Preliminary data on a novel smart glasses system for measuring the angle of deviation in strabismus.

BACKGROUND/OBJECTIVES: To propose a novel smart glasses device for recording eye movement and compare its results to the prism alternate cover test (PACT). SUBJECTS/METHODS: This method comparison study enrolled patients with strabismic conditions, who first underwent conventional strabismus evaluations (PACT in the primary position), followed by the smart glasses NeuroSpeed system (NSS) recording protocols. The video recordings were analysed using specialized software, to calculate the horizontal deviation from the primary position. The results were compared with those of the PACT using Passing‒Bablok regression and Bland‒Altman analysis. RESULTS: This study included 70 individuals aged 4 to 80 years, of which 38 were men and 32 were women. The overall analysis of horizontal deviations using the Passing‒Bablok regression revealed a correlation coefficient (r) of 0.969, with a systemic bias of 0.00, a proportional bias of 0.809, and a perpendicular residual standard deviation of 4.134. CONCLUSIONS: The predictive values of eye movement examinations recorded by the NSS were comparable to those of the PACT. Thus, this new system can provide additional information for ophthalmologists to aid in the diagnosis and measurement of strabismus.

Early Intervention in Orbital Floor Fractures: Postoperative Ocular Motility and Diplopia Outcomes.

Purpose: Orbital floor fractures commonly occur during orbital trauma. Currently, the indications for orbital fracture repair and the appropriate duration between trauma and surgical intervention remain controversial. Methods: Eyes diagnosed with orbital floor fractures that underwent reconstruction surgery were retrospectively reviewed. Demographic data were analyzed. Patients were classified based on the timing of the surgical intervention after injury. Ocular limitation and diplopia were evaluated preoperatively and postoperatively at one week, one month, and three months. Results: Two hundred seventy eyes of 270 patients (174 males and 96 females, mean age: 40.9 ± 16.3 years) were identified. The mean duration from injury to surgical intervention was 18.0 ± 21.2 days (range: 0−117 days). In the subgroup analysis, compared to delayed treatment, the early repair of floor fractures, i.e., within 7 days, was associated with significant motility and diplopia resolution at one week (p = 0.001, p < 0.001), one month (p < 0.001, p < 0.001), and three months (p < 0.001, p < 0.001). Sex and the duration from injury to repair were significantly associated with postoperative ocular motility (p = 0.001; p = 0.024) and diplopia (p < 0.001; p = 0.008) at three months. Multivariate analysis revealed that preoperative limitation and diplopia were correlated with postoperative limitation (p = 0.007) and diplopia (p = 0.001), respectively. Conclusions: The duration between orbital floor fracture and surgical treatment was associated with postoperative limitation and diplopia. Our results suggest that earlier intervention in symptomatic patients with orbital trauma may improve postoperative visual function.

Characteristics of responders to atropine 0.01% as treatment in Asian myopic children.

Recently, low-concentration atropine (0.01%) has gained increased attention in controlling myopia progression with satisfying effects and minimal side effects. However, studies concerning responders to 0.01% atropine are limited. This retrospective observational cohort study aimed to determine the responder characteristics of 0.01% atropine in Asian children. One hundred forty children (aged between 3 and 15 years) receiving 0.01% atropine were analyzed for the factors influencing annual spherical equivalent changes (SE). The mean age was 9.13 (2.6) years, the mean baseline SE was - 1.56 (1.52) diopters (D), and the mean annual SE change was - 0.52 (0.49) D. A 58.63% responder rate (146/249) of myopic control was achieved with 0.01% atropine in our entire cohort under the criteria of less than 0.5 D of myopic progression annually. The subjects were stratified into 4 subgroups based on a cut-off point of baseline SE of - 1.5 D and baseline age of 9 years. The responder rate differed significantly with the highest being the youngest with the lowest myopia subgroups. Our results demonstrated that children with myopia better than - 1.5 D and younger than 9 years had the highest potential to achieve successful myopic control under 0.01% atropine therapy.

A Novel Method Ensuring an Immediate Target Angle After Horizontal Strabismus Surgery in Children.

Purpose: Pediatric strabismus surgery has low success rates and high reoperation rates because of difficult alignment measurements and the nature of different strabismus types. Furthermore, adjustable sutures are not easily employed in children on an OPD basis. Methods: This was a retrospective comparative case study of children less than 12 years old who underwent strabismus surgery and were followed up at least 6 months postoperatively. We proposed a novel method that combines adjustable sutures and corneal light reflexes in regular strabismus surgery to improve surgical results. Efficacy and safety were evaluated and compared with those in a regular fixed-suture group. Results: In total, 128 children (88: exotropia and 41: esotropia) in the novel method group (Group 1) and 109 (71: exotropia and 38: esotropia) in the regular fixed-suture group (Group 2) were enrolled. The primary outcome was the immediate target angle (for esotropia within 4 PD of orthotropia and exotropia within 8 PD of esotropia within the first week postoperatively); the secondary outcome was success at the 6-month visit (angle of deviation < 10 PD). Consequently, there was a significantly higher proportion of achieving the immediate target range and success rate in both exotropic and esotropic patients in Group 1 than in Group 2. A significantly lower reoperation rate was also demonstrated in Group 1. No complications were noted in either group.Conclusions: The novel method enabled a higher proportion of subjects to achieve an immediate target range and success rate and a lower chance of reoperation among both esotropic and exotropic patients.

Successful Resection of Retrobulbar Carcinosarcoma without Recurrence: A Case Report.

Carcinosarcomas are biphasic tumors comprising carcinoma and sarcoma components that occur in many tissues but are rarely found in the orbit. A 70-year-old male presented to the ophthalmic clinic with progressive proptosis, having decreased vision in the left eye for 8 months. On examination, severe exophthalmos and lagophthalmos with limited extraocular movement were noted. Orbital computed tomography scans revealed a large, well-defined, heterogeneously enhanced mass in the left retrobulbar orbital cavity. The tumor was completely resected, and the pathological examination revealed a carcinosarcoma. The prognosis was excellent without local recurrence at 48 months postoperatively. Thus, when considering treatment for effective management of such tumors, tumor resection followed by radiotherapy or chemotherapy is highly recommended.

Surgical and Anatomic Consideration in Endoscopic Dacryocystorhinostomy of a Patient with Damaged Sinonasal Anatomy Post-Caldwell-Luc Surgery: A Case Report.

Background: The Caldwell-Luc (CL) procedure, an outdated operative procedure that is used to treat inflammatory sinus diseases, is rarely performed presently. However, physicians may encounter patients with a history of CL surgery who develop considerable postoperative changes that may lead to diagnostic confusion in imaging evaluation; increase the difficulty of future surgery, such as sinonasal surgery; and increase the incidence of future intraoperative complications. Case summary: A 67-year-old man with a surgical history of chronic sinusitis reported epiphora of the left eye for five years. Balloon dacryocystoplasty was attempted but failed. Endo-DCR (Endoscopic dacryocystorhinostomy) was indicated; however, preoperative CT (computed tomography) imaging and nasal endoscopic examination showed sinonasal anomalies and the loss of internal landmarks for localizing the lacrimal sac. Preoperative CT results indicated previous CL surgery. Endo-DCR was performed with the aid of nasal forceps and a 20-gauge vitreoretinal fiberoptic endoilluminator. A six-month follow-up revealed the complete resolution of symptoms and no signs of recurrence. Conclusions: Epiphora might be a delayed complication of the CL procedure. Before performing endo-DCR, ophthalmologists should be familiar with the sinonasal anatomy and carefully assess preoperative imaging to identify anatomical variations. Nasal forceps and transcanalicular illumination can assist in determining the precise location of the lacrimal sac during endo-DCR.

Accurate Identification of the Trabecular Meshwork under Gonioscopic View in Real Time Using Deep Learning.

PURPOSE: Accurate identification of iridocorneal structures on gonioscopy is difficult to master, and errors can lead to grave surgical complications. This study aimed to develop and train convolutional neural networks (CNNs) to accurately identify the trabecular meshwork (TM) in gonioscopic videos in real time for eventual clinical integrations. DESIGN: Cross-sectional study. PARTICIPANTS: Adult patients with open angle were identified in academic glaucoma clinics in both Taipei, Taiwan, and Irvine, California. METHODS: Neural Encoder-Decoder CNNs (U-nets) were trained to predict a curve marking the TM using an expert-annotated data set of 378 gonioscopy images. The model was trained and evaluated with stratified cross-validation grouped by patients to ensure uncorrelated training and testing sets, as well as on a separate test set and 3 intraoperative gonioscopic videos of ab interno trabeculotomy with Trabectome (totaling 90 seconds long, 30 frames per second). We also evaluated our model's performance by comparing its accuracy against ophthalmologists. MAIN OUTCOME MEASURES: Successful development of real-time-capable CNNs that are accurate in predicting and marking the TM's position in video frames of gonioscopic views. Models were evaluated in comparison with human expert annotations of static images and video data. RESULTS: The best CNN model produced test set predictions with a median deviation of 0.8% of the video frame's height (15.25 µm) from the human experts' annotations. This error is less than the average vertical height of the TM. The worst test frame prediction of this model had an average deviation of 4% of the frame height (76.28 µm), which is still considered a successful prediction. When challenged with unseen images, the CNN model scored greater than 2 standard deviations above the mean performance of the surveyed general ophthalmologists. CONCLUSIONS: Our CNN model can identify the TM in gonioscopy videos in real time with remarkable accuracy, allowing it to be used in connection with a video camera intraoperatively. This model can have applications in surgical training, automated screenings, and intraoperative guidance. The dataset developed in this study is one of the first publicly available gonioscopy image banks (https://lin.hs.uci.edu/research), which may encourage future investigations in this topic.

A simple marking system for accurate intraoperative monitoring and adjustment of cyclotorsion strabismus surgery.

Ocular cyclotorsion is treatable only with surgery. The surgical procedure must be tailored individually to the specific etiologies causing the horizontal and vertical strabismus and its torsional components. An adjustable surgical approach is often used for postoperative or intraoperative adjustments. However, the methods currently used have some limitations. In this study, we propose a simple intraoperative marking system for all cyclotorsion correction surgery. The proposed marking system used three sets of surface markers: external horizontal markings, ocular horizontal markings, and surgical torsion markings, drawn in sequence. We retrospectively analyzed the surgical results using this novel marking system in this single-center, single-surgeon study. Fifteen patients with cyclotorsion who underwent treatment using the proposed marking system as an intraoperative aid between August 2019 and August 2021 were included. The medical charts were thoroughly reviewed, and the pre-and postoperative subjective and objective cyclotorsion were analyzed. Among the study subjects (10 males, 5 females; age range: 6-89 years), 13 had excyclotorsion and 2 incyclotorsion. Preoperative mean net subjective cyclotorsion measured by the double Maddox rod (DMR) test was 6.0° (standard deviation: 10.8°) and mean net disc-to-fovea angle (DFA) was 20.23° (13.21°). The postoperative net DMR and DFA were 0.2° (2.1°) and 14.09° (5.97°), respectively. The mean absolute net DMR and DFA being treated were 9.8° (4.8°) and 9.76° (4.61°). Overall, the proposed intraoperative marking system is a simple and quantitative method to assess, monitor, and adjust the torsional aspect for all strabismus surgeries.

"Pulsating proptosis and heavy eye syndrome precipitated by neurofibromatosis type 1: A case report".

RATIONALE: Neurofibromatosis type 1 (NF1) is a hereditary disease characterized by café-au-lait spots, peripheral neurofibromas, Lisch nodules, optic nerve glioma, and sphenoid wing dysplasia. Pulsating proptosis is associated with a sphenoid bony defect. Heavy eye syndrome is characterized by acquired esohypotropia in patients with high myopia. This study aimed to describe the presentation of pulsating proptosis and heavy eye syndrome precipitated by NF1 and its management. PATIENT CONCERNS: A 41-year-old woman presented with progressive pulsating proptosis and hypodeviation of the right eye over the past 2 years. The axial length of the right eye was 36.81 mm. The right eye presented with esohypotropia and hypoglobus. The ocular motility examination showed limitations in all directions, especially in supraduction. Brain computed tomography revealed sphenoid wing dysplasia of the right orbit. The meningocele protruded through the orbital defect, lifting the globe. Brain magnetic resonance imaging demonstrated superior rectus muscle (SR) medial displacement and lateral rectus muscle inferior displacement. Physical examination revealed café-au-lait macules and neurofibromas on the trunk. DIAGNOSIS: NF1 with pulsating proptosis and heavy eye syndrome. INTERVENTIONS: The patient declined neurosurgery due to risk and economic reasons. To manage her main concern regarding cosmetics, we performed orbital floor decompression, SR resection with advancement, maximal hang-back recession of the inferior rectus muscle, and a partial Jensen's procedure. OUTCOMES: Proptosis was reduced. The eye position became more symmetrical. The range of eye movements was also increased. LESSONS: This case describes a rare synchronous presentation of pulsating proptosis and heavy eye syndrome precipitated by NF1. Adult-onset presentation implied a progressive process in NF1. The case also showed a different etiology from that of typical heavy eye syndrome. It reminds ophthalmologists that orbital imaging should be performed in high myopia patients with strabismus to evaluate the extraocular muscle pathway. Furthermore, the case demonstrated a management that avoided the risk and expensive cost of neurosurgery, which has not been reported.

A Novel Procedure for the Management of Severe Hyphema after Glaucoma Filtering Surgery: Air-Blood Exchange under a Slit-Lamp Biomicroscopy.

Background and Objectives: This study introduces a novel office-based procedure involving air-blood exchange under a slit-lamp microscope for treatment of severe hyphema after filtering surgery. Materials and Methods: This retrospective study enrolled 17 patients (17 eyes) with a diagnosis of primary open-angle glaucoma with severe hyphema (≥4-mm height) after filtering surgery. All patients were treated with air-blood exchange under a slit-lamp using room air (12 patients) or 12% perfluoropropane (C3F8; five patients). Results: The procedures were successful in all 17 patients; they exhibited clear visual axes without complications during follow-up. In the room air group, the mean visual acuity (VA) and hyphema height significantly improved from 1.70 ± 1.07 LogMAR and 5.75 ± 1.14 mm before the procedure to 0.67 ± 0.18 LogMAR and 2.83 ± 0.54 mm after the procedure (p = 0.004; p < 0.001). In the C3F8 group, the mean VA showed a trend, though not significant, for improvement from 1.70 ± 1.10 LogMAR to 0.70 ± 0.19 LogMAR (p = 0.08); the mean hyphema height showed a trend for improvement from 5.40 ± 0.96 mm to 3.30 ± 0.45 mm. Compared with the C3F8 group, the room air group showed the same efficacy with a shorter VA recovery time. Conclusions: "Air-blood exchange under a slit-lamp using room air" is a convenient, rapid, inexpensive, and effective treatment option for severe hyphema after filtering surgery, and may reduce the risk of failure of filtering surgery.

Increased risk for central serous chorioretinopathy in nephrotic syndrome patients: A population-based cohort study.

BACKGROUND: Nephrotic syndrome (NS) is characterized by various etiologies that damage the glomerulus. Central serous chorioretinopathy (CSCR) is a retinal disease characterized by neurosensory detachment of the retina. Several case reports have described the relationship between both. Therefore, we try to analyze the epidemiological associations between NS and CSCR using the National Health Insurance Research Database in Taiwan. METHODS: Data spanning 14 years were extracted from the National Health Insurance Research Database and sub-grouped. The variables were analyzed using Pearson's chi-squared test and Fisher's exact test. The risk factors for disease development with or without comorbidities were examined using an adjusted hazard ratio (aHR). Kaplan-Meier analysis was performed to evaluate the cumulative incidence of CSCR with or without NS. RESULTS: A total of 14 794 patients with NS and 14 794 matched controls without NS were enrolled in this cohort study. The incidence rate of CSCR was higher in the study cohort than in the control cohort (aHR = 3.349, p < 0.001). The overall incidence of CSCR was 44.51 per 100 000 person-years in the study cohort and 33.39 per 100 000 person-years in the control cohort. In both groups, CSCR occurred more frequently in males than in females. Patients aged 40-49, 50-59, and ≥60 years in the study cohort had a significantly higher risk of developing CSCR than those in the control cohort (aHR = 3.445, 5.421, and 4.957, all p < 0.001). NS patient with a 4-week history of steroid usage has a higher risk of developing CSCR (aHR = 2.010, p < 0.001). CONCLUSION: Our data showed that patients with NS have an increased risk of developing subsequent CSCR. Physician should routinely refer their NS patients to ophthalmologist for ophthalmic evaluation. This is the first nationwide epidemiological study reporting the association between these two diseases. Further studies are needed to clarify this relationship.

Relationship between heart failure and central serous chorioretinopathy: A cohort study in Taiwan.

BACKGROUND: Both central serous chorioretinopathy (CSCR) and heart failure (HF) are disorders with a complex pathogenesis, whereas the two diseases might share similar pathogenesis. This study aimed to evaluate whether patients with HF are exposed to potential risk of CSCR by using the National Health Insurance Research Database (NHIRD). METHODS: Data were collected from the NHIRD over a 14-year period. Variables were analyzed with the Pearson chi-square test and Fisher's exact test. The risk factors for disease development were examined by adjusted hazard ratio (aHR). Kaplan-Meier analysis was performed to compare the cumulative incidence of CSCR. RESULTS: A total of 24 426 patients with HF were enrolled in the study cohort, and there were 24 426 patients without HF in the control cohort. The incidence rate of CSCR was higher in the study cohort than in the control cohort (aHR = 4.572, p < 0.001). CSCR occurred more commonly in males than in females. The overall incidence of CSCR was 30.07 per 100 000 person-years in the study cohort and 23.06 per 100 000 person-years in the control cohort. Besides, subgroup analysis revealed that no matter in gender or age group, HF patients were in an increased risk of CSCR diagnosis (male/female, aHR = 3.268/7.701; 20-59 years/≥60 years, aHR = 3.405/5.501, p < 0.001). CONCLUSION: HF is a significant indicator for CSCR. Patients with HF should stay alert for potential disorder of visual impairment. Further prospective studies to investigate the relationship between HF and CSCR could provide more information.

Optical coherence tomography angiography in unilateral multifocal choroiditis and panuveitis: A case report.

RATIONALE: Optical coherence tomography angiography (OCT-A) has the advantage to visualize the microvascular structure of the retina in vivo and was utilized clinically in various neovascular retinal diseases. The OCT-A has also been used to examine the lesion in multifocal choroiditis and panuveitis (MCP). This study aimed to describe a case of MCP and present the disease process of a punched-out lesion in the chorioretina with neovascular activity using OCT-A. PATIENTS CONCERNS: A 32-year-old female Caucasian patient presented with a 2-week history of progressive blurred vision in her right eye with photophobia and a diminished temporal visual field. On presentation, her best corrected visual acuity was 6/60 in the right eye with a prominent anterior uveitis seen under slit lamp examination. DIAGNOSES: Dilated fundus examination of the right eye showed vitritis and multiple, punched-out yellowish-white lesions over the peripheral retina. Additional multimodal imaging (MMI) were done including fluorescein angiography (FA), indocyanine green angiography (ICGA) and fundus autofluorescence (FAF), which all revealed characteristic findings of MCP. In general, the diagnosis of unilateral MCP was made. Furthermore, one of the punched-out lesions in the right eye was particularly selected and examined under OCT and OCT-A, which revealed a subretinal elevated lesion with high flow signal under OCT-A. INTERVENTIONS: Treatment with oral prednisolone at 30 mg daily with topical prednisolone acetate 1% every 2 hours were prescribed, which were gradually tapered down within a 2-month course. OUTCOMES: The patient's best corrected visual acuity of the right eye returned to 6/6 at 2 months after the diagnosis. The flow signal in the OCT-A study of the punched-out lesion had also resolved after steroid treatment. LESSONS: The MCP is an uncommon uveitis with multiple inflammatory chorioretinal lesions. Using multimodal imaging technique, physicians can better differentiate these lesions for diagnosis and for further monitoring. Our results demonstrated that these chorioretinal lesions in MCP may display neovascular activities that might not be seen easily using conventional FA or ICGA study. With OCT-A, ophthalmologists could identify and monitor subtle choroidal neovascularization (CNV) changes over these punched-out lesions.

Application of lateral tarsoconjunctival flap to correct ocular complications of Madelung's disease: A case report and literature review.

RATIONALE: Madelung's disease is a specific type of benign symmetric lipomatosis, which is characterized by overgrowing fat distributed at the neck and shoulder. This excessive fat accumulation may occur in different regions, including vital organs, such as the larynx, trachea, or the orbits. Surgery is usually performed to correct the esthetic or functional concern of the affected area. There are only few case reports mentioned about the orbital involvement of this disease. This study aimed to describe a case of Madelung's disease with ocular complications and the successful treatment using tarsoconjunctival flap. PATIENT CONCERNS: A 90-year-old obese male presented with decreased visual acuity accompanied with severe band form punctate epithelial erosions and ciliary injections in both eyes. Exophthalmos and ectropion of the lower eyelids were observed. DIAGNOSES: Orbital computed tomography revealed a rare entity of Madelung's disease with significant massive deposits of lipomas located symmetrically around the orbit and neck region. INTERVENTIONS: Bilateral lateral tarsoconjunctival flaps with lateral tarsal strip procedures were performed to correct the lower eyelid ectropion-related exposure keratopathy. OUTCOMES: The patient obtained improved visual acuity, intact and clear corneal surfaces, and perfect lower eyelid positions over both eyes. LESSONS: Madelung's disease is a rare condition. There are few reports to describe its ocular complications, due to lipoma overgrowing in the orbit. We shared our successful experience to correct ocular complications using tarsoconjunctival flap technique.

Positron emission tomography/computed tomography scan of Vogt-Koyanagi-Harada syndrome with associated autoimmune thyroid disease: A case report and literature review.

RATIONALE: Vogt-Koyanagi-Harada (VKH) syndrome is a rare disease and could be associated with autoimmune thyroid disease (AITD). This report was aimed to investigate the utility of F-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) for the diagnosis of VKH syndrome with AITD and to perform a literature review on the association between the 2 diseases. PATIENT CONCERNS: A 55-year-old woman without the history of ocular trauma suffered from chronic headache. She was presented with painful blurred vision of both eyes with headache for 2 weeks. Ophthalmic evaluations revealed panuveitis, exudative retinal detachment, and papilloedema in both eyes. The clinical symptoms and presentations are compatible with the diagnosis of VKH syndrome. Other examinations for intraocular infection, malignancy, and lupus choroidopathy were of negative results. The result of contrast-enhanced computed tomography (CT) of the brain was normal. Due to the history of cancer in the patient's families, a F-FDG PET/CT whole-body scan was performed. The result indicated a focal of 2-fluoro-2-deoxy-D-glucose (FDG) uptake at the right upper lobe of the thyroid. Therefore, the patient's thyroid function was examined and the result indicated euthyroidism with detectable thyroid peroxidase/thyroglobulin antibodies. DIAGNOSES: VKH syndrome with associated AITD. INTERVENTIONS: Treatment with intravenous pulse systemic methylprednisolone (1000 mg daily) was prescribed for 3 days and then shifted gradually to tapered oral steroid medication. OUTCOMES: Symptoms of papillitis and serous retinal detachment of VKH syndrome was relieved after steroid treatment LESSONS:: F-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) can be used for the effective diagnosis of VKH syndrome with AITD.