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.

A Proposed Diagnostic Algorithm for Fungal Orbital Infections after 20 Years of Experience in a Tertiary Eye Care Center- Egypt.

METHOD: Medical Records of cases with orbital fungal infection from January 2000 to December 2019 were reviewed. RESULTS: The study included 45 patients. Mucormycosis was proven in 32 (71.1%) and aspergillosis in 13 (28.9%) patients. Thirty-five (77.8%) patients had predisposing factors mainly uncontrolled diabetes. Twenty-seven (60%) patients presented with orbital apex syndrome, 10 (22.2%) with orbital cellulitis and 8 (17.7%) with proptosis. The prognosis was generally poor (31.1% mortality, 8.88% exenteration and 11.1% self-evisceration). The proposed algorithm composed of six atypical clinical presentations mainly acute orbital apex and fulminating orbital cellulitis plus any radiological or microbiological findings. CONCLUSION: The proposed algorithm markedly reduced the complications after 5 years of the study. Once fungal orbital infection is suspected, treatment should start immediately.

Exenterate or Not: A Simple Proposed Management Algorithm for Mucormycosis During the Era of COVID-19 in a Tertiary Eye Care Center in Egypt.

Purpose: To construct a simple management algorithm for cases with orbital mucormycosis during the COVID-19 era. Methods: Retrospective study included records of 30 Egyptian patients with post COVID-19 orbital mucormycosis. They underwent full clinical examination, laboratory investigations, Computed tomography (CT)/magnetic resonance imaging (MRI) of the paranasal sinuses and pathological specimen examination. The proposed algorithm was based on all the available data of the included patients. Results: The mean age of the studied patients was 62.47±11.13 years; 56.6% were females and 63.3% had uncontrolled diabetes mellitus. The main presentation was Orbital apex syndrome (OAS) in 43.3% of the cases. Twenty-six patients (86.6%) received systemic liposomal amphotericin B, while 4 patients (13.3%) received posaconazole. Orbital exenteration was done in 6 patients (20.0%), 4 of them died (66.7%). Twenty-four patients (80%) survived with clinical but not with visual improvement. Conclusion: Systemic antifungal treatment and functional endoscopic sinus surgery (FESS) with extensive debridement of involved necrotic tissues were the main steps to control ROCM. Orbital exenteration should be kept for cases with periorbital tissue affection as it did not increase the final cure rate. The proposed management algorithm is supposed to be simple and easy to follow.

Lateral Rectus Muscle Tendon Elongation by an Auto Graft from the Resected Medial Rectus Muscle as a Monocular Surgery for Large-Angle Sensory Exotropia.

PURPOSE: To evaluate using the resected medial rectus muscle for elongation of the lateral rectus tendon in monocular surgery for large-angle sensory exotropia. PATIENTS AND METHODS: A prospective case series was carried out in Tanta University hospital from January 2017 to June 2018 including 16 patients with large-angle sensory exotropia ≥50PD. The near and distance angles of exotropia were measured; any restrictions in adduction or abduction were recorded and scaled from -4 to 0. Resection of the medial rectus muscle was done first; the resected segment was attached to the lateral rectus muscle after dissection by mattress sutures, and the muscle was recessed after elongation according to the preoperative distance angles. Successful motor alignment was considered if the angle measurement was within 10 PD of orthotropia at distance after 6 months. The stability of the alignment, any motility restrictions, and patient satisfaction were recorded at each follow-up visit until the 6th month. RESULTS: The mean age of the study patients was 30.68±13.30 years. The best-corrected visual acuity of the exotropic eyes by logMAR was 1.2±0.3; the mean of the preoperative distance angle of deviation was -72.19 ±14.26 PD. The mean preoperative adduction and abduction restrictions were -1.19 ±1.52 and -1.13 ±1.09, respectively. There was significant improvement in the distance angle of deviation at the last follow-up after 6 months (p=0.001*). Also, there was improvement in both adduction and abduction restriction from the first to last follow-up. Thirteen patients (81.2%) were satisfied at the 6-month follow-up. CONCLUSION: Elongation of the lateral rectus muscle by an autograft from the resected medial rectus muscle is an easy, effective procedure for large-angle sensory exotropia. Patients achieve good postoperative alignment with minimal restriction of ocular motility.

Anterior Segment Optical Coherence Tomography (AS-OCT) Guided Reversal of Edematous Punctal Occlusion.

AIM: To evaluate the role of anterior segment-optical coherence tomography (AS-OCT) in the diagnosis of punctal stenosis and to compare punctal parameters before and after medical treatment. PATIENTS AND METHODS: The study was conducted on 40 eyes of 24 patients who had acquired inflammatory punctal stenosis and had persistent epiphora (persistent epiphora group - PEG), and 20 eyes of 10 subjects with normal punctal openings as a control group (control group - CG). We measured the outer punctal diameter (OPD), recorded the visibility of the internal punctum and punctal depth (PD) using AS-OCT, before and 1 month after treatment with preservative free methylprednisolone 5% eye drops. Punctal diameter, tear meniscus height (TMH) and Munk's score were compared to the control group before and after treatment. RESULTS: The mean OPD of the PEG before treatment (455.5 ± 174 µm) was significantly smaller than that of the CG (590.9 ± 106.6 µm) (P= 0.002). The mean OPD of the PEG significantly increased to 484.6 ± 175.5 µm after treatment (P <0.001). Also, the visibility of vertical canaliculus lumen and PD were restored in 70% of eyes. The TMH was much higher in the PEG than in the CG before treatment (P<0.05). However, after treatment the difference was not statistically significant. CONCLUSION: AS-OCT parameters were useful in monitoring and measuring the efficacy of medical treatment in relieving punctal edema, which subsequently resulted in reducing the epiphora symptoms.