Surgical treatment versus observation in moderate intermittent exotropia (SOMIX): study protocol for a randomized controlled trial.

BACKGROUND: Intermittent exotropia (IXT) is the most common type of strabismus in China, but the best treatment and optimal timing of intervention for IXT remain controversial, particularly for children with moderate IXT who manifest obvious exodeviation frequently but with only partial impairment of binocular single vision. The lack of randomized controlled trial (RCT) evidence means that the true effectiveness of the surgical treatment in curing moderate IXT is still unknown. The SOMIX (surgical treatment versus observation in moderate intermittent exotropia) study has been designed to determine the long-term effectiveness of surgery for the treatment and the natural history of IXT among patients aged 5 to 18 years old. METHODS/DESIGN: A total of 280 patients between 5 and 18 years of age with moderate IXT will be enrolled at Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China. After initial clinical assessment, all participants will be randomized to receive surgical treatment or observation, and then be followed up for 5 years. The primary objective is to compare the cure rate of IXT between the surgical treatment and observation group. The secondary objectives are to identify the predictive factors affecting long-term outcomes in each group and to observe the natural course of IXT. DISCUSSION: The SOMIX trial will provide important guidance regarding the moderate IXT and its managements and modify the treatment strategies of IXT. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02736526 . Registered April 13, 2016.

Risk of consecutive esotropia after surgery for intermittent exotropia according to passive duction force.

PURPOSE: To determine the relationship between consecutive esotropia (ET) and passive duction force (PDF) in patients with intermittent exotropia (XT). METHODS: The study enrolled 70 patients in whom PDF was measured under general anesthesia prior to XT surgery. The preferred eye for fixation (PE) and the nonpreferred eye for fixation (NPE) were determined using a cover-uncover test. The patients were subdivided into two groups according to the angle of deviation at 1 month postoperation: (1) consecutive ET (CET group), >10 prism diopters (PD) of ET; and (2) non-CET (NCET group), ≤10 ET or residual exodeviation. The relative PDF of the medial rectus muscle (MRM) was obtained by subtracting the ipsilateral PDF of the lateral rectus muscle (LRM) from the PDF of the MRM. RESULTS: The PDFs for the LRM in the PE in the CET and NCET groups were 47.28 g and 58.59 g, respectively (p = 0.147), and 56.18 g and 46.59 g for the MRM (p = 0.11), and in the NPE were 59.84 g and 55.25 g, respectively, for the LRM (p = 0.993), and 49.12 g and 50.53 g, respectively, for the MRM (p = 0.81). However, in the PE, the PDF in the MRM was larger in the CET group than in the NCET group (p = 0.045), which was positively associated with the postoperatively overcorrected angle of deviation (p = 0.017). CONCLUSIONS: An increased relative PDF in the MRM in the PE was a risk factor for consecutive ET after XT surgery. Quantitative evaluation of the PDF could be considered when planning strabismus surgery to achieve the desired surgical outcome.

The effect of virtual reality technology in children after surgery for concomitant strabismus.

Purpose: This study aimed to investigate the effect of virtual reality (VR) technology in children after surgery for concomitant strabismus. Methods: A total of 200 children with concomitant exotropia or concomitant esotropia were randomly divided into a training group and a control group according to the single even number random method (100 cases in each group). Patients in the training group received VR intervention training within 1 week after surgery. Patients in the control group did not receive any training. Results: Six months after the surgery, the orthophoria (the far or near strabismus degree was ≤8Δ) rate was significantly higher in the training group than in the control group (P = 0.001), while the eye position regression rate (compared to the strabismus degree within 1 week after the surgery, the amount of regression >10Δ) was significantly lower in the training group than in the control group (P = 0.001). Six months after the surgery, the number of children with simultaneous vision and remote stereovision was significantly higher in the training group than in the control group (P = 0.017 and 0.002, respectively). The differences in the number of patients with peripheral stereopsis, macular stereopsis, and stereopsis in macular fovea centralis at 1, 3, and 6 months after the surgery between the training and the control groups were not statistically significant (P = 0.916, 0.274, and 0.302, respectively). Conclusion: The intervention of VR technology after strabismus correction effectively improved children's visual function and maintained their eye position.

Refractive changes after strabismus surgery in patients with intermittent exotropia.

OBJECTIVES: To evaluate the long-term refractive changes after horizontal muscle surgery in patients with intermittent exotropia and investigate the correlation between changes in the postoperative refractive error and clinical factors. METHODS: We retrospectively reviewed the clinical data of patients aged < 15 years who underwent unilateral strabismus surgery (lateral rectus recession and medial rectus resection [RR, n = 47], lateral rectus recession and medial rectus plication [RP, n = 81], or lateral rectus recession [LRc, n = 68]). Preoperative and postoperative refractive errors up to four years after surgery were recorded. A mixed model was applied to compare the refractive error between the operated and fellow eyes and identify the factors associated with postoperative refractive changes. RESULTS: The mean age at surgery was 7.5±2.4years, and girls accounted for 56.1% of the study population. There was no significant difference in the change in the spherical equivalent of refractive error between both eyes throughout the postoperative period. In contrast, the operated eyes consistently and significantly showed higher cylindrical power in with-the-rule astigmatism by 0.25D than in fellow eyes. Age, sex, and preoperative refractive error were not correlated with changes in postoperative astigmatism. Meanwhile, the type of surgery showed a significant interaction with the astigmatism changes. RP had less effect on the changes in astigmatism than RR and LRc (p = 0.001 and p = 0.022, respectively). CONCLUSIONS: Horizontal muscle surgery has no long-term effect on the change in the spherical equivalent. However, mild with-the-rule astigmatism is induced and sustained after surgery, and the type of surgery affects the postoperative change of astigmatism.

A cross-sectional study of ophthalmologic examination findings in 5385 Koreans presenting with intermittent exotropia.

The Korean Intermittent Exotropia Multicenter Study (KIEMS) was a retrospective, cross-sectional and multicenter study for the investigation of intermittent exotropia involved 65 strabismus specialists from 53 institutions in Korea. Purpose of this study was to present ophthalmologic findings of intermittent exotropia from the KIEMS. Consecutive patients with intermittent exotropia of ≥ 8 prism diopters (PD) at distance or near fixation were included. Best-corrected visual acuity, cycloplegic refraction data, angles of deviation at several cardinal positions, ocular dominance, fusion control, oblique muscle function, and binocular sensory outcomes were collected. A total of 5385 participants (2793 females; age 8.2 years) were included. Non-dominant eye was more myopic than the dominant eye (- 0.60 vs. - 0.47 diopters, P < 0.001). Mean exodeviation angles were 23.5 PD at distance and 25.0 PD at near fixation. Basic type (86.2%) was the most, followed by convergence insufficiency (9.4%) and divergence excess (4.4%) types. Alternating ocular dominance and good fusion control were more common at near than at distance fixation. Good stereopsis at 40 cm was observed in 49.3% in Titmus stereo test (≤ 60 arcsec) and in 71.0% in Randot stereo test (≤ 63 arcsec). Intermittent exotropia was mostly diagnosed in childhood and patients with the condition showed relatively good binocular functions. This study may provide objective findings of intermittent exotropia in a most reliable way, given that the study included a large study population and investigated comprehensive ophthalmology examinations.

Timely Surgery in Intermittent Exotropia.

INTRODUCTION: Surgical treatment of intermittent exotropia is indicated when periods of monocular deviation become longer or control over deviation deteriorates. However, there is no consensus on the ideal age to perform surgery in patients with intermittent exotropia. PURPOSE: To evaluate ocular alignment and sensory results at 12 months of follow-up, in patients who received surgical treatment for intermittent exotropia at ≤4 years or >4 years. METHODS: A retrospective, observational, analytical, and comparative cohort study was carried out, which included 97 patients treated surgically for X(T), divided into two groups, ≤4 years and >4 years. The motor and sensory results of the patients were evaluated on the first day, 1 month and 12 months of postoperative follow-up. RESULTS: In this study, no statistically significant differences were observed in ocular alignment and postoperative sensory results at 1 year of follow-up between both groups. CONCLUSION: Age is not a variable that influences surgical results in patients with intermittent exotropia. Instead of early or delayed surgery, we propose to use the term "timely surgery."

Double covering with amniotic membrane in restrictive strabismus.

A case of severe restrictive strabismus after a consecutive exotropia surgery is presented. We describe the exitous managment through a technique consist of wrapping with amniotic membrane (AM) the affected muscle where we add a second AM graft in the reconstruction of the ocular Surface.

Unilateral surgery for pediatric sensory exotropia: clinical characteristics and surgical results.

BACKGROUND: To delineate the clinical characteristics and surgical outcomes of large angle sensory exotropia in pediatric patients. METHODS: The medical records of 54 large angle exotropia ≥40 PD patients aged from 1 to 18 years who were operated on between 2018 and 2021 and were followed up for 1 year were reviewed and contacted. Clinical characteristics and surgical outcomes were analyzed retrospectively. Patients were divided into two groups, group S patients had supermaximum recession resection and group E had augmented recession by lateral rectus muscle elongation with an autograft from the resected medial rectus muscle in the same eye. The clinical characteristics and results of both groups were compared. RESULTS: The mean age of the studied patients with sensory exodeviation at the time of surgery was 8.3 ± 4.2 years. Mean of the duration of exotropia was 6.9 ± 2.2 years, and the mean of postoperative follow-up was 14.3 ± 4.2 months. Surgical success was achieved in 73.07% of group S and 82.14% of group E. Recurrence was more common with anterior segment pathology. Larger post-operative distant angles were strongly related to poorer visual acuities P = 0.001 and not related to the age of onset or the duration. Narrowing of the palpebral fissure improved in both groups at the last follow up P = 0.336. The limitation of abduction in both groups improved in the last follow up P = 0.145. CONCLUSION: The outcome of monocular surgery for sensory exotropia in children is satisfactory with no significant differences in results between lateral rectus muscle tendon autograft elongation technique and supermaximum recession resection. Recurrence is more common with anterior segment pathology. Larger post-operative distant angle of deviation is strongly related to poorer visual acuity. CLINICAL TRIAL REGISTRATION: This study was retrospectively registered at clinicaltrials.gov (ID: NCT04286945) on 25-2-2020.

Binocular function in patients with intermittent exotropia accompanied by unilateral congenital ptosis.

Patients with intermittent exotropia (IXT) have a wide range of binocular deficits. This study aims to evaluate the effect of ptosis on the binocular function of patients with IXT. Clinical records of 45 IXT patients with congenital ptosis (IXT-ptosis group) and 58 age-matched IXT patients without ptosis (IXT only group) who presented for eye examination between January 2017 and June 2020 were retrospectively reviewed. Patients with amblyopia were excluded to rule out the effects of visual acuity on binocularity. Best-corrected visual acuity (BCVA), the magnitude of exodeviation at distance and at near, stereopsis, and office-based control scores at the first visit were reviewed. The binocular functions of the two groups were compared. The mean ± SD age of the overall patients was 6.6 ± 2.7 years. There were no significant differences in the distribution of age, sex, spherical equivalent refraction, or BCVA between the two groups (all p > 0.05). Although the office-based control scores at distance and near were slightly worse in the IXT-ptosis group, the differences were not statistically significant (at distance, 2.8 ± 1.87 vs. 2.2 ± 1.13, p = 0.08; at near, 1.8 ± 0.67 vs. 1.6 ± 0.74, p = 0.11). Furthermore, the IXT-ptosis group had worse stereopsis at distance (p = 0.01). There were no significant differences between the two groups in near stereopsis or exodeviation magnitude (p > 0.05). A larger proportion of patients had suppression on the Bagolini test in the IXT-ptosis group than in the IXT-only group (p = 0.04). The IXT-ptosis group had worse distance stereoacuity, and a larger proportion of patients had suppression on the Bagolini test than the IXT only group. In IXT patients, the presence of coexisting ptosis can have a further deleterious impact on binocular function.

Presence and development of strabismus in children with telecanthus, epicanthus and hypertelorism.

Purpose: To study the presence and development of strabismus in children with telecanthus, epicanthus, and hypertelorism. Methods: This is a prospective, longitudinal, and observational study. Sixty children aged between 6 months and 18 years with telecanthus, epicanthus, and hypertelorism in isolation or in combination were recruited. A detailed analysis of the history, determination of best corrected visual acuity, complete evaluation of strabismus, and ocular examination were carried out. The presence of telecanthus, epicanthus, and hypertelorism and associated strabismus, if any, was noted. All children were followed up for a minimum and maximum period of 12 and 18 months, respectively, to analyze the strabismus (previously present) and for detection of strabismus in those who did not have. The data were analyzed descriptively with mean and standard deviation. Chi square test and Fishers exact test were used to analyze the data between the groups. A P value less than 0.05 was considered to be statistically significant. Results: Telecanthus was the most common lid feature (55%). At baseline, ten (16.66%) children had strabismus (six: esotropia; four: exotropia). Two (3.33%) children underwent surgery. One child developed exotropia at the third follow-up (18 months). At the end of the study, 11 (18.33%) children had strabismus. No significant association was seen between lid characteristics and the type of strabismus. Conclusion: Children with telecanthus, epicanthus, and hypertelorism in isolation or in combination may or may not have associated strabismus. These features can pose difficulty in strabismus diagnosis, which mandates a careful examination, especially in younger age groups and small-angle strabismus. On the other hand, children without strabismus need longer follow-up to detect the development of strabismus and to initiate further management at the earliest.

Treatment of convergence insufficiency type intermittent exotropia with bupivacaine injection to the medial rectus combined with lateral rectus recession.

PURPOSE: To evaluate the outcomes of combined bupivacaine HCL (BPX) injection in the medial rectus (MR) muscle with recession of the lateral rectus muscle in the treatment of convergence insufficiency-type intermittent exotropia (CI-IXT). METHODS: The medical records of patients who underwent combined injection-recession treatment from January 2019 to January 2020 for CI-IXT were reviewed retrospectively along with a group of age-matched controls with IXT without CI who underwent only unilateral LR recession during the same period. The following data were extracted from the record: age at surgery, average follow-up period, angle of deviation at distance and near and the difference between them before and after surgical procedure, correction of near and distance deviations, and recession dosage. Successful outcome was defined as a distance deviation in primary gaze between ≤10Δ of exophoria/tropia and ≤5Δ of esophoria/tropia. RESULTS: A total of 10 patients and 20 controls were included. Average follow-up was 13.9 ± 3.67 months in the BPX group and 15.9 ± 3.61 months in the control group (P = 0.17). Postoperative distance deviation measured 8.30Δ ± 5.88Δ in the BPX group and 14.67Δ ± 9.83Δ in the control group (P = 0.80). Distance-near differences were significantly reduced in the CI-IXT group receiving BPX, by a mean of 6.60Δ, from a preoperative mean of 10.50Δ ± 3.65Δ to 3.90Δ ± 3.26Δ (P < 0.01). CONCLUSIONS: BPX injection combined with unilateral lateral rectus recession yields outcomes comparable to bilateral lateral rectus recession for distance deviations, and results in reduction of the distance-near difference in the angle of exotropia.

Analysis of the Changes and Possible Reasons in Aberrations before and after Surgery in Patients with Concomitant Exotropia.

Objective: The objective is to observe the changes in aberrations before and after surgery in patients with common horizontal strabismus and to analyze the possible reasons for the changes. Methods: Forty eyes of 40 cases with concomitant exotropia who underwent strabismus correction at the Ophthalmology Department of Nantong University Hospital from October 2020 to July 2021 were included in this study, all of whom underwent unilateral lateral rectus recession combined with a medial rectus resection in the same eye. Aberration parameters were measured 1 day before surgery and 1 week, 1 month, 3 months, and 6 months after surgery. Differences in the indicators at each time period were compared by analysis of variance (ANOVA) of repeated measures data for a single factor, and data were analyzed using SPSS 25.0 statistical application software. Results: 5 mm pupil diameter: the preoperative and postoperative RMS of total aberration showed statistically significant difference (P < 0.01). Postoperation test (Bonferroni method) and preoperative comparison at each period after surgery showed statistically significant differences between 6 months after surgery (P=0.002) and preoperative comparison. The preoperative and postoperative comparison of RMS in LOAs was statistically significant (P < 0.01); postoperative test (Bonferroni method) and preoperative comparison showed that there were statistically significant differences between 1 week (P=0.033) and 6 months (P=0.002) after operation. The difference of RMS of defocus before and after operation was statistically significant (P < 0.01); postoperation test (Bonferroni method) and preoperative comparison showed that there was statistically significant difference between 6 months after operation (P=0.007) and preoperative comparison. There was statistically significant difference in preoperative and postoperative RMS of HOAs (P=0.013). Postoperative test (Bonferroni method) and preoperative comparison showed that there was statistically significant difference 6 months after surgery (P=0.03). The RMS of secondary astigmatism showed a statistically significant difference before and after operation (P=0.001), and the postoperation test (Bonferroni method) showed a statistically significant difference 6 months after operation (P=0.002). In 5 mm pupil diameter, the preoperative and postoperative RMS of total aberration showed statistically significant difference (P < 0.01), postoperative test (Bonferroni method) was used to compare each period after surgery with that before surgery, and there were statistically significant differences between 1 week after surgery (P=0.034), 3 months after surgery (P=0.033), and 6 months after surgery (P=0.003). The preoperative and postoperative comparison of RMS in LOAs was statistically significant (P < 0.01), postoperative test (Bonferroni method) was used to compare each period after surgery with that before surgery, and there were statistically significant differences between 1 week after surgery (P=0.04), 3 months after surgery (P=0.034), and 6 months after surgery (P=0.004). The difference of RMS of defocus before and after surgery was statistically significant (P=0.002), and the comparison between postoperation test (Bonferroni method) and preoperation showed that the difference was statistically significant 6 months after surgery (P=0.027). The RMS of astigmatism showed statistically significant difference before and after operation (P=0.002), and the postoperation test (Bonferroni method) showed statistically significant difference between 6 months after operation (P=0.009) and before operation. Conclusion: We found that horizontal rectus surgery had a transient effect on LOAs and almost no effect on HOAs. Long-term follow-up is recommended after strabismus surgery to observe eye position and binocular visual function. Because of the high prevalence of strabismus in adolescents, long-term observation of the eye axis and aberration is recommended.

Surgical outcomes and observation in exotropia cerebral palsy children with cortical visual impairment.

PURPOSE: Cortical visual impairment (CVI) is the common cause of pediatric visual impairment in cerebral palsy (CP) while exotropia is the most common strabismus associated with CP. We aim to observe the strabismic surgery outcomes in pediatric patients with CP and CVI. METHOD: Our medical records were collected from pediatric patients treated in our hospital from May 1, 2017 to Jan 1, 2022. With normal intelligence assessment and diagnosis of exotropia in children with CP and CVI, microsurgeries were performed under intravenous combined inhalation anesthesia. The strabismus was examined by the prism test under best vision correction and the contrast sensitivity testing (CST) was measured at five levels of spatial frequencies. RESULT: A total of 38 exotropia patients with CP and CVI were identified and included for analysis during the study period with age ranged from 5 to 12 years (mean 8.45 years) and mean follow up duration was 8.7 months (6-42 months). After bilateral lateral rectus recession (with/without medial rectus resection or inferior oblique transposition), the exotropia amount of participants were obviously revealed from - 30 ~ - 140 (median, IQR: - 50, 40) prism diopters (PD) preoperatively to 0 ~ - 15 (0, 5) PD postoperatively. Statistically significantly improvements were observed at all levels of spatial frequency on CST postoperatively, especially at high spatial frequency areas (p < 0.05). CONCLUSION: Our results demonstrated that the effect of strabismus surgery on exotropia in children with CP and CVI were stable and monocular contrast sensitivity post- operation increased significantly at all spatial frequencies levels.

Comparison of sensory outcomes in patients with successful motor outcome versus recurrent exotropia after surgery for intermittent exotropia.

Here, we compared sensory outcomes between patients with successful motor outcomes and recurrent exotropia after intermittent exotropia surgery. We retrospectively analyzed 303 patients who underwent surgery for intermittent exotropia, divided into two groups: successful motor outcome defined as an alignment between 10 prism diopters (PD) exodeviation and 5PD esodeviation at the final follow-up (Group A, n = 177) and residual or recurrent exotropia defined as exodeviation > 10 PD (Group B, n = 126). Preoperative and postoperative (at final visit) sensory outcomes were compared using the Titmus stereotest and distance Worth 4-dot test. Stereoacuity significantly improved postoperatively in both successful motor outcome group (Group A) and residual or recurrent exotropia group (Group B). However, stereoacuity did not differ between groups preoperatively and postoperatively. On the other hand, fusion rates for the Worth 4-dot test were significantly higher in group A than in group B, preoperatively and postoperatively, and significantly increased postoperatively only in group A. Therefore, the distance Worth 4-dot test may be useful for evaluating postoperative prognosis and preoperative sensory status.

Pattern Strabismus in a Tertiary Hospital in Southern China: A Retrospective Review.

Background and objectives: To analyze demographic and clinical features of pattern strabismus patients and assess the relationship among these clinical variables and risk factors. Materials and Methods: Medical records of pattern strabismus patients who had undergone strabismus surgery at our center between 2014 and 2019 were retrospectively reviewed. Data collected included gender, age at onset, age at surgery, refraction, Cobb angle, pre- and post-operative deviations in the primary position, up- and downgaze, angle of ocular torsion, type/amount of pattern, grade of oblique muscle function and presence/grade of binocular function. To verify the clinical significance of the Cobb angle, 666 patients who had undergone surgery within one week after ocular trauma between 2015 and 2021 were enrolled as controls. Results: Of the 8738 patients with horizontal strabismus, 905 (507 males and 398 females) had pattern strabismus, accounting for 10.36%. Among these 905 patients, 313 showed an A-pattern and 592 showed a V-pattern. The predominant subtype was V-exotropia, followed by A-exotropia, V-esotropia and A-esotropia. Over half of these patients (54.6%) manifested an A- or V-pattern in childhood. The overall mean ± SD Cobb angle was 5.03 ± 4.06° and the prevalence of thoracic scoliosis was 12.4%, both of which were higher than that observed in normal controls (4.26 ± 3.36° and 7.8%). Within A-pattern patients, 80.2% had SOOA and 81.5% an intorsion, while in V-pattern patients, 81.5% had IOOA and 73.4% an extorsion. Patients with binocular function showed decreases in all of these percent values. Only 126 (13.9%) had binocular function, while 11.8% of A-pattern and 15.1% of V-pattern patients still maintained binocular function. Pre-operative horizontal deviation was negatively correlated with binocular function (r = -0.223, p < 0.0001), while the grade of oblique muscle overaction was positively correlated with the amount of pattern (r = 0.768, p < 0.0001) and ocular torsion (r = 0.794, p < 0.0001). There were no significant correlations between the Cobb angle and any of the other clinical variables. There were 724 patients (80.0%) who had received an oblique muscle procedure and 181 (20.0%) who received horizontal rectus muscle surgery. The most commonly used procedure consisted of horizontal rectus surgery plus inferior oblique myectomy (n = 293, 32.4%), followed by isolated horizontal rectus surgery (n = 122, 13.4%). Reductions of pattern were 14.67 ± 6.93 PD in response to horizontal rectus surgery and 18.26 ± 7.49 PD following oblique muscle surgery. Post-operative deviations were less in V- versus A-pattern strabismus. Post-operative binocular function was obtained in 276 of these patients (30.5%), which represented a 16.6% increase over that of pre-operative levels. The number of patients with binocular function in V-pattern strabismus was greater than that of A-pattern strabismus (p = 0.048). Conclusions: Of patients receiving horizontal strabismus surgery, 10.36% showed pattern strabismus. In these patients, 54.6% manifested an A- or V-pattern in childhood, and V-exotropia was the most frequent subtype. Pattern strabismus patients showed a high risk for developing scoliosis. Cyclovertical muscle surgery was performed in 724 of these patients (80.0%), and horizontal rectus surgery was effective in correcting relatively small levels of patterns. Binocular function represented an important factor as being involved with affecting the occurrence and development of pattern strabismus.

Results of fusional vergence therapy in managing consecutive esotropia: A case series.

Purpose: To analyze the efficacy of fusional vergence therapy (FVT) in management of consecutive esotropia with diplopia after intermittent exotropia (IXT) surgery. The current study is carried on how FVT affects the duration of treatment, sensory fusion, and exotropic drift. Methods: This was a retrospective study for the medical record of 11 patients with consecutive esotropia after IXT surgery of 543 patients over the period of 5 year, with mean surgery age of 9.5 (range: 4-33 y). FVT was planned after minimum 6 weeks of surgery and was considered for maximum 24 weeks. Patients underwent a combination of office-based and home-based FVT. Successful outcome of therapy was considered where diplopia resolves in free space and achieves sensory fusion, stereopsis with no manifest deviation. Results: Record of 543 patients who had horizontal muscle surgery for IXT were identified and reviewed. Records of 11 patients who showed consecutive esotropia of 10 prism diopter (PD) or more with normal retinal correspondence, with or without diplopia complaint, after 6 week of surgery and had undergone vision therapy management were reviewed. A successful outcome of binocular single vision with good sensory and motor fusion with no manifest deviation or prism requirement was achieved with in the mean duration of 4.8 month of therapy. With a mean duration of 4 weeks of therapy, the mean angle of deviation reduced by 53% for distance (17 PD to 8 PD) and 27% for near (11 PD to 8 PD) and mean stereopsis improvement by 80% with 94% patients demonstrating sensory fusion on Bagolini test and 94% of patients having no symptoms of diplopia or squint. Conclusion: With nonsurgical management involving refractive error correction, FVT, and prism, consecutive esotropia was resolved in 74% cases. Management of consecutive esotropia with FVT can result in satisfactory sensory fusion and successful motor alignment.

Surgical treatment and muscle protein analysis of V-pattern exotropia in craniosynostosis.

The purpose of this study was to compare the differences of V-pattern exotropia in craniosynostosis and normal children. 39 children were included in this study, 19 craniosynostosis and 20 children in control group. They underwent comprehensive ocular examinations and received strabismus surgery. The extraocular muscle samples were analysed. Compared with the control group, craniosynostosis group had larger deviation in primary and up gaze, larger V pattern, and more severe inferior oblique overaction. For 20-40, and 50-60 prism diopter exotropia, the lateral recession in the craniosynostosis group was larger than that in the control group, 7.13 ± 0.44 mm vs 6.71 ± 0.47 mm, 8.90 ± 0.21 mm vs 7.75 ± 0.46 mm (p = 0.025, 0.000). The anterior transposition of craniosynostosis group was more anterior than that of control group, posterior 1.03 ± 1.24 vs 2.68 ± 0.94 mm (p = 0.000). Compared with the control group, the extraocular muscle abnormality in craniosynostosis was significant, 32% vs 5% (p = 0.031). There were 40 proteins in craniosynostosis group, which were different from those in control group. A larger V pattern and larger deviation is common in craniosynostosis children. For the same PD of deviation, it usually needs more recession in craniosynostosis because of the thinner and weaker extraocular muscles. Collagen related proteins were increased in craniosynostosis, and decreased contraction related protein tropomodulin might play key role for the weakness of EOMs.

Advancement of the muscle insertion toward the limbus as an alternative or adjunct to resection.

PURPOSE: To describe the surgical outcomes of patients that underwent strabismus surgery involving advancement of the muscular insertion line toward the limbus. METHODS: The medical records of patients who underwent rectus muscle advancement surgery between January 2009 and June 2019 and had at least 1 year of follow-up were reviewed retrospectively. Patients were classified into one of four types of deviation: (1) convergence insufficiency, without distance deviation; (2) small-angle distance esotropia, with diplopia; (3) residual strabismus after previous surgery; and (4) large-angle exotropia. The first group underwent 2 mm advancement of the medial rectus insertion bilaterally; the second, 2-3 mm advancement of the lateral rectus muscle bilaterally; the third, 2-3 mm advancement of the lateral or medial rectus muscle, with or without simultaneous resection; and the fourth, 3 mm advancement of the medial rectus with simultaneous resection, with or after maximum recession of the lateral rectus, bilaterally or unilaterally. RESULTS: A total of 25 patients were included (mean age, 28.76 ± 22.75 years): 4 with convergence insufficiency, 3 with small-angle distance esotropia and diplopia, 16 with residual strabismus, and 2 with large-angle exotropia. Mean postoperative follow-up was 4.76 ± 2.03 years. Surgery was successful in all patients at 1 year (residual deviation ≤10Δ), and all but 1 at 5 years; 1 patient required reoperation. CONCLUSIONS: Advancement of the muscle insertion proved successful as an alternative or adjunctive procedure to other forms of muscle tightening in the subtypes of patients evaluated in this study.

Clinical characteristics and surgical approach in Duane retraction syndrome: a study of 691 patients.

PURPOSE: To evaluate the clinical findings of different types of Duane retraction syndrome (DRS). STUDY DESIGN: Retrospective. METHODS: This study was performed on 691 patients with DRS who underwent surgery. Clinical examinations included laterality, abnormal head posture (AHP), corrected distance visual acuity (CDVA), refractive error, amblyopia, deviation, overshoots, and type of surgery. RESULTS: The mean age of patients with DRS was 16.7 ± 12.5 (range 1.0-73) years. The patients included 396 (57.3%) women and 295 (42.7%) men (P < 0.001). DRS type I, was observed in 429 (62.1%), II in 168 (24.3%), III in 88 (12.7%) and IV in 6 (0.9%) patients. Unilateral DRS was observed OS in 628 (90.9%) [471 (%78.9) and OD in 157 (21.1%) eyes (P < 0.001)]. O ther clinical findings were AHP (n = 522, 78.1%), overshoot (n = 236, 34.2%) and amblyopia (n = 118, 17.1%). The prevalence of overshoot in types I, II, and III was 17.5% (75/429), 60.7% (102/168) and 64.8% (57/88), respectively (P < 0.001). The prevalence of amblyopia was significantly lower in patients with AHP (80/522, 15.3%) compared to patients with normal head posture (38/169, 22.5%) (P = 0.023). The mean angle of deviation in the primary position (PP) at distance was 21.7 ± 11.5 △ for esotropic group and 17.8 ± 12.4 △ for exotropic group. Sixty-two (9.0%) patients required second surgery for resolving residual misalignment (1.1 surgeries for each patient). CONCLUSIONS: About two-thirds of DRS patients had AHP, one-third had overshoots, and one-sixth had amblyopia. The results show that different types of DRS are associated with different epidemiological and clinical characteristics.

Long-term strabismus outcomes after unilateral infantile cataract surgery in the Infant Aphakia Treatment Study.

PURPOSE: To characterize long-term strabismus outcomes in children in the Infant Aphakia Treatment Study (IATS). METHODS: This study was a secondary data analysis of long-term ocular alignment characteristics of children aged 10.5 years who had previously been enrolled in a randomized clinical trial evaluating aphakic management after unilateral cataract surgery between 1 and 6 months of age. RESULTS: In the IATS study, 96 of 109 children (88%) developed strabismus through age 10.5 years. Half of the 20 children who were orthophoric at distance through age 5 years maintained orthophoria at distance fixation at 10.5 years. Esotropia was the most common type of strabismus prior to age 5 years (56/109 [51%]), whereas exotropia (49/109 [45%]) was the most common type of strabismus at 10.5 years (esotropia, 21%; isolated hypertropia, 17%). Strabismus surgery had been performed on 52 children (48%), with 18 of these (35%) achieving microtropia <10Δ. Strabismus was equally prevalent in children randomized to contact lens care compared with those randomized to primary intraocular lens implantation (45/54 [83%] vs 45/55 [82%]; P = 0.8). Median visual acuity in the study eye was 0.56 logMAR (20/72) for children with orthotropia or microtropia <10Δ versus 1.30 logMAR (20/400) for strabismus ≥10Δ (P = 0.0003). CONCLUSIONS: Strabismus-in particular, exotropia-is common irrespective of aphakia management 10 years following infant monocular cataract surgery. The delayed emergence of exotropia with longer follow-up indicates a need for caution in managing early esotropia in these children. Children with better visual acuity at 10 years of age are more likely to have better ocular alignment.