Long-term surgical outcomes of basic-type exotropia in patients with hyperopia.

BACKGROUND: To investigate the surgical outcomes of basic-type exotropia in patients with hyperopia. METHODS: The medical records of patients who underwent surgery for basic-type exotropia and had been followed up for ≥ 2 years were retrospectively recruited. Patients with myopia and spherical equivalent (SE) < -1.0 diopters (D) were excluded. The patients were classified according to the SE: group H had a SE ≥ + 1.0 D, and group E had -1.0 ≤ SE < + 1.0 D. The surgical success rate and sensory outcome were compared. Surgical success was defined as exodeviation ≤ 10 prism diopters (PD) and esodeviation ≤ 5 PD at 6 m fixation. Stereoacuity was measured using the Titmus Preschool Stereoacuity Test. RESULTS: Seventy-five patients (24 males and 51 females, mean age 5.1 ± 2.6 years, range 2.7-14.8) were included. The SE ranged from -0.9 to 4.4 and 21 patients were classified into group H and 54 into group E. The success rates were higher in group H than in group E during the entire follow-up period, but the differences were significant only at the final examination. At the final follow-up, 11 of the 21 (52.4%) patients in group H and 15 of the 54 (27.7%) in group E maintained successful alignment, whereas 10 (47.6%) and 38 (70.4%) patients exhibited recurrence. Overcorrection was exhibited in one (1.9%) patient in group E. Sensory results were comparable between the groups. The follow-up period did not differ between the two groups. The survival analysis showed no difference in the surgical results between the two groups. CONCLUSIONS: Surgery for basic-type intermittent exotropia resulted in superior outcomes in patients with hyperopia compared to those with emmetropia.

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.

Ocular motility disorders following coronavirus disease-19 vaccination.

PURPOSE: To describe clinical manifestations and short-term prognosis of ocular motility disorders following coronavirus disease-2019 (COVID-19) vaccination. METHODS: Ocular motility disorders were diagnosed by clinical assessment, high-resolution magnetic resonance imaging, and laboratory testing. Clinical manifestations, short-term prognosis, and rate of complete recovery were analyzed. RESULTS: Sixty-three patients (37 males, 26 females) with a mean age of 61.6 ± 13.3 years (range, 22-81 years) were included in this study. Among 61 applicable patients with sufficient information regarding medical histories, 38 (62.3%) had one or more significant underlying past medical histories including vasculopathic risk factors. The interval between initial symptoms and vaccination was 8.6 ± 8.2 (range, 0-28) days. Forty-two (66.7%), 14 (22.2%), and 7 (11.1%) patients developed symptoms after the first, second, and third vaccinations, respectively. One case of internuclear ophthalmoplegia, 52 cases of cranial nerve palsy, two cases of myasthenia gravis, six cases of orbital diseases (such as myositis, thyroid eye disease, and IgG-related orbital myopathy), and two cases of comitant vertical strabismus with acute onset diplopia were found. Among 42 patients with follow-up data (duration: 62.1 ± 40.3 days), complete improvement, partial improvement, no improvement, and exacerbation were shown in 20, 15, 3, and 4 patients, respectively. CONCLUSION: This study provided various clinical features of ocular motility disorders following COVID-19 vaccination. The majority of cases had a mild clinical course while some cases showed a progressive nature. Close follow-up and further studies are needed to elucidate the underlying mechanisms and long-term prognosis.

Successful Treatment of Optic Neuropathy Associated with Sphenoid Sinus Aspergillosis.

PURPOSE: We report a case of optic neuropathy related to sphenoid sinus aspergillosis which showed good visual recovery with surgery and medical antifungal treatment. METHODS: Observational case study Case Presentation A 62-year-old man presented with decreased visual acuity in the right eye for 3 weeks. His visual acuity was counting fingers in the right eye and 20/20 in the left eye. Relative afferent pupillary defects were detected in the right eye. Optic neuropathy related to invasive fungal sphenoid sinusitis was suspected via radiologic evaluation. Endoscopic sinus surgery was performed and histopathological examination revealed aspergillosis. Amphotericin B combined with ceftriaxone and metronidazole was started. After the fungal culture results were positive for the Aspergillus species, amphotericin B was changed to voriconazole. At 1 month after surgery, visual acuity improved to 20/25. CONCLUSION: Appropriate radiologic evaluation can be helpful when optic neuropathy associated with a fungal infection is suspected, and timely surgical and medial treatment should be considered.

Predictive value of OCT and MRI for postoperative visual recovery in patients with chiasmal compressive lesions.

PURPOSE: We aimed to investigate the predictive value of retinal thickness measured by optical coherence tomography (OCT) and mass biometrics measured using magnetic resonance image (MRI) for visual recovery after surgery for removal of a mass compressing the optic chiasm. METHODS: Consecutive patients who showed typical temporal visual field defect (VFD) with respect to the vertical meridian due to a chiasmal compressive mass and who underwent mass removal surgery were recruited. Ophthalmic examination was performed preoperatively and postoperatively. Retinal thickness was measured by the Cirrus OCT. The height and size of the mass and suprasellar extension (SSE) in both the sagittal and coronal planes were evaluated. Patients were divided into two groups based on the improvement in VFD (mean deviation [MD] change ≥ 5 dB: group R; others: group NR) and clinical characteristics were compared. RESULTS: Fifteen patients were included in the study. Eight (53.3%) patients were allocated into group R and others (7 patients, 46.7%) into group NR. Age, sex, initial visual acuity, initial MD was not different between the two groups. The retinal thicknesses were not different while tumor height, volume, and both sagittal and coronal SSE were significantly different between the two groups. (p = 0.029, 0.014, <0.001, and <0.001, respectively) All MRI parameters showed significant predictive value for the degree of MD recovery. CONCLUSION: MRI showed better predictive value than OCT in predicting postoperative VFD recovery in patients with temporal VFDs due to chiasmal compressive disorder.

Clinical Characteristics for Predicting Recovery of Acquired Fourth Cranial Nerve Palsy.

BACKGROUND: Fourth cranial nerve palsy is the most common disease diagnosed in patients with vertical diplopia. Although it is reported to present a good prognosis, there are currently no agreed on prognostic factors that anticipate the recovery of the palsy other than the etiology. The purpose of this study was to investigate the prognostic factors of acquired fourth cranial nerve palsy. METHODS: The medical records of consecutive patients diagnosed with acquired unilateral fourth cranial nerve palsy from 2010 to 2020 and followed up for ≥6 months were retrospectively reviewed. The cause and degree of palsy, ocular deviation (horizontal, vertical, and cyclo), and fundus torsion were reviewed. The cause of palsy was classified as ischemic, traumatic, intracranial mass, others, or idiopathic. Patients were divided into 2 groups according to palsy recovery: complete recovery (group CR) or not CR (group NCR). The clinical characteristics of the 2 groups were compared, and the risk factors for incomplete recovery were investigated. RESULTS: Thirty-five patients (25 men) were included in the study. The average age was 55.94 ± 16.11 years. CR was achieved in 23 patients (65.7%), and the time to recovery was 3.91 ± 4.03 months. The most common cause was traumatic (40.0%), followed by ischemia (37.1%), intracranial mass (11.4%), others (8.6%), and idiopathic (2.9%). The degree of palsy and fundus torsion was significantly higher in group NCR (P = 0.010 and P = 0.001). Severe oculomotor limitation, large fundus torsion, and intracranial mass cause rather than ischemic cause indicated a higher risk of incomplete or no recovery (P = 0.016, P = 0.009, and P = 0.043). CONCLUSION: Identifying whether a patient has an intracranial mass, severe oculomotor limitation, or large fundus excyclotorsion may be useful for predicting the recovery of acquired unilateral fourth cranial nerve palsy.

An office-based fix-and-follow grading system assessing visual function in preverbal children.

BACKGROUND: Assessing visual function in infants is usually challenging. Fix-and-Follow is a simple and popular method for assessing early development of visual perception in infants, currently however, there is no formal reproducible method for grading the capacity of fix-and-follow. This study was to develop and validate a new fix-and-follow grading system for assessing visual function development in preverbal children. METHODS: In this cross-sectional study, the fix-and-follow grades was evaluated in 21 consecutive preverbal children. Fixation was categorised as grade 1 if there was no response to the target and grade 2 if there was a response but only for < 3 s. Grades of 3 and 4 were assigned based capacities to (1) fix on a moving target for ≥3 s, and (2) shift fixation from one target to another. If only one of these two criteria was met, grade 3 was assigned. If both were met, grade 4 was assigned. Following was evaluated using smooth pursuit movement, where grade 1 indicated no movement, grade 2 partial movement, and grade 3 complete movement. Two ophthalmologists independently applied the grading method in all patients. Then one of two examiners repeated the examinations to investigate the intra-observer agreement of the grading system. RESULTS: Intra-observer agreement was excellent (Kappa coefficient = 0.823) and inter-observer agreement was good (Kappa coefficient = 0.625). All patients who exhibited abnormal ocular movement had score discrepancy between a new fix-and-following grading examination. CONCLUSIONS: The new fix-and-follow grading scale can be applied easily in preverbal children in an office setting, and it proved reliable and reproducible.

The Radiologic Characteristics and Retinal Thickness Are Correlated With Visual Field Defect in Patients With a Pituitary Mass.

BACKGROUND: Investigation of visual field defects (VFDs) is important to decide the treatment and to predict the prognosis in patients with a pituitary mass. The aim of this study was to evaluate the correlation among 2 diagnostic modalities-MRI and optical coherence tomography (OCT)-and VFDs. METHODS: Consecutive patients who showed the presence of a pituitary mass on MRI and in whom ophthalmic examinations were performed were recruited. Height and volume of the mass, sagittal and coronal displacement of optic chiasm, and the direction of mass expansion were measured. Patients were divided into 2 groups according to the presence (VFD group) or absence of VFDs (no VFDs group [NVFD]). The correlation among MRI parameters, OCT parameters, and VFDs were examined, and the diagnostic values of MRI and OCT and the combined value of the 2 modalities were analyzed. RESULTS: Forty-one patients were included. The greatest coefficients of determination were observed between the sagittal displacement and pattern standard deviation (PSD) (R2 = 0.3661, P < 0.001) and between the inferonasal ganglion cell-inner plexiform layer (GCIPL) and PSD (R2 = 0.4079, P < 0.001). The height and the size of the mass in the VFD group were significantly greater as 57% and 148%, respectively, and the VFD group had more severe chiasmal displacement both in the sagittal (165%) and in the coronal (178%) plane (large effect in all). All macular GCIPLs were thinner in the NVFD group (range 9%-26%, large effect), whereas only temporal (25%) and average (11%) values were among peripapillary retinal nerve fiber layers. CONCLUSIONS: The highest correlations with the degree of the VFD were seen in the sagittal displacement of optic chiasm and the inferonasal GCIPL, and these parameters were correlated concurrently. Both modalities showed a good diagnostic value for discriminating VFDs.

Clinical features of strabismus in patients with congenital optic disc anomaly.

PURPOSE: To investigate the clinical features of strabismus in patients with congenital optic disc anomaly and compare and analyze the characteristics of patients who showed changes in the strabismus pattern with those who did not. METHODS: Medical records of the patients who were diagnosed with both strabismus and congenital optic disc anomaly and followed-up for ≥1 year were reviewed retrospectively. Clinical characteristics and ophthalmic features at the initial visit and final follow-up were assessed. Patients with a change in the direction of strabismus or a difference of >10 prism diopters in the deviation angle during the follow-up period were allocated to the changed group. The remaining patients were assigned to the unchanged group. The clinical characteristics of the two groups were compared. RESULTS: Twenty-eight patients (15 boys) were included (mean age, 39.0 months; range, 5-150 months). Three (10.7%) patients were born preterm and four (14.3%) had other underlying systemic disease. Sixteen (57.1%) patients had exotropia, and 12 (42.9%) had esotropia. Concurrent vertical strabismus was present in three (10.7%) patients. Strabismus features changed in 14 (50.0%, changed group) patients and remained unchanged in 14 (50.0%, unchanged group) patients. Age, sex, and laterality did not differ between groups. Preterm birth history (n = 3) and combined systemic disease (n = 4) were only observed in the changed group (p = 0.111 and p = 0.049, respectively). CONCLUSIONS: Considering the possibility of changes in strabismic features, close monitoring of patients with strabismus combined with congenital disc anomaly is essential, particularly in those with preterm birth history or underlying systemic conditions.

SD-OCT parameters and visual field defect in chiasmal compression and the diagnostic value of neural network model.

PURPOSE: To evaluate the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) measurements using spectral domain optical coherence tomography (SD-OCT) in patients with chiasmal compression and analyze the diagnostic value of a neural network model. METHODS: Forty-seven patients with chiasmal compressive disorder were recruited and divided into two groups depending on the visual field defect (perimetric; group 1 and preperimetric; group 2). Fifty-seven normal subjects were also recruited (group 3). Peripapillary RNFL and macular GCIPL were analyzed in each group. A multilayer perceptron was trained using a training dataset and derived a neural network model. The diagnostic performances were compared using the area under the receiver operating curve (AUROC) between each parameters and neural network model. RESULTS: All macular GCIPL parameters, except inferotemporal GCIPL thickness, were thinner in group 1 than in group 2 and group 3, with barely any difference between group 2 and group 3 parameter values. The diagnostic power of the neural network model, minimum GCIPL, and inferonasal GCIPL were superior when compared with other parameters; the diagnostic values of these three parameters are not significantly different in discriminating the patients and normal control. However, the neural network exhibited the best diagnostic power in distinguishing group 2 and group 3. CONCLUSION: Macular GCIPL was reduced in chiasmal compression patients with visual field defect which was not evident in the preperimetric state. Neural network model showed superior diagnostic value in discriminating the preperimetric patients from normal control. The results suggest that neural networks may be helpful in the early diagnosis of chiasmal compression.

Ophthalmic Manifestations of Rathke's Cleft Cyst and Its Association to Radiological Characteristics.

PURPOSE: To evaluate the ophthalmic features of Rathke's cleft cyst (RCC) and its association with radiological characteristics. METHODS: In this retrospective single-center study, patients who showed typical findings suggestive of RCC on magnetic resonance imaging (MRI) and underwent relevant ophthalmic examination were recruited retrospectively. Patients were stratified into two groups according to the presence or absence of ophthalmic symptoms related to RCC. We reviewed patients' demographic information, initial symptoms, endocrinological status, ophthalmic features, and characteristics of MRI. Height, size and location of RCC, as well as the optic chiasm displacement assessed from MRI. RESULTS: Thirty-three patients (20 women and 13 men) were included in this study from among 335 patients with RCC on MRI. Fifteen patients had ophthalmic manifestation related to the cyst (Ophthalmic group), whereas 18 patients were not (Non-ophthalmic group). Headache was the most common initial symptom (15 patients, 45.5%), followed by visual disturbance (7, 21.2%), diplopia (1, 3.0%), retro-orbital pain (1, 3.0%), galactorrhea (1, 3.0%), and peripheral extremity discomfort (1, 3.0%). In seven asymptomatic patients (21.2%), the lesion was an incidental finding during a regular medical examination. Ophthalmic manifestation included visual field defect (14 patients, 93.3%) and diplopia (1 patient, 6.7%). The height, volume, and the coronal and sagittal displacements were larger in the ophthalmic group (P < .001, all). Eleven patients who manifested ophthalmic symptoms underwent excision surgeries and nine of them (81.8%) experienced visual function improvement. CONCLUSION: Appropriate ophthalmic examinations are warranted in patients with RCC, and treatment should be actively considered in patients with ophthalmic manifestations.

Development of a questionnaire to identify ocular torticollis.

Ocular disease is one of the causes of abnormal head positioning. Conventionally, the behavioral characteristics of ocular torticollis patients are different from those of non-ocular torticollis patients, though research addressing the significance of this difference is yet limited. This prospective, cross-sectional study aims to develop a questionnaire based on the clinical features in children with abnormal head posture being ocularly assessed. Children aged ≥ 6 months who visited our rehabilitation medicine clinic with a chief complaint of abnormal head posture were included. Patients with apparent orthopedic and neurological diseases were excluded. A 10-item questionnaire was developed to analyze the behavioral characteristics of patients. The patients were divided into ocular and non-ocular torticollis groups according to ophthalmologic examination results. Thirty-four and 13 patients were assigned to the non-ocular torticollis and ocular torticollis groups, respectively. Five questions were finally selected and the questionnaire was scored as the sum of the scores for the each questions (yes = 1 point, no = 0 point). The median (interquartile range) score of the ocular torticollis group (3.0 (3.0-4.0)) was significantly higher than that of the non-ocular torticollis group (2.0 (1.0-3.0); p = 0.000).Conclusion: Our parent-reported torticollis assessment questionnaire may be useful for screening ocular torticollis. What is known: • Ocular disease is one of the various causes of abnormal head positioning. • The behavioral characteristics of patients with ocular torticollis are different from those of patients with non-ocular torticollis; research on this matter is limited. What is new: • We delveloped a questionnaire to differentiate ocular and postural torticollis and the score of the questionnaire was different between patients with or without ocular disease. • The questionnaire based on behavioral characteristics may help screening and determining the need of ophthalmic evaluation in patients with torticollis.

Strabismus Is Correlated with Gross Motor Function in Children with Spastic Cerebral Palsy.

Purpose: To investigate the correlation between clinical features of strabismus and motor dysfunction classified according to the Gross Motor Function Classification System (GMFCS) in patients with spastic cerebral palsy (CP).Methods: In this retrospective, cross-sectional study in single tertiary medical center, 62 patients who are diagnosed with spastic CP who had an ophthalmic examination between 2006 and 2014 were included. Only patients with vision sufficient to fixate were included and patients with restrictive or paralytic strabismus were excluded. The types of CP were classified as diplegia, hemiplegia, or quadriplegia for distribution of motor impairment. The GMFCS was used to grade gross motor dysfunction, which was then classified as mild (grade 1, 2 and 3) or severe (grade 4 and 5) motor impairment. Strabismus was investigated in terms of direction, constancy, and deviation angle. The relationship between strabismus characteristics and the level of GMFCS and type of CP were assessed.Results: Thirty-eight and 24 patients had mild or severe motor deficit, respectively. Forty patients had strabismus, which was more frequent in patients with severe motor impairment.(P = .014) Exotropia and esotropia occurred with similar frequency. Constant and large-angle strabismus was frequently observed in patients with severe motor impairment.(P < .005, 0.027) The topographical subtype of CP was not related to clinical features of strabismus.Conclusions: The prevalence of strabismus is higher in severe motor impairment. The constancy and angle of strabismus was related to the severity of motor impairment while the topographical subtype of CP has no significant relationship.

Clinical Features of Toxocara-Seropositive Optic Neuritis in Korea.

Purpose: This study was undertaken to analyze the characteristics of optic neuritis in Korean patients seropositive for Toxocara. Methods: We retrospectively reviewed data from patients diagnosed with optic neuritis and followed up for at least one month between 2012 and 2016. Patients were grouped according to Toxocara serological testing outcomes (positive or negative) and clinical characteristics were compared. Results: The seropositive and seronegative groups comprised 13 and 12 patients, respectively. The seropositive patients were older (56.8 years versus 34.5 years), reported ocular pain less frequently (30.8% versus 91.7%), and showed more frequent asymmetric optic disc swelling (72.7% versus 22.2%). During follow-up, visual acuity of all seronegative patients improved to 20/40 or better, compared with 38.5% of the seropositive group. Conclusion: Atypical features such as painless, older age, or asymmetric disc swelling in optic neuritis may be related to seropositivity for Toxocara, suggesting the possibility of undiagnosed Toxocara optic neuropathy.