Anterior transposition of the inferior oblique and anti-elevation syndrome - how far to go?

Purpose: To study the incidence of postoperative anti-elevation syndrome in relation to the magnitude of anterior transposition of the inferior oblique. Methods: A retrospective chart review was conducted for all patients submitted to anterior transposition of the inferior oblique from 2000 to 2020. Anti-elevation syndrome was defined as limitation of elevation of the abducting eye, resulting in a secondary upshoot of the contralateral adducting eye. Results: A total of 312 eyes of 170 patients were enrolled in the study. The incidence of anti-elevation syndrome was 20.4% when the inferior oblique was positioned 4 mm posterior to the temporal border of the inferior rectus insertion; 23.5% when sutured 2 mm posterior to the temporal border of the inferior rectus insertion and 32.8% when placed at the same level of the inferior rectus insertion with two sutures vertically aligned. When the posterior border of the inferior oblique was horizontally aligned with the anterior border and positioned adjacent to the inferior rectus insertion, in a "J shape" fashion, the incidence of anti-elevation was 41.8%. Conclusions: The anterior transposition of the inferior oblique with "J" deformity increases the risk of anti-elevation syndrome. Additionally, placing the sutures more anteriorly than 2 mm posterior to the inferior rectus insertion increases the incidence of this finding.

Two birds, one stone: a surgical approach for third nerve palsy with aberrant regeneration.

Aberrant regeneration in third nerve palsies, linking medial rectus contraction to the levator palpebrae muscle, is a great opportunity for surgical planning to address both the ptosis and horizontal deviation in a single procedure. We report a case of severe ptosis associated with exotropia that was successfully corrected with a single horizontal strabismus surgery owing to aberrant regeneration and discuss the basis underlying the surgical planning.

Vision screening using a smartphone platform.

OBJECTIVE: The main aim of this study was to evaluate the performance of a platform designed for pediatricians to screen amblyopia using a smartphone. METHODS: The medical records of consecutive children who received visual screening using a smartphone platform were retrospectively reviewed. The smartphone was used with a flash concentrator case and a software for capturing images of both eyes simultaneously by a photorefraction mechanism. The platform performance was compared to the comprehensive ophthalmological examination, which is considered the gold standard for detecting amblyopia. Sensitivity, specificity, positive predictive value, and negative predictive value of the software in detecting amblyopia risk factors were calculated. RESULTS: A total of 157 children were included, with a mean age of 6.0±.5 years (range 5-7). In 94% of the cases, the software was able to analyze the images and release a result, determining whether or not the child presented with amblyopia risk factors. Compared to the ophthalmological examination, the smartphone platform sensitivity in detecting amblyopia risk factors was 84%, the specificity was 74%, the positive predictive value was 86%, and the negative predictive value was 70%. CONCLUSIONS: The sensitivity and specificity of the smartphone photoscreening platform to detect amblyopia risk factors were within the range of traditional instrument-based vision screening technology. A smartphone photorefraction platform appears to be a promising cost-effective alternative to assist pediatricians and minimize obstacles to vision screening and amblyopia detection. Future studies are needed to gather additional comparative data.

Oculometric parameters of hyperopia in children with esotropic amblyopia.

PURPOSE: To study the oculometric parameters of hyperopia in children with esotropic amblyopia, comparing amblyopic eyes with fellow eyes. METHODS: Thirty-seven patients (5-8 years old) with bilateral hyperopia and esotropic amblyopia underwent a comprehensive ophthalmic examination, including cycloplegic refraction, keratometry and A-scan ultrasonography. Anterior chamber depth, lens thickness, vitreous chamber depth and total axial length were recorded. The refractive power of the crystalline lens was calculated using Bennett's equations. Paired Student's t-tests were used to compare ocular biometric measurements between amblyopic eyes and their fellow eyes. The associations of biometric parameters with refractive errors were assessed using Pearson correlation coefficients and linear regression. Multivariable models including axial length, corneal power and lens power were also constructed. RESULTS: Amblyopic eyes were found to have significantly more hyperopic refraction, less corneal power, greater lens power, shorter vitreous chamber depth and shorter axial length, despite similar anterior chamber depth and lens thickness. The strongest correlation with refractive error was observed for the axial length/corneal radius ratio (r(36) = -0.92, p < 0.001 for amblyopic and r(36) = -0.87, p < 0.001 for fellow eyes). Axial length accounted for 39.2% (R(2)) of the refractive error variance in amblyopic eyes and 35.5% in fellow eyes. Adding corneal power to the model increased R(2) to 85.7% and 79.6%, respectively. A statistically significant correlation was found between axial length and corneal power, indicating decreasing corneal power with increasing axial length, and they were similar for amblyopic eyes (r(36) = -0.53, p < 0.001) and fellow eyes (r(36) = -0.57, p < 0.001). A statistically significant correlation was also found between axial length and lens power, indicating decreasing lens power with increasing axial length (r(36) = -0.72, p < 0.001 for amblyopic eyes and r(36) = -0.69, p < 0.001 for fellow eyes). CONCLUSIONS: We observed that the correlation among the major oculometric parameters and their individual contribution to hyperopia in esotropic children were similar in amblyopic and non-amblyopic eyes. This finding suggests that the counterbalancing effect of greater corneal and lens power associated with shorter axial length is similar in both eyes of patients with esotropic amblyopia.

Strabismus and Artificial Intelligence App: Optimizing Diagnostic and Accuracy.

Purpose: Clinical evaluation of eye versions plays an important role in the diagnosis of special strabismus. Despite the importance of versions, they are not standardized in clinical practice because they are subjective. Assuming that objectivity confers accuracy, this research aims to create an artificial intelligence app that can classify the eye versions into nine positions of gaze. Methods: We analyzed photos of 110 strabismus patients from an outpatient clinic of a tertiary hospital at nine gazes. For each photo, the gaze was identified, and the corresponding version was rated by the same examiner during patient evaluation. Results: The images were standardized by using the OpenCV library in Python language, so that the patient's eyes were located and sent to a multilabel model through the Keras framework regardless of the photo orientation. Then, the model was trained for each combination of the following groupings: eyes (left, right), gaze (1 to 9), and version (-4 to 4). Resnet50 was used as the neural network architecture, and the Data Augmentation technique was applied. For quick inference via web browser, the SteamLit app framework was employed. For use in Mobiles, the finished model was exported for use in through the Tensorflow Lite converter. Conclusions: The results showed that the mobile app might be applied to complement evaluation of ocular motility based on objective classification of ocular versions. However, further exploratory research and validations are required. Translational Relevance: Apart from the traditional clinical practice method, professionals will be able to envisage an easy-to-apply support app, to increase diagnostic accuracy.

Vision for the Future Project: Screening impact on the prevention and treatment of visual impairments in public school children in São Paulo City, Brazil.

OBJECTIVES: Uncorrected refractive errors are the leading cause of visual impairment in children. In this cross-sectional retrospective study, we analyzed a social visual screening program for school children in São Paulo, Brazil, evaluated its impact on the prevention and treatment of children's visual disabilities, and assessed its epidemiological outcomes to outline suggestions for its improvement. METHODS: First-grade children from public schools were submitted to prior visual screening by their teachers. Selected children were forwarded to the hospital's campaigns for a second screening by ophthalmologists and treatment if needed. Data were analyzed for age, sex, visual acuity, biomicroscopy, refractive errors, ocular movement disorders, amblyopia, number of donated spectacles, and number of children forwarded to specialized care. RESULTS: A total of 1080 children were included with mean age of 6.24±0.45 years. Children with normal ophthalmological exam, 591 (54.7%; 95% confidence interval [CI]: 51.7%-57.7%) were dismissed and considered false-positives. Myopia, hyperopia, and astigmatism components were found in 164 (15.2%; CI: 13.1%-17.4%), 190 (17.6%; CI: 15.3%-20.0%), and 330 (30.5%; CI: 27.8%-33.4%) children, respectively. Amblyopia was diagnosed in 54 (5%; CI: 3.5%-6.4%) children, and 117 (10.8%; CI: 9.8%-12.8%) presented ocular movement disorders. A total of 420 glasses were donated. CONCLUSION: Epidemiological findings for amblyopia and refractive errors are consistent with those of similar studies. The expressive number of diagnoses performed and number of glasses donated to underprivileged children depict the importance of such projects. New guidelines to improve their cost-effectiveness, such as professional training and community sensitization, are imperative.

Bilateral superior oblique temporal tenectomy for the treatment of A-pattern strabismus.

PURPOSE: To assess the efficacy of superior oblique temporal tenectomy 6.0 mm from its insertion to treat A-pattern strabismus of all magnitudes. METHODS: The clinical records of patients with A-pattern eso- or exotropia associated with bilateral superior oblique overaction who underwent bilateral superior oblique 6.0 mm temporal tenectomy at a single institution over a 17-year period were reviewed retrospectively. Outcome measures were change in the A pattern and correlation with preoperative A pattern. RESULTS: A total of 102 patients were included. The mean preoperative A-pattern deviation was 21Δ ± 9Δ, with a postoperative pattern collapse of 18Δ ± 10Δ. Change in A pattern was significantly correlated with the preoperative A pattern (r = 0.70; P <0.001). In patients with an A pattern of ≥25Δ, the preoperative deviation was 31Δ ± 7Δ, with a postoperative pattern collapse of 27Δ ± 9Δ. In 76% of patients with A pattern of <25Δ and in 72% of patients with A pattern ≥25Δ, the A pattern was corrected to <10Δ. The average percentage of A pattern correction was 89% in patients with pattern deviation <25Δ and 86% in patients with pattern deviation ≥25Δ. CONCLUSIONS: In our study cohort, bilateral superior oblique temporal tenectomy was an effective and self-adjusting procedure for A-pattern strabismus associated with superior oblique overaction. Larger preoperative A patterns did not show a significant trend toward larger residual postoperative deviations compared with smaller preoperative patterns. A uniform dose of bilateral superior oblique temporal tenectomy collapses A patterns of all magnitudes.

Intermittent exotropia evaluation using the propedeutics proposed by Kushner: a 25-year study.

PURPOSE: To evaluate the clinical and surgical impacts of phenomena that could occur in intermittent exotropia. METHODS: The medical records of intermittent exotropia cases from 1991 to 2014 were retrospectively reviewed. All patients underwent a series of measures, including a protocol to assess monocular occlusion based on the propedeutics proposed by Kushner. RESULTS: Outdoor sensitivity was observed in 31% of patients with an undercorrection rate of 44% vs. 18% of cases with no outdoor sensitivity. After 1 h of monocular occlusion, 41% of all patients achieved an increase in deviation with an undercorrection rate of 40%, whereas 25% did not. CONCLUSION: The results show the importance of complete propedeutics, since there is a higher rate of late undercorrection in cases with outdoor sensitivity and increased deviation after occlusion.

[Intraoperative adjustable strabismus surgery under drop anesthesia in patients with Graves' orbitopathy]. / Cirurgia de estrabismo ajustável no peroperatório com anestesia tópica em pacientes com orbitopatia de Graves.

PURPOSE: To report the clinical features of strabismus associated with Graves' orbitopathy, and the results of surgery with adjustable suture under drop anesthesia. METHODS: The charts of 13 patients who had surgical treatment for strabismus related to Graves' orbitopathy at Hospital das Clínicas of University of São Paulo were retrospectively reviewed. Ocular motility, sensorial examination and the follow-up after strabismus correction were studied. RESULTS: Preoperatively, the most common type of deviation was esotropia with hypotropia. Adjustable recession was done in nine patients and a second surgery occurred in 3 patients. After follow-up of at least six months, 8 of 13 patients were orthotropic or had a small phoria with some degree of binocular vision. CONCLUSION: In this study, 62% (8/13) of patients showed hypotropia with esotropia, probably because fibrotic and restrictive muscles (medial and inferior rectus). In nine of 13 patients adjustable recession with a good postoperative alignment of the eyes was performed. Adjustment of strabismus surgery under drop anesthesia in patients with Graves' orbitopathy was successful in restoring binocular vision with minimum complications.

Comparison of the temporal hemifield and nasal hemifield sensitivity in patients with early-onset convergent strabismus.

OBJECTIVE: To analyze the hypothesis that a reduction in sensitivity of the nasal visual hemifield would lead to an increase in the nasotemporal asymmetry of the visual field in patients under two years of age with early-onset convergent strabismus in comparison with normal patients. METHODS: Both eyes of 66 patients - 33 esotropes and 33 normals - were studied. Patients' age ranged from 7 to 30 years. The examination consisted of a static perimetry using the Humphrey field analyzer 700 Series' Sita Standard program. RESULTS: An accentuation of the nasotemporal asymmetry was seen in the 33 esotropes and was related to an evident decrease of sensitivity in the most peripheral of the points studied along the horizontal meridian of the visual field. The quantitative sum of values of sensitivity of these points showed an average reduction of -15.71% in relation to the normal patients. CONCLUSION: There was a clear accentuation of the nasotemporal asymmetry of sensitivity in esotropes when compared to normal patients. There was no difference in sensitivity between the two eyes in either normals or esotropes.

[Simplified intraoperative adjustable suture technique for horizontal strabismus surgery: a study of 153 cases]. / Técnica de sutura ajustável per-operatória simplificada para a correção de desvios horizontais: estudo de 153 casos.

PURPOSE: To evaluate the simplified intraoperative adjustable suture technique for horizontal strabismus surgery. METHODS: Data charts of all patients who underwent horizontal strabismus surgery by the simplified intraoperative adjustable suture technique at the Strabismus Department of the "Hospital das Clínicas" of the University of São Paulo in the period from January 2001 to November 2005 were evaluated retrospectively. Using this technique, the adjustment was calculated based on the corneal light reflection, having considered the difference between the measures in the awake state and with the anesthetized patient. RESULTS: One hundred fifty-three patients were operated on, 73 (47.8%) cases of esotropia (ET) and 80 (52.2%) of exotropia (XT). Under anesthesia, 123 (80.4%) patients had the eye position modified: 69 (56.1%) were less esotropic, 51 (41.5%) were more exotropic and 3 (2.4%) were less exotropic. Surgery was adjusted in 60 (39.2%) patients: 30 were esotropia and 30 were exotropia. Surgical success was defined as an eso- or exodeviation within 10 prism diopters, in a follow-up period of at least 180 days. The overall success rate was 71.6%. CONCLUSIONS: The simplified intraoperative adjustable suture technique, described in 2003 in a study performed on 49 patients operated on by the same surgeon, was shown to be efficient in this larger series of patients operated on by different surgeons. This technique should be considered in patients who do not cooperate in other adjustment techniques, aiming at improved success rates.

Two birds, one stone: a surgical approach for third nerve palsy with aberrant regeneration / Tratamento cirúrgico de paralisia de terceiro nervo craniano com regeneração aberrante

ABSTRACT Aberrant regeneration in third nerve palsies, linking medial rectus contraction to the levator palpebrae muscle, is a great opportunity for surgical planning to address both the ptosis and horizontal deviation in a single procedure. We report a case of severe ptosis associated with exotropia that was successfully corrected with a single horizontal strabismus surgery owing to aberrant regeneration and discuss the basis underlying the surgical planning.

RESUMO A regeneração aberrante nas paralisias do terceiro nervo, ligando a contração do reto medial ao músculo levantador da pálpebra, é uma grande oportunidade para fazer um planejamento cirúrgico para tratar tanto a ptose quanto o desvio horizontal em um procedimento único. Relatamos uma ptose grave associada à exotropia corrigida com sucesso com uma única cirurgia de estrabismo horizontal devido à regeneração aberrante e discutimos as bases do planejamento cirúrgico.

Vision screening using a smartphone platform / Triagem visual usando uma plataforma no smartphone

ABSTRACT Objective: The main aim of this study was to evaluate the performance of a platform designed for pediatricians to screen amblyopia using a smartphone. Methods: The medical records of consecutive children who received visual screening using a smartphone platform were retrospectively reviewed. The smartphone was used with a flash concentrator case and a software for capturing images of both eyes simultaneously by a photorefraction mechanism. The platform performance was compared to the comprehensive ophthalmological examination, which is considered the gold standard for detecting amblyopia. Sensitivity, specificity, positive predictive value, and negative predictive value of the software in detecting amblyopia risk factors were calculated. Results: A total of 157 children were included, with a mean age of 6.0±.5 years (range 5-7). In 94% of the cases, the software was able to analyze the images and release a result, determining whether or not the child presented with amblyopia risk factors. Compared to the ophthalmological examination, the smartphone platform sensitivity in detecting amblyopia risk factors was 84%, the specificity was 74%, the positive predictive value was 86%, and the negative predictive value was 70%. Conclusions: The sensitivity and specificity of the smartphone photoscreening platform to detect amblyopia risk factors were within the range of traditional instrument-based vision screening technology. A smartphone photorefraction platform appears to be a promising cost-effective alternative to assist pediatricians and minimize obstacles to vision screening and amblyopia detection. Future studies are needed to gather additional comparative data.

RESUMO Objetivo: Avaliar a performance de uma plataforma desenvolvida para pediatras para triagem de ambliopia utilizando um smartphone. Métodos: Os prontuários consecutivos de crianças submetidas a triagem visual usando uma plataforma no smartphone foram analisados retrospectivamente. Uma capa concentradora de flash foi utilizada no smartphone com um software para capturar imagens simultâneas dos dois olhos por um mecanismo de fotorrefração. A performance da plataforma foi comparada ao exame oftalmológico completo, considerado o padrão ouro para detecção de ambliopia. Foram calculados sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo do software em detectar fatores de risco para ambliopia. Resultados: Foram incluídas 157 crianças com idade média de 6.0±0.5 anos (variação de 5 a 7 anos). Em 94% dos casos, o software foi capaz de analisar as imagens e fornecer um resultado, determinando se a criança apresentava ou não fatores de risco para ambliopia. Comparados ao exame oftalmológico, a sensibilidade da plataforma no smartphone em detectar fatores de risco para ambliopia foi de 84%, a especificidade foi de 74%, o valor preditivo positivo foi de 86% e o valor preditivo negativo foi de 70%. Conclusões: A plataforma de triagem por fotorrefração usando o smartphone apresentou sensibilidade e especificidade para detectar fatores de risco para ambliopia semelhantes às encontradas em instrumentos tradicionais de triagem por fotorrefração. Uma plataforma no smartphone é uma alternativa custo-efetiva promissora para auxiliar pediatras a minimizar os obstáculos para triagem visual e detecção da ambliopia. Estudos futuros são necessários a fim de reunir dados comparativos adicionais.

Persistent diplopia and strabismus after cataract surgery under local anesthesia.

BACKGROUND AND PURPOSE: Diplopia is an infrequent complication described for retrobulbar local anesthesia. The objective of this study is to report the clinical characteristics and treatments for this surgical complication. METHODS: Retrospective study of medical records. PERIOD: 5.3 years ending February 2005. During this period, 20453 cataract surgeries were performed. The anesthesia used was retrobulbar block with ropivacaine diluted with hyaluronidase. Nineteen patients reported diplopia due to strabismus after the cataract surgical procedure and were referred for evaluation at the Extrinsic Ocular Motility Department. RESULTS: Persistent diplopia after cataract surgery occurred in 19 (0.093%) of the 20453 cases. The types of deviations found were: exotropia (n=3), esotropia (n=5), hypertropia (n=1), exotropia + hypertropia (n=5) and esotropia + hypertropia (n=5). Small deviations and dysfunction of the lateral rectus muscles were most commonly seen. Prism was applied to 4 patients, eye muscle surgery was the option in 8 patients, orthoptic treatment was performed in 3 patients and for 2 patients the decision was to only observe progress. Overall, binocular vision was restored in eleven of the nineteen patients. CONCLUSIONS: Persistent diplopia due to strabismus is an infrequent complication after cataract surgery with retrobulbar block. Etiology of this disorder of extrinsic ocular motility is variable, including mixed components. We stress the importance of adequate preoperative history of strabismus and evaluation of extrinsic ocular motility. Considering the reported incidence of this problem is as high as one in 25 cataract surgeries, one should advise the patient of the possibility of persistent postoperative diplopia and the possible need for surgical intervention and/or prism to treat the symptoms.

[Sensorial strabismus: a study of 191 cases]. / Estrabismo sensorial: estudo de 191 casos.

PURPOSE: To evaluate the charts of patients with sensorial strabismus regarding range of different aspects, such as etiology, the type and the amount of deviation, relationship between the type of deviation and the patient's age when the disease occurred and the surgical outcome. METHODS: A retrospective analysis of data charts of 191 patients seen at the section of Ophthalmology at the University of São Paulo, from September 1990 to July 2002. RESULTS: There were 84 male and 107 female patients. The most frequent diagnosis responsible for low vision in the squinted eye was atrophic chorioretinitis in 49 patients. Eighty-seven were exotropes and 97 were esotropes. Fifty patients were operated on, but 8 of them were lost to follow-up. In 90.5% the surgical outcome was successful: less than 15 prismatic diopters of hyper or undercorrection after surgery. CONCLUSIONS: The good surgical outcome seen in this and other studies enhances and justifies the need for surgical correction of this type of strabismus.

[Strabismic amblyopia: a retrospective study on patients from a university hospital]. / Ambliopia por estrabismo: estudo retrospectivo de pacientes em hospital universitário.

PURPOSE: To evaluate the influence of compliance with treatment, severity of amblyopia and age at the beginning of treatment in patients with strabismic amblyopia submitted to patching. METHODS: The data were selected from medical records of 569 patients seen at the Department of Ophthalmology, University of São Paulo during the period of 1983 to 2000. EXCLUSION CRITERIA: loss of follow-up, age over 12 years, presence of nystagmus and other ocular diseases. The patients were divided into four groups according to age and classified based on the type of strabismus, compliance with treatment and severity of amblyopia. Statistical analysis was performed using Fisher's test. RESULTS: 198 (34.8%) patients were enrolled in the study. There was no difference regarding compliance among the age groups. The best success rate was obtained when there was good compliance with the treatment, independent of the degree of amblyopia. But worse compliance was observed among the patients with more severe amblyopia, who were the majority of patients of the study, and who showed the worst success rate. The success rate was not related to the patients' age. CONCLUSION: The study showed that compliance with patching plays a fundamental role in therapeutic efficacy. Thus, age at the beginning of treatment alone did not influence the success rate since it was possible to obtain good compliance independent of age. In addition, worse results were associated with severe amblyopia and less compliance.

Vision for the Future Project: Screening impact on the prevention and treatment of visual impairments in public school children in São Paulo City, Brazil

OBJECTIVES: Uncorrected refractive errors are the leading cause of visual impairment in children. In this cross-sectional retrospective study, we analyzed a social visual screening program for school children in São Paulo, Brazil, evaluated its impact on the prevention and treatment of children's visual disabilities, and assessed its epidemiological outcomes to outline suggestions for its improvement. METHODS: First-grade children from public schools were submitted to prior visual screening by their teachers. Selected children were forwarded to the hospital's campaigns for a second screening by ophthalmologists and treatment if needed. Data were analyzed for age, sex, visual acuity, biomicroscopy, refractive errors, ocular movement disorders, amblyopia, number of donated spectacles, and number of children forwarded to specialized care. RESULTS: A total of 1080 children were included with mean age of 6.24±0.45 years. Children with normal ophthalmological exam, 591 (54.7%; 95% confidence interval [CI]: 51.7%-57.7%) were dismissed and considered false-positives. Myopia, hyperopia, and astigmatism components were found in 164 (15.2%; CI: 13.1%-17.4%), 190 (17.6%; CI: 15.3%-20.0%), and 330 (30.5%; CI: 27.8%-33.4%) children, respectively. Amblyopia was diagnosed in 54 (5%; CI: 3.5%-6.4%) children, and 117 (10.8%; CI: 9.8%-12.8%) presented ocular movement disorders. A total of 420 glasses were donated. CONCLUSION: Epidemiological findings for amblyopia and refractive errors are consistent with those of similar studies. The expressive number of diagnoses performed and number of glasses donated to underprivileged children depict the importance of such projects. New guidelines to improve their cost-effectiveness, such as professional training and community sensitization, are imperative.

Recession and measured, graded anterior transposition of the inferior oblique muscles for V-pattern strabismus: outcome of 44 procedures in 22 typical patients.

PURPOSE: This study aimed to evaluate the efficacy of recession and graded anterior transposition of the inferior oblique (IO) muscle to correct or to reduce V-pattern strabismus and associated IO overaction. METHODS: The technique used was that proposed by Wright, using the temporal border and the insertion of the inferior rectus as the reference points to locate the new insertion. In a retrospective study, 51 patient histories were analyzed and from this group, 22 patients were selected as most typical examples. Patients with hypertropias greater than 6 prism diopters (PD), a dissociated vertical deviation (DVD) greater than 8 PD or decompensated DVD were excluded. RESULTS: A total of 44 eye surgeries on 22 patients were analyzed. We observed favorable results ("statistically significant") concerning the reduction of the IO overaction or V incomitance. In 45.5% (20 eyes) the IO function was normalized, in 15.9% (7 eyes) there was a reduction to -1 (underaction) and in 34.1% (15 eyes) there was a reduction, but there still remained a +1 overaction. In 77.3% of the patients there was a "satisfactory" outcome of the V pattern, defined as a residual incomitance less than 10 PD. CONCLUSION: In this group of patients with V-pattern strabismus and IO overaction, the recession and measured, graded anterior transposition based on Wright's technique showed satisfactory results ("statistically significant") in correcting the V incomitance and normalizing or reducing the IO overaction.

Intermittent exotropia evaluation using the propedeutics proposed by Kushner: a 25-year study / Avaliação de exotropia intermitente usando propedêutica proposta por Kushner: estudo de 25 anos

ABSTRACT Purpose: To evaluate the clinical and surgical impacts of phenomena that could occur in intermittent exotropia. Methods: The medical records of intermittent exotropia cases from 1991 to 2014 were retrospectively reviewed. All patients underwent a series of measures, including a protocol to assess monocular occlusion based on the propedeutics proposed by Kushner. Results: Outdoor sensitivity was observed in 31% of patients with an undercorrection rate of 44% vs. 18% of cases with no outdoor sensitivity. After 1 h of monocular occlusion, 41% of all patients achieved an increase in deviation with an undercorrection rate of 40%, whereas 25% did not. Conclusion: The results show the importance of complete propedeutics, since there is a higher rate of late undercorrection in cases with outdoor sensitivity and increased deviation after occlusion.

RESUMO Objetivo: Avaliar os impactos clínico e cirúrgico dos fenômenos que podem ocorrer na exotropia intermitente. Métodos: Os prontuários de casos de exotropia intermitente de 1991 a 2014 foram revisados retrospectivamente. Todos os pacientes foram submetidos a uma serie de medidas incluindo o protocolo com oclusão monocular com base na propedêutica proposta por Kushner. Resultados: Outdoor sensitivity foi observada em 31% dos pacientes com taxa de subcorreção de 44% vs. 18% dos casos sem outdoor sensitivity. Após 1 hora de oclusão monocular, 41% de todos os pacientes apresentaram um aumento no desvio com uma taxa de subcorreção 40%, enquanto 25% não. Conclusão: Os resultados demonstram a importância da propedêutica completa, uma vez que há maior taxa de subcorreção tardia nos casos de outdoor sensitivity e maior desvio após a oclusão.

Teratogen exposure and congenital ocular abnormalities in Brazilian patients with Möbius sequence.

Purpose: To assess the sociodemographic profiles, teratogen exposures, and ocular congenital abnormalities in Brazilian patients with Möbius sequence. Method: Forty-four patients were recruited from the Brazilian Möbius Sequence Society. This cross-section comprised 41 patients (age, mean ± standard deviation, 9.0 ± 5.5 years) who fulfilled the inclusion criteria. The parent or caregiver answered a questionnaire regarding sociodemographic data and pregnancy history. Patients underwent ophthalmological assessments. They were subdivided into groups according to misoprostol exposure during pregnancy, and the two groups were compared. Results: Mothers/caregivers reported unplanned pregnancies in 36 (88%) cases. Of these, 19 (53%) used misoprostol during their first trimesters. A stable marital status tended to be more frequent in the unexposed group (P=0.051). Incomplete elementary school education was reported by two (11%) mothers in the exposed group and by three (14%) mothers in the unexposed group (P=0.538). The mothers' gestational exposures to cocaine, marijuana, alcohol, and cigarettes were similar in both groups (P=0.297, P=0.297, P=0.428, and P=0.444, respectively). One (5%) case of Rubella infection during pregnancy was found in the unexposed group. The main malformations in the exposed and unexposed groups were the following: strabismus (72% and 77%, respectively), lack of emotional tearing (47% and 36%, respectively), and lagophthalmos (32% and 41%, respectively). Conclusion: Stable marital statuses tended to be more frequent among mothers that did not take misoprostol during pregnancy. Exposures to other teratogens and the main ocular abnormalities were similar in both groups.