Factors Affecting Outcomes of Stereoacuity in Partially Refractive Accommodative Esotropia with Motor Success Treated by Preoperative Prism Correction and Surgery.

Purpose: Favorable stereoacuity does not develop in all patients with partially refractive accommodative esotropia (PRAET) successfully aligned, and there have been few previous reports on the factors influencing stereoacuity outcomes in patients with PRAET treated with prismatic correction (PPC) and/or surgery. This study aimed to analyze factors affecting stereoacuity outcomes in patients of PRAET treated with PPC and surgery. Study Design: Retrospective study. Methods: Sixty-six patients with alignment within 10 prism diopters at final visit with PPC and surgery were included. According to the final stereoacuity, patients were grouped into the fine group (≤60 arcsec (")), the coarse group (60 "<, 3000" ≤), and absent stereoacuity group. Preoperative patient characteristics were compared among three groups using analysis of variance. Comparison of final stereoacuity among three groups based on age at onset (very early: ≤6 months; early: >6 months, ≤2 years; late: >2 years) was carried out with the Kruskal-Wallis test. Results: There were no differences in ages at initial PPC, at surgery, at final visit, durations of misalignment, of PPC, or after surgery; however, significant differences in ages at onset and initial visit were found. Age at onset in the absent group was significantly earlier than those of the fine and the coarse groups (p < 0.001 and p < 0.001, respectively). Moreover, of the 25 patients with age at onset >2 years, 18 patients (72%) showed fine or coarse stereoacuity (p < 0.001). Conclusion: Although stereoacuity outcomes in patients with early onset were poor despite of the finally successful alignments obtained with PPC and surgery, fine stereoacuity and coarse stereoacuity were obtained in 24% and 44% of patients with age at onset >2 years.

Medial rectus insertion site in cases of acute acquired comitant esotropia associated with excessive digital device usage.

PURPOSE: To compare the distance of the medial rectus muscle insertion to the limbus (DMIL) between patients with acute acquired comitant esotropia (AACE) associated with excessive digital device usage (EDDU) and exotropic patients. STUDY DESIGN: Retrospective study. METHODS: The medical records of 72 eyes of 44 patients with EDDU were retrospectively analyzed. The DMIL was measured from the anterior part at the midpoint of the medial rectus muscle insertion into the anterior limbus using a caliper after dissecting the medial rectus muscle with two control sutures at 12 o'clock and 6 o'clock. The DMIL in the non-fixation eye was compared between 44 patients with AACE and 23 patients with exotropia. RESULTS: The mean daily EDDU was 6.5 ± 3.1 h. The mean cycloplegic refractive errors (spherical equivalent: SE) were - 3.18 ± 2.52 diopters (D) OD and - 3.03 ± 2.42 D OS. The mean DMIL in the 72 eyes of 44 patients with AACE associated with EDDU was 4.30 ± 0.66 mm. The difference in DMIL of non-fixation eyes between 44 AACE patients and 23 exotropic patients was significant (4.28 ± 0.65 mm vs. 5.28 ± 0.50 mm, p < 0.0001). However, the SE in 44 non-dominant eyes of AACE was - 3.08 ± 2.56 D, significantly stronger than - 1.22 ± 1.93 D in the 23 exotropic eyes (p = 0.008). CONCLUSION: DMIL in patients with AACE associated with EDDU was significantly shorter. This anatomical anomaly may be an etiology of AACE associated with EDDU.

Endoscopic Surgery for Congenital or Acquired Cataract Associated with Persistent Fetal Vasculature: A Case Series.

PURPOSE: Persistent fetal vasculature (PFV) is a congenital malformation caused by a failure in regression of the primary vitreous and hyaloid vessels. An abnormal PFV occurs in the anterior and posterior segments of the eye. Surgery for PFV carries the risk of retinal detachment. We report four cases of cataracts associated with PFV, in which our novel surgical technique with an intraocular endoscope was safely performed. METHODS: Lensectomy and vitrectomy were performed in cases 1, 3, and 4, while lensectomy, vitrectomy, and intraocular lens implantation using an endoscope were performed in case 2. In all cases, after lens removal, a slit at the posterior lens capsule was created to avoid the retrolental fibrovascular membrane using underwater electric coagulation. Moreover, the endoscope was inserted, by which the intraocular region was observed to determine the treatment method for the fibrovascular membrane and vitreous stalk. No additional surgeries were required for complications before or after any of the surgeries. RESULTS: Using an endoscope during cataract surgery associated with PFV, observing the vitreous stalk at high magnification and ensuring safe treatment were possible. CONCLUSIONS: Endoscopic surgery could be considered an effective method for treating PFV-associated cataracts.

Incomplete homonymous hemianopsia progressing to junctional scotoma due to a large internal carotid artery aneurysm: A case report.

Visual field disorders caused by cerebral aneurysms are diverse, nonspecific, and vary in their degree of compression. They should be distinguished from those caused by other common diseases, such as glaucoma.

Clinical presentations of acquired comitant esotropia in 5-35 years old Japanese and digital device usage: a multicenter registry data analysis study.

PURPOSE: To describe clinical presentations of acquired comitant esotropia and digital device use in children, adolescents, and young adults without neurological problems. STUDY DESIGN: Multicenter prospective observational study. METHODS: Patients with acquired comitant esotropia, without intracranial diseases aged 5-35 years at the time of visit, who were seen at pre-registered facilities within 1 year of onset were enrolled. The duration from the onset of symptoms and the time of digital device usage approximately 1 month before onset and their lifestyles were surveyed. Visual acuity, cycloplegic refraction, and strabismus angles were measured. Data were analyzed in three age groups (Child: 5-12 years, Adolescent: 13-18 years, and Young adult: 19-35 years). RESULTS: Between November 2019 and December 2021, 218 patients were enrolled from 55 facilities, and 194 patients (including 62 children, 69 adolescents, and 63 young adults) were analyzed. The child group spent the least amount of time using digital devices (children: 159; adolescents: 210; young adults: 267 min/work day, p < 0.05; (mean time in the same order below) 229, 338, 314 min/holiday, p < 0.05) and had the largest strabismus angle (mean strabismus angle at near: 30, 22, 18 PD, p < 0.01; at far: 28, 26, 21 PD, p<0.05). CONCLUSION: The clinical features of acquired comitant esotropia and hand-held digital device usage differed between children aged ≤ 12 years and older patients. This report gives the current clinical characteristics of young patients with acquired esotropia and digital device usage.

Relationship Between Suppression Scotomas and Stereoacuity in Anisometropic Amblyopia With Successfully Treated Visual Acuity.

Purpose: The purpose of this study was to investigate the relationship among suppression scotoma size, stereoacuity, and four-prism base-out test (4ΔBOT) results in anisometropic amblyopia with successfully treated visual acuity. Methods: We included 103 cases of anisometropic amblyopia successfully treated for visual acuity without strabismus. Stereoacuity was measured using a Randot Stereotest. The size of the suppression scotomas was measured using a new device, the polarized four dot (P4D) test. This is a modification of the Worth 4 dot test (W4D) device. The patients were divided into three groups based on the 4ΔBOT results: normal (group A = 29 cases), subnormal (group B = 48 cases), and abnormal (group C = 26 cases) response groups. The horizontal diameter of the suppression scotomas and stereoacuity in logarithmic values with a base of 20 seconds of arc (″) were compared among the 3 groups. Results: The mean age at P4D testing was 8.4 ± 2.1 years. The average horizontal diameters of the suppression scotomas were 0.35 ± 0.79Δ, 2.01 ± 0.82Δ, and 5.50 ± 2.72Δ in groups A, B, and C, respectively, showing significant differences (A versus B: P < 0.0001, A versus C: P < 0.0001, and B versus C: P < 0.0001; 1-way ANOVA). The average logarithmic stereoacuity were 1.07 (24.95″), 1.22 (38.84″), and 1.47 (82.79″) in groups A, B, and C, respectively, thereby showing significant differences between the groups (A versus B: P < 0.0001, A versus C: P < 0.0001, and B versus C: P < 0.0001; 1-way ANOVA). Stereoacuity and horizontal diameter of the suppression scotoma were strongly correlated (r = 0.732, P < 0.0001). Conclusions: The suppression scotoma size measured using P4D correlated significantly with stereoacuity and the 4ΔBOT results.

Surgical Outcomes with and without Prism Adaptation of Cases with Acute Acquired Comitant Esotropia Related to Prolonged Digital Device Use.

Purpose: To analyze surgical results of 32 cases with acute acquired comitant esotropia (AACE) related to prolonged use of digital devices (DDs). Patients and Methods: Medical records of cases with AACE related to prolonged use of DDs that had undergone surgery were retrospectively revised. Complete medical history and full ophthalmological examinations before and surgery were obtained for all cases. All cases also underwent neurological examinations using brain and orbital imaging. Motor success was considered as alignment within 10 prism diopters (Δ) at both near and distance. Sensory success was defined as stereopsis ≤60 arcsec. Nineteen cases (Group S) underwent surgery alone and 13 cases were treated with surgery and prism adaptation (Group S+P). Motor and sensory outcomes were compared between groups. Results: Mean age at first visit was 22.0 ± 9.0 years and mean daily use of DDs use was 6.3 ± 3.4 hours. Mean angle of preoperative alignment for distance and near were 26.5 ± 13.0Δ and 24.6 ± 16.4Δ, respectively. Surgery was performed at a mean of 23.3 ±3.5 years old and mean angle of alignment at final examination for distance and near were 5.8 ± 7.7Δ and 3.5 ± 5.7Δ, respectively. Final motor and sensory success rate were 84% and 53%, respectively. No significant differences in motor or sensory outcomes were evident between groups at initial or last visit. Conclusion: Favorable motor and sensory outcomes were achieved with surgical intervention with and without prism adaptation for AACT related to prolonged use of DDs.

A case of functional visual loss diagnosed through bilateral randomized visual field testing with a trick method.

Purpose: To report a case of functional visual loss (FVL) diagnosed through bilateral randomized visual field testing using Imo vifa with a trick method. Observations: A 27-year-old man complained of visual field abnormality in his left eye after falling from a height of 4 m. The left eye had a best-corrected visual acuity (BCVA) of 20/16 and a critical flicker frequency (CFF) of 44.5 Hz at the first visit. Commotio retinae was observed in the inferior retina of the left eye, and the pupillary light reflex was normal. Computed tomography and magnetic resonance imaging of the head revealed no abnormalities. However, the Goldmann perimeter (GP) showed constriction of visual field in the left eye. Since traumatic optic neuropathy was suspected initially; therefore, two courses of methylprednisolone pulse therapy were administered. However, the BCVA and CFF gradually worsened to 20/200 and 14 Hz, respectively. Nevertheless, his pupillary light reflex was still normal, and GP showed a spiral visual field. Thus, we suspected that this was a case of FVL and performed bilateral randomized visual field testing using Imo vifa in three steps as a trick method. In the first step, we performed the normal method for bilateral randomized visual field testing. In the second and third steps, we explained to the patient that only the right or left eye would be examined on purpose; bilateral randomized visual field testing was then performed. The results of examinations revealed left homonymous hemianopsias and normal and concentric contraction of the visual field in both eyes. These results could not be explained by organic disease, and the patient was diagnosed with FVL. Conclusions and Importance: Bilateral randomized visual field testing using Imo vifa with a trick method was useful for diagnosing FVL.

Accuracy and Correlation of the Kinect-Based Semi-Automatic Scoring Method for Measuring Anomalous Head Posture as Compared to the CROM® Device.

Objective: To determine the reliability of the Kinect-based semi-automatic scoring method (KSSM) using Kinect for Windows v2 for head posture compared to the cervical range-of-motion (CROM) device. Methods and Analysis: Head positions between -40° and +40° of chin up/down (X), head turn (Y), and lateral tilt (Z) were measured in 10° increments in healthy volunteers. Their head positions were simultaneously measured using the KSSM and CROM. The following four points were analyzed: the success rate of the KSSM, the correlation between the two methods, the comparison of results by 95% limits of agreement (LA), and proportional error at 95% LA. Results: The measurability of the KSSM for all positions within ±30° of the X, Y, and Z axes was 100%. The correlations for both methods were 0.979 (95% CI: 0.967-0.987), 0.985 (0.976-0.991), and 0.988 (0.981-0.993) for the X-, Y-, and Z-axes, respectively. The simple linear regression analysis equations for 95% LA were Y=-0.024X-0.452 for X axes, Y=0.024X-0.363 for Y axes, and Y=-0.045X+0.217 for Z axes (95% confidence interval for each axis: -0.055-0.007, -0.006-0.050, and -0.071-0.018). However, the proportional biases were small because the predictive values of the differences in head positions from -40° to 40° determined by the equations were within ± 5° for chin up/down and within ± 3° for head tilt. Conclusion: Head posture measurements using the KSSM and CROM were found to be similar when used in clinical settings.

Effects of Bilateral Medial Rectus Resection on Motor Outcomes in Infantile Exotropia.

Purpose: To evaluate the effects of bilateral medial rectus resection (BMRres) on motor outcomes in infantile exotropia. Methods: We evaluated 19 cases of infantile exotropia surgery. The mean age at surgical alignment was 4.8±3.4 years (range, 1.5-11.8 years). The surgical procedures included BMRres (5 cases), BMRres with unilateral lateral rectus recession (ULRR) (3 cases), bilateral lateral rectus recession (BLRR) (8 cases), unilateral lateral rectus recession and medial rectus resection (uniRandR) with contralateral lateral rectus recession (2 cases), and uniRandR (1 case). After dividing the cases into two groups (BMRres group, n=8; other group, n=11), the outcomes at 1 day and at 1, 3, and 6 months after surgery were compared. Surgical outcomes were defined as (1) success: distant esotropia ≤5 prism diopters (Δ) or exotropia ≤10Δ, (2) recurrence: exotropia >10Δ, or (3) overcorrection: esotropia >5Δ. Results: Although postoperative distant deviations at 1 day were not different between the two groups, the BMRres group showed smaller distant deviations at 1, 3, and 6 months than the other group (p=0.015, 0.019, and 0.006, respectively). Success rates of the BMRres and other groups were 88% and 73% at 1 day, 100% and 36% at 1 month, 88% and 27% at 3 months, 88% and 18% at 6 months, respectively. Although there were no significant differences between the two groups within 3 months after surgery, surgical outcomes in the BMRres group 6 months after surgery were significantly better than those in the other group (p=0.003). Conclusion: BMRres is a better procedure than others for infantile exotropia to achieve desirable motor outcomes after surgery.

Abnormal biorbital angle in children with infantile exotropia.

PURPOSE: The causative factors of infantile exotropia are unknown. The purpose of this study was to investigate the relationships between the biorbital angle and the pathogenesis of infantile exotropia. STUDY DESIGN: Retrospective. METHODS: Of all patients diagnosed as infantile exotropia with onset prior to 12 months of age between 2010 and 2017, 31 patients without any neurological disorders or developmental delay were identified. The angle between both lateral walls of the orbit, defined as the biorbital angle, was measured in the horizontal plane at the optic nerve and where the horizontal extraocular muscles appeared on axial magnetic resonance imaging (MRI) or computed tomography (CT) of the orbit. These patients' data were compared with those of 129 ophthalmologically normal children. All subjects of this study were Japanese. RESULTS: The mean biorbital angle was significantly larger in patients with infantile exotropia than in the normal children (106.6 ± 5.7° vs 94.2 ± 5.1°, p < 0.001). Of the patients with infantile exotropia, 21 (68%) had an angle outside the 95% confidence interval calculated in normal children. All cases were divided into a constant (15 cases) and intermittent (16 cases) group; there was no significant difference between them in the mean biorbital angles (107.9 ± 5.6° vs 105.4 ± 5.8°, p = 0.224). No correlations were identified between the biorbital angle and the angle of exodeviation, either distant or near. CONCLUSIONS: Children with infantile exotropia have a larger biorbital angle. This anatomical abnormality may be an associate factor of infantile exotropia.

Relationship between stereopsis outcome and timing of surgical alignment in infantile esotropia.

PURPOSE: To clarify the relationship between stereopsis outcome and timing of surgical alignment in infantile esotropia. METHODS: The medical records of otherwise healthy patients with infantile esotropia who underwent surgery by 8 years of age were divided into the following groups according to age at time of surgery: very early surgery (≤8 months), early surgery (>8 to ≤24 months) and late surgery (>24 months). Binocular response and stereopsis were compared between groups. RESULTS: A total of 76 patients were included: 22 in the very early group, 30 in the early group, and 24 in the late group. Binocular response at near was found in 96% of the very early group and in 80% of the early group, significantly higher than the 50% of the late group (P < 0.001 and P < 0.05 [Dunn test], resp.). Stereopsis was present in 77% of the very early group, significantly higher than the 20% of the early group and 13% of the late group (P < 0.001 [Dunn test]). A significant correlation was also found between age (months) at surgery and stereopsis (seconds) outcome (logarithmic fit: y = 2539.4ln(x) + 147.2; R2 = 0.2691; P < 0.001). CONCLUSIONS: In this study cohort, earlier surgery was associated with better binocularity in patients with infantile esotropia. Our results suggest that very early surgery, at ≤8 months, can improve the chance for postoperative stereopsis, with the caveat that some infants might have had spontaneous esotropia resolution.

Developmental change of the biorbital angle in normal Japanese infants.

Purpose: To investigate postnatal changes in the biorbital angle in normal Japanese children. Subjects and methods: Axial imaging of the orbit in the transverse plane of the horizontal extraocular muscles was obtained in 129 ophthalmologically healthy infants (age ranging from a few months to 11 years). The opening angle between both lateral walls of the orbit was defined as the biorbital angle. Results: The mean biorbital angle in 11 infants less than a year of age was 105.0°±6.0°. The mean biorbital angles for each of the subsequent age groups were 97.7°±3.1°, 96.2°±4.0°, 96.3°±4.1°, 92.8°±3.8°, 92.3°±2.3°, 93.1°±2.8°, 91.5°±3.9°, 91.9°±2.3°, 91.4°±2.3°, and 90.9°±3.1°. The mean biorbital angle in infants less than a year old was significantly larger than those found in the groups of infants older than 1 year (P<0.01, Newman-Keuls test). Conclusion: The biorbital angle in infants less than a year old was larger than that found in infants older than 1 year, with this larger biorbital angle potentially the causative factor of the observed exotropia seen in 70%-80% of newborns gradually disappearing in most cases by 2-4 months of age.

Influence of timing of initial surgery for infantile esotropia on the severity of dissociated vertical deviation.

PURPOSE: The purpose of this study was to clarify whether the timing of initial surgery for infantile esotropia contributes to better sensory outcomes and to the severity of dissociated vertical deviation (DVD). METHODS: This retrospective study examined 55 children, aged 8 years and younger, who underwent esotropia surgery. Based on age at the time of the surgery, patients were divided into the very early surgery group (birth to 8 months, N = 14), early surgery group (9-24 months, N = 23) and late surgery group (25 months and older, N = 18). Sensory and motor outcomes of the three groups were statistically evaluated. RESULTS: No significant differences in the incidences of DVD were noted among the three groups at the final visit. However, all DVDs of the very early surgery group were latent, whereas 38.9% of the DVDs for both near and distance of the late surgery group were manifest. Significant differences were found among the three groups for the proportion of patients with manifest DVD, latent DVD and without DVD, and for the incidence of additional surgery for manifest DVD (p < 0.05, G-test). CONCLUSION: Early surgery for infantile esotropia decreases the severity of DVD and lowers the need for an additional operation for DVD.