Incidence of infectious complications following strabismus surgery.

A total of 167 cases (0.111%) of infectious complications (endophthalmitis, orbital cellulitis, preseptal cellulitis, and postoperative infection) were identified in patients after strabismus surgery. The incidence of postoperative endophthalmitis was approximately 1 per 13,700 strabismus surgeries (0.007%) among 151,011 strabismus surgeries in US claims databases.

Trends in congenital nasolacrimal duct obstruction surgical procedures in the United States from 2003 to 2016.

In this population-based retrospective cohort study, the Optum claims dataset was used to identify children <4 years of age with the diagnosis of nasolacrimal duct obstruction during the period 2003-2016. A total of 156,044 children were identified, of whom 16,538 (9.43%) underwent a surgical procedure. There was a downward trend for the frequency of all types of treatments but particularly for facility-based probings.

Endophthalmitis after pediatric cataract surgery in the United States: report using an insurance claims database.

PURPOSE: To describe the characteristics and incidence of children developing endophthalmitis within the first 90 days following pediatric cataract surgery. SETTING: Deidentified commercial and Medicare Advantage health claims across the United States. DESIGN: Population-based retrospective cohort study. METHODS: In a retrospective review of approximately 58 million charts in Optum's deidentified Clinformatics Data Mart Database, patients aged <13 years who underwent cataract surgery in one or both eyes with or without primary intraocular lens (IOL) implantation between 2003 and 2017 were identified. Excluded were patients with traumatic cataract, <90 days of continuous insurance coverage, a prior diagnosis of endophthalmitis, and a diagnosis of endophthalmitis occurring after 90 days of cataract surgery. The main outcome measure was the incidence of endophthalmitis occurring within the first 90 days of cataract surgery and the odds ratio for developing endophthalmitis according to demographic and intraoperative factors. RESULTS: Cataract surgery was performed on 789 eyes (52.6% male), with a median age of 4 (interquartile range 1-8) years. The rate of IOL implantation at the time of cataract surgery was 66.8%. Endophthalmitis was diagnosed in 4 of 789 eyes (0.51%). The median time to diagnosis of endophthalmitis was 6.5 days (range: 5-44 days). There was no significant association between endophthalmitis and age, sex, or primary IOL implantation. CONCLUSIONS: In this large insurance claims database, the incidence of endophthalmitis following pediatric cataract surgery reported was more than the rate previously reported by any study with patients of a similar age.

An Overview of the Korean Intermittent Exotropia Multicenter Study by the Korean Association for Pediatric Ophthalmology and Strabismus.

The Korean Intermittent Exotropia Multicenter Study (KIEMS), which was initiated by the Korean Association of Pediatric Ophthalmology and Strabismus, is a collaborative multicenter study on intermittent exotropia in Korea. The KIEMS was designed to provide comprehensive information, including subjective and objective findings of intermittent exotropia in a large study population. A total of 65 strabismus specialists in 53 institutions contributed to this study, which, to date, is one of the largest clinical studies on intermittent exotropia. In this article, we provide a detailed methodology of the KIEMS to help future investigations that may use the KIEMS data.

The Effect of Absorbable and Non-absorbable Scleral Suture on Strabismus Surgery in the Rabbits.

Purpose: To evaluate and compare the histopathological changes in a rabbit model, following strabismus surgery using either absorbable or non-absorbable suture materials. Methods: Superior rectus muscle recession was performed in rabbits using either an absorbable (Vicryl®) or non-absorbable (Prolene®) suture material. Hematoxylin-eosin staining was performed and histologic changes in the sclera were evaluated at the first, second, fourth, and eighth weeks, postoperatively. Moreover, the postoperative scleral thickness was measured and the postoperative pattern of arrangement of scleral fibers was analyzed. Results: Suture material-induced limited inflammatory reaction and formation of new vessels were observed in the study subjects, in the early postoperative phase, in both the Vicryl® and Prolene® groups. In the Vicryl® group, multinucleated giant cells were dominant during the inflammatory phase, and replacement by fibrotic scar tissues was observed. In the Prolene® group, the suture material was observed to be intact, and the inflammatory reactions around the sutures were observed to be less severe compared to the Vicryl® group. Meanwhile, neither group exhibited reduction in scleral thickness or irregular rearrangement of scleral fibers. Conclusions: The current histological study demonstrated that there was no significant postoperative scleral tissue changes after a strabismus surgery. Furthermore, the absorbable suture material was observed to induce inflammatory reactions of greater severity, compared to the non-absorbable suture material, in scleral tissues.

Incidence of Strabismus and Amblyopia Among Children Initially Diagnosed With Pseudostrabismus Using the Optum Data Set.

PURPOSE: To determine the frequency of strabismus among children initially diagnosed with pseudostrabismus using big data. DESIGN: Population-based retrospective cohort study. METHODS: Setting: Population-based retrospective cohort study using claims data. StudyPopulation: 17,885 children diagnosed with pseudostrabismus at age ≤3 years who were later diagnosed with strabismus using the Optum deidentified Clinformatics Data Mart Database (2003-2016). We excluded patients diagnosed with strabismus before the diagnosis of pseudostrabismus or diagnosed simultaneously with strabismus and pseudostrabismus. OBSERVATIONS: We assessed age, refractive error, and presence of amblyopia. Patients with pseudostrabismus were compared to a group of patients from the Optum data set diagnosed with esotropia, exotropia, and unspecified heterotropia who had not been previously diagnosed with pseudostrabismus. MainOutcomeMeasures: Incidence of strabismus, among patients initially diagnosed with pseudostrabismus vs those without an initial diagnosis of pseudostrabismus. RESULTS: Strabismus was diagnosed in 9.6% (n = 1,725) of children initially diagnosed with pseudostrabismus at a median age of 1.65 years (IQR: 1.17-2.46) compared to 1.7% (136,047 of 7,787,743) of children in the control group (P < .001). Strabismus was diagnosed more than a year later in the pseudostrabismus group (3.32 years; IQR: 2.28-4.74) compared with the control group (2.28 years, IQR: 1.43-3.16) (P < .001). Esotropia was the most common type of strabismus in both groups (pseudostrabismus, 69.7%; control, 62.1%). A total of 377 children (21.9%) in the pseudostrabismus group underwent strabismus surgery compared with 12.1% of children in the control group (P < .001). CONCLUSIONS: Young children diagnosed with pseudostrabismus are at increased risk of developing strabismus and undergoing strabismus surgery.

Pattern of Extraocular Muscle Involvements in Miller Fisher Syndrome.

BACKGROUND AND PURPOSE: The most-common initial manifestation of Miller Fisher syndrome (MFS) is diplopia due to acute ophthalmoplegia. However, few studies have focused on ocular motility findings in MFS. This study aimed to determine the pattern of extraocular muscle (EOM) paresis in MFS patients. METHODS: We consecutively recruited MFS patients who presented with ophthalmoplegia between 2010 and 2015. The involved EOMs and the strabismus pattern in the primary position were analyzed. Antecedent infections, other involved cranial nerves, and laboratory findings were also reviewed. We compared the characteristics of the patients according to the severity of ophthalmoplegia between complete ophthalmoplegia (CO) and incomplete ophthalmoplegia (IO). RESULTS: Twenty-five patients (15 males and 10 females) with bilateral ophthalmoplegia were included in the study. The most-involved and last-to-recover EOM was the lateral rectus muscle. CO and IO were observed in 11 and 14 patients, respectively. The patients were aged 59.0±18.4 years (mean±SD) in the CO group and 24.9±7.4 years in the IO group (p<0.01), and comprised 63.6% and 21.4% females, respectively (p=0.049). Elevated cerebrospinal fluid protein was identified in 60.0% of patients with CO and 7.7% of patients with IO (p=0.019) for a mean follow-up time from the initial symptom onset of 3.7 days. CONCLUSIONS: The lateral rectus muscle is the most-involved and last-to-recover EOM in ophthalmoplegia. The CO patients were much older and were more likely to be female and have an elevation of cerebrospinal fluid protein than the IO patients.

Postoperative Muscle Migration Through Stretched Scar Formation After Superior Rectus Muscle Nonscleral Sutured Resection in Rabbit Eyes.

PURPOSE: To determine whether suturing to the residual muscle stump induces postoperative muscle migration after superior rectus muscle (SRM) resection in rabbit eyes. METHODS: Twenty-four eyes in 12 rabbits were randomly divided into two groups. Each group underwent a 3-mm SRM resection. The muscle stump was not removed in one randomly assigned eye in each rabbit and the resected muscle was sutured to the residual muscle stump (residual muscle stump group). In the other eye, the muscle stump was completely removed and the resected muscle was sutured to the original insertion site (control group). At postoperative weeks 1, 2, and 4, the distances between the most anterior aspect of the reattached muscle and the corneal limbus were measured. Histopathologic differences at the new attachment sites were assessed between the two groups at postoperative week 4. RESULTS: The mean distance between the corneal limbus and SRM was 2.97 ± 1.00 mm in the residual muscle stump group and 1.99 ± 0.40 mm in the control group at postoperative week 2 (P = .026) and 3.14 ± 0.78 mm in the residual muscle stump group and 1.81 ± 0.44 mm in the control group at postoperative week 4 (P = .002). Connective tissue, fibrosis, and myofibroblast proliferation in the front of the SRM were identified based on histopathologic findings. CONCLUSIONS: Postoperative loosening associated with a stretched scar frequently occurred in cases with suturing to the residual muscle during rectus muscle resection and could result from fibrosis and connective tissue proliferation in front of the rectus muscle. [J Pediatr Ophthalmol Strabismus. 2019;56(4):254-260.].

Clinical Manifestations of Strabismus in Patients with Primary Congenital Glaucoma.

Purpose: To determine the clinical manifestations and risk factors of developing strabismus in primary congenital glaucoma (PCG) patients who underwent glaucoma surgery. Methods: A retrospective case-series study of 54 PCG patients who were followed for at least 3 years after glaucoma surgery. The subjects were divided into 2 groups based on the occurrence of strabismus. Age at glaucoma diagnosis and surgery, visual acuity, intraocular pressure, amblyopia, cup-disc ratio, and orthoptic status were compared between the 2 groups. Results: Twenty of 54 patients (37.0%) developed strabismus after glaucoma surgery. The mean ages at the time of glaucoma diagnosis and surgery were 3.2 ± 2.7 months and 3.4 ± 2.8 months in the strabismus group and 24.3 ± 19.1 months and 26.4 ± 18.9 months in the non-strabismus group, respectively (p < .05). In addition, the mean logMAR visual acuities were 0.87 ± 0.38 in the strabismus group and 0.24 ± 0.21 in the non-strabismus group (p < .05). The proportion of patients experiencing amblyopia was 90.0% in the strabismus group. Low visual acuity and young age at glaucoma surgery were significant predictors of developing strabismus. Kaplan-Meier survival analysis demonstrated that the probability of developing strabismus after glaucoma surgery was 50.6% at 10 years post-surgery. Conclusions: PCG patients who developed strabismus after glaucoma surgery were diagnosed with glaucoma and underwent surgery at a younger age, exhibited a worse mean best corrected visual acuity, and exhibited a higher amblyopia incidence than did patients in the non-strabismus group.

Is Severe and Long-lasting Linezolid-induced Optic Neuropathy Reversible?

Linezolid is a useful drug for treating drug-resistant tuberculosis. However, the associated toxicities, especially optic neuritis, are a major obstacle for its long-term use. We recently experienced a case of severe optic and peripheral neuropathy during the treatment of multidrug-resistant tuberculosis. The treatment continued for 12 months despite severe optic and peripheral neuropathy. At eight months after the discontinuation of the drug, the optic neuropathy recovered, but the peripheral neuropathy did not. Considering the grave prognosis of drug-resistant tuberculosis, the continuation of linezolid despite neurotoxicity under close observation may be a suitable option.

Immunoglobulin G4 (IgG4)-Positive Ocular Adnexal Mucosa-Associated Lymphoid Tissue Lymphoma and Idiopathic Orbital Inflammation.

PURPOSE: To report clinical and pathological characteristics of idiopathic orbital inflammation and ocular adnexal mucosa-associated lymphoid tissue (MALT) lymphoma with immunoglobulin G4 (IgG4)-positive plasma cells. METHODS: A retrospective histopathological review and clinical case series. A total of 51 biopsy samples from January 2005 to December 2015 were used in this study, including 21 cases of biopsy-confirmed idiopathic orbital inflammation and 30 cases of biopsy-confirmed ocular adnexal MALT lymphoma. Most cases of ocular adnexal lymphoma were conjunctival tissue. Retrospective immunohistochemical studies were performed to estimate the IgG4 and IgG4/IgG ratios. Histopathologic features, demographic and clinical data, radiologic findings, treatment, and follow-up information for each patient were analyzed. RESULTS: Among idiopathic orbital inflammation, 6 (28.6%) of the 21 patients were diagnosed as "probable" ocular adnexal IgG4-related diseases and 13 (43.3%) of the 30 patients were diagnosed as MALT lymphoma with IgG4-positive plasma cells. Six cases of 13 IgG4-positive MALT lymphoma group had contralateral chronic inflammatory lesions infiltrated by IgG4-positive plasma cells, which was significantly (p = 0.007) higher than that in the IgG4-negative group. Conjunctival involvement was 69% of the IgG4-positive MALT lymphoma cases. Bilateral involvement of the ocular adnexa was significantly (p = 0.02) more frequent among IgG4-positive MALT lymphoma patients than that in IgG4-positive idiopathic orbital inflammation patients. Recurrence rate in the IgG4-positive group was higher (p = 0.05) than that in the IgG4-negative group but not significantly. CONCLUSIONS: This study presented an unusual framework of ocular adnexal IgG4-related inflammation, in conjunctiva. It is important to understand contralateral chronic inflammatory lesions and their relationship with IgG4-positive MALT lymphoma. Tissue biopsy and IgG4 immunostaining are required for all cases because IgG4-positive MALT lymphoma can arise from a pre-existing IgG4-positive chronic inflammatory lesions. This is the first study that performs IgG4 immunostaining for tissue from a relatively large number of conjunctival MALT lymphomas in a single center. Therefore, it will help to diagnose conjunctival lymphoproliferative disease.

Classification of Lacrimal Punctal Stenosis and Its Related Histopathological Feature in Patients with Epiphora.

PURPOSE: To evaluate the classification of punctal stenosis based on the shape of the external punctum, clinical characteristics and histopathologic features. METHODS: Patients who experienced tearing and were diagnosed with punctal stenosis were evaluated in this study. Punctal stenosis was classified according to the shape of the lower external punctum, which included membranous type, slit type, horseshoe type, and pinpoint type. Tear meniscus height, 2% fluorescein dye disappearance test and lacrimal pathway irrigation were measured or performed. For treatment, a punctal snip operation and silicone tube placement were performed, and the peripunctal histopathological findings were evaluated. RESULTS: Punctal stenosis was classified into four types: membranous type (17 eyes, 21.5%), slit type (11 eyes, 13.9%), horseshoe type (25 eyes, 31.6%), and pinpoint type (26 eyes, 32.9%). The tear meniscus was significantly higher, and the 2% fluorescein dye disappeared significantly more slowly in the punctal stenosis group. However, correlation of the tear meniscus height and 2% fluorescein dye disappearance test with the punctum shape was not statistically significant. A history of previous chemotherapy was significantly associated with the occurrence of punctal stenosis, especially the membranous type (p < 0.05). Histopathologic evaluation of the punctum showed differences between the punctum types. Pinpoint puncta exhibited a high density of muscle fibers, while they were faintly visible in the membranous type. CONCLUSIONS: Acquired punctal stenosis has various shapes, and the major types of stenotic puncta exhibited unique histopathologic features. Punctal stenosis and its pathophysiology may be related to multiple factors, such as age and systemic 5-fluorouracil chemotherapy history.

Effects of upper lid blepharoplasty on visual quality in patients with lash ptosis and dermatochalasis.

AIM: To assess the effects of upper lid blepharoplasty on visual quality. METHODS: Seventy-three eyelids of 39 patients were subjected to upper lid blepharoplasty. Pre- and post-operative contrast sensitivity, visual acuity, vertical palpebral aperture and the degree of lash ptosis were measured. RESULTS: The mean log contrast sensitivities under photopic (P=0.017) and scotopic conditions (P=0.009) were improved after surgery, and these differences were significant. The degree of lash ptosis was also decreased after blepharoplasty (P<0.001). CONCLUSION: In our study, a significant increase in contrast sensitivity was found after surgery. These results suggest that upper lid blepharoplasty can be helpful for improving visual quality.

Reduction in Rectus Muscle Recession Depending on the Distance Between Rectus Muscle Suture Placement and Scleral Insertion in Rabbit Eyes.

PURPOSE: To quantitatively determine how a large tendon remnant reduces the effect of the rectus muscle recession procedure with respect to the distance between the placement of the muscle suture and the scleral insertion. METHODS: Thirty-six eyes from 18 rabbits were randomly divided into four groups according to the distance between the superior rectus muscle suture placement and the scleral insertion (1, 2, 3, and 4 mm). The superior rectus muscle was sutured at the previously listed distances from the insertion. Each superior rectus muscle was reattached using a scleral pass at a site 4 mm posterior to its original insertion. The amount of recession was measured as the distance between the most anterior aspect of the reattached muscle and the original insertion site. RESULTS: The mean amount of recession was 4.07 ± 0.25 mm in the 1-mm group and 2.76 ± 0.55 mm in the 4-mm group at postoperative week 4. There were significant differences in the amount of recession between the four groups. Linear regression analyses revealed a significant relationship between the distance of the muscle suture placement from the scleral insertion and the amount of recession (r(2) = 0.521). The superior rectus muscle was estimated to be reattached 0.437 mm anterior to the desired location for every 1 mm that the muscle suture was placed posterior to the scleral insertion. CONCLUSIONS: The potential error that depends on the distance between the muscle suture placement and the scleral insertion should be considered to reduce undercorrection and ensure a good surgical outcome.

Differences between patient expectations and actual strabismus surgery experience in adults.

OBJECTIVE: To provide objective information on patient discomfort after strabismus surgery. DESIGN: Prospective cohort study. PARTICIPANTS: Forty-nine consecutive adult patients undergoing strabismus surgery. METHODS: A questionnaire was used to evaluate the following on a scale of 0 (absent) to 10 (very severe): patients' expectations of pain, blurred vision, daily life disruption, diplopia, conjunctival redness, foreign body sensation, eyelid swelling, postoperative nausea and vomiting (PONV), and preoperative cosmetic satisfaction. Patients answered the questionnaire at 6 hours, 1 day, 2 days, 3 days, 1 week, 2 weeks, 1 month, and 3 months after surgery, focusing on the actual experience. Patient was also investigated according to previous surgical history and the surgery type. RESULTS: In the 42 patients included in the analyses, postoperative pain (p = 0.049) and PONV (p = 0.039) occurred at significantly lower-than-anticipated levels. Blurred vision (p = 0.019), daily life disruption (p = 0.009), and conjunctival redness (p < 0.001) occurred at significantly higher-than-expected levels, and patients felt that conjunctival redness was the most severe symptom occurring immediately after surgery. Patients who required vertical or oblique muscle procedures (p = 0.046) or had undergone previous ophthalmic surgery (p = 0.025) experienced higher levels of postoperative pain than they had preoperatively anticipated. CONCLUSIONS: Preoperative anticipations were quite different from actual postoperative experiences in adults undergoing strabismus surgery. Our results will allow surgeons to objectively educate patients before the operation about the postoperative course and to explain the inconveniences and minor side effects expected during the recovery process.

Changes in refractive error in patients with accommodative esotropia after being weaned from hyperopic correction.

BACKGROUND: To determine the long-term changes in refractive error and ocular alignment in patients with accommodative esotropia (AET) who were able to discontinue wearing hyperopic glasses because of emmetropisation. METHODS: Forty-seven patients with refractive AET who achieved emmetropisation and orthotropia without hyperopic glasses and were followed up for at least 3 years were enrolled. All of the patients had been prescribed the weakest possible glasses for best corrected vision. Refractive error and ocular alignment were analysed after the cessation of hyperopic glasses use. RESULTS: The mean length of follow-up was 5.7±3.21 years after successful weaning from hyperoptic glasses. The mean spherical equivalent (SE) of the refractive error was -1.01±1.53 dioptres (D), and the mean esotropia (ET) was 1.0±8.70 Δ at the final visit. Myopia developed in 55.3% of all patients. The mean myopic progression rate per year was -0.19±0.23 D/year. Forty-one patients (87.2%) showed orthotropia; in addition, three of the patients (6.4%) developed ET, and three (6.4%) developed exotropia (XT). The six patients who had ET or XT all showed myopia. Two of the three patients who developed ET underwent surgery. Both patients initially had a low degree of hyperopia and a high ratio of accommodative convergence to accommodation (AC/A). The initial hyperopia correlated with the SE refractive error at the final follow-up (p<0.001). CONCLUSIONS: When emmetropisation occurs early in patients with AET, it is necessary to note the development of myopia and the deterioration of ocular alignment.

Acute angle-closure glaucoma in a patient with miller fisher syndrome without pupillary dysfunction.

PURPOSE: To report a case of an angle-closure glaucoma in a patient with Miller Fisher syndrome (MFS) without pupillary dysfunction. METHODS: We present a case report of a 75-year-old male presenting with total ophthalmoplegia, complete bilateral ptosis, and gait disturbance. He was diagnosed with MFS without pupillary dysfunction, which precipitated unilateral acute angle-closure glaucoma (AACG) due to complete lid ptosis. RESULTS: The initial ocular examination revealed hand motion in the right eye. Intraocular pressure, as assessed by Goldmann applanation tonometry, was 50 mm Hg, and gonioscopic findings revealed a closed angle on the right eye. After maximal tolerated medical therapy, laser peripheral iridotomy was performed. The unilateral AACG with MFS resolved without further incident. CONCLUSIONS: This is the first reported case of a patient with MFS without autonomic dysfunction and AACG. We believe that pupillary dysfunction or lid ptosis due to neurological disorders may increase the possibility of AACG.

The clinical characteristics and surgical outcomes of epiblepharon in korean children: a 9-year experience.

Purpose. To examine the demographic characteristics, clinical features, surgical outcomes, and long-term prognoses of epiblepharon in Korean children. Methods. Epiblepharon patients who were followed for ≥ 6 month following surgical correction between January 2005 and December 2013. The patient demographics, clinical features, concomitant disorders, surgical outcomes, and complications were retrospectively reviewed. Results. A total of 768 epiblepharon records were included in the analysis. The mean patient age was 6.55 ± 2.37 years. At presentation, 712 patients (92.8%) complained of typical epiblepharon symptoms. The mean patient age at surgery was 6.95 ± 2.52 years, with 629 patients (81.9%) on the lower lid and 72 patients (9.4%) on the upper lid and 82 patients (10.7%) undergoing surgery on both lids. The eyelid was well everted with no recurrence in 740 patients (96.4%). Conclusion. Epiblepharon frequently occurs in Korean children and is correctable with a simple surgery. Recurrence and serious complications do not occur often, and any suspicions of epiblepharon should be investigated. A thorough ocular examination can lead to a correct diagnosis and timely corrective surgery. Most procedures are successful and prevent secondary complications that often occur with uncorrected epiblepharon.