Bilateral optic disc collaterals secondary to high-flow dural arteriovenous fistula: a diagnostic dilemma.

A man in his 80s, with a history of diabetes, hypertension and coronary artery disease, presented with bilateral painless progressive vision loss 2 years prior. His examination showed subnormal best corrected visual acuity of 20/50 and 20/80 in the right eye and left eye (LE), respectively, grade II relative afferent pupillary defect in LE, normal anterior segment, intra-ocular pressure (IOP) and defective colour vision in both eyes (BE). Fundus examination revealed optic disc pallor, disc collaterals and grade 2 hypertensive retinopathy in BE. Automated perimetry showed advanced field loss in BE. MRI of the brain and orbits with contrast showed signs of raised intracranial pressure, and magnetic resonance angiogram of the brain showed multiple arterio-venous channels along with the right transverse and sigmoid sinuses. The patient was referred to a neuroradiologist for further evaluation, and cerebral angiogram confirmed multifocal high-flow dural arterio-venous fistulae at right jugular foramen, transverse and sigmoid sinuses. He underwent Onyx liquid embolization.

Paracentral acute middle maculopathy in a patient with Myelin Oligodendrocyte glycoprotein antibody associated optic neuritis.

Purpose: There is insufficient literature reporting the concurrent occurrence of retinal ischemic lesions with optic neuritis. In this case report, we present a distinctive instance of Optic Neuritis with a positive Myelin Oligodendrocyte glycoprotein (MOG) antibody, accompanied by retinal ischemia manifesting as paracentral acute middle maculopathy (PAMM) lesions. Observations: Our patient is a 25-year-old female who tested positive for MOG antibodies and exhibited retinal PAMM lesions without any apparent underlying ischemic cause. She received intravenous pulse steroid therapy, and her symptoms and signs completely resolved one month later. Conclusion: PAMM can serve as an initial manifestation of Myelin Oligodendrocyte glycoprotein Antibody Associated Disease (MOGAD). This case has the potential to contribute to the existing literature, facilitating a deeper exploration of the pathophysiology of retinal ischemia in MOG associated optic neuritis.

Pediatric myopic strabismus fixus: clinical features and surgical outcomes of silicone band loop myopexy.

PURPOSE: To evaluate the clinical profile of myopic strabismus fixus (MSF) in children and surgical outcomes of silicone band loop myopexy. METHOD: We retrospectively reviewed records of children presenting with MSF who underwent silicone band loop myopexy between January 2008 and December 2020 at a tertiary eye care center. Data concerning demographics, refractive error, axial length, extra-ocular motility, and ocular alignment pre-operatively and post-operatively, intra- and post-operative complications, ocular and systemic associations, were evaluated. The long-term effects of band loop myopexy on ocular alignment stability, motility improvement, and myopia progression were analyzed. Surgical outcome was defined as post-operative orthotropia or heterotropia less than or equal to 20 PD. RESULTS: A total of0 eyes of 7 patients (median age: 5 years; 5 boys and 2 girls) who underwent band loop myopexy were included in the study. Among them, three children underwent bilateral and four children underwent unilateral band loop myopexy. Medial rectus recession was performed only in two patients as a part of initial procedure. The median follow-up duration was 7 years. Most of the children, i.e. six of them presented with esotropia-hypotropia and only one patient presented with exotropia-hypotropia complex. The median pre-operative measurements were esotropia of 62.5 PD, hypotropia of5 PD, and exotropia of4 PD. Postoperative average primary position deviation measured was close to 9-10 PD of esotropia. The overall motility improved to -1 from -3. CONCLUSION: The clinical profile of MSF in children is almost similar to adults. This condition is a rare entity among adults as well as children. Majority of children with MSF presented with esotropia-hypotropia complex. Silicone band loop myopexy with or without medial rectus recession proves to be a reliable surgical procedure as it provides stable outcomes in terms of ocular alignment and motility among children.

Subnormal visual acuity after compliant amblyopia therapy: residual/refractory amblyopia or co-existing pathology? - a retrospective analysis.

Purpose: To assess the prevalence of alternate etiology/co-existing pathology among patients with amblyopia, and to characterize factors contributing to over-diagnosis of amblyopia. Methods: We retrospectively reviewed records of children (from 1 January 2016 to 31 December 2019) who were initially diagnosed as "amblyopia" but later an alternate diagnosis for subnormal vision was established. Patients who had a best corrected visual acuity (BCVA) of ≤20/32 (0.2 logMAR) after compliant amblyopia therapy were divided into 2 groups: those with refractory amblyopia (BCVA improvement from baseline <1 logMAR line) and residual amblyopia (BCVA improvement from baseline >1 logMAR line). Data was collected for presence/absence of amblyogenic risk factors, history, ocular examination, and investigations leading to the final alternate diagnosis. We analyzed the factors that contributed to the initial over-diagnosis of amblyopia using the diagnostic error evaluation and research (DEER) taxonomy tool. Results: During the study period, 508 children with an initial diagnosis of amblyopia met the study criteria. Among these 508 children, 466 were diagnosed to have amblyopia alone, while 26 children (5.1%, median age: 7 years, 17 boys: 9 girls) were revised to have an alternate diagnosis/co-existing pathology. These 26 patients comprised of 2 groups: children referred to us as amblyopia but rediagnosed to have an alternate diagnosis; and a second subset, initially diagnosed by us to have amblyopia, but later found to have alternate diagnosis/co-existing pathology. Subclinical optic neuritis (50%, 13 children), and occult macular dystrophy (OMD) (38.4%, 10 children) were the most frequent alternative diagnoses. Children with ametropic amblyopia (8/26, 30.7%) were most frequently misdiagnosed. Risk factors that led to an initial diagnosis of amblyopia were: high refractive error and heterotropia in 7 patients each (26.9%), anisometropia in 12 (46.1%), and prior pediatric cataract surgery in 4(15.3%). No improvement in BCVA in 21/26 (80.7%) children led to suspicion of co-existing etiology. Other clues were optic disc pallor (11), subnormal color vision (7), history of parental consanguinity in 7, and preceding febrile illness/rhinitis in 1 child. The DEER taxonomy tool suggested that the most common reasons for diagnostic errors were over-emphasis on amblyopia. Conclusion: Our study suggests that 5% of children diagnosed with amblyopia might have co-existing/alternate etiology. Most common co-existing etiologies were subclinical optic neuropathy, and OMD. No improvement in BCVA, subtle history and examination findings prompted further workup. Not considering co-existing etiologies was the most common reason for an initial overdiagnosis of amblyopia.

Sound suppresses earliest visual cortical processing after sight recovery in congenitally blind humans.

Neuroscientific research has consistently shown more extensive non-visual activity in the visual cortex of congenitally blind humans compared to sighted controls; a phenomenon known as crossmodal plasticity. Whether or not crossmodal activation of the visual cortex retracts if sight can be restored is still unknown. The present study, involving a rare group of sight-recovery individuals who were born pattern vision blind, employed visual event-related potentials to investigate persisting crossmodal modulation of the initial visual cortical processing stages. Here we report that the earliest, stimulus-driven retinotopic visual cortical activity (<100 ms) was suppressed in a spatially specific manner in sight-recovery individuals when concomitant sounds accompanied visual stimulation. In contrast, sounds did not modulate the earliest visual cortical response in two groups of typically sighted controls, nor in a third control group of sight-recovery individuals who had suffered a transient phase of later (rather than congenital) visual impairment. These results provide strong evidence for persisting crossmodal activity in the visual cortex after sight recovery following a period of congenital visual deprivation. Based on the time course of this modulation, we speculate on a role of exuberant crossmodal thalamic input which may arise during a sensitive phase of brain development.

Facial dysmorphism in congenital rubella syndrome.

PURPOSE: To investigate the dysmorphic facial features in congenital rubella syndrome (CRS) and describe their associations with ocular and systemic features. METHODS: The medical records of children diagnosed with CRS between 2016 and 2021 were retrospectively reviewed for ocular and systemic features. CRS was diagnosed either on the basis of positive serology for rubella antibodies or with the classic triad of congenital cataract, sensorineural hearing loss, and congenital heart defect. Children with photographic documentation of the face were analyzed independently by three experienced investigators for facial dysmorphic features (triangular face, microcephaly, broad forehead, low anterior hairline, whorl on the anterior hairline, prominent nose, micrognathia). The dysmorphic feature was recorded as present only when at least two of the three examiners confirmed its existence. RESULTS: CRS was diagnosed in 237 children: mean age at presentation, 5.45 ± 4.5 years; 126 males (53%); bilateral cataract, 176 (75%). Positive serology for rubella antibodies was noted in 153 children (65%). Photographic record of facial features was documented in 127 (54%). The most common dysmorphic facial feature was wide forehead (82 [65%]), followed by low anterior hairline with whorl (41 [32%]). However, microcornea (P = 0.9801), cataract (P = 0.8342), pupillary sphincter atrophy (P = 0.7421), and salt and pepper retinopathy (P = 0.8803) were not significantly associated with the presence of facial dysmorphism. Congenital heart disease was significantly associated with facial dysmorphism (P = 0.0308). Sensorineural hearing loss was not associated with the presence of facial dysmorphism (P = 0.8463). CONCLUSIONS: Facial dysmorphism is common in children with CRS, but it was not predictive of the presence of ocular manifestations of CRS in this cohort.

Agreement Between Virtual Reality Perimetry and Static Automated Perimetry in Various Neuro-Ophthalmological Conditions: A Pilot Study.

Our objective was to compare the agreement between virtual reality perimetry (VRP) (order of magnitude, OM) and static automated perimetry (SAP) in various neuro-ophthalmological conditions. We carried out a retrospective analysis of visual field plots of patients with various neuro-ophthalmological conditions who underwent visual field testing using VRP and SAP and between 1 January and 31 May 2022. Two fellowship-trained neuro-ophthalmologists compared the visual field defects observed on both devices. Per cent agreement was used to compare the interpretation of the two examiners on both techniques. The study criteria were met by 160 eyes from 148 patients (mean age 44 years, range 17-74 years). The most common aetiologies were optic atrophy due to various causes, optic neuritis, ischaemic optic neuropathy, and compressive optic neuropathy. Overall, we found good agreement between VRP and SAP for bitemporal (93.8%), hemianopic (90.8%), altitudinal (79.4%), and generalised visual field defects (86.4%). The agreement was acceptable for central/centrocaecal scotomas and not acceptable for enlarged blind spots. Between the two examiners there was good agreement for bitemporal (92.3%), hemianopic (82%), altitudinal (83%), and generalised field defects (76.4%). The results of our study suggest that VRP gives overall good agreement with SAP in various neuro-ophthalmological conditions, especially those likely to produce hemianopic, altitudinal, and generalised visual field defects. This could be useful in various settings; however, future larger studies are needed to explore real-world utilisation.

Early visual experience refines the retinotopic organization within and across visual cortical regions.

Early visual areas are retinotopically organized in human and non-human primates. Population receptive field (pRF) size increases with eccentricity and from lower- to higher-level visual areas. Furthermore, the cortical magnification factor (CMF), a measure of how much cortical space is devoted to each degree of visual angle, is typically larger for foveal as opposed to peripheral regions of the visual field. Whether this fine-scale organization within and across visual areas depends on early visual experience has yet been unknown. Here, we employed 7T functional magnetic resonance imaging pRF mapping to assess the retinotopic organization of early visual regions (i.e., V1, V2, and V3) in eight sight recovery individuals with a history of congenital blindness until a maximum of 4 years of age. Compared with sighted controls, foveal pRF sizes in these individuals were larger, and pRF sizes did not show the typical increase with eccentricity and down the visual cortical processing stream (V1-V2-V3). Cortical magnification was overall diminished and decreased less from foveal to parafoveal visual field locations. Furthermore, cortical magnification correlated with visual acuity in sight recovery individuals. The results of this study suggest that early visual experience is essential for refining a presumably innate prototypical retinotopic organization in humans within and across visual areas, which seems to be crucial for acquiring full visual capabilities.

Prevention and management of childhood progressive myopia: National consensus guidelines.

Myopia is a major public health problem worldwide, including India, with the global prevalence of myopia increasing rapidly over decades. The clinical and socioeconomic impact of myopia is also expected to rise with rising prevalence. Therefore, the focus has now been shifted to prevent the incidence and progression of myopia. However, there is lack of any standardized guidelines for myopia management. This document aims to generate a national-level expert consensus statement on the management of childhood myopia in the Indian scenario. The expert panel of pediatric ophthalmologists consisted of 63 members who met in a hybrid meeting. A list of topics deliberating discussion in the meeting was provided to the experts in advance and they were instructed to provide their opinions on the matter during the meet. The panel of experts then gave their views on each of the items presented, deliberated on different aspects of childhood myopia, and reached a consensus regarding the practice patterns in the Indian scenario. In case of opposing views or lack of a clear consensus, we undertook further discussion and evaluated literature to help arrive at a consensus. A written document is prepared based on recommendations explaining definition of myopia, refraction techniques, components and methods of workup, initiation of anti-myopia treatment, type and timing of interventions, follow-up schedule, and indications for revised or combination treatment. This article formulates evidence-based guidelines for progressing myopes and pre-myopes and also establishes uniformity in the management of childhood myopia in the country.

Visual outcomes and safety profile of intraocular lens implantation versus aphakia in children with microspherophakia with no subluxation.

OBJECTIVE: To study the visual, refractive and surgical outcomes of intraocular lens (IOL) implantation versus aphakia in children with microspherophakia. DESIGN: Retrospective, comparative, non-randomised interventional study. METHODS: All consecutive children with microspherophakia who satisfied the inclusion criteria were included. The eyes that underwent in-the-bag IOL implantation and those that were left aphakic were included in groups A and B, respectively. The postoperative visual outcomes, IOL stability and complications during the follow-up period were studied. RESULTS: 22 eyes (13 patients, male 76%), of which 12 eyes were in group A and 10 eyes in group B. The mean±SE of age at surgery was 9.4±1.4 and 7.3±0.9 years in group A and group B, respectively (p value 0.18). The mean follow-up of group A was 0.9±0.4 years (median 0.5 years; Q1 0.04, Q3 2.16) and group B was 1.3±0.9 years (median 0.147 years; Q1 0.08, Q3 0.39) (p value 0.76). All the baseline biometric variables including best-corrected visual acuity (BCVA) were comparable in each group. The final BCVA in logMAR adjusted for follow-up was comparable in both group A (0.29±0.06) and group B (0.52±0.09) (p value 0.06). Mean predictive error of IOL power in microspherophakia was 0.17±0.43.The most common complication in group A was visual axis opacification of two eyes (16.7%, 95% CI 2.9% to 49.1%), of which one eye (8.3%, 95% CI 0.4% to 40.2%) needed membranectomy. Vitreous in anterior chamber was the most common complication in group B, seen in two eyes (20%, 95% CI 3.5% to 55.8%), of which one eye (10%, 95% CI 0.5% to 45.9%) underwent YAG laser vitreolysis. The survival analysis (p value 0.18) was comparable in each group. CONCLUSION: In-the-bag IOL is an option, which can be considered in selected cases of microspherophakia in developing nations where regular follow-up and economic constraints are a major concern.

Different strokes for anterior capsulorhexis in pediatric cataract.

Background: A successful outcome in pediatric cataract surgery is determined by an intact, curvilinear anterior capsulotomy which is dependent on the type and density of cataract, the morphology of the anterior capsule, and associated anterior segment pathologies. Purpose: This video highlights 10 different techniques which can be used for capsulorhexis in pediatric cataract. Synopsis: The choice of technique for capsulorhexis in pediatric cataract is on case basis, namely the gold standard manual capsulotomy aided by rhexis forceps (1. Standard capsulorhexis/2. Vitrector, Vitrectorhexis), with an assistance from capsular staining (3. Blue-rhexis), or by coaxial illumination (4. Coaxial-rhexis) or by just the sheen of capsule (5. Sheen-rhexis). The anterior chamber can be maintained using ophthalmic visco-elastic device (Visco-rhexis) or by irrigation fluid (6. Hydro-rhexis). A speed-breaker in the routine capsulotomy is the presence of plaque which is managed by rhexis forceps (7. Plaque-rhexis) or by a vitrector (vitrectorhexis) or a pair of micro-scissors (8. Scissor rhexis). Above all, the technology of femto-second-laser-assisted (9. Femto-rhexis) and zepto-pulse-precision capsulotomy (10. Zepto-rhexis) is also illustrated. Highlights: This video highlights the 10 different techniques of capsulorhexis in pediatric cataract surgery. Video Link: https://youtu.be/TgDrk5RYdbI.

The development of oscillatory and aperiodic resting state activity is linked to a sensitive period in humans.

Congenital blindness leads to profound changes in electroencephalographic (EEG) resting state activity. A well-known consequence of congenital blindness in humans is the reduction of alpha activity which seems to go together with increased gamma activity during rest. These results have been interpreted as indicating a higher excitatory/inhibitory (E/I) ratio in visual cortex compared to normally sighted controls. Yet it is unknown whether the spectral profile of EEG during rest would recover if sight were restored. To test this question, the present study evaluated periodic and aperiodic components of the EEG resting state power spectrum. Previous research has linked the aperiodic components, which exhibit a power-law distribution and are operationalized as a linear fit of the spectrum in log-log space, to cortical E/I ratio. Moreover, by correcting for the aperiodic components from the power spectrum, a more valid estimate of the periodic activity is possible. Here we analyzed resting state EEG activity from two studies involving (1) 27 permanently congenitally blind adults (CB) and 27 age-matched normally sighted controls (MCB); (2) 38 individuals with reversed blindness due to bilateral, dense, congenital cataracts (CC) and 77 age-matched sighted controls (MCC). Based on a data driven approach, aperiodic components of the spectra were extracted for the low frequency (Lf-Slope 1.5 to 19.5 Hz) and high frequency (Hf-Slope 20 to 45 Hz) range. The Lf-Slope of the aperiodic component was significantly steeper (more negative slope), and the Hf-Slope of the aperiodic component was significantly flatter (less negative slope) in CB and CC participants compared to the typically sighted controls. Alpha power was significantly reduced, and gamma power was higher in the CB and the CC groups. These results suggest a sensitive period for the typical development of the spectral profile during rest and thus likely an irreversible change in the E/I ratio in visual cortex due to congenital blindness. We speculate that these changes are a consequence of impaired inhibitory circuits and imbalanced feedforward and feedback processing in early visual areas of individuals with a history of congenital blindness.

Unraveling congenital ptosis with the aid of the pediatric perimeter device.

Background: Ocular morbidity with an early onset can have a significant impact on the long-term development of an individual. Hence, careful assessment of visual functions early on is very important. However, testing infants always poses a challenge. Standard tools to assess infants' visual acuity, ocular motility, and so on rely on the clinician's quick subjective judgments of an infant's looking behavior. Eye movements are usually observed from head rotations or spontaneous eye movements in infants. Judging eye movements in the presence of strabismus is even more challenging. Purpose: This video shows a 4-month-old infant's viewing behavior captured during a visual field screening study. The recorded video aided in the examination of this infant that was referred to a tertiary eye care clinic. The additional information captured through the perimeter testing is discussed. Synopsis: The Pediatric Perimeter device was developed to address visual field extent and gaze reaction time assessment in the pediatric population. As a part of a large-scale screening study, infants' visual fields were tested. During this screening, a 4-month-old infant presented with a ptosis in the left eye. The infant was consistently missing the light stimuli presented in the left upper quadrant in the binocular visual field testing. The infant was referred to a tertiary eye care center to a pediatric ophthalmologist for further examination. During clinical examination, the infant was suspected to either have congenital ptosis or monocular elevation deficit. But the diagnosis of the eye condition was unsure owing to the poor cooperation of the infant. With the aid of Pediatric Perimeter, the ocular motility was consistent with limitation of elevation in abduction, indicating a possible monocular elevation deficit with congenital ptosis. The infant was also noted to have Marcus Gunn jaw-winking phenomenon. The parents were assured and asked for a review in 3 months. In the subsequent follow-up, the Pediatric Perimeter testing was performed, and the recording showed a full extraocular motility in both eyes. Hence, the diagnosis was changed to only congenital ptosis. The probable explanation for missing the target in the left upper quadrant in the first visit is postulated further. The left upper quadrant is the superotemporal visual field of the left eye and the superonasal visual field of the right eye. As the left eye had ptosis, the superotemporal visual field could have been obstructed and hence the stimuli missed. The normative extent for the nasal and superior visual field is just about 30° for a 4-month-old infant. Hence, the right eye also perhaps missed the stimuli in its superonasal visual field extent. This video highlights the utility of the Pediatric Perimeter device in providing a magnified view of the infant's face along with greater visibility of ocular features from the infrared video imaging. This can potentially help the clinician to easily observe different ocular/facial abnormalities such as extraocular motility disorders, lid functions, and in identifying unequal pupil size, media opacities, and nystagmus. Highlights: The presence of congenital ptosis in younger infants might predispose as superior visual field defect and could also masquerade as a limitation in elevation. Video link: https://youtu.be/Lk8jSvS3thE.

Stimulus-evoked and resting-state alpha oscillations show a linked dependence on patterned visual experience for development.

Persistent visual impairments after congenital blindness due to dense bilateral cataracts have been attributed to altered visual cortex development within a sensitive period. Occipital alpha (8-14 Hz) oscillations were found to be reduced after congenital cataract reversal, while participants performed visual motion tasks. However, it has been unclear whether reduced alpha oscillations were task-specific, or linked to impaired visual behavior in cataract-reversed individuals. Here, we compared resting-state and stimulus-evoked alpha activity between individuals who had been treated for dense bilateral congenital cataracts (CC, n = 13, mean duration of blindness = 11.0 years) and age-matched, normally sighted individuals (SC, n = 13). We employed the visual impulse response function, adapted from VanRullen and MacDonald (2012), to test for the characteristic alpha response to visual white noise. Participants observed white noise stimuli changing in luminance with equal power at frequencies between 0 and 30 Hz. Compared to SC individuals, CC individuals demonstrated a reduced likelihood of exhibiting an evoked alpha response. Moreover, stimulus-evoked alpha power was reduced and correlated with a corresponding reduction of resting-state alpha power in the same CC individuals. Finally, CC individuals with an above-threshold evoked alpha peak had better visual acuity than CC individual without an evoked alpha peak. Since alpha oscillations have been linked to feedback communication, we suggest that the concurrent impairment in resting-state and stimulus-evoked alpha oscillations indicates an altered interaction of top-down and bottom-up processing in the visual hierarchy, which likely contributes to incomplete behavioral recovery in individuals who experienced transient congenital blindness.

Sight restoration in congenitally blind humans does not restore visual brain structure.

It is unknown whether impaired brain structure after congenital blindness is reversible if sight is restored later in life. Using structural magnetic resonance imaging, visual cortical surface area and cortical thickness were assessed in a large group of 21 sight-recovery individuals who had been born blind and who months or years later gained sight through cataract removal surgery. As control groups, we included 27 normally sighted individuals, 10 individuals with permanent congenital blindness, and 11 sight-recovery individuals with a late onset of cataracts. Congenital cataract-reversal individuals had a lower visual cortical surface area and a higher visual cortical thickness than normally sighted controls. These results corresponded to those of congenitally permanently blind individuals suggesting that impaired brain structure did not recover. Crucially, structural brain alterations in congenital-cataract reversal individuals were associated with a lower post-surgery visual acuity. No significant changes in visual cortex structure were observed in sight-recovery individuals with late onset cataracts. The results demonstrate that impaired structural brain development due to visual deprivation from birth is not fully reversible and limits functional recovery. Additionally, they highlight the crucial importance of prevention measures in the context of other types of aberrant childhood environments including low socioeconomic status and adversity.

Clinical Profile, Neuroimaging Characteristics, and Surgical Outcomes of Patients With Acute Acquired Non-accommodative Comitant Esotropia.

PURPOSE: To report the clinical presentations, neuroimaging findings, and surgical outcomes in patients with acute acquired non-accommodative comitant esotropia (AACE). METHODS: A retrospective review of records of all patients diagnosed as having AACE between January 2011 and December 2019 across three tertiary eye care centers was done. Cases with AACE onset after age 1 year were included. Patients were divided into two groups based on age of onset of esotropia: childhood (16 years or younger) and adult (older than 16 years). Surgical success was defined as postoperative horizontal deviation of 8 prism diopters (PD) or less at the last follow-up visit. RESULTS: A total of 338 patients (220 males and 119 females; mean age at presentation: 12.60 ± 9.8 years) met the study criteria. The mean age at onset of esotropia in the childhood and adult onset groups was 3.61 ± 1.1 and 26.6 ± 8.7 years, respectively. There were significantly more individuals with myopia (30%) in the adult onset group compared to the childhood onset group (6%) (P = .004). Thirty-seven (16%) had positive neuroimaging findings (16.4% adult onset vs 9.4% childhood onset). A total of 148 (44%) patients underwent surgery for esotropia, and the overall success rate was 73%. Mean preoperative esotropia was comparable in either group (P = .20), but surgical success was better in the adult onset group (75.6% vs 66.3% in the childhood onset group). Mean duration of follow-up postoperatively was 13.6 ± 12 months. CONCLUSIONS: Two-thirds of the patients had childhood onset of AACE. Intracranial pathology was found in 1 of 6 patients. Surgical success was better in the adult onset group, which was not influenced by preoperative esotropia, neuroimaging findings, or refractive status, but was dependent on age at onset of esotropia and duration between onset and intervention. [J Pediatr Ophthalmol Strabismus. 2023;60(3):218-225.].

Secondary Intraocular Lens Implantation (IOL) in Children- What, Why, When, and How?

PURPOSE: To provide a comprehensive review on secondary IOL implantation in children who have undergone primary surgery at an early age and are aphakic aiming at answering common dilemmas among pediatric ophthalmologists. METHOD OF LITERATURE REVIEW: A systematic literature search was done using keywords like secondary intraocular implantation, congenital cataractand surgical aphakia. Various novel case reports, retrospective case studies and review articles covering different aspects of secondary IOL implantation were searched and reviewed using PubMed and Google scholar journal search engines. RESULTS: This article highlights various aspects of secondary IOL implantation like the appropriate timing should be when the child is entering preschool, with the proper technique being in bag fixation is the most preferred method with least associated complications and the IOL type should be decided based on the fixation site. CONCLUSION: Secondary IOL implantation can accomplish good and stable long-term outcomes in children. It is the most accepted mode of optical correction once the appropriate age is achieved.

"Peek-a-boo" Sign in Pediatric Cataract Surgery.

The authors demonstrate a "peek-a-boo" sign for intra-operative evaluation of the posterior pole of the fundus during pediatric cataract surgery. [J Pediatr Ophthalmol Strabismus. 2022;59(5):e54.].

Active vision in sight recovery individuals with a history of long-lasting congenital blindness.

What we see is intimately linked to how we actively and systematically explore the world through eye movements. However, it is unknown to what degree visual experience during early development is necessary for such systematic visual exploration to emerge. The present study investigated visual exploration behavior in ten human participants whose sight had been restored only in childhood or adulthood, after a period of congenital blindness due to dense bilateral congenital cataracts. Participants freely explored real-world images while their eye movements were recorded. Despite severe residual visual impairments and gaze instability (nystagmus), visual exploration patterns were preserved in individuals with reversed congenital cataract. Modelling analyses indicated that similar to healthy controls, visual exploration in individuals with reversed congenital cataract was based on the low-level (luminance contrast) and high-level (object components) visual content of the images. Moreover, participants used visual short-term memory representations for narrowing down the exploration space. More systematic visual exploration in individuals with reversed congenital cataract was associated with better object recognition, suggesting that active vision might be a driving force for visual system development and recovery. The present results argue against a sensitive period for the development of neural mechanisms associated with visual exploration.SIGNIFICANCE STATEMENTHumans explore the visual world with systematic patterns of eye movements, but it is unknown whether early visual experience is necessary for the acquisition of visual exploration. Here, we show that sight recovery individuals who had been born blind demonstrate highly systematic eye movements while exploring real-world images, despite visual impairments and pervasive gaze instability. In fact, their eye movement patterns were predicted by those of normally sighted controls and models calculating eye movements based on low- and high-level visual features, and they moreover took memory information into account. Since object recognition performance was associated with systematic visual exploration it was concluded that eye movements might be a driving factor for the development of the visual system.