PURPOSE:To evaluate the diagnostic accuracy of the Melbourne Rapid Fields (MRF) tablet perimeter in comparison with the Humphrey Visual Field (HVF) analyzer in detecting visual field defects in patients with neuro-ophthalmic conditions. METHODS:This prospective observational study was conducted on 15 patients with neuro-ophthalmic conditions showing confirmed visual field defects on HVF. Each patient also underwent visual field testing using the MRF application on an iPad. Test results were reviewed by both masked and unmasked observers to classify defect patterns. Agreement between instruments and observers, test duration, and diagnostic value were analyzed. RESULTS:29 eyes were tested in total. The mean age of the subjects was 34.8 ± 1.86 years, and 73.3% were male. Diagnoses included suprasellar masses, traumatic optic neuropathy, occipital infarcts, optic neuritis, toxic optic neuropathy, and radiation-induced optic neuropathy. There was high agreement of visual field defect patterns between MRF and HVF. The mean test duration for HVF and MRF was 268.86 s and 238.38 s respectively (p < .001). Cohen's kappa coefficient demonstrated substantial interobserver concordance. CONCLUSIONS:MRF perimetry provides results comparable to HVF in detecting neuro-ophthalmic visual field defects and offers a time-efficient and a cost-effective method, particularly useful for bedside or remote screening.
Cataracts are the leading cause of reversible blindness in the world. Their prevalence is expected to dramatically increase with the anticipated global population growth by 2050, consequently increasing the need for cataract surgery. As cataract surgery evolves, novel types of intraocular lenses (IOLs) are also emerging. Extended depth of focus (EDOF) lenses are a recently introduced lens technology that was approved for commercial use in 2016. The lens optics create a focal zone with an overlap for near and far images, enabling an enhanced depth of focus for intermediate vision with little impact on distance vision. Reports of sensorimotor decompensation, such as ocular misalignment and diplopia, following cataract surgery have been described in the literature, particularly in patients with a history of strabismus or diplopia. However, there is very limited literature to determine if newer multifocal IOLs, such as EDOF lenses, carry the same risk of sensorimotor decompensation. The purpose of this report is to describe two cases with sensorimotor disturbances after uncomplicated bilateral EDOF IOL implantation, the first being decompensation of stereopsis in a patient with previously well-controlled accommodative esotropia, and the second involving the development of vertical diplopia post-operatively.
BACKGROUND:Simultaneous contraction of the medial and lateral rectus muscles results in Duane Retraction Syndrome (DRS). The presence of a familial pattern in some cases suggests an autosomal dominant mode of transmission. Despite the variable presentation of this syndrome, its cause remains unclear. Describing the potential factors contributing to DRS in monozygotic twins may be effective in explaining its etiology. CASE PRESENTATION:We report a unique case of monoamniotic monozygotic twins case both 7-year-old Iranian girls with DRS type I, inherited from their 36-year-old father with DRS type III. There was no clinical manifestation of DRS in the 38-year-old Iranian mother. One twin exhibited bilateral DRS, whereas the other manifested DRS exclusively in the right eye. In contrast, their father had DRS limited to the left eye. The unique laterality discordance in monozygotic twins emphasizes the role of gene expression patterns in the variability of DRS. These findings highlight the complex nature of clinical expression of DRS. Furthermore, we recognize the need to consider additional factors, such as placental dynamics, the environment, epigenetic modifications, and vascular development, for a comprehensive understanding of this condition. CONCLUSION:While genetic factors may play a fundamental role in understanding DRS in twins, it is important to consider the interaction of placental, environmental, epigenetic, and vascular developmental factors for a comprehensive approach.
PURPOSE:To evaluate the effect of unilateral medial rectus (MR) recession for the correction of 20 to 30 ∆ of esotropia. METHODS:Pediatric patients with esotropia (ET) with a surgical target of 20 to 30 prism diopters (∆) were included in a prospective study to determine the effect of unilateral MR recession. The surgical target angle was calculated as the average of the distant angle with glasses and near without glasses, or the average of distant and near angles without glasses (if non-significant refractive error), or the average of near angles with and without glasses (if ET was measured using the modified Krimsky test). The study endpoint was the last follow-up visit, conducted at least 3 months postoperatively. A successful motor outcome was defined as orthotropia or a horizontal tropia of 10∆ or less at distance and near. RESULTS:The study included 21 patients, 1 to 12 years of age. Patients were followed up for 3 to 43 (mean+/-SD 12.5+/-10.6) months. A successful outcome was achieved in 85.7%, with no correlation to the surgical target angle or the amount of recession (p > .05). The 14.3% failure rate was attributed to undercorrections. Persistent lateral incomitance was observed in 10.5% of cases and was not correlated with the surgical target angle or the amount of recession (p > .05). Persistent limited ductions were mild (-1). CONCLUSIONS:This prospective study of pediatric patients showed that unilateral MR recession is a reasonable surgical approach for treating esotropia of 20-30 ∆, with small rates of undercorrection and duction limitation, and no overcorrection.
BACKGROUND:Accommodative spasm (AS) is an involuntary condition characterized by excessive contraction of the ciliary muscle, leading to exaggerated accommodative response and fluctuating refractive error. The reported prevalence of accommodative spasm ranges from 2.6% in an Indian clinic cohort to 37.19% in Chinese school children. Since the COVID-19 pandemic, accommodative spasm has been reported in 20% of symptomatic patients associated with increased near work and digital screen exposure. It often presents with headache, photophobia, blurred distance vision, and eye strain. This case report describes bilateral accommodative spasm in a 14-year-old female who presented with blurred distance vision in left eye and headaches. CASE PRESENTATION:Best-corrected visual acuity was 20/20 in the right eye and 20/400 in the left eye; near acuity was N6 in both eyes. Objective refraction using an open-field autorefractor (WAM-5500) showed fluctuating myopia. Retinoscopy revealed a vacillating reflex, and a lead of accommodation on dynamic retinoscopy suggesting accommodative instability, which was further confirmed by excessive accommodative responses measured using open-field autorefractor. Baseline ocular biometry revealed axial length within the normal range, increased lens thickness, and reduced anterior chamber depth. The patient was treated with 1% atropine sulfate eye ointment, administered twice daily for three days. Cycloplegic refraction on day four showed resolution of the spasm with a stable retinoscopic reflex. RESULTS:After a 21-day atropine washout, repeat retinoscopy confirmed the absence of accommodative instability. Post-mydriatic ocular biometry showed no change in axial length but significant improvements in lens thickness and anterior chamber depth. CONCLUSION:This case highlights the potential role of objective ocular biometry as an adjunctive tool in accommodative spasm, providing additional structural insights that may aid clinical diagnosis and treatment monitoring.
OBJECTIVE:To study the clinical profile and surgical outcomes of patients with bilateral Duane syndrome with exotropia. METHODS:The records of all consecutive patients diagnosed with bilateral Duane syndrome with exotropia in primary gaze (2010-2024) were reviewed. Patient demography, age at presentation, and type of Duane syndrome were studied in the clinical profile. The pre-operative and post-operative details of angle of deviation, abnormal head posture, horizontal ocular ductions, grade of globe retraction, and overshoot were evaluated for the surgical outcomes. RESULTS:Forty-five patients (male, 51%) were diagnosed with bilateral Duane syndrome with exotropia, of which 38% underwent surgical correction. The mean age at presentation was 18.06 ± 12.08 years. Of the total, 37% were emmetropic and 29% amblyopic. Bilateral type 3 Duane syndrome (49%) was the most common presentation. The mean pre-operative deviation for distance and near was 29.84 ± 17.73Δ and 32.49 ± 18.44Δ, respectively. The mean change in angle of deviation post-operatively for distance and near was 23 ± 5Δ and 26 ± 5Δ, respectively. The average angle of deviation at the final follow-up for distance was 8 ± 12Δ and near 12 ± 12Δ. Surgical success for primary position deviation, abnormal head posture, globe retractions, and overshoots was achieved in 59%, 86%, 57%, and 50% patients, respectively. CONCLUSION:Bilateral type 3 is the most common bilateral Duane syndrome with exotropia. Individualized surgical management (algorithm) ensures optimal alignment and head posture correction.
Superior oblique myokymia is a rare condition characterized by spontaneous episodes of high frequency, low amplitude, usually unilateral torsional oscillopsia. Surgical treatment is indicated when medical therapy fails to improve symptoms. The traditional surgical recommendation is an ipsilateral full-tendon superior oblique tenectomy to remove all attachments of the superior oblique tendon to the sclera. This approach will likely result in a secondary superior oblique palsy, requiring simultaneous weakening of the ipsilateral inferior oblique muscle. We report a patient presenting with diplopia and oscillopsia in the setting of superior oblique paresis and myokymia with persistent symptoms after initial superior oblique tuck. An alternative surgical approach consisting of superior oblique anterior one-third nasal tenectomy and contralateral inferior rectus recession resulted in marked improvement of oscillopsia associated with superior oblique myokymia while minimizing the risk of inducing downgaze diplopia often observed with superior oblique tenectomy.
PURPOSE:The COVID-19 lockdown has had a profound impact on people's lifestyles - especially the youth - through school closures and home confinement. Accordingly, the excessive use of smartphones and digital devices made adolescents vulnerable to the adverse effects of excessive near work on the eyes. METHOD:Four adolescents (10-17 years) with acute acquired divergence insufficiency esotropia were evaluated. RESULTS:The mean age of our patients was 14 years old (10-17). Their mean deviation at distance was 32.5 PD (25-40 PD), and their mean near deviation was 13 PD (8-20 PD). All patients had normal neurological examinations and exhibited normal brain and orbital MRI results. Excessive near work with digital devices such as smartphones after the COVID-19 lockdown was the only risk factor identified. All cases were successfully treated with bilateral lateral rectus resection. A 3.5- to 5.5-mm bilateral lateral rectus resection corrected 25 to 40 PD esotropia at distance without overcorrection at near. CONCLUSION:Decreased outdoor activities and excessive near work during the COVID-19 pandemic could be associated with divergence insufficiency esotropia in adolescents. Bilateral lateral rectus resection is an acceptable surgical treatment.
Intracranial hypertension (ICH) in children refers to increased pressure within the skull. The skull normally contains the brain, blood vessels, meninges, and cerebrospinal fluid (CSF). Abnormalities in any of these intracranial structures may cause ICH. The differential diagnosis for pediatric ICH includes brain tumors; intracranial hemorrhages; intracranial infections; craniosynostosis; disorders of CSF production, clearance, or abnormal CSF contents; and pseudotumor cerebri syndrome (PTCS), which may be primary (also known as idiopathic intracranial hypertension [IIH]) or secondary. Children with suspected ICH should undergo a thorough history and examination, focused on determining whether the child has papilledema and/or abducens nerve palsy. The differential diagnosis of papilledema includes other causes of optic disc edema, such as optic neuritis, as well as pseudopapilledema. The differential diagnosis of abducens nerve palsy includes Duane syndrome and other causes of childhood esotropia. In children with suspected papilledema, ancillary ophthalmic testing including visual fields, optical coherence tomography (OCT), fundus photography, autofluorescence, fluorescein angiography, and ultrasonography may be indicated. The systemic workup for children with suspected ICH includes neuroimaging and lumbar puncture in certain cases. Management of children with ICH is focused on treating any underlying cause and lowering intracranial pressure with medications or surgery.
Congenital optic disc anomalies are uncommon causes of vision loss that may be recognized shortly after birth but may also be identified in later childhood and sometimes well until adulthood. They may be unilateral or bilateral and isolated or associated with other systemic findings. In some conditions the origin of the developmental abnormality is understood as in the case of optic disc colobomas resulting from failure of closure of the embryonic fissure whereas in others the cause is hypothetical. Recognition of these anomalies is usually by direct observation though ancillary testing may aid in the diagnosis. Understanding the spectrum of congenital optic disc anomalies can help the clinician with diagnosis and treatment, counsel the patient and their family regarding prognosis, and to recognize when further evaluation is indicated.
BACKGROUND:Traumatic penetrating carotid-cavernous fistula (CCF) is an uncommon complication of craniofacial trauma, particularly in pediatric patients. Prompt recognition is essential to prevent irreversible visual and neurological deficits. CASE PRESENTATION:We describe a 2.5-year-old boy who sustained a penetrating nasal injury caused by a screwdriver. He initially presented with epistaxis and subsequently developed left-sided proptosis, chemosis, and restricted ocular motility. Early imaging studies were inconclusive, and orbital cellulitis was initially suspected. DIAGNOSIS AND MANAGEMENT:A delayed diagnosis of a direct (Type A) CCF was ultimately confirmed using digital subtraction angiography (DSA). The patient underwent successful endovascular embolization combined with internal carotid artery (ICA) stenting. CONCLUSION:This case highlights the need for a high index of suspicion for CCF in children presenting with atypical orbital findings following facial trauma, even when initial imaging doesn't reveal definitive pathology.
Teprotumumab has been shown to be effective in reducing inflammation and proptosis in patients with thyroid eye disease. This study focused on the short and long-term effects of teprotumumab on diplopia and strabismus. Twenty patients were followed after receiving teprotumumab, on average, 2 years post-treatment, with a range of 1 to 5 years. Detailed sensorimotor exams including prism and alternate cover test were performed. All patients but one had a decrease in proptosis, ranging from 1 to 10 mm, with an average of 3.4 mm. Fifteen patients had diplopia in primary position pre-treatment. Forty six percent had a clinically significant improvement in diplopia when treatment was initially finished. This decreased to 33% after 10 to 18 months post treatment due to diplopia symptoms returning. Three patients whose diplopia did not improve with treatment initially, relapsed (had an increase in TED symptoms). The patients in this study remained stable after 18 months up to 5 years post-treatment. It is advisable to follow patients with active disease regularly for diplopia changes up to 18 months post-treatment.
BACKGROUND:Orbital apex syndrome (OAS) is a rare, sight-threatening condition caused by injury or compression of neurovascular structures in the orbital apex, which, depending on the underlying etiology, may even pose a life-threatening risk. Prompt recognition and intervention are essential to prevent permanent visual loss and systemic complications. CASE PRESENTATION:We report a 10-year-old child presenting with acute left-sided proptosis, eyelid edema, ophthalmoplegia, and optic disc edema, following a history of orbital cellulitis and meningitis in early childhood. Imaging revealed a middle cranial fossa meningocele (MEC) extending into the orbital apex, associated with sinusitis and purulent meningitis. Ophthalmic examination demonstrated severe restriction of left-eye movements, proptosis, and a relative afferent pupillary defect. A multidisciplinary team - including ophthalmology, neurology, ENT, and radiology - initiated urgent intravenous antibiotics, resulting in rapid systemic and ocular improvement. The patient subsequently underwent cranial osteoplasty to repair the skull base defect. At discharge and four-month follow-up, visual acuity was normal, extraocular movements had largely recovered, and imaging showed intact retinal nerve fiber layers. CONCLUSION:This case underscores the importance of early recognition and collaborative management in OAS. Middle cranial fossa meningoceles, though rare, should be considered among potential structural causes of orbital apex compression.
PURPOSE:To assess the impact of intermittent exotropia (IXT) on eye-related quality of life (ERQOL), reading speed, motor skills, and self-perception in children. PATIENTS AND METHODS:Fifty-one children with basic or pseudo divergence excess IXT (4-13y) were assessed with the triple office control score, a graded clinical measure of exotropia control. Children with IXT also completed at least one of four behavioral evaluations, including ERQOL (PedEyeQ), reading speed (Readalyzer), motor skills (Movement Assessment Battery for Children-2), and self-perception (Self-perception Profile for Children), along with visual acuity and stereoacuity. Results were compared to those of age-matched controls (n = 353) and associations with IXT control score were analyzed. RESULTS:Children with IXT and their parent had significantly lower ERQOL scores in all domains compared to controls (Ps < .001). Reading speed was comparable to controls (p = .66). However, children with IXT showed poorer Manual Dexterity (Ps < .001) and Aiming and Catching motor skills (p = .009) in older children. Older children reported lower self-perception in Scholastic competence, Social competence, Athletic competence, and Physical appearance domains (Ps < .05). Worse IXT control scores were associated with lower self-perception of Cognitive/Scholastic competence and Maternal acceptance. CONCLUSION:Children with IXT experience reduced ERQOL, impaired motor skills, and lower self-perception. These findings highlight the broad developmental impact of IXT, beyond visual function.
Introduction: This study aims to describe an objective and simple method to estimate the alignment of eyes under general anesthesia (GA) in strabismus subjects, which may vary from the angle measured preoperatively.Materials and Methods: Through the operating microscope, pictures of the eye position of 94 subjects with horizontal strabismus were captured under GA. A curved caliper was placed parallel to the horizontal meridian, and the distance between the center of cornea and the corneal reflex spot of the microscope was measured. The eye position was estimated with a quantified Hirschberg method for each eye, and the values were added to reflect the global binocular angle of deviation. To validate this method, four strabismus surgeons blindly evaluated the strabismus angle based on these pictures, and the results were compared. Agreement between the four measurements was estimated using the ICC (Intraclass Correlation Coefficient) index.Results: ICC coefficients and their 95% confidence interval were 0.93 (0.88-0.95) for the overall angle, 0.91 (0.89-0.94) for the right eye and 0.86 (0.77-0.91) for the left eye, indicating good to excellent reliability of these measurements.Conclusion: Evaluating the evolution of the strabismus under GA may be of clinical interest and have potential therapeutical consequences. The described technique is fast, convenient, and reliable and provides a tool to encourage surgeons to take into account this parameter of strabismus.
BACKGROUND:There is sparse literature on radiological findings in cases of monocular elevation deficit (MED). We conducted this study to report magnetic resonance imaging (MRI) characteristics of extra-ocular muscles and oculomotor nerves in patients with congenital MED and to investigate its patho-mechanisms. METHODS:We included patients with congenital MED without prior strabismus surgery. The cross-sectional area (CSA) of the extra-ocular muscles in quasi-sagittal and quasi-coronal scans was measured manually on 2-mm-thick T2-weighted MRI images using Osirix MD software. Oculomotor nerves were imaged with balanced steady state free precession (bFFE) sequence. Clinical findings of Bell's phenomenon and forced duction test (FDT) for inferior rectus (IR) muscle were recorded. RESULTS:Eleven patients were included. The median CSA of superior rectus (SR) muscle at mid-orbit section was significantly lesser in the affected eye (8.83 mm2, Inter-quartile range (IQR): 5.39-11.36 mm2) than in the normal eye (13.63 mm2, IQR: 10.99-16.92 mm2), p = .02. From 11 patients, 10 had a thinner SR muscle on the affected side. Bell's phenomenon was intact in six patients. Forced duction test was positive for IR muscle in five cases. Oculomotor nerve was thinner on the affected side in two patients. CONCLUSIONS:Majority patients with congenital MED have a hypotrophic SR muscle, due to dysinnervation or primary muscle pathology. Bell's phenomenon may or may not be present in these conditions, and its presence does not warrant a supra-nuclear cause.
Background and Purpose: Brown syndrome is an ocular motility disorder that was first described by Harold Brown in 1950. The pathology is attributed to the superior oblique tendon and sheath. It creates a vertical deviation with limitation of elevation of the affected eye in adduction. There is no standard management strategy. The purpose of this paper is to summarize the methods introduced so far, along with their advantages and disadvantages.Patients and Method: Related articles from 1950 to 2022 were searched in Google Scholar, PubMed, and Scopus based on the keywords of this article.Results: Management of Brown syndrome includes observation and, in some cases, surgical intervention. Until now, several surgical approaches have been reported, including nongraded procedures (superior oblique nasal tenotomy or tenectomy) and graded procedures (superior oblique tendon lengthening, split-tendon lengthening, and superior oblique tendon thinning).Conclusion: Since surgical results are unpredictable and spontaneous recovery has been reported in 75% of patients, care must be taken in selecting patients for surgery. It seems that graded and reversible procedures appear to have advantages over other methods.
Recent anatomic and functional studies of the extraocular muscles have led to a new understanding that their proper function is dependent upon a complex collagenous orbital scaffolding. This structure, for which the term "pulley system" is a useful concise designation, maintains the positions of the eye muscles relative to the globe, to each other, and to the orbit. Disruption of this system results in muscle displacement and dysfunction. Novel strabismus surgical procedures designed to utilize this new anatomic knowledge may yield powerful results while lowering ophthalmic risk. Such procedures include pulley posterior fixation, retro-equatorial myopexy, pulley sleeve fusion, angled advancement, angled resection, angled recession, advancement of a muscle's retracted or separated orbital layer, flap tear repair, pulley repair, and loop myopexy.
This case report highlights an atypical clinical presentation featuring ipsilateral head, neck, shoulder, and eye pain with erythema, edema of the right eyelid and conjunctiva, alongside classic signs of dorsolateral medullary syndrome, also known as Wallenberg Syndrome, characterized by ipsilateral Horner's syndrome and contralateral loss of body pain and temperature in a 37-year-old female. The correct diagnosis of Wallenberg syndrome was achieved through the collaborative effort of eye care professionals, primary care, emergency, and neurology specialties in medicine.
