Long-term Motor and Sensory Outcomes After Unilateral Medial Rectus Recession-Lateral Rectus Resection for Infantile Esotropia.

PURPOSE: To report long-term motor and sensory outcomes after unilateral medial rectus recession-lateral rectus resection for infantile esotropia. METHODS: The medical records of patients who had undergone unilateral medial rectus recession-lateral rectus resection for infantile esotropia and were followed up postoperatively for a minimum of 10 years were reviewed retrospectively. RESULTS: A total of 100 patients were included. The mean age at surgery was 2.9 ± 2.2 years (range: 2.5 months to 9.0 years). The mean postoperative follow-up was 15.7 ± 4.4 years (range:10.0 to 27.5 years). Overall, 54 patients (54%) had surgical success at their last follow-up visit. Age at first surgery, strabismus duration, degree of hyperopia, preoperative size of deviation, presence of dissociated vertical deviation, inferior oblique overaction, or both dissociated vertical deviation and inferior oblique overaction, and the number of esotropia surgeries did not predict motor outcome after surgery. Consecutive exotropia developed in 43% of patients (constant in 18% and intermittent in 25%). Residual and recurrent esotropia occurred in 20% and 21% of patients, respectively. Refractive accommodative esotropia developed in 17% of patients and there was a high accommodation convergence/accommodation ratio esotropia in 2%. Peripheral binocular single vision was achieved in 54% of patients and stereopsis in 1%. Patients with 1.5 years or less of strabismus duration had better chances of achieving peripheral binocular single vision. CONCLUSIONS: Nearly half of the patients with infantile esotropia achieved a successful long-term motor outcome and peripheral binocular single vision. Consecutive exotropia occurred frequently. Recurrent esotropia and refractive accommodative esotropia developed in some patients, and a high accommodation convergence/accommodation ratio esotropia in a few. Stereopsis outcome was extremely poor. [J Pediatr Ophthalmol Strabismus. 2024;61(2):106-113.].

Short-term and Long-term Status of Monocular Eye Closure in Sunlight After Surgical Treatment of Intermittent Exotropia.

PURPOSE: To evaluate short-term and long-term status of monocular eye closure in sunlight after surgical treatment of intermittent exotropia. METHODS: The medical records of consecutive patients 4 years and older who underwent surgery for intermittent exotropia with monocular eye closure in sunlight were reviewed retrospectively. Monocular eye closure status on short-term and long-term postoperative follow-up was analyzed to determine whether the status on short-term follow-up remained or changed on long-term follow-up. RESULTS: A total of 37 patients were included (mean age: 10.64 ± 6.05 years). Thirteen patients (35%) were postoperatively observed for 6 months or less (short-term) and 24 (65%) for a mean 7.12 ± 2.89 years (long-term). Monocular eye closure disappeared in 16 patients (43%) and persisted in 21 (57%) on short-term follow-up. There was no significant difference in eye closure status between short-term and long-term follow-up in 24 patients. Eight of 9 patients (89%) with disappearance of eye closure on short-term follow-up maintained this status on long-term follow-up and 1 patient (11%) had reappearance of eye closure. Eleven of 15 patients (73%) with persistence of eye closure on short-term follow-up maintained this status on long-term follow-up and 4 (27%) had disappearance of eye closure. Three patients had a fluctuation in eye closure status during long-term follow-up. CONCLUSIONS: Monocular eye closure disappeared in nearly 40% of patients on short-term follow-up and in 50% on long-term follow-up after surgery for intermittent exotropia. Monocular eye closure status on short-term follow-up remained on long-term follow-up in most patients and changed in a few patients. [J Pediatr Ophthalmol Strabismus. 2023;60(2):114-119.].

Comparison of Long-term Stereoacuity Improvement Between Patients With Initial Subnormal Stereopsis and Nil Stereopsis in Refractive Accommodative Esotropia.

PURPOSE: To compare improvement in long-term stereoacuity between patients with refractive accommodative esotropia (RAET) with initial subnormal stereopsis (between 120 and 1,980 arcsec of stereoacuity) and nil stereopsis. METHODS: The medical records of patients 4 years and older who had RAET with initial subnormal stereopsis and nil stereopsis and a minimum follow-up period of 5 years were retrospectively reviewed. Improvement in stereoacuity at the last follow-up visit and the factors that could influence it were compared between the initial subnormal stereopsis and the nil stereopsis groups. RESULTS: A total of 79 patients (mean age: 6.3 ± 1.9 years) were included: 31 patients with initial subnormal stereopsis and 48 patients with nil stereopsis. The mean follow-up time was 11.7 ± 1.8 years (range: 5 to 21 years). At the last follow-up visit, a statistically significantly greater number of patients with initial subnormal stereopsis demonstrated improvement in stereoacuity and also achieved 60 arcsec of stereoacuity compared with those with nil stereopsis. Age at onset, duration of esodeviation, mean hyperopia, amblyopia, anisometropia, and follow-up duration were not significantly different between the initial subnormal stereopsis and the nil stereopsis groups. The initial mean near and distance deviations with hyperopic correction were significantly smaller in patients with initial subnormal stereopsis. A significantly greater number of patients with initial sub-normal stereopsis had fusion at distance. CONCLUSIONS: Patients with RAET with initial subnormal stereopsis have greater chances of stereoacuity improvement and recovery of 60 arcsec of stereoacuity than those with nil stereopsis. Patients who initially have nil stereopsis may develop normal stereoacuity. Smaller initial deviations with hyperopic correction and fusion at distance indicate a favorable prognosis for stereoacuity improvement. [J Pediatr Ophthalmol Strabismus. 2022;59(4):248-253.].

Comparison Between the Deviations After 1 and 24 Hours of Diagnostic Occlusion for Basic and Divergence Excess Types of Intermittent Exotropia.

PURPOSE: To compare the clinically significant (5 prism diopters [PD] or greater) changes in deviations after 1 and 24 hours of diagnostic monocular occlusion specifically for basic and divergence excess types of intermittent exotropia. METHODS: In this prospective study, diagnostic monocular occlusion was performed at 1 and 24 hours before surgery in patients with intermittent exotropia. A change of 5 PD or greater in near and distance deviation after occlusion was considered clinically significant and used as the cut-off point for analysis. The mean clinically significant changes between the deviations after 1 and 24 hours of occlusion in patients with basic and divergence excess types of intermittent exotropia were compared. RESULTS: A total of 21 patients with basic type and 20 patients with divergence excess type intermittent exotropia were included. No statistically significant differences were found for the mean near and distance deviations, the number of patients who had a clinically significant (5 PD or greater) increase, or the magnitude of increase in near and distance deviations after 1 hour versus 24 hours of diagnostic occlusion in patients with both types of intermittent exotropia. CONCLUSIONS: Diagnostic monocular occlusion for 1 hour is sufficient in patients with basic and divergence excess types of intermittent exotropia. [J Pediatr Ophthalmol Strabismus. 2022;59(1):41-45.].

Long-term Motor and Sensory Outcomes After Unilateral Lateral Rectus Recession-Medial Rectus Resection for Basic Intermittent Exotropia.

PURPOSE: To report long-term motor and sensory outcomes after unilateral lateral rectus recession-medial rectus resection for basic intermittent exotropia. METHODS: The medical records of patients who had undergone unilateral lateral rectus recession-medial rectus resection for basic intermittent exotropia and were observed postoperatively for a minimum of 10 years were reviewed retrospectively. RESULTS: A total of 41 patients were included (mean age: 6.07 ± 2.96 years; range: 3 to 17 years). The mean postoperative follow-up was 13.28 ± 3.27 years (range: 10 to 23 years). Overall, 19 patients (46%) had surgical success at their most recent follow-up visit. Age at onset of strabismus, age at surgery, strabismus duration, preoperative size of near and distance deviation, presence of stereopsis, and initial postoperative overcorrection did not predict motor outcome after surgery. Twenty-five patients (74%) achieved stereopsis. None of the 4 patients without binocular single vision preoperatively achieved stereopsis, compared to 3 of 7 patients (43%) with peripheral binocular single vision (P = .02). Five of 7 patients (71%) with a preoperative stereoacuity of 120 to 240 seconds of arc improved to 60 seconds of arc. Age at surgery did not predict stereopsis. Patients with a strabismus duration of 5 years or less achieved a better stereopsis. CONCLUSIONS: Fewer than half of the patients with basic intermittent exotropia achieved a successful long-term surgical outcome. Age at surgery, strabismus duration, preoperative stereopsis, and an initial postoperative overcorrection did not predict motor outcome. A pre-operative absence of binocular single vision indicated a poor prognosis for stereopsis. A shorter duration of strabismus predicted a better stereopsis after surgery. [J Pediatr Ophthalmol Strabismus. 2020;57(5):326-332.].

Long-term motor and sensory outcomes after surgery for the nonaccommodative component of partially refractive accommodative esotropia.

PURPOSE: To report long-term motor and sensory outcomes after surgery for the nonaccommodative component of partially refractive accommodative esotropia (PRAET). METHODS: The medical records of consecutive patients ≤11 years old operated for the nonaccommodative component of PRAET and followed postoperatively for at least 10 years were retrospectively reviewed. RESULTS: A total of 47 patients were included (median age, 3.0 years). The mean postoperative follow-up was 12.15 ± 2.05 years (range, 10.00-17.50 years). Overall, 23 patients (49%) had surgical success; 10 (21%), decompensation; and 7 (15%), esotropia with a high ratio of accommodative convergence to accommodation (AC/A) or consecutive exotropia. The median age at surgery, mean cycloplegic refraction, median near and distance deviation, presence of binocular vision, and amblyopia did not predict decompensation, a high AC/A ratio esotropia, and consecutive exotropia. Eight patients (18%) achieved stereopsis. Patients with an older age at onset (2.87 ± 1.31 years) and a shorter duration of strabismus (≤4 years) achieved better stereopsis. CONCLUSIONS: Nearly half of our patients with PRAET achieved a successful ocular alignment after surgery for the nonaccommodative component. Some developed decompensation, a high AC/A ratio esotropia, or consecutive exotropia. Few patients achieved stereopsis. Older age at onset and a shorter duration of strabismus predicted a better stereopsis outcome.

Post penetrating keratoplasty glaucoma: cumulative effect of quantifiable risk factors.

PURPOSE: To ascertain the incidence, identify risk factors and calculate cumulative effect of risk factors in patients developing glaucoma following optical penetrating keratoplasty. MATERIALS AND METHODS: We carried out retrospective analysis of 445 patients, those underwent optical PK and had a minimum follow up of 6 m. Data on post-operative intra-ocular pressure (IOP) recorded at 3, 6, 9, 12 and 18 m or more was analyzed. Various risk factors including age, sex, indications for penetrating keratoplasty, pre-existing glaucoma and type of surgical procedures performed were analyzed by using univariate analysis and logistic regression technique. RESULTS: Ninety (21%) of eyes developed post-PK glaucoma. On applying logistic regression, age, sex, indication of surgery, pre-existing glaucoma were found to be significant risk factors for the development of post-PK glaucoma (P < 0.05). Using logistic regression equation the cumulative risk of developing post-PK glaucoma in an individual patient can be calculated. CONCLUSIONS: Male patients, aged more than 40 years, having opaque grafts as an indication and with pre-existing glaucoma were found to be higher risk of developing post-PK glaucoma. Patients at higher cumulative risk for development of post-PK glaucoma may be closely monitored during follow-up.

Long-term treatment results of accommodative esotropia.

PURPOSE: To report the long-term ocular alignment outcomes of patients with accommodative esotropia. METHODS: The medical records of consecutive patients ≤12 year of age diagnosed with refractive accommodative esotropia (esotropia eliminated or decreased to within 10(Δ) with full hyperopic correction) and followed for at least 10 years were retrospectively reviewed. RESULTS: A total of 107 patients were included (mean age, 4.81 ± 2.64 years). The mean follow-up period was 12.02 ± 2.25 years (range, 10-21 years). At the first examination performed 10 years after spectacle correction (mean, 10.2 years), 85 patients (79%) had orthophoria or esotropia ≤10(Δ) at both near and distance fixation, 14 (13%) had consecutive exotropia, 5 (5%) had decompensation and 3 (3%) had esotropia with a high ratio of accommodative convergence to accommodation (AC/A). The mean time interval between presentation and prescription of full hyperopic correction, initial cycloplegic refraction, and presence of amblyopia was not associated with consecutive exotropia, decompensation, or a high AC/A ratio esotropia. CONCLUSIONS: Whereas most patients with refractive accommodative esotropia maintained normal long-term ocular motility with spectacle treatment, some developed consecutive exotropia, nonaccommodative esotropia, or esotropia with a high AC/A ratio.

Alopecia following oral acyclovir for the treatment of herpes simplex keratitis.

The authors report acyclovir-induced alopecia in a patient treated for herpetic keratouveitis. A 32-years-old female was diagnosed with herpetic keratouveitis. She was placed on prednisolone acetate (1%) suspension four times a day, atropine sulfate (1%) thrice a day, and oral acyclovir 400 mg twice-daily. Three weeks following oral acylovir, keratouveitis improved, but she developed alopecia without any drug eruptions. Oral acyclovir was discontinued. Three months later, alopecia completely resolved. Alopecia may be considered a possible complication following oral acyclovir.

Repositioning of pedicle conjunctival flap performed for refractory corneal ulcer.

A 50-year-old male was referred with a previous history of conjunctival flap (CF) for a nonhealing fungal corneal ulcer with extreme corneal thinning in the right eye. The peritomy for the CF extended from 6:30 to 9:30 clock h on the cornea. The CF was disengaged, peritomy area deepithelialized, and CF was repositioned. He later underwent penetrating keratoplasty and achieved 20/40 best corrected visual acuity. The authors present a new concept for surgically repositioning CF s to the original site immediately after healing of the corneal ulcer.

Scleral Patch Graft Augmented Cyanoacrylate Tissue Adhesive for Treatment of Moderate-Sized Noninfectious Corneal Perforations (3.5-4.5 mm).

PURPOSES: To describe a new technique of scleral tissue augmented cyanoacrylate tissue adhesive (CTA) application and to evaluate its efficacy in noninfectious corneal perforations that measure between 3.5 and 4.5 mm. METHODS: Retrospective noncomparative case series included 16 consecutive patients diagnosed with moderate-sized corneal perforations measuring 3.5 to 4.5 mm who were treated with scleral patch graft augmented glue application. A partial-thickness scleral patch equal to the size of corneal perforation was placed in the corneal perforation site. After the area was sufficiently dried, CTA was applied on the interface of the host cornea and scleral patch. The ability of the scleral patch graft with CTA to seal the perforation and allow complete wound healing was considered a successful outcome. RESULTS: The corneal perforation healed in 14 eyes (87.5%), with a mean of 5.65 weeks (range, 5-9 weeks). One eye (6.25%) developed microperforation that required additional CTA to seal the wound. Three eyes (18.75%) required reapplication of the scleral patch graft and CTA. The 2 eyes (12.50%) that failed scleral patch with CTA were successfully treated with tectonic penetrating keratoplasties. In all 5 eyes (100%), the corneal perforations as a result of Mooren ulcer healed in a mean 5.80 weeks (range, 5-7 weeks). One patient developed retinal detachment with proliferative vitreoretinopathy and cataract after trauma. CONCLUSIONS: Scleral patch graft augmented CTA technique is a successful alternative treatment method to emergent penetrating keratoplasty for corneal perforations that measure 3.5 to 4.5 mm.

A comparison of ocular alignment success of hang-back versus conventional bilateral lateral rectus muscle recession for true divergence excess intermittent exotropia.

PURPOSE: To assess whether hang-back or conventional bilateral lateral rectus muscle recessions were more successful in achieving a satisfactory postoperative ocular alignment in patients with true divergence excess intermittent exotropia. METHODS: The medical records of consecutive patients with true divergence excess intermittent exotropia who underwent bilateral lateral rectus muscle recession using hang-back or conventional techniques were retrospectively analyzed. All surgeries were performed by a single surgeon using the same standard table of surgical dosage. We compared the preoperative characteristics and motor surgical outcomes between the two groups. Success was defined as alignment within 10(Δ) of intermittent exotropias at distance and near. Any amount of postoperative esotropia was considered a failure. RESULTS: A total of 42 patients were included: 13 in the hang-back group and 29 in the conventional group. The mean age at surgery, mean preoperative deviation at near and distance, mean amount of lateral rectus muscle recession, and mean follow-up duration were not statistically significantly different between groups. At the most recent follow-up, the conventional group had a significantly greater success rate (≤10(Δ) of intermittent exotropia) than the hang-back group (83% vs 31%, P = 0.0009). There was no statistically significant difference in the mean amount of lateral rectus recession between patients with successful and unsuccessful surgical outcomes in both groups. CONCLUSIONS: Within the limitations of this study, conventional bilateral lateral rectus recessions were more effective than hang-back recessions in achieving a successful postoperative alignment in patients with true divergence excess intermittent exotropia.

How often are spectacle lenses not dispensed as prescribed?

Spectacles are routinely prescribed by the ophthalmologist and dispensed by the opticians. We investigated how frequently the spectacles are not dispensed as prescribed and whether the frequency of inaccurate spectacles would decrease if the patients, at the time of collecting spectacles, ask the optician to verify that the spectacles have been dispensed accurately. We found inaccurate spectacles in about one-third of our patients and incorrect spherocylinders more frequently with an error in the spherical element and cylinder axis. These inaccuracies decreased significantly when patients while collecting spectacles, asked the optician to verify the accuracy of the spectacles dispensed. It is suggested that while prescribing spectacles, the patients should be made aware of the possibility of dispensing errors. To decrease the frequency of incorrect spectacles, the patients while collecting spectacles, should ask the optician to check whether the spectacles have been dispensed accurately.

Persistent corneal edema after collagen cross-linking for keratoconus.

PURPOSE: To present a new complication of persistent corneal edema after collagen cross-linking (CXL) in keratoconus patients. DESIGN: Retrospective case series of postoperative corneal edema after CXL. METHODS: study population: All patients who underwent CXL treatment with subsequent corneal edema. Patients with stromal haze were excluded. intervention: The CXL treatments used the Dresden protocol with corneal thickness of more than 400 µm after epithelium was removed. main outcome measure: The resolution of corneal edema after surgery. RESULTS: Postoperative corneal edema was identified in 10 (2.9%) of 350 patients who were followed up for a mean of 14 ± 4 months. The edema started on postoperative day 1 (10/10) and increased for 3 weeks. Additional findings included: deep vascularization (2 eyes; 20%), iris atrophy (6 eyes; 60%), pigment dispersion (5 eyes; 50%), persistent epithelial defect (3 eyes; 30%), and infectious keratitis (1 eye; 10%). Specular microscopy was unsuccessful, but the fellow untreated eyes had normal endothelial counts. Intraocular pressure and lenticular evaluations were normal. Corneal edema improved in 4 patients and resolved in 1 patient. In these 5 patients, the logarithm of the minimal angle of resolution best-corrected visual acuity was 0.5 ± 0.18. Penetrating keratoplasty was offered to 5 patients when improvement plateaued at 3 months, but only 2 patients underwent penetrating keratoplasty. CONCLUSIONS: CXL is a safe and effective procedure with few known side effects. This case series reports the possibility of corneal endothelial damage with visually significant corneal edema after CXL treatment. Based on the extent of endothelial damage, patients may require penetrating keratoplasty.

Development of refractive accommodative esotropia in children initially diagnosed with pseudoesotropia.

PURPOSE: To determine the clinical characteristics of children with pseudoesotropia who later develop refractive accommodative esotropia. METHODS: We retrospectively reviewed the records of consecutive patients diagnosed with pseudoesotropia from 2003 to 2010. Inclusion criteria included age 3 years or younger at the time of diagnosis, history of strabismus, verifiable positive or negative family history of strabismus, hypermetropia detected with atropine refraction, prism and cover test measurements performed with and without refractive correction at follow-up visits, and a minimum follow-up of 1 year. RESULTS: A total of 51 children met inclusion criteria (average age, 1.48 ± 0.79 years; range, 3-36 months; mean follow-up, 2.9 years). Refractive accommodative esotropia developed in 15.7% of the children at a mean age of 2.78 ± 1.06 years. It developed in 53.9% of the children with pseudoesotropia who had >1.50 D of hypermetropia compared to 2.6% of those who had ≤ 1.50 D hypermetropia (P = 0.0001). A positive family history of strabismus (P = 0.193) and initial age at presentation with pseudoesotropia (P = 0.571) were not predisposing factors. CONCLUSIONS: Children aged ≤ 3 years diagnosed with pseudoesotropia should undergo cycloplegic refraction. If >1.50 D hypermetropia is detected, patients should be monitored for the development of refractive accommodative esotropia.