Purpose: To compare the efficacy of the original and augmented Fink techniques in the surgical correction of V-pattern strabismus associated with primary inferior oblique overaction. Methods: We conducted a retrospective chart review of patients who underwent concurrent horizontal strabismus surgery (recess - resect procedure) and bilateral symmetric inferior oblique recession using either the standard Fink technique (corresponding to an 8-mm recession) or augmented variants (9, 10, or 11-mm recession). The primary outcome assessed was reduction in V-pattern strabismus, measured in prism diopters (PD) using prism and alternate cover testing in primary position,upgaze, and downgaze. Results: Twenty-nine patients were studied. Ten underwent the standard Fink procedure with bilateral 8-mm recessions. The remaining patients received augmented recessions: 8 patients with 1 mm (9 mm total), 2 patients with 2 mm (10 mm total), and 9 patients with 3 mm (11 mm total) beyond Fink's original point. Greater inferior oblique recession correlated with larger postoperative reduction of V-pattern strabismus. The 11-mm group achieved the greatest correction, significantly more than the 8-mm (p = .002) and 9-mm groups (p = .018). The 9-mm group showed more variability in outcomes, while the 10-mm group had intermediate corrections but limited by a small sample size (n = 2). Conclusions: Augmenting the Fink technique by placing the inferior oblique insertion more inferiorly enhances correction of V-pattern strabismus, especially with 11-mm recessions, without causing significant anteriorization. These findings indicate that progressive augmentations can be customized based on the severity of the V-pattern. Larger, prospective studies are needed to validate these findings and refine surgical protocols.
PURPOSE:To evaluate binocular visual function in amblyopic patients who achieved optimal visual acuity following treatment with either conventional patching alone or combined patching and structured Active vision therapy (AVT). METHODS:This retrospective chart review included 67 patients with non strabismic refractive amblyopia (31 patching; 36 combined treatment) who achieved best-corrected visual acuity (BCVA) ≤0.17 logMAR in both eyes after treatment. The combined treatment consisted of patching with structured active vision therapy incorporating anti-suppression, accommodative, vergence, and visuomotor exercises. Post-treatment assessment included stereoacuity (log seconds of arc), vergence parameters (phoria, near point of convergence, fusional vergence), accommodative lag, accommodative facility (monocular and binocular), and binocular sensory status. Within-group changes were analyzed using Wilcoxon signed-rank tests; between-group comparisons were performed using Mann-Whitney U tests. Effect sizes (r) were calculated for intergroup comparisons. RESULTS:Both groups demonstrated significant reduction in accommodative lag (p < .001). Post-treatment stereoacuity was significantly better in the combined treatment group (p < .001; r = 0.724). The combined treatment group also showed superior vergence function, with larger positive fusional vergence amplitudes (r = 0.60) and improved near point of convergence (r = 0.488). Monocular and binocular accommodative facility were significantly higher in the combined treatment group (r = 0.656 and r = 0.690, respectively). Treatment duration was significantly shorter in the combined treatment group (p < .001). CONCLUSIONS:Combined patching and structured AVT group was associated with superior binocular vision function outcomes and reduced treatment duration. However, due to the non-randomized, retrospective design of the study, findings should be interpreted with caution. AVT is a more intensive treatment requiring greater motivation, adherence, supervision, and access to care.
Background: Impaired depth perception can be caused by monocular blur and is assessed with a range of stereotests, but differences in test presentation result in varying outcomes. A new testing system Optonet includes a stereo test which has not been evaluated in terms of the impact of blur; therefore, the aim of this study was to compare the effect of simulated impaired visual acuity across differing stereotests including Optonet. Method: Participants aged ≥18 years with visual acuity ≤0.3 logMAR in either eye and <0.2 logMAR interocular difference were included. Visual acuity (VA) was tested using the ETDRS test for near (40cms) and distance (4 meters). Stereoacuity was measured with Frisby, TNO, and Optonet, a random dot-based test on an iPad with red/blue glasses. Blur was induced with Bangerter foils 0.2 and 0.4 and VA and stereodata were remeasured. An arbitrary value of 5000" of arc was given if stereoacuity was not measurable. Results: Twenty-five participants (23 females and 2 males), median age 21 (IQR:2, Range 19-38), were included. Near VA (Median ± IQR) with 0.2 and 0.4 Bangerter foil (right eye) was 0.36 ± 0.18 and 0.50 ± 0.19 logMAR, respectively, with 0.00 ± 0.15 logMAR in left eye. TNO demonstrated the largest degradation compared to Frisby and Optonet (no foil: 60" (TNO) 20" (Frisby) 40" (Optonet), 0.2 foil: 240" (TNO) 40" (Frisby) 119" (Optonet), 0.4 foil: 2000" (TNO) 85" (Frisby) 158" (Optonet)). Significant differences in the amount that stereoacuity was reduced occurred between Frisby and TNO (p < .05, Friedman's two-way analysis of variance). Conclusion: Differences in stereoacuity are evident across stereotests under simulated conditions of blur. For accurate repeatable measures of stereoacuity, a consistent stereotest should be used. Random dot tests such as TNO and Optonet are impacted more by blur than Frisby with Optonet showing the greatest sensitivity to blur.
Purpose: To determine the sensitivity and specificity of visual acuity (VA) for the detection of refractive errors in preschool children from the Sydney Pediatric Eye Disease Study. Methods: Data from both eyes were pooled for a total of 2332 observations. Children aged 3-6 years had a comprehensive eye examination including VA (monocularly tested using the Electronic Visual Acuity HOTV test) and cycloplegic (cyclopentolate 1%) refraction using the table-mounted autorefractor (RK-F1 Auto Ref-Keratometer; Canon, Tokyo, Japan). Clinically significant refractive error was defined as: Myopia ≤-1.00D, Hyperopia ≥+3.00D (Moderate Hyperopia ≥+3.00D - <+5.00D, High Hyperopia ≥+5.00D) and Astigmatism ≥+1.00D. VA cutoffs used were <6/12, <6/9 and <6/7.5. Ethics approval was obtained by the Human Research Committee, University of Sydney and adheres to the tenants of the Declaration of Helsinki. Results: There was low sensitivity for detection of myopia at a cutoff of <6/12 (41.2%), with moderate sensitivity at <6/9 (58.8%), and high sensitivity (82.4%) and specificity (83.9%) at <6/7.5. Across the three cutoffs, there was low sensitivity for detection of astigmatism (<6/12: 14.7%, <6/9: 22.5%, <6/7.5: 54.3%) and hyperopia (<6/12: 13.8%, <6/9: 21.1%, <6/7.5: 52.3%). This was particularly true for those with moderate levels of hyperopia (sensitivity <6/12: 5.0%, <6/9: 8.8%, <6/7.5: 45.0%). High hyperopia was better detected, particularly at the <6/7.5 cutoff (72.4%); however, had low sensitivity at <6/12 (37.9%) and <6/9 (55.2%). ROC analysis for detection of clinically significant refractive error revealed an area under the curve (AUC) of 0.708 (p < .001) for <6/7.5. This was comparatively lower at <6/9 (AUC = .606) and <6/12 (AUC = .572, all p < .001). Conclusion: VA was valid for detecting myopia at the <6/7.5 cutoff for preschool children. Astigmatism and hyperopia, even at high levels, did not consistently impact VA. This remains a challenge for detecting significant refractive errors when screening in preschool children.
Purpose: To compare the ocular alignment of children with literacy-based learning difficulties to at-level peers. Methods: Australian primary-school-aged children were recruited to two groups according to learning difficulty status: at-level group (ALG and learning difficulties group (LDG). Cover test, prism, and alternate cover test, convergence near point, accommodation, fusional ranges, near and distance visual acuity, stereoacuity, and ocular motility were assessed at a single visit in 2023. Results: Eleven children (aged 7 to 12 years, 68.2% female) were recruited in each group. A latent deviation of small angle was observed at near in 81.8% (n = 9, median -3.1 PD) of children in the learning difficulties group but only 36.4% (n = 4, median -0.4 PD) in the at-level group (p = .080). The absolute magnitude of deviation for near was also larger in the LDG (n = 11, 6 PD) than the ALG (n = 11, 0 PD, p = .055). Reduced accommodative near point binocularly (p = .024), stereoacuity at near (p = .009), and near vision (oculus dexter [OD] p = .010, oculus sinister [OS] p = .053) were observed in the learning difficulties group. Conclusions: Latent deviations may be more prevalent among children with literacy-based learning difficulties. Accommodative near point, stereoacuity, and near vision may be reduced in this patient cohort. The differences found between the groups in this study indicate that clinicians should include assessment of accommodation, near vision, stereoacuity, and eye position when testing the vision and binocular vision of children with literacy-based learning difficulties.
Purpose: To explore the relationship between motor fusion and stereoacuity in adults with normal binocular single vision.Method: A sample of 31 adult participants was recruited by convenience sampling. The inclusion criteria included age 18-40 and no history of uncorrectable vision loss or strabismus. Examinations included visual acuity, orthoptic assessment and non-cycloplegic autorefraction (Canon RK-F2). Stereoacuity was performed using Precision Vision's Real Depth Stereo Test, Frisby Stereo Test, Titmus Stereo Fly Test and TNO. Prism fusion ranges were performed at 33 cm and 6 m, using an accommodative target. Written informed consent was obtained from all participants prior to the examination.Results: Participants had a mean age of 23.16 ± 2.48 years, were 80.6% female and 71% had myopia. Most were orthophoric (58.1%) at distance fixation and exophoric (67.7%) at near fixation. There was a moderate and significant correlation between distance and near convergence by prism fusion ranges (r = 0.64, p < .001). There was a moderate negative correlation between near convergence by prism fusion and stereoacuity using the Real Depth Stereo Test (r = -0.42, p = .018) and Frisby Stereo Test (r = -0.52, p = .003). However, there was no correlation between near convergence by prism fusion with Titmus (r = 0.19, p = .36) or TNO (r = -0.31, p = .1). Near divergence fusion range was not significantly correlated to any stereoacuity test (all p > .05).Conclusion: There was a significant relationship between convergence fusion range and stereoacuity measured using the Frisby and Real Depth stereo tests in this population of adults with normal binocular single vision.
PURPOSE:The Harada-Ito procedure aims to reduce symptomatic excyclotropia. We report a case series of unilateral and bilateral superior oblique (SO) palsies that underwent Harada-Ito procedures and our approach to surgical decision-making in these complex cases. Our surgical techniques are described, including the Fells modification of the Harada-Ito and our "plus" and "with resection" of the transposed portion of the SO tendon variations. METHODS:A retrospective review of Harada-Ito procedures was undertaken. Demographic data were extracted on diagnosis, etiology, and previous and subsequent strabismus surgery. Pre- and 3-month postoperative measurements and final visit outcome were recorded. RESULTS:Twenty-nine patients underwent Harada-Ito procedures for unilateral (n = 10) or bilateral (n = 19) SO palsies. Twenty-seven patient notes were available for review of their measurements. In unilateral SO palsy, our surgery resulted in a near deviation change of mean (SD) 7.6PD (6.8) horizontal, 7.7PD (7.3) vertical, and 7.4 degrees (5.3) torsion. While Harada-Ito surgery in isolation resulted in a near deviation change of mean (SD) 2.3PD (1.7) horizontal; 7.3PD (3.3) vertical and 5.5 degrees (4.1) torsion.In patients with bilateral SO palsies, our surgery resulted in a near deviation change of mean (SD) 7.6PD (9.9) horizontal, 8.1PD (9.6) vertical, and 12.7 degrees (6.4) torsion. While Harada-Ito surgery in isolation resulted in a near deviation change of mean (SD) 6.8PD (6.0) horizontal; 2.4PD (1.1) vertical and 9.4 degrees (3.0) torsion.In unilateral SO palsy, two underwent further strabismus surgery. At the last available visit, 8/9 were discharged with BSV and 1/9 was discharged asymptomatic without BSV. In bilateral SO palsies, 7/19 underwent further strabismus surgery. At the last available visit, 15/19 were discharged with BSV, 3/19 were discharged asymptomatic without BSV and 1/19 required an occlusive contact lens. CONCLUSIONS:Unilateral and bilateral SO palsies with symptomatic excyclotropia are challenging to treat. Nine patients (33%) required more than one surgical procedure to eliminate torsion and achieve BSV, even with our individualized approach for the Harada-Ito. Comparison of the outcomes of different Harada-Ito variations is difficult due to the complex and heterogeneous cohort. Most cases achieved BSV (23/27, 85%) or were asymptomatic (3/27, 11%) at final visit.
PURPOSE:Rectus muscle resection is a standard strengthening procedure in horizontal strabismus surgery, but it requires muscle disinsertion and tissue excision. Rectus muscle plication has been proposed as a vessel-sparing alternative that preserves the muscle insertion and may reduce selected technical risks. This review evaluates the comparative effectiveness, safety, and short- to medium-term outcomes of plication versus resection in horizontal strabismus surgery. METHODS:This systematic review was conducted according to PRISMA guidelines and registered in PROSPERO. MEDLINE, CENTRAL, Google Scholar, and Web of Science were searched for comparative studies published through January 2025. Eligible studies directly compared rectus muscle plication with resection for horizontal strabismus. Risk of bias was assessed using RoB 2 for randomised trials and the Newcastle-Ottawa Scale for non-randomised studies. RESULTS:Fifteen studies were included, comprising six randomised controlled trials and nine non-randomised comparative studies. Overall, 501 patients underwent plication and 576 underwent resection. Both procedures produced clinically meaningful improvement in ocular alignment, with most studies reporting final residual deviations within or near 10 prism dioptres. Across studies reporting formal success rates, plication success ranged from 27.8% to 100% and resection success from 55.3% to 100%; however, success definitions varied substantially, limiting direct comparison. Most studies found no statistically significant difference between procedures. Early overcorrection and postoperative diplopia were lower with plication in some studies. Complications were generally mild. No anterior segment ischaemia was reported, and no slipped or lost muscles were reported in any plication group. Conjunctival swelling or muscle hump after plication was transient and self-resolving. CONCLUSION:Rectus muscle plication appears to be a safe and effective alternative to resection for horizontal strabismus, with broadly comparable short- and medium-term alignment outcomes. Plication offers technical advantages, including preservation of anterior ciliary circulation and avoidance of muscle disinsertion, but evidence for long-term durability remains less certain, especially in paediatric intermittent exotropia. Future studies should use standardised success definitions, stratify outcomes by strabismus subtype and age group, and include longer follow-up. Registration: PROSPERO [CRD42024560726].
PURPOSE:Conventional prism-cover strabismus measurement is compromised by nonstandard and poorly repeatable target locations. We developed a general method to quantify incomitant strabismus in repeatable, defined gazes and illustrate its application to commonly performed surgical strategies in anatomically confirmed cases of superior oblique (SO) palsy. METHODS:Hess screen alignment data were obtained before, 1 week, and 3-7 months after surgery in 19 patients with unilateral SO atrophy demonstrated by magnetic resonance imaging. Five underwent ipsilateral inferior oblique (IO) recession, four contralateral inferior rectus (IR) recession, and 10 underwent both. An automated program measured scanned Hess charts at 21 fixation targets at ±15° and 30° horizontal and vertical eccentricities for each fixating eye. Heat maps were created across the fixation field, quantifying strabismus angles, surgical effects, and secular trends. Individual heat maps were pointwise averaged for affected and fellow eyes, and according to the type of surgery: ipsilateral IO recession, contralateral IR recession, and combined. RESULTS:Pre-operative alignment maps demonstrated three incomitant hypertropia patterns addressed by distinct surgical approaches. Recession of the IR alone produced immediate and stable correction of hypertropia with minimal incomitant effect. Recession of the IO corrected large lateral incomitance and had progressively improving late effects. Combining these approaches corrected lateral incomitance and hypertropia in infraversion, with progressively improving late effect. CONCLUSION:Alignment heat maps allow intuitive visualization of selective strabismus surgical strategies treating varied incomitance in SO palsy, reflecting progressive improvement in alignment when surgery includes IO recession.
PURPOSE:Congenital hypoplasia of the extraocular muscles is a rare cause of strabismus. This article aims to report the case of a 39-year-old female with esotropia and a hypoplastic lateral rectus muscle (LRM). METHODS:Case report. RESULTS:The patient presented with esotropia measuring 35 prism diopters (PD), no evidence of stereoptic vision, and an otherwise normal examination. No surgery had ever been performed on her LRMs. During surgery for bilateral LRM resection, her left LRM was revealed to be severely hypoplastic, allowing for muscle hooks to be visible under the muscle sheath. Her surgery was successful. CONCLUSION:The patient's presentation and history may suggest myogenic etiology, rather than neurogenic. Diagnosis of Duane's syndrome did not match our differential; we thus hypothesize a congenital, structural hypoplasia of the left LRM. Cases such as the one described are important for timely diagnosis and tailored surgery planning.
AIMS/PURPOSE:Acute-onset strabismus in highly myopic children raises a broad differential diagnosis. In this article, we report a pediatric case with high myopia and prolonged near focus who presented concomitant esotropia during treatment with atropine 0.05% eye drops. METHODS:Case report. RESULTS:A four-year-old male presented with progressive myopia, and a habit of prolonged near focus and excessive screen time. He had moderate myopia in both eyes, with no sign of strabismus. Due to the rapid progression of the refractive error over the next visits, low-dose atropine (LDA) drops 0.05% were prescribed. One month later, the patient developed esophoria which soon converted to esotropia. LDA treatment was discontinued with the child's axial length increasing, consistent with continued progression of myopia. Finally, he was switched over to peripheral defocus spectacles. Three years following his initial visit, his tests show stable visual acuity and AL and an esotropia measuring 45 PD. The patient has been scheduled for strabismus surgery. CONCLUSIONS:LDA is an increasingly useful method to control myopia progression; however, any potential side effects should be reported. To our knowledge, this case is one of the first reports of esophoria converting to esotropia in a young patient after atropine was used to control myopic progression.
PURPOSE:Patients with strabismus are at substantially elevated risk for scoliosis. This study aimed to determine whether anisometropia confers any independent or additive risk for scoliosis within this specific, high-risk population. METHODS:This retrospective cross-sectional study included 561 strabismus surgery candidates aged 10-35 years. Scoliosis was radiographically defined as a Cobb angle ≥ 10°. Anisometropia was defined as a spherical equivalent difference ≥ 1.0 D. We performed multivariable logistic regression, subgroup analyses, and interaction tests to evaluate associations between scoliosis and demographic, systemic, and ocular factors. RESULTS:The prevalence of scoliosis was 19.6%. Female sex (adjusted OR = 1.62, 95% CI: 1.05-2.51, p = .032) and lower BMI (adjusted OR = 0.85 per 1 kg/m2 increase, 95% CI: 0.78-0.91, p < .001) were independent risk factors. In contrast, anisometropia showed no association with scoliosis (p = .901), and no dose-response relationship existed between their severities (p = .593). Interaction effects between anisometropia and other ocular factors were not statistically significant. CONCLUSIONS:In strabismus patients, scoliosis risk is primarily associated with systemic factors (low BMI, female sex) rather than refractive asymmetry. The null finding for anisometropia supports the sensory reweighting hypothesis, indicating its impact may be masked in the context of a profound binocular defect. These results redirect clinical screening focus toward anthropometric and sex-based assessment.
PURPOSE:To compare the motor and sensory outcomes of botulinum toxin A (BTA) injection and unilateral medial rectus recession (MRR) in patients with small-moderate angle esotropia. METHODS:This retrospective cohort study included patients with 10-25 prism diopter (PD) esotropia, including non-accommodative, partially accommodative, residual, and infantile subtypes, who underwent either BTA injection or unilateral MRR. Preoperative and postoperative ocular alignment was evaluated at 1, 3, 6, and 12 months. Motor success was defined as postoperative deviation within 0-10 PD. Sensory outcomes were assessed based on stereopsis and worth 4 dot test changes. Non-parametric tests (Mann - Whitney U, Wilcoxon signed-rank) were used for continuous variables, and Chi-square or Fisher's exact tests for categorical variables. RESULTS:A total of 38 patients were included (18 BTA, 20 MRR). The surgical group demonstrated significantly better early alignment at 1 month (p < .001). However, the differences in motor alignment between the groups gradually decreased, and by the 3rd, 6th, and 12th months their alignment values had become similar (p = .577, p = .067, and p = .083, respectively). Undercorrection was more frequent in the BTA group (33.3% vs. 5.0%, p = .038), and five patients required a repeat injection. Sensory outcomes (stability/improvement/deterioration) showed no significant differences between groups (p > .05 for all). No major complications occurred in either group. CONCLUSION:Both BTA injection and unilateral MRR provide satisfactory motor alignment in moderate-angle esotropia, although early postoperative outcomes favor surgery. The long-term similarity of motor outcomes and comparable sensory results suggest that BTA may serve as a minimally invasive, repeatable alternative particularly in younger patients or those with small-to-moderate deviations.
PURPOSE:Carotid-cavernous fistulas (CCFs) produce abnormal arteriovenous communication between the carotid circulation and the cavernous sinus, leading to orbital venous hypertension and neuro-ophthalmic manifestations. Although endovascular embolization is the treatment of choice and usually results in rapid hemodynamic normalization, delayed ocular motor sequelae after successful closure remain incompletely characterized. We report a case of persistent and worsening abducens nerve paresis and chronic orbital venous congestion following embolization of a direct CCF. METHODS:This case report describes longitudinal neuro-ophthalmologic follow-up over more than four years. Clinical assessment included best-corrected visual acuity, slit-lamp examination, intraocular pressure measurement, dilated fundus examination, and structured ocular motility evaluation using serial Hess chart testing. Retinal morphology was assessed with spectral-domain optical coherence tomography, and orbital and intracranial vascular structures were evaluated with MRI and time-of-flight MR angiography. RESULTS:A 78-year-old woman presented with intermittent diplopia and mild right abduction deficit. Imaging confirmed a right-sided direct CCF, which was successfully treated with endovascular embolization. Shortly after treatment, she developed marked worsening of right abducens nerve paresis with constant diplopia and transient visual acuity reduction. Retinal venous complications developed after treatment, with central retinal vein occlusion and macular edema resolving after intravitreal aflibercept. Persistent VI nerve paresis gradually improved after botulinum toxin injection into the right medial rectus muscle, and serial Hess chart analysis documented progressive expansion of the binocular single vision field, indicating partial functional recovery of abducens nerve function. Long-term imaging showed persistent asymmetry of orbital venous drainage and later development of >50% stenosis of the intracavernous-ophthalmic segment of the internal carotid artery without recurrent fistulous flow. CONCLUSION:This case highlights that delayed neuro-ophthalmic complications and venous congestion may occur despite successful CCF embolization. Post-embolization worsening of the abducens nerve paresis may reflect hemodynamic alterations affecting the cavernous sinus and orbital venous circulation. Gradual functional improvement was observed during long-term follow-up, although interpretation of the natural recovery trajectory is limited by botulinum toxin treatment. These findings further support that angiographic cure does not necessarily indicate complete functional recovery and emphasize the importance of long-term neuro-ophthalmologic and motility follow-up after CCF embolization.
PURPOSE:To evaluate the clinical characteristics, motility deficits, strabismus patterns, and management outcomes in patients developing strabismus following Endonasal Sinus Surgery (ESS). METHODS:This retrospective study was conducted over 10 years (2015-2025) at a tertiary eye care center. Demographic details, type and severity of ocular motility restriction, strabismus pattern, imaging findings, and management (surgical, prisms, or observation) were documented. Outcomes were assessed in terms of ocular alignment and symptomatic improvement. RESULT:Ten patients were identified, with male-to-female ratio of 4:1 (8:2) and mean age of 40.3 years (range 24-62 years). Ocular motility limitation was present in (n = 9; 90%) patients. Limitation of adduction was most commonly present involving the medial rectus n = 7; 70%. Large angle exotropia was the predominant pattern, with a deviation range of 30-75 prism diopters (PD). Management varied: five patients (50%) underwent strabismus surgery, showing improvement but residual deviation in most; one patient (10%) was managed with prisms, achieving partial symptomatic relief; and three patients (30%) were observed conservatively. One patient (10%) was lost to follow up and did not receive further management. Despite intervention, restrictive cases showed incomplete recovery. CONCLUSION:Strabismus is a rare but a significant (functional) complication following Endonasal sinus surgery, typically presenting as restrictive large-angle exotropia. Surgical correction and prisms provide functional improvement, though complete resolution is uncommon considering the extent of the injury. Early recognition and multidisciplinary management are crucial to optimize outcomes.
INTRODUCTION:Functional endoscopic sinus surgery (FESS) is a widely used procedure for chronic sinusitis. Although it is generally considered a safe procedure, serious ophthalmic complications might occur. In this report, we discuss the results of Foster augmented full tendon vertical muscle transposition (VRT) with and without resection for two cases presented with iatrogenic complete medial rectus transection following FESS. METHODS:Case 1: A 43-year-old female presented with significant left eye motility limitation after FESS. Examination revealed left very large-angle exotropia 60 prism diopters (PD), severe limitation in adduction of -4, and MRI confirmed medial rectus muscle transection. The patient underwent left eye Foster augmented full tendon vertical rectus transposition (VRT), followed by maximum left lateral rectus muscle recession with Botox injection. Case 2: A 31-year-old male presented with diplopia and left eye motility limitation following FESS. On examination, there was a large angle exotropia of 40 PD, hypotropia of 20 PD, and limitation in adduction of -4 in the left eye. Imaging showed medial orbital wall injury and complete medial rectus transection. He underwent Foster augmented full tendon VRT surgery with resection. RESULTS:Case 1: Over 3 years, alignment stabilized at 25 PD exotropia with improved adduction -2, no diplopia in the primary position. Case 2: Postoperatively, the patient achieved orthophoria and no diplopia in the primary position, maintained for 1 year of follow-up.Discussion: Early recognition of medial rectus injury and appropriate selection of surgical techniques are essential to optimize ocular alignment and reduce diplopia. These cases illustrate that Foster augmented full tendon VRT, with or without resection, can provide meaningful functional and cosmetic improvement in patients with iatrogenic medial rectus transection.
PURPOSE:Ophthalmic associations of West syndrome, a rare clinical triad comprising infantile spasms, a pathognomonic electroencephalogram pattern of paroxysmal activity called hypsarrhythmia and global developmental delay, usually associated with neuro-radiological anomalies, have been sparsely reported. We observed primary concomitant horizontal strabismus, mostly exotropia, and palpebral aperture abnormalities, mostly epicanthal folds, in a large subset of these subjects presenting to our tertiary care pediatric hospital and pediatric ophthalmology services. METHODS:This was a cross-sectional, observational, hospital-based study designed to descriptively record ophthalmic findings in children with West Syndrome with the aim to establish the array of ophthalmic associations of this condition. One hundred and eighteen consecutive subjects with the diagnosis of West syndrome, referred from the pediatric neurology division to the pediatric ophthalmology division, were recruited prospectively and evaluated comprehensively. RESULTS:Primary concomitant horizontal strabismus (PCHS) was observed in 80/118 (67.79%) patients, exotropia in 58 and esotropia in 22 cases. Patients with PCHS had a significantly earlier age of onset as well as significantly increased number of drugs required to control the spasms as compared to the children without strabismus. 40/80 (50%) subjects of West Syndrome with PCHS demonstrated palpebral aperture anomalies, especially epicanthal folds, significantly more than subjects of WS without PCHS. CONCLUSIONS:PCHS along with eyelid and palpebral fissure anomalies are visible phenotypes and thus, very useful ophthalmological clinical biomarkers for early identification of children with increased severity of West Syndrome, which aids the pediatric neurologist toward early management of this life-threatening recalcitrant seizure disorder, while imaging and electro-encephalography evaluation is ongoing.
PURPOSE:To report the surgical outcomes of the treatment of vertical deviation in patients with Möbius syndrome. METHODS:A retrospective review of the medical records of patients diagnosed with Möbius syndrome treated at the Ricardo Gutiérrez Children's Hospital between 2010 and 2024 was performed. Age, sex, and horizontal and vertical ocular deviations before and after surgery were recorded. Ocular deviation was measured using the alternate prism and cover test or Krimsky test according to patient cooperation. RESULTS:Sixty-two children were included, of whom 18 underwent surgical treatment. Most surgically treated patients presented with esotropia and were managed with bilateral medial rectus recession, with a mean recession of 7 mm (range: 4-12 mm). The mean preoperative horizontal deviation was 53 prism diopters (PD) of esotropia (range: 25-70 PD). Only 2 of 62 patients presented with exotropia. Vertical deviation was clinically evident in 14 of 62 patients, but only 5 underwent surgical correction. In all surgically treated cases, the vertical deviation corresponded to dissociated vertical deviation (DVD). One patient underwent bilateral superior rectus recession combined with horizontal surgery, one patient underwent unilateral superior rectus recession, and three patients underwent inferior rectus plication as a second procedure, achieving excellent postoperative alignment. CONCLUSIONS:Although esotropia with bilateral abduction limitation represents the predominant pattern in Möbius syndrome, vertical deviation is clinically evident in almost one quarter of patients. Inferior rectus plication proved to be a safe and effective technique for the surgical resolution of hypertropia in these cases.
INTRODUCTION:Intraconal dermoid cysts are a rare clinical entity. They are typically associated with symptoms such as proptosis, orbital pain, and diplopia. However, atypical presentations without these common features can occur, making diagnosis more challenging. METHODS:We describe a clinical case of a one-year-old child who presented with left hypertropia and restricted depression in the absence of proptosis or other clinical manifestations. High-resolution orbital and cranial magnetic resonance imaging (MRI) was performed. RESULTS:Orbital MRI revealed an intraconal lesion consistent with a dermoid cyst. Complete surgical excision of the cyst was performed. Histopathological findings confirmed the diagnosis of dermoid cyst. Excision resulted in resolution of hypertropia and improvement of ocular motility. DISCUSSION:This case highlights an unusual presentation of an orbital dermoid cyst. Despite their rarity, such cysts should be considered in the differential diagnosis of hypertropia, particularly when a restrictive pattern is observed without obvious external signs like proptosis.
