PURPOSE:To describe an ab externo surgical technique for submacular band removal in pediatric patients with rhegmatogenous retinal detachment (RRD) complicated by proliferative vitreoretinopathy (PVR). METHODS:Ten eyes of 10 pediatric patients diagnosed with RRD and PVR grade C associated with submacular bands. All eyes underwent submacular band removal using an ab externo transscleral approach combined with scleral buckling and 23-gauge pars plana vitrectomy. Preoperative localization of submacular bands was performed using optical coherence tomography and/or B-scan ultrasonography, with intraoperative targeting guided by Resight viewing. RESULTS:Submacular band removal via the ab externo approach was successfully performed in all 10 eyes. The mean patient age was 10.8 ± 3.2 years (range, 5-16 years). Preoperative hypotony (intraocular pressure <6 mmHg) was present in three eyes. Postoperatively, visual acuity improved in four patients, remained stable in four, and worsened in two. No cases of postoperative epiretinal membrane formation or significant subretinal hemorrhage were observed. Retinal reattachment was achieved in 9 of 10 eyes (90%), while one eye progressed to pre-phthisis. CONCLUSIONS:Ab externo submacular band removal appears to be a useful adjunct to pars plana vitrectomy in selected pediatric RRD cases with PVR, allowing relief of submacular traction without the need for retinotomy.

Inferior oblique muscle overaction (IOOA) is a common cause of vertical strabismus. Most published comparisons cover two or three techniques. We evaluated 1-year outcomes of a severity-guided algorithm comparing four weakening techniques for IOOA: disinsertion, myectomy, anterior transposition (AT), and nasal transposition (NT). In this retrospective comparative cohort study, 286 eyes of 200 patients with IOOA (grade + 1 to + 4) were treated by disinsertion (n = 141), myectomy (n = 29), AT (n = 94), or NT (n = 22), selected by the operating surgeon according to preoperative IOOA severity (minimum 1-year follow-up). Pre- and postoperative IOOA grade, abnormal head posture (AHP), and horizontal deviation were compared with non-parametric tests; a patient-level sensitivity analysis was performed. Success (postoperative IOOA grade 0 or + 1 without underaction) is reported with 95

OBJECTIVE:To evaluate vertical motility development in patients with Brown syndrome who have undergone different types of superior oblique (SO) muscle surgery. DESIGN:A retrospective analysis was conducted on the medical records of 174 patients who underwent surgery for Brown syndrome. SETTING:The age of the patients, mean visual acuity (VA), the type of surgery, pre- and postoperative abnormal head posture (AHP), and vertical deviation were investigated. PATIENTS:The study comprised patients who were followed up with Brown syndrome and were undergoing surgery for strabismus and AHP. INTERVENTIONS:These individuals exhibited limitations in active elevation during adduction and severe restrictions in elevating the adducted eye, as assessed by forced duction testing (FDT). Three different surgical procedures were performed. MAIN OUTCOME MEASURES:Pre- and postoperative vertical deviation and AHP were measured. RESULTS:There were 76 male patients and 98 female patients with a mean age of 13.34 ± 5.47 (6-35 years). Fifty-two patients received SO nasal tenotomy, 56 received SO temporal tenotomy, and 66 received SO tendon elongation. Of the 36 patients (20.7%) who had a vertical deviation rate at the 1-year follow-up, 20 underwent the second procedure (SO temporal or nasal tenotomy for hypotropia and inferior oblique anterior transposition for hypertropia), and two underwent the third procedure (inferior oblique anterior transposition for hypertropia). In the first year following surgery, the average vertical deviation in the primary position was 6.85 ± 2.27∆, compared to 15.43 ± 5.27 ∆ before surgery. Following the second and third operations, the average vertical deviation was 2.38 ± 1.59∆ ( P < 0.005). CONCLUSION:The success rate was found to be higher in SO tenotomies.

Background/Objectives: To evaluate the long-term outcomes of strabismus treatment in children with cerebral palsy (CP) and to investigate factors associated with postoperative alignment success and the development of consecutive strabismus. Methods: The retrospective, single-center study included 73 children with CP and strabismus who were followed from January 2015 to December 2024. Demographic characteristics, ophthalmological findings, treatment methods, and postoperative outcomes were assessed. Ocular deviation was measured through prism and alternate cover testing or a modified Krimsky test, and surgical success was defined as a final deviation of ≤10 prism diopters (PD). Patients were assessed at the patient level. Comparisons between exotropic and esotropic patients and between patients who had consecutive exotropia and those who had successful alignment were made using appropriate statistical tests. Results: Study participants included 55 patients with esotropia (75.3%) and 18 patients with exotropia (24.7%). The mean follow-up period was 32.6 ± 7.18 months. A successful ocular alignment was achieved in 32 of 46 patients (69.6%) with esotropia and in 10 of 17 patients (58.8%) with exotropia following surgical treatment and/or BTA. Consecutive exotropia developed exclusively in patients initially treated for esotropia (39.1% vs. 0%, p = 0.001). Patients with consecutive exotropia underwent surgery at a younger age and had larger preoperative deviation angles than those who had successful alignment, but these differences were not statistically significant. Conclusions: Strabismus treatment provides satisfactory long-term motor alignment in many children with cerebral palsy. However, consecutive exotropia following esotropia surgery remains a common postoperative condition and is the principal source of alignment instability in this population. Younger surgical age and larger preoperative deviations were more common among patients with consecutive exotropia, but no statistically significant associations between the evaluated clinical variables and consecutive exotropia were identified in the exploratory univariate analyses.

To evaluate the demographic and clinical characteristics, surgical techniques, and postoperative outcomes in patients with exotropic Duane retraction syndrome (DRS) at a tertiary referral strabismus center. This retrospective study included 109 patients with exotropic DRS (Type 1, n = 78; Type 2, n = 20; Type 3, n = 11) evaluated between 1995 and 2023. Surgical indications were exotropia ≥ 20 prism diopters (PD) in primary position or abnormal head posture (AHP) ≥ 10°. Procedures included lateral rectus (LR) recession (3–7 mm), Y-splitting of the LR, vertical rectus transposition, and adjunctive techniques. Botulinum toxin type A (BTX-A) was administered in selected cases. The cohort comprised 79 females (72.5

Objectives:In this study, a new technique that does not cause lower eyelid retraction in patients with excessive limitation of movement and vertical strabismus due to inferior rectus (IR) fibrosis in thyroid eye disease was introduced. Methods:There were six patients with their six eyes with their mid-term results. Operation Technique:According to the deviation amount, a 7-14 mm length bovine pericardium (Tutopatch®) was inserted between the distal end of the tendon and the beginning of the muscle fibers, which are located between the tendon's distal end and the tendon muscle junction to the IR with 6/0 non-absorbable suture. Results:There were six cases with a mean 19.5±5.2 PD (PD: prism diopters) (14-26 PD) vertical deviation and severe up-gaze limitations with a mean -4.1±0.75. The post-operative vertical deviation was a mean of 3.5±1.22 PD, and the limitation of upgaze was a mean of -1.3±0.4. Conclusion:This procedure provides effective results in reducing gaze limitation and vertical deviation in thyroid patients without causing any problems in the eyelids.

Objectives: To compare the iris vessel density results before and after rectus plication, a vessel-sparing procedure, and resection/recession surgery using a non-invasive method, optical coherence tomography angiography (OCT-A). Methods: This single-center, prospective observational study was held in Beyoglu Eye Research and Training Hospital. Ten patients were included in the study after excluding patients with systemic or ocular diseases, nystagmus or fixation loss. The anterior segment module of the OCT-A was utilized, and the eye-tracking feature was disabled to obtain the highest image quality. OCT-A imaging was performed one day before or on the day of the surgery and within three days after surgery. Results: Ten patients (8 females) were included in the study. Five had esotropia, meanwhile 5 had exotropia. Two patients received muscle plication in one eye, and the other three received one rectus plication and antagonist recession on the same eye. Preoperative and postoperative images were analyzed both qualitatively and quantitatively with device software and ImageJ. The vessel density near the plicated rectus decreased less after surgery. The mean preoperative and postoperative vessel densities were 53.68% and 49.62% in the plication group (p>0.05). However, they were 60.19% preoperatively and 54.26% postoperatively in the resection/recession group (p=0.043). Conclusion: In this study, OCT-A was utilized for the first time to evaluate the qualitative and objective quantitative changes in iris vessel density after rectus plication and recession/resection surgeries. The quantitative comparisons demonstrated that the iris vessel density decreased less after vessel-sparing surgery. Iris OCT-A shows promise for evaluating changes in iris vessel density.

Introduction: This study aimed to investigate the impact of strabismus on self-concept in school-aged children and to evaluate changes in self-concept six months after strabismus surgery. Subjects and Methods: This prospective multicenter study included children aged 7-15 years who underwent strabismus surgery at the Strabismus Units of Beyoğlu Eye Research and Training Hospital and Marmara University Hospital between December 2023 and June 2024. Self-concept was assessed using the validated Turkish version of the Piers-Harris Self-Concept Scale (PHSCS) before surgery and six months postoperatively. Only patients with complete preoperative and postoperative assessments were included in the final paired analysis. Results: A total of 116 children were enrolled, of whom 84 (42 boys and 42 girls; mean age, 10.9 ± 2.2 years) had complete data and were included in the final analysis. Overall, 73.6% of participants reported that strabismus affected their daily lives, with 77.4% describing this impact as negative. Furthermore, 65.5% stated that strabismus affected their relationships with friends. Following surgery, 80.9% of participants were satisfied with the surgical outcome, and 85.7% would recommend the procedure to others. The mean total PHSCS score increased from 58.2 ± 10.4 preoperatively to 59.0 ± 10.1 postoperatively, although this difference did not reach statistical significance (p = 0.05). In contrast, the Physical Appearance and Attributes subscale showed a significant improvement after surgery (8.3 ± 1.6 vs. 8.9 ± 1.9, p < 0.005), whereas no significant changes were observed in the remaining subscales. Conclusions: School-aged children with strabismus may experience psychosocial challenges related to their condition, particularly in their interactions with peers. Although overall self-concept remained largely unchanged, self-perception of physical appearance improved following strabismus surgery. These findings suggest that surgical correction may contribute to improvements in selected aspects of self-concept; however, larger prospective controlled studies are needed to confirm these observations.

To identify the incidence and clinical outcomes of scleral perforation during posterior fixation suture surgery in strabismus patients. This was a retrospective chart review of patients who underwent posterior fixation suture surgery at the Strabismus Unit of Beyoglu Eye Training and Research Hospital between January 2017 and March 2021. Patients with complete ophthalmological records were included. Data collected included surgical indication, visual acuity, and retinal findings. Patients with suspected scleral perforation were evaluated and monitored in collaboration with the vitreoretinal unit. A total of 152 eyes from 121 patients (67 females, 54 males; mean age: 12.3 ± 16.2 years, range 2–55) were included. Scleral perforation occurred in 6 patients (3

To investigate the effect of refractive errors on the results of patients followed up with infantile esotropia (IE) and treated with botulinum neurotoxin (BNT) injection. The files of patients with IE who presented to the ophthalmology pediatric ophthalmology unit and underwent BNT injection into both medial rectus muscles between 2019 and 2021 were reviewed retrospectively. Sixty eyes of 30 patients were included in the study. Patients with additional systemic or ocular diseases and those with a history of ocular surgery were excluded. Distance and near deviations were measured (with the prism cover test or Krimsky method) before and at the first, third, and sixth months after BNT injection. In Group 1 (n = 20) with a spherical equivalent of + 2.0 diopters (D) or less, the mean near and distance deviation value was both 36.8 ± 12.7 prism diopter (PD) before injection. In Group 2 (n = 10) with a spherical equivalent of above + 2.0 D, the near deviation was measured as 35.0 ± 7.1 PD and distance deviation as 31.8 ± 7.9. At six months after BNT injection, the near and distance deviation values were 20.6 ± 12.3 and 20.6 ± 11.6 PD, respectively in Group 1 and 10.1 ± 10.3 and 8.8 ± 10.8 PD, respectively in Group 2. The change in deviation did not statistically significantly differ between the groups (p > 0.05), but the distance and near deviation values were lower in Group 2 at sixth months after BNT injection. BNT injection is a preferred method in IE. Higher hypermetropic values seem to increase the success of BNT injection.

Purpose To compare the efficacy of bilateral lateral rectus recession with vertical tendon transposition (LRVT) and LRVT combined with inferior oblique (IO) disinsertion for V-pattern exotropia. Methods The medical records of patients who had mild-to-moderate (+1 and +2) inferior oblique overaction (IOOA) and underwent half-tendon-width upward LRVT (transposition group), and LRVT with IO disinsertion (combined surgery group) for V-pattern exotropia and who had at least 3 years of postoperative follow-up were reviewed retrospectively. Results A total of 45 patients were included: 22 in the transposition group and 23 in the combined surgery group. Preoperatively, there were no differences in V pattern, IOOA, or horizontal misalignment in primary position, upgaze, or downgaze between groups. The amount of exotropia in the primary position was 30.2Δ ± 10.7Δ in the transposition group, and 31.6Δ ± 14.1Δ in the combined surgery group (P = 0.974). A significant decrease in V pattern was observed in the combined surgery group and the transposition group at 6 months and 3 years postoperatively (P < 0.001). The reduction of V pattern in the combined surgery group at 6 months (20.2Δ ± 7.8Δ vs 15.6Δ ± 6.9Δ [P = 0.02]) and 3 years (20.1Δ ± 8.1Δ vs 15.2Δ ± 7.1Δ [P = 0.014]) was found to be greater than the transposition group. There were no differences in the success rate in the primary position at 6 months (P > 0.05). Conclusions Both tendon transposition with horizontal rectus surgery and combined tendon transposition and IO-weakening surgery decreased V-pattern exotropia. However, combined surgery had a greater effect on decreasing V pattern in patients with mild-to-moderate IOOA.

PURPOSE:In this prospective study, we aimed to make a quantitative assessment of the lacrimal glands before and after radioactive iodine (RAI) treatment in patients with hyperthyroidism and thyroid cancer.METHODS:The study included 80 eyes of 40 patients. There were 25 patients in group 1 (hyperthyroid group) and 15 patients in group 2 (thyroid cancer group). Group 1 has received low dose ( 131 I) and group 2 high dose ( 131 I). Before, and at the first and sixth month after RAI treatment, all patients underwent ophthalmological examinations, Schirmer tests, TBUT tests, tear osmolarity (TO), and ocular surface examinations.RESULTS:The age and sex characteristics of both groups were similar. Although no significant change was observed in tear film tests before and after treatment in group 1, a significant decrease in Schirmer and TBUT values and a significant increase in TO were observed in group 2 in the first month after treatment. These values returned to normal in the sixth month. Although no Schirmer test was observed lower than 10 mm in any patient before RAI treatment, the Schirmer test was measured 5 to 10 mm in 4 (10%) patients in group 2 in the first month after treatment. Again, in these patients, TBUT was below 10 seconds and TO was greater than 308 mOsm/L.CONCLUSIONS:In this study, although no change was observed in tear function tests in patients receiving low doses of RAI, a decrease in tear secretion and an increase in TO were detected in patients receiving high doses in the early period.

Purpose: To compare the surgical outcomes in patients who had a failed botulinum toxin A injection before surgery versus those who had surgery as primary treatment (primary surgery) for infantile esotropia. Methods: The fi les of patients who had strabismus surger y in the Strabismus Unit of Beyoglu Eye Training and Research Hospital between January 2012 and March 2022 were reviewed. This study included 104 eyes of 52 patients with infantile esotropia. The angle of deviation before and 1, 3, and 6 months after botulinum toxin A injection or surgery, complications, pattern deviations, family history, abnormal head position, history of prematurity, intensive care unit admission, and consanguineous marriage were noted. A successful outcome was defined as ocular alignment of 10 prism diopters (PD) or less. Results: The study population consisted of 52 patients: 27 (52%) boys and 25 (48%) girls. In the botulinum toxin A group (n = 26), the mean age at admission was 14.0 +/- 6.8 months, whereas the mean preoperative near and far angle of deviation were 41.92 +/- 12.2 and 41.3 +/- 13.0 PD, respectively. The mean age at the time of surgery was 40.6 +/- 18.1 months. In the primary surgery group (n = 26), the mean age at admission was 34.0 +/- 15.9 months. The mean preoperative near and far angle of deviation were 37.3 +/- 8.0 and 35.3 +/- 10.5 PD, respectively. The mean age at the time of surgery was 48.1 +/- 18.5 months. The success rates 6 months after treatment in the botulinum toxin A group and the primary surgery group were 76.9% and 88.5% in near (P > .05) and 80.8% and 88.5% in far (P > .05), respectively. Three patients had transient ptosis and one had consecutive exotropia after botulinum toxin A injection. Conclusions: In infantile esotropia treatment, strabismus surgery after failed botulinum toxin A injection compared to primary surgery has statistically comparable surgical success rates.

PurposeTo determine our rate of conjunctival cyst developing after strabismus surgery and to minimize its formationMaterials and MethodsThe data of 4026 eyes of 2662 patients were included in our retrospective analysis of, those that underwent strabismus surgery at the Beyoglu Eye Training and Research Hospital Strabismus Unit between 2015 and 2021. Clinical characteristics and follow-up data of patients were recorded together with age, sex, and operation type. All patients were examined postoperatively on 1st day, 1st month and 6th month.ResultsThe mean age of the patients was 15.66 & PLUSMN; 11.81 (1-59 years). While two eyes were operated on in 1494 patients, one eye was operated on in 1168 patients. The surgeries performed were recession and/or resection of the horizontal and vertical rectus muscles and inferior and superior oblique procedures. The conjunctival cyst was detected in 11 patients postoperatively between 20 days and 8 months. The cyst was detected on the nasal side in 7 cases and temporal in 4.ConclusionConjunctival cyst is a rare complication after strabismus surgery and it is thought to be caused by a proliferation of the conjunctival epithelium. In addition to proper closure of the conjunctiva, attention to personal hygiene, avoidance of contacts that may increase suture contamination, and attention to the fact that the operation period is not long are actions that can help prevent conjunctival cyst formation.

Objective  The aim of this study was to quantitatively assess the macular and retinal nerve fiber layer thicknesses in patients with hyperthyroidism and thyroid cancer undergoing radioactive iodine (RAI) therapy. Study Design  This prospective study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Bagcilar Training and Research Hospital Clinical Research Ethics Committee. Written informed consent was obtained from the patients following a detailed explanation of the study objectives and protocol. Patient selection was randomized. Patients scheduled for RAI treatment in the Nuclear Medicine Clinic were referred to the ophthalmology clinic, respectively. Patients without additional ocular pathology were included in the study. Methods  All patients had received RAI therapy using Iodine-131 for hyperthyroidism or thyroid cancer. A complete ophthalmological examination and measurement of macular and retinal nerve fiber layer thickness using optical coherence tomography were performed on all patients before and at the first and sixth months and in first year after RAI treatment. The results were prospectively evaluated. Results  The study included 80 eyes of 40 patients. The hyperthyroid group was group 1, and the thyroid cancer group was group 2. There were 25 patients in group 1 and 15 patients in group 2. The mean age was 43.76 ± 11.85 years (range: 22-65 years) in group 1 and 39.87 ± 9.13 years (range: 30-58 years) in group 2. There was no significant difference between the two groups regarding age and sex ( p  > 0.05). In both groups, no significant difference was found in the macular thickness and retinal nerve fiber layer thicknesses values obtained in both eyes before and after the RAI treatment. Conclusion  As a result of our study, we observed that RAI intake did not harm the retinal layer.

Purpose: The aim of this study is to present six cases of pulled-in-two syndrome (PITS) in strabismus surgeries and to discuss our prevention and management strategies. Methods: This is a retrospective study presenting cases of PITS during strabismus operations. The medical records of the subjects who underwent operation in the strabismus unit of Beyoglu Eye Training and Research Hospital were reviewed retrospectively, from January 2000 till March 2022. Detailed ophthalmological examination records and angle of deviation were noted. Results: A total of six cases (four males and two females) with a mean age of 37.2 ± 28.0 (min 9-max 71) years were included in this study. All of the cases had congenital fibrosis of extraocular muscles (CFEOM). The most commonly involved muscle was medial rectus (83%). Majority of cases (67%) were adults. In all cases, the muscle was found and reattached to the globe. No patients had diplopia after surgery. Conclusion: PITS is a rare complication that can be seen during strabismus surgeries, and CFEOM patients are in the risk group. Therefore, surgeons should be cautious and prepared in risky patients to be able to manage this complication.

PURPOSE:To evaluate the retinal and choroidal microvasculature after strabismus surgery using swept-source optical coherence tomography angiography (OCTA). METHODS:Thirty-three eyes of 33 patients who underwent horizontal rectus surgery for strabismus were included in this retrospective study. The unoperated fellow eyes were used as the control group. The macular microvasculature was assessed using a 3 × 3 scan pattern centred on the fovea preoperatively, and one week and one month postoperatively. The vessel density (VD) of superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC) were automatically analyzed. The foveal avascular zone (FAZ) was calculated manually using the tool of the device. RESULTS:The VD in SCP demonstrated a significant difference between operated and fellow eyes at one week (p = 0.017). Moreover, a significant increase was observed in the mean VD values in SCP of operated eyes after surgery (p = 0.037). The VD in DCP exhibited no significant differences between operated and fellow eyes before and after strabismus surgery. However, there was a significant difference in VD was observed between operated and fellow eyes one week after surgery (p = 0.001). The mean VD in CC was significantly increased in the operated eyes one week after surgery compared to preoperative values (p = 0.006). CONCLUSION:This study revealed that strabismus surgery may cause transient alterations both in retinal and choroidal microcirculation in the early postoperative period.

Objectives: To evaluate the effectiveness of the conjunctival suture tied internally and externally on patient comfort and suture dissolution in the postoperative period in patients who underwent symmetrical strabismus surgery. Methods: In 50 patients who underwent surgery in the Beyoğlu Eye Training and Research Hospital Strabismus Unit, the conjunctiva was closed by tying the conjunctival suture externally in the right eye and internally tying the left eye. Absorbable 8/0 polyglactin suture was used for conjunctival suturing in all patients. Pain, itching, tearing and, discomfort sensations of the patients were questioned and a slit-lamp examination for conjunctival inflammation and dissolution of the suture were evaluated on the postoperative 1st day, 1st week, 1st month, and 6th weeks. Results: Twenty-two patients were female and 28 were male. The mean age of the patients was 7.24 ± 4.83 (range: 4-17) years. When the pain, stinging and discomfort of the patients were questioned, 46% of the patients stated that they felt more comfortable in the left eye on the 1st and 10th days, while 48% of the patients stated that they were equal in both eyes. When we evaluated the melting of the suture and conjunctival redness, it was observed that the suture in the left eye was melted prematurely at a rate of 40% and, the conjunctival redness resolved early in the first month. There were equal pain and redness in both eyes at a rate of 54%. Conclusions: In strabismus surgery, the closure of the conjunctiva by tying the suture internally is thought to increase patient comfort in the postoperative period.

PURPOSE To evaluate the outcomes of combined bupivacaine HCL (BPX) injection in the medial rectus (MR) muscle with recession of the lateral rectus muscle in the treatment of conver-gence insufficiency-type intermittent exotropia (CI-IXT).METHODS The medical records of patients who underwent combined injection-recession treatment from January 2019 to January 2020 for CI-IXT were reviewed retrospectively along with a group of age-matched controls with IXT without CI who underwent only unilateral LR recession during the same period. The following data were extracted from the record: age at surgery, average follow-up period, angle of deviation at distance and near and the difference between them before and after surgical procedure, correction of near and dis-tance deviations, and recession dosage. Successful outcome was defined as a distance devi-ation in primary gaze between <= 10 degrees of exophoria/tropia and <= 5 degrees of esophoria/tropia.RESULTS A total of 10 patients and 20 controls were included. Average follow-up was 13.9 +/- 3.67 months in the BPX group and 15.9 +/- 3.61 months in the control group (P = 0.17). Post-operative distance deviation measured 8.30 degrees +/- 5.88 degrees in the BPX group and 14.67 degrees +/- 9.83 degrees in the control group (P = 0.80). Distance-near differences were significantly reduced in the CI-IXT group receiving BPX, by a mean of 6.60 degrees, from a preoperative mean of 10.50 degrees +/- 3.65 degrees to 3.90 degrees +/- 3.26 degrees (P \ 0.01).CONCLUSIONS BPX injection combined with unilateral lateral rectus recession yields outcomes compara-ble to bilateral lateral rectus recession for distance deviations, and results in reduction of the distance-near difference in the angle of exotropia. ( J AAPOS 2022;26:249.e1-5)