Eight-Year Outcomes of Bilateral Lateral Rectus Recessions versus Unilateral Recession-Resection in Childhood Basic-Type Intermittent Exotropia.

PURPOSE: To report 8-year outcomes from a randomized controlled trial (RCT) comparing bilateral lateral rectus muscle recession (BLRc) with unilateral recession-resection (R&R) for childhood intermittent exotropia (IXT). DESIGN: Eight-year follow-up of RCT cohort. PARTICIPANTS: Of 197 randomized participants, 123 agreed to continue follow-up after the 3-year outcome visit (baseline age, 3-< 11 years; basic-type IXT, 15-40 prism diopters [Δ] by prism and alternate cover test [PACT]; baseline stereoacuity, ≤ 400 arcsec; no prior surgery). METHODS: After the RCT primary outcome at 3 years, annual follow-up from 4 through 8 years with treatment at investigator discretion. MAIN OUTCOME MEASURES: Suboptimal surgical outcome by 8 years after randomization, defined as any of the following at any visit: exotropia of 10 Δ or more by simultaneous prism cover test (SPCT) at distance or near, constant esotropia (ET) of 6 Δ or more by SPCT at distance or near, loss of near stereoacuity by 0.6 log arcsec or more from baseline, or reoperation. Secondary outcomes included (1) reoperation by 8 years and (2) complete or near-complete resolution at 8 years, defined as exodeviation of less than 10 Δ by SPCT and PACT at distance and near and 10 Δ or more reduction from baseline by PACT at distance and near, ET of less than 6 Δ at distance and near, no decrease in stereoacuity by 0.6 log arcsec or more from baseline, and no reoperation or nonsurgical treatment for IXT. RESULTS: The Kaplan-Meier cumulative probability of suboptimal surgical outcome through 8 years was 68% (55 events among 101 at risk) for BLRc and 53% (42 events among 96 at risk) for R&R (difference, 15%; 95% confidence interval [CI], -2% to 32%; P = 0.08). Complete or near-complete resolution at 8 years occurred in 15% (7/46) for BLRc and 37% (16/43) for R&R (difference, -22%; 95% CI, -44% to -0.1%; P = 0.049). The cumulative probability of reoperation was 30% for BLRc and 11% for R&R (difference, 19%; 95% CI, 2%-36%; P = 0.049). CONCLUSIONS: Despite no significant difference for the primary outcome, the 95% CI did not exclude a moderate benefit of R&R, which together with secondary outcomes suggests that unilateral R&R followed by usual care may yield better long-term outcomes than BLRc followed by usual care for basic-type childhood IXT using these surgical doses. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Randomized Trial of Binocular Dig Rush Game Treatment for Amblyopia in Children Aged 7 to 12 Years.

PURPOSE: To compare visual acuity (VA) improvement in children aged 7 to 12 years with amblyopia treated with a binocular iPad game plus continued spectacle correction vs. continued spectacle correction alone. DESIGN: Multicenter randomized clinical trial. PARTICIPANTS: One hundred thirty-eight participants aged 7 to 12 years with amblyopia (33-72 letters, i.e., approximately 20/200 to 20/40) resulting from strabismus, anisometropia, or both. Participants were required to have at least 16 weeks of optical treatment in spectacles if needed or demonstrate no improvement in amblyopic-eye visual acuity (VA) for at least 8 weeks prior to enrollment. METHODS: Eligible participants (mean age 9.6 years, mean baseline VA of 59.6 letters, history of prior amblyopia treatment other than spectacles in 96%) were randomly assigned to treatment for 8 weeks with the dichoptic binocular Dig Rush iPad game (prescribed for 1 hour per day 5 days per week) plus spectacle wear if needed (n = 69) or continued spectacle correction alone if needed (n = 69). MAIN OUTCOME MEASURES: Change in amblyopic-eye VA from baseline to 4 weeks, assessed by a masked examiner. RESULTS: At 4 weeks, mean amblyopic-eye VA letter score improved from baseline by 1.3 (2-sided 95% confidence interval [CI]: 0.1-2.6; 0.026 logMAR) with binocular treatment and by 1.7 (2-sided 95% CI: 0.4-3.0; 0.034 logMAR) with continued spectacle correction alone. After adjusment for baseline VA, the letter score difference between groups (binocular minus control) was -0.3 (95% CI: -2.2 to 1.5, P = 0.71, difference of -0.006 logMAR). No difference in letter scores was observed between groups when the analysis was repeated after 8 weeks of treatment (adjusted mean: -0.1, 98.3% CI: -2.4 to 2.1). For the binocular group, adherence data from the iPad indicated that slightly more than half of the participants (58% and 56%) completed >75% of prescribed treatment by the 4- and 8-week visits, respectively. CONCLUSIONS: In children aged 7 to 12 years who have received previous treatment for amblyopia other than spectacles, there was no benefit to VA or stereoacuity from 4 or 8 weeks of treatment with the dichoptic binocular Dig Rush iPad game.

Doses of medial rectus muscle recessions for divergence insufficiency-type esotropia.

We evaluated whether doses of bilateral medial rectus recessions greater than Parks's tables yielded superior outcomes for adult-onset divergence insufficiency. Forty-two patients underwent bilateral medial rectus recessions. Dose was analyzed as the average total per muscle (surgery + suture adjustment if performed) and compared with the standard dose tables (based on preoperative distance esodeviation), as difference between dose performed and dose indicated by Parks's tables. Each participant was classified as having received either Parks's dose (within 0.5 mm) or a dose greater than Parks's dose. Success was defined as "rarely" or "never" diplopia in distance straight-ahead gaze and reading. For patients classified as success, the mean difference between actual surgical dose performed and Parks's dose was calculated. Success was 91% (29/32) in those receiving greater than Parks's dose versus 67% (6/9) with Parks's dose (difference = 24%; 95% CI, -5% to 60%). The mean surgical dose was 1.0 mm greater than Parks's tables for the 35 successes (at 10 weeks) versus 0.7 mm greater for the 6 failures (difference = 0.4 mm; 95% CI, -0.2 to 0.9). For medial rectus recessions in adult-onset divergence insufficiency-type esotropia, a surgical dose 1 mm greater than Parks's tables, for each muscle, is a reasonable strategy.

Medical Student Perception of Strabismus in Race Implicit Association Test.

PURPOSE: To determine whether the appearance of strabismus is noted in a race implicit association test by medical students. METHODS: Medical students participated in a survey evaluating for the appearance of strabismus in photographs from a commonly used race implicit association test. Analysis was performed to determine whether strabismus was perceived equally between both groups tested. RESULTS: Photographs of six individuals of African descent were perceived as having strabismus more frequently (62%) than photographs of individuals of European descent (31%; odds ratio: 3.85; 95% CI: 3.34 to 4.44; P < .0001). Participants who identified as Black or African American similarly perceived strabismus more frequently in individuals of African descent (58%) than those of European descent (24%; odds ratio: 4.36; 95% CI: 2.13 to 8.96; P < .0001). CONCLUSIONS: Photographs used in a common race implicit association test appear to differ not only in ethnicity but also in extraocular alignment. Because extraocular alignment is a known cause of negative prejudice, results of this particular implicit association test should be interpreted with caution. [J Pediatr Ophthalmol Strabismus. 2023;60(5):372-376.].

Increasing incidence and risk factors for divergence insufficiency esotropia.

PURPOSE: To document the increasing incidence of divergence insufficiency (DI) esotropia and to identify risk factors for DI. METHODS: All patients with a diagnosis of esotropia seen by one provider (DLG) over 41 years were identified from the medical record. Patients with onset of strabismus before age 10 years or with prior strabismus surgery were excluded. Cases of esotropia associated with thyroid eye disease, scleral buckles, trauma, neurological diseases, or atypical misalignment were included but not labeled as DI regardless of the distance versus near deviation. The remaining patients, whatever the original diagnosis, were retrospectively categorized as having, or not having, DI, using a uniform criterion: distance esotropia ≥5Δ more than near esotropia. RESULTS: The percentage of DI patients among acquired esotropia patients increased significantly between the first and second half of the 41-year period, from 11.8% to 29.4% (P < 0.001). Multivariate logistic regression identified advancing age and the use of progressive addition lenses as risk factors for the development of DI. CONCLUSIONS: The incidence of DI is increasing. DI's association with age and progressive addition lenses may help us to understand its etiology and to decrease the prevalence of this condition in the future.

A prospective study of treatments for adult-onset divergence insufficiency-type esotropia.

PURPOSE: To describe 10-week and 12-month outcomes following treatment for divergence insufficiency-type esotropia in adults. METHODS: In this prospective observational study, 110 adults with divergence insufficiency-type esotropia, with a distance esodeviation measuring 2Δ to 30Δ and at least 25% larger at distance than near, and binocular diplopia present at least "sometimes" at distance, were enrolled at 28 sites when initiating new treatment. Surgery, prism, or divergence exercises/therapy were chosen at the investigator's discretion. Diplopia was assessed at enrollment and at 10-week and 12-month outcome examinations using a standardized diplopia questionnaire (DQ). Success was defined as DQ responses of "rarely" or "never" when looking straight ahead in the distance, with no alternative treatment initiated. RESULTS: Of the 110 participants, 32 (29%) were prescribed base-out prism; none had received prior treatment for esotropia. Success criteria were met by 22 of 30 at 10 weeks (73%; 95% CI, 54%-88%) and by 16 of 26 at 12 months (62%; 95% CI, 41%-80%). For the 76 (68%) who underwent strabismus surgery (82% of whom had been previously treated with prism), success criteria were met by 69 of 74 at 10 weeks (93%; 95% CI, 85%-98%) and by 57 of 72 at 12 months (79%; 95% CI, 68%-88%). CONCLUSIONS: In this study cohort, both base-out prism as initial therapy and strabismus surgery (usually following prism) were successful in treating diplopia for most adults with divergence insufficiency-type esotropia when assessed during the first year of follow-up.

Overminus Lens Therapy for Children 3 to 10 Years of Age With Intermittent Exotropia: A Randomized Clinical Trial.

IMPORTANCE: This is the first large-scale randomized clinical trial evaluating the effectiveness and safety of overminus spectacle therapy for treatment of intermittent exotropia (IXT). OBJECTIVE: To evaluate the effectiveness of overminus spectacles to improve distance IXT control. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial conducted at 56 clinical sites between January 2017 and January 2019 associated with the Pediatric Eye Disease Investigator Group enrolled 386 children aged 3 to 10 years with IXT, a mean distance control score of 2 or worse, and a refractive error between 1.00 and -6.00 diopters (D). Data analysis was performed from February to December 2020. INTERVENTIONS: Participants were randomly assigned to overminus spectacle therapy (-2.50 D for 12 months, then -1.25 D for 3 months, followed by nonoverminus spectacles for 3 months) or to nonoverminus spectacle use. MAIN OUTCOMES AND MEASURES: Primary and secondary outcomes were the mean distance IXT control scores of participants examined after 12 months of treatment (primary outcome) and at 18 months (3 months after treatment ended) assessed by an examiner masked to treatment group. Change in refractive error from baseline to 12 months was compared between groups. Analyses were performed using the intention-to-treat population. RESULTS: The mean (SD) age of 196 participants randomized to overminus therapy and 190 participants randomized to nonoverminus treatment was 6.3 (2.1) years, and 226 (59%) were female. Mean distance control at 12 months was better in participants treated with overminus spectacles than with nonoverminus spectacles (1.8 vs 2.8 points; adjusted difference, -0.8; 95% CI, -1.0 to -0.5; P < .001). At 18 months, there was little or no difference in mean distance control between overminus and nonoverminus groups (2.4 vs 2.7 points; adjusted difference, -0.2; 95% CI, -0.5 to 0.04; P = .09). Myopic shift from baseline to 12 months was greater in the overminus than the nonoverminus group (-0.42 D vs -0.04 D; adjusted difference, -0.37 D; 95% CI, -0.49 to -0.26 D; P < .001), with 33 of 189 children (17%) in the overminus group vs 2 of 169 (1%) in the nonoverminus group having a shift higher than 1.00 D. CONCLUSIONS AND RELEVANCE: Children 3 to 10 years of age had improved distance exotropia control when assessed wearing overminus spectacles after 12 months of overminus treatment; however, this treatment was associated with increased myopic shift. The beneficial effect of overminus lens therapy on distance exotropia control was not maintained after treatment was tapered off for 3 months and children were examined 3 months later. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02807350.

Diagnosis of Accommodative Spasm Aided by Handheld Photoscreener.

We report a case of accommodative spasm in an 8-year-old girl discovered by handheld photoscreener. The patient was found to have a Chiari I malformation, and managed with atropine drops and reading glasses, ultimately with improvement in her symptoms. We believe this to be the first case of accommodative spasm diagnosis aided by the use of a handheld photoscreener.

Pathological Examination of Plicated Medial Rectus Muscle for Treatment of Re-recurrent Exotropia.

Plication and resection are surgical procedures commonly used for the treatment of strabismus. Further studies are needed to understand the postoperative effects of plication on muscle tissue. This case report examines a pathological section of a plicated medial rectus muscle, revealing myocyte injury and replacement with fibroconnective tissue. [J Pediatr Ophthalmol Strabismus. 2018;55:e20-e21.].

Topical timolol for an iris hemangioma.

Extraocular infantile hemangiomas have been shown to respond to oral and topical beta blockers, while there is little literature regarding the management of intraocular infantile hemangiomas with beta blockers. This case report discusses the management of an iris hemangioma with topical timolol, a treatment previously unreported in the literature.

Deficiency of depression in adduction: clinical characteristics and surgical management of the "inverted Brown pattern".

PURPOSE: To evaluate the clinical characteristics and surgical management of patients with an "inverted Brown pattern," which is defined clinically as a hypertropia with greatest deviation in down-and-in gaze of the higher eye, having the appearance of superior oblique muscle underaction but without significant inferior oblique muscle overaction. METHODS: The medical records of patients with this misalignment pattern who had cyclovertical muscle surgery at our institution from 2003 through 2015 were retrospectively reviewed; medical records were analyzed for pre- and postoperative motility patterns, fundus torsion, intraoperative findings, and type of strabismus surgery. RESULTS: A total of 45 patients presenting with a hyperdeviation worse in down-and-in gaze of the higher eye were included in the study. Of these, 25 (56%) had previously had inferior oblique-weakening procedures. The remainder included those with untreated superior oblique paresis (22%), previous orbital trauma (18%), or other ocular surgery (4%). The mean preoperative hyperdeviation in straight-ahead gaze was 8.7(Δ), compared with 0.9(Δ) postoperatively. Surgical success, defined as the absence of diplopia in straight-ahead gaze and not requiring further cyclovertical surgery, was achieved in 78% of patients. CONCLUSIONS: The motility pattern referred to as the "inverted Brown pattern" can develop in patients with orbital trauma, as previously described, or in association with superior oblique muscle paresis, most commonly after prior surgery to weaken the inferior oblique muscle. Weakening or reweakening of the inferior oblique muscle appears to correct this misalignment pattern, despite the absence of significant inferior oblique overaction preoperatively.

Nonabsorbable versus absorbable sutures in large, hang-back medial rectus muscle recessions.

PURPOSE: To investigate the value of nonabsorbable sutures in reducing the incidence of consecutive exotropia after large, "hang-back" medial rectus recessions. METHODS: The medical records of patients who underwent medial rectus recession of ≥6.5 mm in individuals ≤2 years of age, or ≥7.0 mm in those >2 years were retrospectively reviewed. Patients were divided into two groups based on suture material used: absorbable, polyglactin 910 sutures (44 patients); nonabsorbable, polyester sutures (50 patients). Preoperative measurements, ductions, strabismus surgery, and postoperative results were analyzed. Inadequate anchoring of the medial rectus muscle was suspected when consecutive exotropia developed 4-7 weeks after surgery after initial satisfactory alignment and was confirmed if during reoperation the medial rectus muscle appeared recessed >2 mm beyond the originally intended recession. RESULTS: Consecutive exotropia due to inadequate anchoring of the medial rectus muscle occurred in 11 of 66 muscles (17%) in the absorbable suture group. The muscle was found 6-10 mm posterior to the intended recession. Limited duction in the field of action of the involved medial rectus muscle occurred in 9 of the 11 muscles (82%). None of the eyes with nonabsorbable sutures showed inadequate anchoring. The incidence of consecutive exotropia was higher in the absorbable suture group (30%) than in the nonabsorbable suture group (6%) (P < 0.005). CONCLUSIONS: Using nonabsorbable suture for large, hang-back medial rectus recessions greatly reduces the incidence of consecutive exotropia that can occur when absorbable suture dissolves.

Accuracy of double Maddox rod with induced hypertropia in normal subjects.

BACKGROUND AND PURPOSE: The double Maddox rod is a commonly used instrument to test for cyclotorsion in the clinical setting. This paper assesses the ability of patients without torsional complaint to accurately demonstrate torsional status with varying degrees of induced hypertropia as tested by double Maddox rod. METHODS: Thirty-seven orthophoric subjects underwent double Maddox rod testing with vertical prism of 3(Δ), 10(Δ), 16(Δ), 20(Δ), and 30(Δ). Subjective torsion was recorded for each prism diopter. RESULTS: Mean subjective torsion was recorded as 0.95°, 1.6°, 1.9°, 2.1°, and 2.2° for 3(Δ), 10(Δ), 16(Δ), 20(Δ), and 30(Δ), respectively. Torsion increased in a logarithmic manner as modeled by R™ software version 2.15.2. CONCLUSIONS: The double Maddox rod test as commonly used in clinical practice is both subjective and prone to administrator and subject error. Subjects have more difficulty properly aligning the double Maddox rod as distance between images is increased. It is also possible that recruitment of the oblique muscles during attempted vertical fusion leads to subjective torsion during double Maddox rod testing in otherwise normal participants.