative-convergence to accommodation (AC/A), and the frequency of amblyopia and anisometropia were compared. RESULTS: Forty seven patients with decreased hyperopia and 156 patients with sustained hyperopia were included. The decreased-group started to wear spectacles later than the sustained-group (5.0 ± 2.3 years vs. 4.1 ± 2.4 years). The mean SE of the hyperopic eye in the decreased-group was significantly greater at the initial visit than in the sustained-group (6.29 ± 2.18 D vs. 5.47 ± 1.38 D); was identical at the 1 year follow-up (4.83 ± 1.72 D vs. 4.89 ± 1.55 D); and significantly lower at the last follow-up (3.15 ± 1.72 D vs. 4.65 ± 1.56 D). In the decreased-group, the mean hyperopia of 3.14 ± 2.02 D decreased during a mean period of 3.9 years, especially during the first year after spectacle correction. At baseline, the frequency and angle of esotropia at both distant and near with/without hyperopic correction was significantly larger in the sustained-group. The frequency of amblyopia and anisometropia and the AC/A were identical between the two groups, while the frequency of amblyopia at the last follow-up was significantly lower in the decreased-group. CONCLUSIONS: Some patients with hyperopia of +4.00 D or greater who had none or a small angle of esotropia and improved amblyopia showed a decrease in hyperopia with age.

Use of the Bispectral Index to Predict Eye Position of Children during General Anesthesia

PURPOSE: To assess the relationship between eye position and anesthesia depth using the bispectral index (BIS) value, a parameter derived from electroencephalography data. METHODS: We investigated the relationship between BIS value and eye position in 32 children who underwent surgery for epiblepharon under general anesthesia. BIS values were recorded continuously throughout the procedure (from induction to awakening). Eye positions were video-recorded and analyzed after surgery. The vertical position of each eye was scored according to its height in relation to the medial canthus. An eye position in which the upper eyelid covered one-third of the cornea was defined as a significant ocular elevation. RESULTS: The BIS value correlated inversely with the end-tidal concentration of each anesthetic agent, whereas it correlated positively with the eye elevation score (eye position = 0.014 × BIS + 0.699, p = 0.011). The mean eye position score was significantly greater in patients whose BIS values were over 65. Eleven patients (34.4%) had significant ocular elevation; their mean concurrent BIS value was 61.6. Two of these patients had elevation during surgery and 9 had elevation during emergence from anesthesia. CONCLUSIONS: We found that high BIS values were correlated with low levels of anesthetic concentration and high eye position, suggesting that BIS monitoring may be useful for predicting eye position during anesthesia. Particular attention must be given to eye position during ophthalmic surgery. Anesthesia depth can be maintained by assuring that the BIS value remains below 65.

Smartphone Fundus Photography in an Infant with Abusive Head Trauma

PURPOSE: To report fundus photography using a smartphone in an infant with abusive head trauma. CASE SUMMARY: An 8-month-old male infant presented to the emergency room with decreased consciousness and epileptic seizures that the parents attributed to a fall from a chair. He had no external wounds or fractures to the skull or elsewhere. However, computerized tomography of the brain revealed an acute subdural hematoma in the right cranial convexity and diffuse cerebral edema, leading to a midline shift to the left and effacement of the right lateral ventricle and basal cistern. The attending neurosurgeon promptly administered a decompressive craniectomy. Immediately after the emergency surgery, a fundus examination revealed numerous multi-layered retinal hemorrhages in the posterior pole extending to the periphery in each eye. He also had white retinal ridges with cherry hemorrhages in both eyes. We acquired retinal photographs using the native camera of a smartphone in video mode. The photographer held the smartphone with one hand, facing the patient's eye at 15–20 cm, and held a 20 diopter condensing lens at 5 cm from the eye in the other hand. Our documentation using a smartphone led to a diagnosis of abusive head trauma and to obtain the criminal's confession, because the findings were specific for repetitive acceleration-deceleration forces to an infant`s eye with a strong vitreoretinal attachment. CONCLUSIONS: This ophthalmic finding had a key role in the diagnosis of abusive head trauma. This case presented the diagnostic use of a smartphone for fundus photography in this important medicolegal case.

A Case of Cavernous Sinus Dural Arteriovenous Fistula Following Tolosa-Hunt Syndrome

PURPOSE: To report a case of cavernous sinus dural arteriovenous fistula following Tolosa-Hunt syndrome. CASE SUMMARY: A 64-year-old female with a history of hypertension, presented with blepharoptosis and periorbital pain in the right eye and diplopia. Her right pupil was dilated. She had right exotropia and right hypertropia with inability to elevate, depress, and adduct the right eye. Magnetic resonance imaging including angiography, revealed hyperintensities in the right cavernous sinus consistent with inflammation and no vascular abnormalities. Three days after oral corticosteroid therapy, the pain disappeared. A presumptive diagnosis was Tolosa-Hunt syndrome presenting as a form of complete oculomotor nerve palsy. Two months later, she experienced severe pain in the right periocular area, even though blepharoptosis was resolved and ocular motility was improved. A rapid response to high-dose intravenous corticosteroids was consistent with recurrence of Tolosa-Hunt syndrome. Three months later, she had normal ocular motility, but developed a conjunctival injection, pulsatile orbital bruits, and exophthalmos in the right eye. Cerebral angiography showed a cavernous sinus dural arteriovenous fistula. She received a transvenous coil embolization and her symptoms markedly improved over 2 months. CONCLUSIONS: Tolosa-Hunt syndrome, a granulomatous inflammation in the cavernous sinus may be followed by cavernous sinus dural arteriovenous fistula and should be considered during follow-up.

The Effect of Amblyopia Treatment with Patching on Ocular Alignment

PURPOSE: To evaluate the effect of patching on ocular alignment in children with unilateral amblyopia. METHODS: We evaluated the change in ocular alignment during and after patching in patients who had started amblyopia treatment with patching, and analyzed the aspects of change according to the cause and severity of amblyopia, type and magnitude of deviation, type of refractive error, and age at initiation. A change of eight prism diopters (PD) or more in horizontal deviation, or two PD or more in vertical deviation was considered significant. RESULTS: A total of 209 patients were enrolled; 135 had amblyopia associated with anisometropia, 50 with strabismus, 19 with combined cause, and 5 with deprivation. After patching, there was no change in distant deviation in 177 patients (84.7%), while a decrease was noted in 23 patients (11.0%) and an increase in nine patients (4.3%). The angle of deviation decreased in 7.4% of anisometropic amblyopia, 20.0% of strabismic amblyopia, 10.5% of combined amblyopia, and 20.0% of deprivation amblyopia. The angle of deviation increased in 4.4% of anisometropic amblyopia, 5.3% of combined amblyopia, and 40.0% of deprivation amblyopia. The angle of deviation decreased in 24.2% of exodeviation, and 21.6% of esodeviation, but there was no change in vertical deviation among the studied patients. The angle of deviation decreased in 31.9% of patients with deviation greater than 8 PD. The change did not differ according to severity of amblyopia, type of refractive error, or age. Among the successes, decrease in deviation was more common until they achieved equal visual acuity between both eyes, while the increase during tapering of patching. CONCLUSIONS: Change in ocular alignment may occur after patching in some patients with amblyopia, and seems to be more frequent in cases associated with horizontal deviation greater than 8 PD.

Ocular Myasthenia Gravis in Monozygotic Twins with Mirror-image Myopic Anisometropia

No abstract available.

Systemic Lupus Erythematosus Presenting as Monocular Elevation Deficiency

PURPOSE: To report a case of monocular elevation deficiency as the presenting manifestation of systemic lupus erythematosus (SLE). CASE SUMMARY: A 23-year-old, otherwise healthy female presented with a 3-day history of vertical diplopia and headache. She had a left hypotropia, which worsened in adduction and supra-duction and a profound inferior oblique underaction (-3). Magnetic resonance imaging showed an enhancement around the left superior oblique muscle and multiple infarctions in the left midbrain. On repetitive serological tests, anemia, lymphopenia, and anti-phospholipid antibody were positive. A presumptive diagnosis was a myositis of left superior oblique muscle and hyper-coagulation related with anti-phospholipid antibody. Two months after high-dose steroid treatment, the vertical diplopia was resolved. Five months later, the left hypotropia recurred as a more severe form with the inability to elevate the left eye in all directions. In addition, the infarction associated with vasculitis recurred in the left midbrain. As the treatment with high-dose steroid failed to relieve her ocular symptoms, recession of the left inferior rectus was performed 8 months later. One month after the surgery, she developed multiple lesions of erythematous nodosa with tenderness. Skin biopsy of the lesion in the fingers showed the histological findings consistent with lupus. CONCLUSIONS: Eye movement abnormality can be an initial manifestation of SLE, which should be considered as a differential diagnosis especially in young female patients.

Comparison of Manifest Refraction and Cycloplegic Refraction Using Retinoscopy or an Autorefractor in Children

PURPOSE: To compare the measurements between manifest refraction and cycloplegic refraction using retinoscopy or an autorefractor in children and to investigate factors affecting the difference. METHODS: A total of 388 children with a mean age of 7.4 ± 3.6 years were examined using retinoscopy and a Grand Seiko GR-3500KA autorefractor before and after cycloplegia. We compared the difference in spherical and cylindrical components between refractions and analyzed the results according to gender, age, type of refractive error, amblyopia, strabismus, and neuro-developmental disorder. A difference in refractions of ±0.50 D or more was considered as a significant discrepancy. RESULTS: Before cycloplegia, the spherical portion of the refractive error via autorefractor measurement was more myopic than for the retinoscopic measurement in 47.2% of patients, and the cylindrical portion was greater in 37.1%. The spherical discrepancies were more common in children aged < 7 years, with hyperopia, or amblyopia (respectively, p = 0.002, p < 0.001, and p = 0.033). After cycloplegia, the spherical component of the refractive error by auto-refraction differed from retinoscopic measurement in 29.4% of patients, and the cylindrical portion differed in 30.7%. However, the difference was not significant and there was no difference according to clinical features. More than half of the children with discrepancies in the spherical component between retinoscopic refractions before and after cycloplegia had a discrepancy between auto-refraction and retinoscopic refraction before cycloplegia, and the two discrepancies had a significant correlation. CONCLUSIONS: Auto-refraction after cycloplegia can estimate retinoscopic values partially. Nevertheless, 30% of the children still showed a discrepancy. The discrepancy of manifest refraction or auto-refraction compared to retinoscopic refraction with cycloplegia should be considered in younger children, cases with hyperopia or amblyopia, and cases with a difference in auto-refraction and retinoscopic refraction before cycloplegia.

Comparison of Improvement Rates between Distance and Near Visual Acuity in Children with Unilateral Amblyopia

PURPOSE: To compare the improvement rates of distance visual acuity (VA) with that of near VA in amblyopic eyes of children with unilateral amblyopia. METHODS: The medical records of children with unilateral amblyopia successfully treated with patching were reviewed. During subsequent visits for amblyopia treatment, subjects had best-corrected VA measured at 4 meters and 1/3 meters every 2 months. Duration of treatment to achieve equal VA between both eyes and improvement rates were compared between distance and near, and analyzed according to the cause and severity of amblyopia, or age. RESULTS: A total of 76 children with amblyopia due to anisometropia and/or strabismus started amblyopia treatment at a mean age of 5.8 years and were followed up during a mean period of 16.4 months. Baseline VA was better at near than at distance in 52 children (68.4%), and better at distance than at near in 4 (5.3%). The mean duration of treatment was 5.4 months at distance and 3.9 months at near. However, the improvement rate considering the amount of improvement of VA was faster at distance; 0.11 log MAR/month at distance, and 0.08 log MAR/month at near (p = 0.016). The improvement rate differences between distance and near did not differ based on the cause of amblyopia, or age, whereas in mild amblyopia the improvement rate of distance VA was significantly faster than near. Additionally, children with better initial near VA tended to have a faster improvement rate of distance VA. CONCLUSIONS: Although baseline VA was better at near than at distance in more patients, the improvement rate was faster at distance than at near. Children with better initial near VA appeared to have a faster improvement rate of distance VA.