Dark Irides Research Articles

Noninfectious Outcomes of Intravitreal Antibiotic Steroid Injection and Topical Nonsteroidal Antiinflammatory Drugs Versus Triple Drop Therapy After Cataract Surgery

To compare noninfectious outcomes of intravitreal antibiotic steroid (IVAS) injection (moxifloxacin-triamcinolone) and postoperative topical nonsteroidal antiinflammatory drugs (NSAID) with a standard 3-drop therapy (TDT) regimen (topical antibiotic, steroid, and NSAID) in patients after cataract surgery. Retrospective comparative clinical cohort study. In 3 study centers in the United States, a total of 2143 eyes (N = 2143 patients) underwent cataract surgery with IVAS-NSAID or TDT between 2017 and 2022. Preoperative data were included, including patients' age, iris color, medical history, and ocular history. Postoperative data, including best-corrected visual acuity, intraocular pressure (IOP), and the need for IOP-lowering medications, were recorded at 1-week, 1-month, and 6-month time points. The primary outcome measures were postoperative complications, defined as persistent anterior chamber inflammation, persistent corneal edema (PCE), rebound inflammation, and cystoid macular edema, were compared between the 2 groups. There were 1079 eyes in the IVAS-NSAID group and 1064 eyes in the TDT group. Best-corrected visual acuity and IOP were similar between IVAS-NSAID and TDT eyes at all time points. A portion (11.6%) of TDT eyes experienced postoperative complications compared with 6.5% in IVAS-NSAID eyes (P < .001). Femtosecond laser-assisted cataract surgery was associated with increased rates of PCE in IVAS-NSAID eyes, and eyes with dark irides had a higher incidence of cystoid macular edema, PCE, and rebound inflammation in the IVAS-NSAID group. The IVAS-NSAID regimen overall had similar postoperative outcomes and fewer complications compared with the TDT regimen. IVAS-NSAID may be considered a safe alternative to topical regimens in non-femtosecond laser-assisted cataract surgery and patients with light irides.

COMPARISON OF THE DILATING EFFECT OF THREE MYDRIATIC AGENTS ON DARK IRIDES

Dilation of pupil has been a major component of diagnostic eye examination inOptometric practice. Although mydriatic agents are used in clinical procedures, thereis no satisfactory explanation for the preference of one over another. This studycompared the dilating effect of three different mydriatic agents on dark irides ofninety healthy subjects; comprising 48 males and 42 females aged 16-30 (mean age18.77±0.52) years divided into three groups of 30 subjects each. One drop of 1%tropicamide eye drop was instilled into the right eye of Group 1 subjects, One drop of1% homatropine eye drop was instilled into the right eye of Group 2subjects, whileOne drop of 2.5% phenylephrine eye drop was instilled into the right eye of Group 3subjects, The left eye (control eye), received a placebo of one drop of 10mg/mlBenzyl Alcohol in all the subjects in the three groups. Baseline measurements wererecorded prior to instillation, thereafter mydriatic effect was assessed over a periodof 40 minutes starting at 5 minutes and thereafter at 10 minute interval using thehand held pupillometer. Results showed that after 40 minutes of instilling the 3mydriatic agents to the right eyes, there was a statistically significant difference(p&lt;0.05) in the pupil diameter of all the subjects in the three groups .Maximum meanpupillary dilation was 7.10±0.27mm, 6.00±0.56mm, and 4.80±0.36 mm for 1%tropicamide, 1% homatropine, and 2.5% phenylephrine respectively after 40minutes. Therefore it can be concluded that significant differences exist in themydriatic effect of the three mydriatic agents.

Large irides enhance the facial attractiveness of Japanese and Chinese women

Since large eyes are often perceived to enhance facial attractiveness, many individuals are motivated to change their eyes' appearance. Colored contact lenses are often used by young women to darken the limbal rings of their irides, to increase their facial attractiveness. Among Westerners, wearing contact lenses with limbal rings enhances facial attractiveness; a similar effect might exist for East Asians whose irides are darker; although, the mechanism underlying these preferences in Westerners and East Asians might differ. In this study, we investigated whether larger irides increased the attractiveness of Japanese and Chinese women, and whether this effect was accompanied by changes in perceived friendliness or youthfulness. We manipulated eye size by enlarging only the iris or the whole eye, and asked participants to rate face stimuli in terms of facial attractiveness, friendliness, and youthfulness. We found that larger irides enhanced not only attractiveness but also perceived youthfulness and friendliness, and that there was a significant correlation between attractiveness and friendliness. Further, iris-enlarged faces were perceived as more attractive even when the iris was originally dark, as enlarged dark irides were confused with dilated pupils, which are often perceived as a sign of attraction.

Identifying the white forelock for early visual stimulation and speech therapy among X-men (van der Hoeve-Halbertsma-Waardenburg syndrome) in ophthalmology

A day-old male neonate presented with white forelock on his forehead. On evaluation, the neonate had telecanthus, broad nasal bridge, and surprisingly homochromic but hypochromic irides bilaterally. The W-index was 2.38 which was an indication of Type 1 Waardenburg syndrome (WS) with dilated fundus evaluation revealing pigmentary deficit in the retina depicting a orangish hue. The corneal diameter was 9 mm in both eyes. Both the external auditory meatus and external ears appeared normal. The parents who had a history of second-degree consanguineous marriage had visual acuity of 20/20 with normal dark brown irides and normal fundi. Genetic counseling, visual rehabilitation, and auditory evaluation to rule out sensory neural hearing loss were stressed upon for good quality of life, which is mandatory among neonates diagnosed with van der Hoeve-Halbertsma-Waardenburg syndrome.

Effect of over-the-counter brimonidine tartrate 0.025% ophthalmic solution on pupil size in healthy adults

PurposeTo evaluate the effect of brimonidine tartrate 0.025% ophthalmic solution on pupil size under scotopic conditions in healthy adultsMethodsPupil size was measured in 56 eyes of 28 volunteer participants using a pupillometer under scotopic conditions. Age, gender, and iris color were recorded. Subjects using any ophthalmic medications other than artificial tears were excluded. The pupil size was subsequently measured again under scotopic conditions 60 min after instillation of brimonidine tartrate 0.025% ophthalmic solution.ResultsStatistically significant miosis was seen after instillation of brimonidine tartrate 0.025% (p = 0.04). Average pupil size prior to brimonidine 0.025% instillation was 7.28 ± 1.05 mm, and average pupil size after instillation of brimonidine 0.025% was 6.36 ± 1.68 mm, a reduction of − 23.7% in pupil area. Subjects with light irides demonstrated a greater miotic effect than subjects with dark irides (1.55 mm vs. 0.67 mm, p < 0.0001), with a pupil area reduction of − 37.6% and − 17.4%, respectively. The amount of miosis was independent of initial pupil size.ConclusionsBrimonidine tartrate 0.025% causes significant miosis in scotopic settings, although the effect is not as great in darker colored eyes. Further studies are needed to determine the latency and duration of the effect and whether the amount of miosis is clinically significant.

A tale of ptosis, pharmacological tests, and Pancoast tumour

Horner syndrome (HS) classically presents with ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis and caused by a lesion along the oculosympathetic pathway from the hypothalamus to eye. The diagnosis of HS in a patient presenting with partial ptosis may be easily missed in the Asian patient. This is mainly due to the dark irides, making detection of anisocoria on direct visualization difficult. Index of suspicion must be high, especially in the absence of any extraocular motility or lid abnormalities. We present a case where a healthy asymptomatic patient presented with partial ptosis and diagnosis of HS was eventually confirmed through pharmacological tests. Non-targeted imaging with a simple chest X-ray revealed an apical lung lesion which eventually turned out to be malignant. Although it is a typical textbook description, this case highlights the importance of careful history and examination in an otherwise healthy patient presenting with mild ptosis.

Commentary: The utility of automated pupillometry in retinal disorders.

Pupillary light reflex (PLR) remains an integral part of ocular examination providing an insight into the retinal, optic nerve, and brain stem functions. An altered PLR has significance in a multitude of ocular disorders such as third nerve palsies, optic neuritis, and central retinal vein occlusion.[123] A relative afferent pupillary defect (RAPD), detected by the swinging flashlight test, is indicative of an asymmetrical/unilateral retinal pathology or an optic nerve lesion and was first described by Levatin in 1959. Although the use of neutral density filters and standardized clinical grading has helped in quantifying RAPD, these methods remain limited by variable test conditions and observer bias.[4] The evaluation of RAPD with a swinging flashlight test is further hampered in patients with dark irides and small and/or poorly reacting pupils. Automated pupillometry helps in eliminating these barriers and provides an objective, standardized, and reproducible assessment of the pupillary function. In addition, the automated pupillometer is capable of assessing multiple variables, including pupillary size, constriction velocity, dilation velocity, and the latency of PLR. One of the earliest utilization of pupillometry in ophthalmology was described by Bloom et al.[3] in their study of central retinal vein occlusion. In eyes developing rubeosis, they observed a greater mean RAPD using neutral density filters, while infrared pupillometry revealed greater pupillary diameter and latency of constriction with a slower rate of pupillary constriction. They also concluded that because of the subjective nature of RAPD assessment, pupillometry was a more specific test generating a higher amount of measurable data and hence recommended its further development. Using pupillometry, Jain et al.[5] observed altered pupillary dynamics in the early stages of diabetic retinopathy and further observed that the dynamics deteriorated with the increasing severity of retinopathy. The importance of pupil assessment is heightened in neuro-ophthalmology cases to clinch the diagnosis. Kim et al.[1] evaluated the pupillary response in isolated third nerve palsy cases using an automated, infrared pupillometer. The ability of the automated pupillometer to quantify the pupillary response enabled them to calculate the pupillary constriction ratio, which they found to be highly specific for detecting third nerve palsy due to compressive etiologies. They were also able to distinguish microvascular ischemic third nerve palsy from those due to compressive lesions using digital pupillometry. Optic nerve disorders, including optic neuritis and nonarteritic anterior ischemic optic neuropathy (NAION), can significantly affect the PLR. Yoo et al.[2] observed a decreased pupillary constriction velocity, constriction ratio, and latency in acute optic neuritis and NAION using automated pupillometry. They also concluded that a delayed constriction latency and PLR recovery were features suggestive of optic neuritis over NAION. Although the role of PLR and automated pupillometer in age-related macular degeneration (ARMD) has been described in previous studies, the current study demonstrated its role in assessing macular lesions in choroidal neovascular membranes (CNVM) and also correlated the structural dimensions assessed on optical coherence tomography with RAPD scores.[678] Although the current study provides useful insights into the role of pupillometry in ARMD, the cross-sectional design does not address the role of evaluating the PLR in monitoring treatment response and disease progression, thus warranting further studies. Also, it would be interesting to evaluate the role of CNVM components such as subretinal fluid, intraretinal fluid, and subretinal hemorrhage on the RAPD scores. To conclude, automated pupillometry has a potential role to play in the monitoring of disease progression and response to therapy in ARMD and myriad other retinal disorders. Further studies are needed to expand the horizons about the role of this noninvasive, objective test for retinal pathologies. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Anisocoria assessment in subjects with dark irides – Custom-built infrared screening device vs. millimeter ruler

PurposeDetection of anisocoria in those with dark irides is difficult, and failure to detect anisocoria can have dire consequences. Whether infrared pupillometry and gross measurement would yield different prevalence rates for anisocoria in those with dark irides is unknown. We compared the frequency of anisocoria in healthy adults with dark irides assessed with mm ruler versus infrared pupillometry. MethodsPupil diameters in light (L) and dark (D) conditions were obtained to identify anisocoria in 59 human subjects with dark irides using two techniques. To avoid bias, gross measurements (S) with ruler were taken first. Pupils were imaged under infrared illumination mounted in a spectacle frame with mm tape attached. Adobe Photoshop was used to measure pupil sizes on the digital images (O). ResultsProportions of anisocoria by group were SL .034, OL .130, SD 0.00, OD .135. Fisher's exact test showed that anisocoria in dim light was more frequent with the infrared photo technique. Exact binomial probability testing showed that the anisocoria in SL and SD conditions was not different from an expected proportion of 5%; whereas anisocoria in OL condition was not different from an expected proportion of 20%, and anisocoria in OD condition was not different from expected proportions of 10, 15, and 20%. ConclusionsIn people with dark irides, ruler measurements of pupil size underestimate the frequency of anisoria in dim lighting conditions compared to the use of infrared pupillometry. Whether detection rates of pathologic anisocoria differ with measurement technique remain to be explored.

Incidence and quantification of corneal haze by Pentacam Scheimpflug densitometry following photorefractive keratectomy for myopia in virgin and post corneal transplant eyes with dark irides

PurposeTo assess the incidence and quantification of corneal haze after myopic photorefractive keratectomy in virgin and post corneal transplant eyes with dark irides. MethodsIn this retrospective study at the tertiary eye hospital, the corneal haze was evaluated by slit-lamp and quantified by Pentacam Scheimpflug densitometry after myopic photorefractive keratectomy with mitomycin C in virgin eyes (group I) and post corneal transplant eyes (group II) with dark irides over 12 months. ResultsGroup I compromised 126eyes from 77patients (35males and 42females) aged 31.31 years (24.11–36.18 years), and group II compromised 44eyes from 33patients (18males and 15females) aged of 32.25 years (26.15–36.66 years). The incidence of corneal haze was 9.5% (95%CI: 5.0%–16%) and 6.8% (95%CI: 1.4–18.7%) in group I and II respectively (p = 0.587). The corneal densitometry was 22.69 ± 8.28GSU preoperatively and 17.98 ± 3.13GSU at 12 months postoperatively (p = 0.010) in group I. The corneal densitometry was 21.86 ± 6.22GSU preoperatively and 21.23 ± 4.29GSU at 12 months postoperatively (p = 0.815) in group II. High corneal maximal densitometry was associated with the thin central corneal thickness (p = 0.027), the presence of haze (p = 0.028), post-keratoplasty (p = 0.004), steep keratometry (p = 0.035). ConclusionThe incidence of corneal haze was comparable in virgin and post corneal transplant eyes. The Pentacam Scheimflug densitometry can be helpful in the diagnosis of corneal haze; however, the cutoff values need to be studied further in larger studies.

Incidence and quantification of corneal haze by Pentacam Scheimpflug densitometry following photorefractive keratectomy for myopia in virgin and post corneal transplant eyes with dark irides

PURPOSE:To assess the incidence and quantification of corneal haze after myopic photorefractive keratectomy in virgin and post corneal transplant eyes with dark irides.METHODS:In this retrospective study at the tertiary eye hospital, the corneal haze was evaluated by slit-lamp and quantified by Pentacam Scheimpflug densitometry after myopic photorefractive keratectomy with mitomycin C in virgin eyes (group I) and post corneal transplant eyes (group II) with dark irides over 12 months.RESULTS:Group I compromised 126eyes from 77patients (35males and 42females) aged 31.31 years (24.11–36.18 years), and group II compromised 44eyes from 33patients (18males and 15females) aged of 32.25 years (26.15–36.66 years). The incidence of corneal haze was 9.5% (95%CI: 5.0%–16%) and 6.8% (95%CI: 1.4–18.7%) in group I and II respectively (P = 0.587). The corneal densitometry was 22.69 ± 8.28GSU preoperatively and 17.98 ± 3.13GSU at 12 months postoperatively (P = 0.010) in group I. The corneal densitometry was 21.86 ± 6.22GSU preoperatively and 21.23 ± 4.29GSU at 12 months postoperatively (P = 0.815) in group II. High corneal maximal densitometry was associated with the thin central corneal thickness (P = 0.027), the presence of haze (P = 0.028), post-keratoplasty (P = 0.004), steep keratometry (P = 0.035).CONCLUSION:The incidence of corneal haze was comparable in virgin and post corneal transplant eyes. The Pentacam Scheimflug densitometry can be helpful in the diagnosis of corneal haze; however, the cutoff values need to be studied further in larger studies.

Tropicamide has limited clinical effect on cycloplegia and mydriasis when combined with cyclopentolate and phenylephrine

To examine the cycloplegic and mydriatic effect of tropicamide omission from a common pediatric eye drop combination. Consecutive children examined at the Ann & Robert H. Lurie Children's Hospital of Chicago from June 8, 2017 to September 6, 2017 were enrolled prospectively. Tropicamide, cyclopentolate, and phenylephrine (TCP) was instilled in one eye; cyclopentolate and phenylephrine (CP), in the other. Spherical equivalent, maximum pupil size, and pupillary constriction in response to photostimulation were measured before and 30minutes after instillation using an autorefractor and pupillometer. Iris pigmentation was examined as a between-subjects variable. A total of 75 children 4-11years of age were included. Mean differences in spherical equivalent between TCP and CP were not statistically significant (P=0.95). Significant interactions between eye drop regimen and iris pigmentation were observed for pupil size (P=0.001) and constriction percentage (P=0.02). Among only patients with dark irides, TCP yielded slightly larger pupils (7.70 vs 7.31mm [P<0.001]) that were less responsive to light (5.75% vs 8.07% [P=0.002]). All pupils dilated to ≥6.0mm, with equivalent proportions achieving ≥7.0mm for TCP and CP (P=0.18). TCP and CP elicited equivalent cycloplegic effects. Mydriatic differences between the regimens, although statistically significant in dark irides, were of limited clinical magnitude, and all pupils achieved sufficient dilation for funduscopy.

Brushfield spots and W\xf6lfflin nodules unveiled in dark irides using near-infrared light

Wölfflin nodules and Brushfield spots were described essentially in light colored irides. The purpose of our study is to determine if these iris features are also present in dark irides, hidden by melanin granules of the anterior leaf of the iris. We examined iris images, taken with standard visible white, as well as with near-infrared light of children with Down syndrome and without. Using white light, Brushfield spots were seen in 21% of children with Down syndrome, and Wölfflin nodules in 12% of controls (p < 0.001), all noted in those with lightly colored irides. Brushfield spots were detected in 67% of children with Down syndrome using near-infrared light compared to 21% using white light (p < 0.001). Wölfflin nodules were detected in 19% of controls using near-infrared light compared to 12% using white light. Peripheral iris thinning was present in 63% of children with Down syndrome but in only 23% of those without (p = 0.001). Contraction furrows were less frequent in children with Down syndrome (16%) compared to controls (74%)(p < 0.001). Near-infrared light unveils Brushfield spots and Wölfflin nodules in dark irides. Clearing this discrepancy should assist in the elucidation of their pathophysiologic origin. A high prevalence of peripheral iris thinning is also present in children with Down syndrome along with a heretofore unreported reduction in iris contraction furrows.

Brushfield spots and Wölfflin nodules unveiled in dark irides using near‐infrared light

Brushfield spots and Wölfflin nodules unveiled in dark irides using near‐infrared light

Shave Excision With Keratopigmentation for Limbal Dermoid

To describe a modified technique of corneal tattooing for concomitant cosmetic rehabilitation in eyes with limbal dermoid. Case series. Three patients between 12 and 20 years of age with grade I limbal dermoid underwent shave excision with corneal tattooing. All patients had dark brown irides. Chemical keratopigmentation was performed over the bed using 2% gold chloride with 1% hydrazine hydrate as reducing agent to yield a dark brown color. Bandage contact lens was applied. Epithelium over the operated area healed by day 10. Visual acuity was maintained in all eyes with minimal change in keratometry. The dye was well retained in the tattooed area at 1 year. No complications such as infection, pseudopterygium, or local limbal stem-cell deficiency were observed. Corneal tattooing along with simple shave excision provides good cosmetic results in cases of limbal dermoids.

Effect of iris show on perceived upper eyelid height

ObjectiveTo introduce “iris show,” the amount of visible iris tissue between the superior pupil border and the upper eyelid margin, to evaluate the effect of iris show on perceived upper eyelid height, and to discuss potential nonsurgical treatment options for mild blepharoptosis. MethodsParticipants completed a survey containing 4 subject photographs. These photographs depicted images of varying iris colouration (blue, green, light brown, and dark brown) with identical upper eyelid marginal reflex distance (MRD1) values, but asymmetric pupil size/amount of visible iris show. Study participants were asked to select the eyelid that appeared “droopier,” or choose “same height.” Statistical analyses used 1-tailed and 2-tailed t tests. Results390 participants completed the survey. In photographs of blue and green irides, both eyelids had equal MRD1s, but the eyelid with less iris show was perceived as more ptotic (p = 0.002 and 0.03, respectively). In patients with dark brown irides, eyelid heights were perceived as identical despite differences in iris show (p = 0.002). ConclusionsDecreased iris show corresponds to perceived lowering of the upper eyelid in light-coloured irides (e.g., blue and green), but may be less impactful in brown and/or dark brown irides where the iris tissue is less distinguishable from the pupil. Topical instillation of apraclonidine may represent a nonsurgical option for treatment of mild blepharoptosis in patients with light irides as it both elevates the upper eyelid margin and induces miosis, resulting in an increase in iris show and corresponding enhanced perception of upper eyelid elevation.

Utility of 1% Tropicamide in Improving the Quality of Images for Tele-Screening of Diabetic Retinopathy in Patients with Dark Irides

ABSTRACTPurpose: To compare the quality of fundus photographs taken before and after instillation of one drop of tropicamide.Methods: The 45º fundus photographs were taken with a non-mydriatic fundus camera in three conditions of the pupil; pre-mydriatic, 10 minutes after one drop of tropicamide, and fully dilated. Two photographs were taken in each condition; one centered on the macula and the other on the optic disc. Two vitreoretinal specialists graded the images.Results: A total of 1768 fundus photographs of 149 diabetic patients with dark irides were included. There were more ungradable images (38.1% and 50.3%, graders 1 and 2, respectively) in the non-mydriatic state than partially- (4.6% and 11.5%) or fully-dilated (15.4% and 10.0%) conditions (p < 0.001, both graders). Partially and fully dilated states had similar rates of ungradable images (p = 0.56 and p = 0.54, graders 1 and 2, respectively). Test–retest reliability (repeatability) was 92.5% and 74.3% for the two graders, respectively. Inter-grader agreement was moderate (Kappa = 0.50).Conclusion: Non-mydriatic fundus photographs have a high rate of ungradable images in patients with dark irides. Instillation of only one drop of tropicamide improves the quality of fundus photographs, which is not furthered by adding more drops. This strategy can be used in tele-ophthalmology programs.

GUNN'S DOTS IN RETINAL IMAGES OF 2,286 ADOLESCENTS: Prevalence, Retinal Distribution and Associations.

To investigate the epidemiology of Gunn's dots and their associations in a population-based cohort of children. Red-free fundus photographs from 2,286 children aged 11 years to 14 years from the Sydney Myopia Study were graded. Gunn's dots were manually marked and counted within a 6 mm grid centered on the optic disc. One or more Gunn's dots were seen in at least one eye in 82.6% of children. The median number of Gunn's dots per eye was 46 (range 0-482). Most Gunn's dots were found inferior and superior of the optic disc (49.3% and 45.8%, respectively, of the total number of Gunn's dots in the population). The odds for having 1 or more Gunn's dots were 3-fold greater in children with dark brown irides compared with children with blue irides (odds ratio 2.99, 95% CI 1.81 to 4.94, P < 0.0001 adjusted for age, sex, retinal nerve fiber layer thickness, refraction, ethnicity, and axial length). In the same analysis, the presence of 1 or more Gunn's dots was less frequent in children with thin retinal nerve fiber layers (first quartile) compared with children with thick retinal nerve fiber layers (fourth quartile) (odds ratio 0.68, 95% CI 0.49-0.93, P = 0.016). No disease or disease-marker associations were identified. Gunn's dots were visible on fundus photographs in most of the school children, most of the dots being located inferiorly and superiorly to the optic disc. Fundus photographically visible Gunn's dots were associated with darker irides and thicker retinal nerve fiber layers. Gunn's dots are a common and apparently harmless finding in children. Assessment of their clinical significance will require long-term follow-up.

Association of iris surface features with iris parameters assessed by swept-source optical coherence tomography in Asian eyes

Background/aimsTo characterise the association of iris surface features (crypts, furrows and colour) with iris volume and curvature assessed by swept-source optical coherence tomography (SSOCT) in Asian eyes.MethodsIris crypts (by number...

Comparison of laser iridotomy using short duration 532-nm Nd: YAG laser (PASCAL) vs conventional laser in dark irides.

To evaluate the outcome of laser iridotomy using 532-nm Nd: YAG laser (PASCAL) with short pulse duration and Nd: YAG laser compared to conventional combined laser iridotomy. Retrospective, nonrandomized, comparative case series. Forty-five eyes of 34 patients underwent laser iridotomy. Twenty-two eyes underwent iridotomy using short duration PASCAL and Nd: YAG laser, and 23 eyes underwent iridotomy using conventional combined laser method. The average settings of PASCAL were 60 µm and 700-900 mW with a short duration of 0.01s to reduce the total applied energy. The conventional laser was 50 µm and 700-900 mW for 0.1s. After photocoagulation with these laser, the Nd: YAG laser was added in each group. Endothelial cell counts of pre-iridotomy and 2mo after iridotomy were measured and compared. All eyes completed iridotomy successfully. The total energy used in the PASCAL group was 1.85±1.17 J. Compared to conventional laser 13.25±1.67 J, the energy used was very small due to the short exposure time of PASCAL. Endothelial cell counts were reduced by 0.88% in the PASCAL group and 6.72% in the conventional laser group (P=0.044). The change in corneal endothelial cell counts before and after iridotomy was significant in conventional combined laser iridotomy group (P=0.004). Combined PASCAL and Nd:YAG laser iridotomy is an effective and safe technique in the dark brown irides of Asians. Furthermore, the short duration of exposure in PASCAL offers the advantages of reducing the total energy used and minimizing the corneal damage.

Acute Adult Onset Comitant Esotropia Associated with Accommodative Spasm

Acute onset comitant esotropia associated with spasm of accommodation in children and adults is a rare clinical condition. When occurring with pupillary miosis and restricted ocular motility, it is referred to as "spasm of near reflex" (SNR) and may require neurological investigation. The natural history of SNR depends on its etiology. There is little information in the literature regarding the long-term follow-up of SNR and the stability of visual signs and symptoms following cessation of treatment. We report a case of SNR in an otherwise healthy young male, and discuss the presentation, clinical investigations, management, response to treatment, and 1-year follow-up. A 23-year-old male patient reported to the clinic with sudden onset of blurred vision, inward deviation of the eyes, and binocular diplopia. On examination, he was diagnosed to have acute onset esotropia resulting from SNR. He was treated with cycloplegic medications and vision therapy. The condition resolved following 1 year and there has been no recurrence. Acute adult onset esotropia occurring with accommodative spasm responds favorably to cycloplegic medications but may need a longer course of treatment for successful resolution and stability.