The Challenge of Strabismus Surgery for Patients with Hemianopic Visual Field Defects Associated with Ocular Deviations.

Homonymous and heteronymous hemianopias associated with strabismus are a therapeutic challenge because surgery may result in diplopia, decrease the visual field (VF), and/or lead to recurrence of the deviation. We present four cases: two homonymous hemianopias and two heteronymous hemianopias. Of the four patients, three had exotropia and one had esotropia. The origin of hemianopias was neoplastic in two cases and traumatic in two cases. Strabismus surgery was performed in three cases, but only one case had a good result; recurrence of the deviation and diplopia occurred in the other two cases. In conclusion, exotropia may develop as a compensatory mechanism in a patient with congenital or early-onset homonymous hemianopia and realigning the eyes could reduce the binocular VF and cause diplopia. In heteronymous hemianopias, there is little risk of the surgery causing diplopia, but the strabismus is unstable because of the absence of binocular vision and vergence reflexes if VF loss includes the macula. Further, strabismus, in association with hemianopia, may be caused by coexistent cranial nerve and/or gaze palsy. The prognosis, objective, and results of the strabismus operation should be clearly discussed with the patients or their guardians before it is performed if hemianopias are present.

Distance stereopsis in patients with accommodative esotropia.

PURPOSE: We aimed to evaluate distance stereoacuity (DS) in patients with successfully treated accommodative esotropia (AET) and its association with other clinical factors. METHODS: The medical records of 176 children with refractive AET with a follow-up period ≥ 1 year were reviewed to identify a cohort of patients who achieved a stable alignment within 4 prism diopters (PD) of orthotropia at both distance and near fixation. Age of onset, duration of misalignment, uncorrected near and distance deviation, accommodative convergence/accommodation ratio, refractive error, presence of anisometropia and amblyopia, near stereopsis were evaluated as predictors of outcome. DS was measured using the Distance Randot Stereo test and near stereoacuity by Randot Stereotest. The patient group was compared with 50 age-matched normal controls for DS. RESULTS: Fifty-six patients were included, and 38 patients had DS at the final visit. All patients with DS attained uncontoured near stereopsis (UCNS). UCNS was present only in 11 patients without DS (p = 0.001). Anisometropia (p = 0.997), uncorrected near deviation (p = 0.224), distance deviation with correction (p = 0.255), and high hypermetropia (p = 0.998) were not associated with DS. The multivariable regression model showed a significant positive correlation between UCNS and DS (OR = 31.14 (95% CI 2.25-430.48); p = 0.01). Contoured near stereopsis outcome was significantly different between the patients with and without DS (p = 0.001 for animals and p = 0.003 for circles). Compared with the control group, the patient group yielded lower DS scores (p = 0.001). CONCLUSION: Distance Randot Stereotest can be useful in measuring binocular vision recovery after successful realignment in refractive AET patients. Patients attaining normal scores for near stereopsis tests after optical correction revealed subnormal thresholds for DS.

Advances in the diagnosis and treatment of acute acquired comitant esotropia.

Acute acquired comitant esotropia (AACE) is mainly characterized by sudden onset, accompanied by diplopia, without extraocular muscles paralysis or ocular motility disorders. In recent years, the incidence of AACE has been increasing, researchers have found that this phenomenon may be related to the widespread use of electronic devices and the increase in the number of people working from home during the COVID-19 pandemic. However, its neural mechanisms have not been fully elucidated. This article primarily reviews the latest developments in the diagnosis and treatment of AACE from the perspectives of etiology and treatment methods, aiming to provide direction for future in-depth exploration of the pathogenesis and treatment approaches of this disease.

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

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

The effects of refractive status on the outcomes of strabismus surgery in patients with esotropia.

BACKGROUND: The success of the strabismus surgery can hinge on several factors. One of these factors is refractive condition like hyperopia or myopia. Our study seeks to evaluate the surgical outcomes in patients with esotropia and myopia. METHODS: This case-control study encompassed all surgical cases of esotropia at Torfe and Negah Hospital between 2016 and 2021, which satisfied our specified inclusion criteria. The initial variables from electronic medical records were collected, including demographic, clinical, and surgery-related factors. At the final follow-up appointment, the level of eye deviation, both at distance and near, was recorded. We considered the operation a "success" for patients with a post-surgery distance eye deviation of 10(Pd) or less. Patients with greater deviation were classified as surgery failure. Statistical analyses were executed using SPSS software (version 16.0), and a P-value less than 0.05 was considered significant. RESULTS: Of the 194 patients evaluated, 112 were incorporated into the study. Surgical failure was observed in 14.29% of myopic patients, 29.79% of hyperopic patients, and 31.82% of emmetropic patients. The myopia group displayed a 0.19 odd ratio for surgical failure compared to the combined hyperopia and emmetropia groups, not statistically significant (OR: 0.19, CI 95%: 0.03-1.02). Additionally, patients diagnosed with Lateral Rectus Under-action were found to be 6.85 times more likely to experience surgery failure(OR: 6.85, CI 95%: 1.52-30.94). An elevated risk of surgical failure was also identified in patients who underwent Inferior Oblique Weakening procedure, indicated by a 3.77-fold increase in the odds ratio for failure(OR: 3.77, CI 95%: 1.08-13.17). CONCLUSION: In our study, despite numerical disparities, there was no statistical difference among the success rates of all esotropia patients with different refractive errors. The patients with LRUA or IOOA showed lower success rates. Myopic patients had higher post-op overcorrection with lower reoperation rates compared to hyperopic or emmetropic patients.

Factors influencing the therapeutic effect of hyperopic correction on esotropia in patients with partially accommodative esotropia.

OBJECTIVES: To collate data on partially accommodative esotropia (PAET) to better understand this condition's aetiology and to evaluate and predict the therapeutic effect of a hyperopic correction on PAET. METHODS: Eighty-nine consecutive patients diagnosed with PAET with a spherical equivalent (SE) refractive error >+2.50 D were included in this retrospective review. Clinical characteristics, including gender, age, SE, angle of esodeviation, accommodative convergence/accommodation (AC/A) ratio, near-distance disparity (NDD) and anatomical features of the rectus muscles were compared among different PAET subgroups. Multiple linear regression was used to identify independent factors that influenced the therapeutic effect of a hyperopic correction on esotropia. RESULTS: No significant differences were observed for the angle of esodeviation as a function of age in individuals with PAET. The incidence of SE in PAET participants >9 years old was significantly greater than in those <5 and 6-8 years of age. The therapeutic effect of hyperopic correction on esotropia was positively associated with SE both at distance and near. In addition, the limbus insertion distance (LID) of the lateral rectus (LR) muscle was positively associated with NDD at distance, but negatively associated at near. CONCLUSION: A greater incidence of hyperopia was observed in older (>9 years old) PAET patients. A hyperopic correction had a greater effect on esotropia in individuals with a higher SE, larger LID of the LR muscle and a smaller NDD.

Pilot Study Assessing the Effect of Exam Room Length on the Measurement of Strabismus.

PURPOSE: Our study aims to investigate the effect of decreasing distance from the patient to the fixation target on the measurement of strabismus with a known distance-near disparity. METHODS: Strabismus measurements were taken by one pediatric ophthalmologist at our standard distance of 18 feet and compared to those taken at 16, 14, 12, and 10 feet from the fixation target. A clinically meaningful difference was defined as >2.5 prism diopters (PD), since a difference of that magnitude may alter surgical planning. RESULTS: Thirty-nine subjects, including 22 exotropes and 17 esotropes, were included in this study. Mean prism diopter difference (PDD) in the exotrope group at lengths of 16, 14, 12, and 10 feet compared to 18 feet were 1.3 (SD 1.9, range 0-6), 1.3 (SD 2.2, range 0-8), 1.7 (SD 3.2, range 0-14), and 2.8 (SD 4.4, range 0-14), respectively. Among esotropes, the mean PDD at the same distances were 1.1 (SD 1.9, range 0-7), 2.1 (SD 2.6, range 0-7), 3.9 (SD 4.9, range 0-19), and 4.3 (SD 5.1, range 0-19). The percentages of exotropes with a PDD of >2.5 at 16, 14, 12, and 10 feet compared to 18 feet were 13.6% (n = 3), 13.6% (n = 3), 18.2% (n = 4), and 27.3% (n = 6), respectively. In the esotrope group, 11.8% (n = 2), 35.3% (n = 6), 47.1% (n = 8), and 47.1% (n = 8) had a PDD of >2.5 at the same distances, respectively. CONCLUSION: This pilot study is the first to investigate the change in measured angle of strabismus at various non-mirrored distances from the patient to the fixation target. Our methodology defines a framework that could be used in a higher-powered study to further our understanding of the effect of room length on strabismus evaluation.

Long-term Ocular Alignment and Sensory Outcomes After Medial Rectus Recession for High AC/A Ratio Esotropia.

PURPOSE: To report long-term ocular alignment and sensory outcomes after medial rectus recession for high accommodative convergence/accommodation (AC/A) ratio esotropia. METHODS: The medical records of consecutive patients who had undergone unilateral or bilateral medial rectus recession for high AC/A ratio esotropia and were observed postoperatively for a minimum of 5 years were reviewed retrospectively. RESULTS: A total of 34 patients were included. Twenty-three patients (68%) used bifocals preoperatively. The mean age at surgery was 11.5 ± 4.4 years (range: 2.5 to 19.0 years). The mean postoperative follow-up was 7.5 ± 2.3 years (range: 5.0 to 15.25 years). Overall, 21 patients (62%) had surgical success at their last follow-up visit. Age at surgery, preoperative angle of distance and near deviation, distance-near disparity, and preoperative bifocal wear did not predict motor outcome after surgery. Preoperative presence of peripheral binocular single vision was a significant favorable factor for surgical success. At the last follow-up visit, 21% of patients had a recurrence of high AC/A ratio esotropia and 9% each had consecutive exotropia (intermittent [3%] and constant [6%]) and basic esotropia. Peripheral binocular single vision was achieved in 64% of patients and stereopsis in 28%. Bifocal segment was eliminated postoperatively in 70% of patients. CONCLUSIONS: Nearly two-thirds of patients with high AC/A ratio esotropia achieved a successful long-term motor outcome and peripheral binocular single vision, and nearly one-fourth achieved stereopsis. Recurrence of high AC/A ratio esotropia occurred in some patients, and consecutive exotropia and basic esotropia in a few. Bifocal segment was eliminated postoperatively in 70% of patients. [J Pediatr Ophthalmol Strabismus. 2024;61(5):344-350.].

Surgical treatment outcomes in heavy eye syndrome - a case series.

Results: The study cohort comprised five patients, each presenting with unilateral high axial myopia and classic clinical features of HES, including large angle esotropia, hypotropia, and restricted abduction and supraduction. All patients displayed evident superotemporal globe prolapse on MRI imaging, corresponding to the downward displacement of the LR muscle and medial shift of the SR muscle.Following the surgical procedure, all patients demonstrated significant improvements in both vertical and horizontal deviations, effectively addressing the primary clinical manifestations of HES.Conclusions: In the management of HES, several surgical approaches have been explored, yielding mixed results. Our study, employing the technique of partial muscle splitting and scleral fixation, offers a promising avenue for effectively addressing this challenging condition. By adapting the full loop myopexy technique originally proposed by Yokoyama et al. we achieved satisfactory ocular alignment in all five patients. Notably, this approach mitigates the risk of anterior segment ischemia by preserving the unsecured portions of the SR and LR muscles along with MR retroequatorial myopexy.These findings support the consideration of this surgical technique as a safe and effective option for managing HES, providing both cosmetic and functional improvements to afflicted individuals.

Long-Term Effects of Botulinum Toxin A Versus Incisional Surgery for Management of Partially Accommodative Esotropia in Children: Comparison of Three Approaches.

PURPOSE: To compare the effect of bilateral medial rectus injection of botulinum toxin A (BTX-A), bilateral medial rectus muscle recession surgery (BMR rc), or unilateral medial rectus muscle recession combined with lateral rectus muscle resection surgery (R&R), in the management of partially accommodative esotropia (PAET) in children. DESIGN: Retrospective comparative clinical study. METHODS: The study cohort included 98 patients diagnosed with PAET who had BTX-A injection or incisional surgery between December 2014 and January 2023. The main outcome measures included motor and sensory results as well as complications. Follow-up was at least 12 months for all patients. RESULTS: There were 28 patients in the BTX-A group, 45 in the R&R group, and 25 in the BMR rc group. The motor success rates at distance and near fixation respectively were 50% (14/28) and 54% (15/28) in the BTX-A group, which were lower than that of the R&R group (78% [35/45], 84% [38/45]) and the BMR rc group (72% [18/25], 84% [21/25]) (P = .042 for near and P = .006 for distance). For patients with onset age <2.5 years old, there was no statistical difference amongst the 3 surgical approaches (P = .656). For patients with onset age ≥2.5 years, the motor success rate of the R&R group (81% [26/32]) and the BMR rc group (88% [14/16]) was higher than that in the BTX-A group (38% [5/13]; P = .004). There was no statistical difference in sensory outcomes for patients regardless of onset age or treatment methods (P > .05 for all). During follow-up, 4% (2/45) of patients in the R&R group and 20% (5/25) in the BMR rc group developed consecutive exotropia; no patient in the BTX-A group was overcorrected (P = .017). CONCLUSIONS: Bilateral medial rectus muscle injection with BTX-A in patients with PAET is a safe, accessible, and low-cost alternative. Although motor success rates were higher, overall, in patients treated with incisional surgery, for patients with earlier age of onset (≤ 2.5 years old), BTX-A injection may be preferred to incisional surgery. In older children treated with unilateral recession-resection surgery, fewer developed consecutive exotropia.

Effect of 4-week preoperative prism adaptation in preventing postoperative residual esotropia.

BACKGROUND: Preoperative prism adaptation (PPA) simulates postoperative status and possibly can predict postoperative undercorrection before surgery in esotropia. The present study aimed to assess the effect of 4-week PPA in preventing postoperative residual esotropia. METHODS: Seventy-five (75) esotropes who had undergone surgery at a single strabismus center were retrospectively enrolled. They included 25 basic, 31 acute comitant, 10 partially accommodative, and 9 recurrent esotropia patients. The preoperative deviation angle, which had been determined using the alternating prism and cover test, was fully corrected with press-on prisms 4 weeks before surgery. If there was an increase of 5 PD or more of esodeviation, the prisms were changed accordingly at 2 weeks. The deviation angle measured at 4 weeks was determined as the surgical target angle. Patients were then divided into increase (≥ 5 PD increase of angle during 4-week PPA) and non-increase groups. Success was defined as either esodeviation of 8 PD or under or exodeviation of 5 PD or under at distance at postoperative 6 months. RESULTS: The increase group included 44 patients (58.7%). The mean deviation angle before PPA was 27.4 PD, and after the 4-week PPA, there was an average increase of 9.4 PD. The success rate was 90.9% in the increase group and 96.8% in the non-increase group (p = 0.316). There were no intergroup differences in preoperative clinical characteristics, esotropia types, postoperative deviation angle or postoperative near stereopsis (p > 0.05). CONCLUSIONS: The results of this study indicated a beneficial effect of 4-week PPA in esotropia of various types, specifically by uncovering the hidden esodeviation in the increase group and simulating the postoperative alignment in both the increase and the non-increase groups.

Effects of cycloplegia on crystalline lens morphology and location in acute acquired concomitant esotropia.

PURPOSE: The study aims to compare morphology and location of crystalline lens between acute acquired concomitant esotropia (AACE) patients and control subjects, both before and after cycloplegia. METHODS: This is a prospective and observational clinical study. Morphological and locational parameters of the crystalline lens in 53 AACE patients and 32 control subjects were assessed before and after cycloplegia using CASIA2 system, which represents the latest swept-source anterior segment optical coherence tomography. Cycloplegic refraction was recorded by administering 1% atropine in patients younger than 12 years and 1% cyclopentolate in those > 12 years old. Morphological parameters included anterior radius of curvature (ARC), posterior radius of curvature (PRC), lens thickness (LTH), and equivalent diameter of lens (LED). Locational parameters comprised lens decentration (LD) and lens tilt (LT). Comparison of these parameters before and after cycloplegia were conducted between AACE and controls. Additionally, the study analyzed and compared the changes in these parameter post-cycloplegia. RESULTS: Our findings suggest no significant difference in morphological parameters including ARC, PRC, LTH and LED between AACE patients and controls before or after cycloplegia. However, 2D-modeling data in the 0° meridian revealed that variation post-cycloplegia of LD (lens shift) in right eyes was different in AACE patients, measuring - 0.03(0.08) [median(interquartile range)] which was significantly distinct from the control group, exhibiting a measurement of 0.01(0.06) (z = - 2.373, p = 0.018). In left eyes, a similar trend was observed with lens shift in the 0° meridian being 0.02(0.06) in AACE, significantly differing from control group's measurement of - 0.02(0.08) (z = - 2.809, p = 0.005). Further, correlation analysis revealed that larger temporal shift of lens was associated with greater changes in ARC (r = 0.294, p = 0.006) and LTH (r = - 0.230, p = 0.031). CONCLUSIONS: The morphological features of the crystalline lens were similar in AACE patients and controls; however, the change of lens location by cycloplegia was observed only in AACE patients, suggesting an association with excessive accommodation.

Doses of medial rectus muscle recessions for divergence insufficiency-type esotropia.

We evaluated whether doses of bilateral medial rectus recessions greater than Parks's tables yielded superior outcomes for adult-onset divergence insufficiency. Forty-two patients underwent bilateral medial rectus recessions. Dose was analyzed as the average total per muscle (surgery + suture adjustment if performed) and compared with the standard dose tables (based on preoperative distance esodeviation), as difference between dose performed and dose indicated by Parks's tables. Each participant was classified as having received either Parks's dose (within 0.5 mm) or a dose greater than Parks's dose. Success was defined as "rarely" or "never" diplopia in distance straight-ahead gaze and reading. For patients classified as success, the mean difference between actual surgical dose performed and Parks's dose was calculated. Success was 91% (29/32) in those receiving greater than Parks's dose versus 67% (6/9) with Parks's dose (difference = 24%; 95% CI, -5% to 60%). The mean surgical dose was 1.0 mm greater than Parks's tables for the 35 successes (at 10 weeks) versus 0.7 mm greater for the 6 failures (difference = 0.4 mm; 95% CI, -0.2 to 0.9). For medial rectus recessions in adult-onset divergence insufficiency-type esotropia, a surgical dose 1 mm greater than Parks's tables, for each muscle, is a reasonable strategy.

Neonatal Macular Hemorrhage in a Term Healthy Infant: 18-Year Follow-up.

Unobstructed binocular vision is required during the critical period of vision development to obtain optimal visual acuity in each eye and binocular stereopsis. In this article, we report 18-year follow-up of a full-term, otherwise healthy infant noted to have dense premacular hemorrhage occluding the visual axis in the left eye on retinal imaging performed 48 hours after birth. Serial examinations by the retina service were performed weekly for 10 weeks as the hemorrhage resolved spontaneously. Shortly thereafter, visual acuity revealed fixation was present, but the mother noted intermittent left eye esodeviation. At 90 days of life, the infant was seen by pediatric ophthalmology and started on 1 to 2 hours patching of the right eye daily for the esotropia, which was maintained through 24 months. At 18 years of age, the patient had orthophoria alignment, no spectacle correction, vision of 20/20 in the right eye and 20/25 in the left eye, and normal binocularity and stereopsis. Intermittent esodeviation on the left eye was observed when the patient was fatigued. Early identification of a visual axis occlusion led to prompt referral for the esotropia and initiation of patching therapy. This patient ultimately achieved a very favorable visual functional outcome that may not have been possible without early detection and management. This case report describes the longest-term published follow-up of a neonatal macular hemorrhage. [Ophthalmic Surg Lasers Imaging Retina 2024;55:354-357.].

Mechanisms for Positive Bielschowsky Head Tilt Testing in Horizontal Strabismus.

PURPOSE: To elucidate the induced effects of horizontal strabismus on the Bielschowsky Head Tilt Test (BHTT). DESIGN: Prospective clinical study. METHODS: Prospective analysis of BHTT testing in 85 patients with exotropia and 71 patients with esotropia who were examined in a strabismus clinic. RESULTS: Eighty-four of 85 patients with exotropia (98.82%) showed a positive BHTT with an induced hyperdeviation on the side of the tilt (to both sides in 67% and to one side in 32%). Fifty-seven of 71 patients with esotropia (80.2%) showed a positive BHTT with an induced hypodeviation on the side of the tilt (to both sides in 57.7% and to one side in 22.5%). These induced vertical deviations were greater in patients with larger horizontal deviations and in those with constant rather than intermittent deviations; however, they were not influenced by the presence or absence of associated primary oblique muscle overaction. CONCLUSIONS: Exotropia and esotropia produce hyperdeviations during BHTT testing, with a hyperdeviation on the side of the tilt observed in patients with exotropia, and hypotropia on the side of the tilt observed in patients with esotropia. These diametrical results are not attributable to any preexistent alteration of neurologic output inherent to these two forms of horizontal strabismus or to associated torsion. Rather, they arise directly from the altered anatomical positions of the two eyes, which cause the eyes to approximate their visual axes more closely to the vertical rectus muscles (in exotropia) and the oblique muscles (in esotropia), enabling the vertical actions of specific cyclovertical muscles to predominate in response to altered utricular output generated by the BHTT.

Long-term surgical outcomes of one-muscle vs. two-muscle horizontal strabismus surgery.

PURPOSE: While horizontal strabismus surgery is generally considered to have favorable outcomes, success rates can vary by type of procedure. Our purpose is to compare the long-term outcomes of patients who underwent one-muscle vs. two-muscle horizontal strabismus surgery. METHODS: This is a retrospective study comparing one-muscle to two-muscle strabismus surgery for small to moderate angle horizontal strabismus. Demographic data and eye exam parameters were compared at baseline and postoperatively (6 months up to 6 years). Surgical success was defined as a post-operative angle of 10 PD or less. We also compared outcomes by strabismus type: esotropia vs exotropia and adjusted the analysis for previous strabismus surgery. RESULTS: Out of 89 patients with moderate angle horizontal strabismus (25 PD or less), 17 patients had a one-muscle operation, and 72 patients had two-muscle surgery. The mean age was 14.12 ± 9.30 years and 11.70 ± 11.30 years for the one-muscle and two-muscle groups, respectively (p = .74). The baseline characteristics of both groups were comparable. Follow-up time was 32.82 ± 26.93 months in one-muscle and 37.67 ± 23.81 in two-muscle groups (p = .29). Success rate was 70.6% for the one-muscle group and 68.10% for the two-muscle group (p = .69). Outcomes were similar when divided into esotropia and exotropia. The success rate was not affected by previous strabismus surgeries nor by the initial angle of deviation. CONCLUSION: One-muscle and two-muscle horizontal strabismus surgery had similar long-term outcomes and did not differ by strabismus type nor by angle of deviation.

Sensory exotropia versus sensory esotropia: A comparative clinical features study.

PURPOSE: This study aimed to compare the preoperative clinical features of patients with sensory esotropia (ET) and sensory exotropia (XT). METHODS: In a retrospective study, the medical records of 13,252 patients who underwent strabismus surgery were reviewed at the Farabi Eye Hospital, Iran, from 2012 to March 2022. There were 1017 patients with sensory horizontal strabismus whose, in their worse eye, had corrected distance visual acuity (CDVA) equal to or <20/160 tested with the Snellen chart. RESULTS: The mean age of patients was 29.0 ± 12.4 years [574 (56.4%) males and 443 (43.6%) females]. Sensory XT and ET were observed in 717 (70.5%) and 300 (29.5%) patients, respectively (P<.001). The mean CDVA in the strabismic and non-strabismic eyes was 1.40 ± 0.75 and 0.05 ± 0.13, respectively (P<.001). Also, the CDVA in the strabismic eyes was significantly worse in the patients with sensory XT than in the patients with sensory ET (P<.001). Sphere and spherical equivalent (SE) components were more hyperopic in both eyes of patients with sensory ET than sensory XT (P<.001). In sensory ET group, the mean horizontal deviation at far and near was significantly higher than the sensory XT group (both P<.001). The prevalence of moderate and severe amblyopia among all patients with sensory strabismus was 274 (26.9%) and 727 (71.5%), respectively (P<.001). There were 398 (39.1%) patients who needed more than one surgery. CONCLUSION: The frequency of sensory XT was about 2.5 times more than the sensory ET. Most patients with sensory ET were operated at a younger age, had better CDVA, more hyperopic spherical and SE, and higher angle of deviation compared with patients with sensory XT. The chance of reoperation in patients with sensory strabismus was about 40%.

A Comparison of Chemodnervation to Incisional Surgery for Acute, Acquired, Comitant Esotropia: An International Study.

PURPOSE: To compare the efficacy of botulinum toxin injections to strabismus surgery in children with acute, acquired, comitant esotropia (ACE), and to investigate factors predicting success. DESIGN: International, multi-center nonrandomized comparative study METHODS: Setting: Cloud-based survey. STUDY POPULATION: Children aged 2 to 17 years who underwent a single surgical intervention for ACE. INTERVENTIONS: Botulinum toxin injection ("chemodenervation" group) or strabismus surgery ("surgery" group). MAIN OUTCOME MEASURES: Primary measure: success rate at 6 months in propensity-matched cohort, defined as total horizontal deviation of 10 prism diopters or less with evidence of binocular single vision. Secondary measure: Risk factors for poor outcomes in the full cohort. RESULTS: Surgeons from 19 centers contributed. There were 74 patients in the chemodenervation group and 97 patients in the surgery group. In the propensity-matched data (n = 98), success rate was not significantly different at 6 months (70.2% vs 79.6%; P = .2) and 12 months (62.9% vs 77.8%; P = .2), but was significantly lower in the chemodenervation group at 24 months (52% vs 86.4%; P = .015). Irrespective of treatment modality, treatment delay was associated with lower success rates at 6 months, with median time from onset to intervention 4.5 months (interquartile range (IQR): 2.1, 6.7) in the success group and 7.7 months (IQR: 5.6, 10.1) in the failure group (P < .001). CONCLUSIONS: In children with ACE, success rate after chemodenervation was similar to that of surgery for up to 12 months but lower at 24 months. Those with prompt intervention and no amblyopia had the most favorable outcomes, regardless of treatment modality.

Outcomes of "a new modification of Jensen technique combined with medial rectus recession" in patients with complete sixth cranial nerve palsy.

BACKGROUND: To report the outcomes of "our modified Jensen technique" for treating esotropia in cases with complete sixth cranial nerve (CN VI) palsy. METHODS: This study is a 30-year case series of isolated complete CN VI palsy who underwent combined medial rectus recession and our modified Jensen operation. We modified the original technique by anchoring the muscle-unifying sutures to the sclera near the equator using a non-absorbable suture. Major outcomes such as postoperative diplopia, face turn, horizontal and vertical eye deviations, and abduction limitation were assessed. Successful surgery was defined as orthotropia or esotropia equal to or less than 8 prism diopters (PD) and the absence of any vertical deviation. RESULTS: Fifty-three cases with a mean age of 28 years old were included in this study. The male-to-female ratio was 3 to 1. Forty-five cases (85%) presented with unilateral palsy, whereas 8 patients (15%) had bilateral palsy. Trauma was the most common etiology (85%). Diplopia or face turn, presented in 42 patients before the operation, remained in seven cases after the operation. Primary position esotropia, which was the main complaint in all patients, decreased from 49 PD to 4 PD in unilateral palsy and from 101 PD to 10 PD in bilateral palsy. The mean reduction of abduction deficit was 1.78 in unilateral and 1.75 in bilateral palsy. The success rate was 76% in unilateral and 62% in bilateral palsy. CONCLUSION: Our modified Jensen operation was effective in treating patients with complete CN VI palsy, producing no significant permanent complications.