Hirschberg Test Research Articles

A challenging case of scleral buckle-related restricted strabismus with unexpected good postoperative outcomes: A case report

Abstract Strabismus surgery in a scleral buckle patient is a challenging task that requires precise planning and meticulous surgical skills to accomplish a successful outcome. We report a case of a 32-year-old male who presented with complaints of diminution of vision in the right eye (RE) for 23 years and outward deviation of RE for 5 years after blunt trauma with a ball. The patient was diagnosed with RE total retinal detachment (RD) with traumatic retinal dialysis. He underwent scleral buckling as RD surgery in 2004 followed by silicon oil removal 6 months later elsewhere. On ocular examination of the RE, the best corrected visual acuity was perception of light with accurate projection of rays in all four quadrants, there was grade III relative afferent pupillary defect with an exotropia of 20° on Hirschberg test. The prism bar reflex test revealed an exotropia of 50 prism diopters (PD) [Figure 1]. An anterior segment examination revealed posterior subcapsular and cortical cataracts. After taking a retina clinic opinion, the patient underwent uneventful RE cataract surgery with in-bag implantation of a foldable implant cataract surgery first, followed by strabismus surgery under a guarded visual prognosis. Clinically significant adhesion and the presence of the scleral buckle posed a magnificent challenge during the strabismus surgery. The plan was improvised to 8 mm lateral rectus recession with 4 mm hang loose recession irrespective of a large deviation under local anesthesia. To our surprise, a satisfactory primary position alignment within 10 PD (orthophoria) was achieved, which was maintained on subsequent follow-up visits. We report an interesting and challenging case of restrictive strabismus due to scleral buckle which emphasizes that surgical procedures and their outcomes may not always align with expectations. Therefore, it is necessary to adopt a flexible and customized approach to effectively manage such instances.

Unrevealing abducens palsy vs. divergence insufficiency: A comprehensive review

Background: The article "Unraveling Abducens Palsy vs. Divergence Insufficiency" provides a comprehensive review of two common ophthalmological conditions, namely Abducens Palsy and Divergence Insufficiency. Aim: In this review article, we aim to unravel the key differences between these conditions, providing healthcare professionals with valuable insights for accurate diagnosis. It provides a comprehensive analysis of the clinical features, diagnostic criteria, etiology, and management strategies for each condition. Methods: A systematic literature search was conducted in electronic databases, including PubMed, MEDLINE, and Google Scholar. Case reports, clinical trials, observational studies, and review articles were considered. The extracted data included information on the clinical presentation, diagnostic tests, etiology, and treatment options for these conditions. Results: The authors emphasize the importance of a thorough ophthalmological examination, including the Hirschberg test and forced duction test, in diagnosing Abducens Palsy accurately. The article also explores the potential causes of Divergence Insufficiency, such as age-related changes and neurologic disorders. The management strategies for both conditions are thoroughly discussed, encompassing both conservative and surgical approaches. Conclusion: The authors present a comprehensive analysis of the clinical features, diagnostic criteria, and management strategies for these two conditions.It serves as a valuable resource for healthcare professionals, providing them with the necessary knowledge to accurately diagnose and manage Abducens Palsy and Divergence Insufficiency. Further research in this field is warranted to enhance our understanding of the underlying mechanisms and optimize treatment outcomes.

Effect of the prism and Maddox rod test as the surgical target for type III acute acquired comitant esotropia.

This study aims to explore more accurate and efficient examination methods to provide precise target surgical measurements for patients with type III acute acquired comitant esotropia (AACE). The study conducted a retrospective analysis of 108 patients diagnosed with AACE who received surgical treatment at the Department of Ophthalmology, the First Affiliated Hospital of Fujian Medical University, from January 2018 to September 2023. All patients underwent examinations of the deviation angle, including the Hirschberg test, prism and Maddox rod test (PMT), and prism and alternate cover test (PACT). For the PACT, the minimum value (PACTmin) and maximum value (PACTmax) were obtained based on differences in examination methods, as well as the deviation angle range (PACT range), which represents the difference between PACTmax and PACTmin. Postoperatively, these patients were followed up for at least 6 months to assess changes in eye position and whether diplopia symptoms recurred. In both near and distant examinations, the results of PACTmax were significantly greater than those of PACTmin (p < 0.001), while the deviation angles obtained from PACTmax and PMT showed no significant statistical difference [p = 0.689 (33 cm), p = 0.436 (5 m)]. There was a strong linear correlation between PACTmin and PMT at both near (R = 0.8887) and distant (R = 0.8950) distances, but each PACTmin corresponded to multiple PMT values. There was no significant difference between the results of PACT range at near and distant distances (p = 0.531). The deviation angles obtained by PMT and PACTmin significantly decreased postoperatively compared to preoperative values, and diplopia disappeared in all patients, with alternative cover test showing no movement or presenting as an esophoria state. The PMT can provide precise target surgical measurements for type III AACE, making it a fast, effective, and cost-efficient examination method. It is worthy of being promoted and applied in clinical practice.

A Case of Moyamoya Disease in Morning Glory Syndrome

Purpose: We report a diagnosis of Moyamoya disease based on brain magnetic resonance imaging (MRI) and brain magnetic resonance angiography (MRA) performed in a child diagnosed with morning glory syndrome.Case summary: A 6-year-old boy visited the hospital with a chief complaint of exodeviation of his left eye that started at 1 year of age. The corrected visual acuity was 20/30 in the right eye and 20/400 in the left. The Krimsky test showed exotropia of 35 prism diopters (PD) for near vision and 30 PD for distance. Fundus photography showed an enlarged optic disc with funnel-shaped excavation in the left eye. With a diagnosis of morning glory syndrome accompanied by exotropia, the patient underwent brain MRI and brain MRA. The patient had no neurological symptoms such as headache and muscle weakness. Moyamoya disease was diagnosed, as brain MRI and MRA showed tiny tortuous vessels forming collateral vessels from the lenticulostriatal arteries, left posterior cerebral artery, and left middle meningeal artery, which originated from the external carotid artery.Conclusions: Moyamoya disease can occur in children with morning glory disease. Brain MRI and MRA can help to diagnose Moyamoya disease. Caution is needed because transient ischemic attack, cerebral infarction, and cerebral hemorrhage may occur in patients with Moyamoya disease.

SUCCESSFUL DIFFERENT TREATMENT IN INTERMITTENT EXOTROPIA: CASE SERIES

Introduction : In intermittent exotropia, management's goals are to diminish deviation by improving fusion control.&#x0D; Case Illustration : Case 1: A 19-year-old woman has complained of squinting and blurred vision since the age of 3 years. The visual acuity of both eyes (OU) was 0.05, with a BCVA of 0.63. Hirschberg's test was exotropia 15o . The exotropia after the cover test (Figure 1A) improved without blinking. The prism cover test was 35 D in near and distance. Patient was diagnosed with exotropia, an intermittent basic type with good control, astigmatism, and myopia compositus OU. Three months after, with refraction correction and occlusion, the Hirschberg test revealed orthotropia (Figure 1B). Case 2: A 7-year-old boy has suffered of squinting and blurred vision from the age of 6 years. The visual acuity of both eyes was 0.63 with a BCVA of 1.0. Hirschberg's test was exotropia 30° (Figure 2A). The prism cover test was 50 D in near and distance. Exotropia intermittent basic type, poor control, and bilateral astigmatism were diagnosed in the patients. The patient had surgery for bilateral lateral rectus recession. Hirschberg test 1 day Postoperatively, orthotropia was present (Figure 2B).&#x0D; Discussion : In exodeviation, control mechanisms relate to therapy compliance and different deviation angles. Intermittent exotropia can be progressive due to loss of fusion control and cause persistent deviation.&#x0D; Conclusion : For patients with exotropia with intermittent good control, non-surgical management can give good results. Surgical management is considered for large angle deviations in patients with poor control.

Hemi-Jensen Procedure as Heavy Eye Syndrome Treatment: A Case Series

Introduction : Heavy eye syndrome is an acquired myopia-associated strabismus characterized by esotropia and hypotropia accompanied by abduction and elevation limitations. This case series reports two heavy eye syndrome patients that underwent hemi-Jensen procedure combined with medial rectus recession with good postoperative result.&#x0D; Case Illustration : A 60-year-old female had right eye (RE) fixed inward and bilateral high myopia (S-13.00 D). RE Hirschberg test: &gt;45° esotropia and hypotropia and RE axial length (AL) 28.3 mm. Second patient, a 53-year-old female, had both eyes fixed inward and bilateral high myopia (S-12.00 D). Both eyes Hirschberg test: &gt;45° esotropia and hypotropia, left eye AL 31.4 mm, and prephthisis RE. Intraoperative identification of both patients revealed displacement of superior and lateral rectus muscles. No surgery performed on prephthisis eye. Hemi-Jensen procedure combined with medial rectus recession resulted in orthophoria (first patient) and central position in primary gaze (second patient), with improved ocular motility on both patients.&#x0D; Discussion : Heavy eye syndrome occurs in eyes with high myopia. The elongated globe in high myopia results in superotemporal herniation of the globe and superior and lateral rectus muscles displacement, which increases depression and adduction force. Hemi-Jensen procedure is a loop myopexy procedure which corrects the deviated muscle paths in heavy eye syndrome. Concurrent medial rectus recession can be performed with hemi-Jensen procedure if there is likely contracture of medial rectus.&#x0D; Conclusion : Heavy eye syndrome is a strabismus fixus condition which occurs in eyes with high myopia. Hemi- Jensen procedure is an effective treatment for heavy eye syndrome which improves ocular alignment and motility.

SUCESSFULL MANAGEMENT OF CHILDHOOD BASIC-TYPE ESOTROPIA IN ADULT PATIENT

Introduction : Strabismus in adults may indicate other pathological causes, such as neurological disorders or trauma. Diagnosis of esotropia in adult patients has to be made carefully to determine the right treatment. Management’s goal of strabismus in adult patients is mainly cosmetic by diminishing deviation.&#x0D; Case Illustration : A 46-year-old woman, complaint of inward deviation of both eyes since childhood. There were no complaints of double vision, headaches, nor trauma history. Visual acuity of right eye was 0.4 with BCVA and left eye was 0.8 with BCVA 0.8. Hirschberg test was 45o (Figure 2A). Prism cover test was 75 PD base out in near and distance. Patient was diagnosed with basic-type esotropia. The patient already given spectacles but the deviation persisted so she underwent bilateral medial rectus recess surgery (Figure 2B). Ocular alignment without spectacles 1 week after surgery showed orthotropia and small esophoria. (Figure 2C).&#x0D; Discussion : Each esotropia types has a different treatment approach. Basic-type esotropia with large deviation usually needs surgical treatment. Management of childhood onset strabismus in adult patients is challenging because those patients have lesser ability to maintain fusion. Older patients and large deviation are poor prognostic factors to achieve good functional and cosmetics outcome after strabismus surgery.&#x0D; Conclusion : Establishing a definite diagnosis in adult strabismus patients, including esotropia, is challenging. Careful diagnosis and management decision will determine the outcome of the patient’s condition.

A GOOD RESULT IN COMBINATION OF LARGE SUPERIOR RECTUS RECESSION AND PRISMATIC GLASSES IN UNILATERAL DISSOCIATION VERTICAL DEVIATION: A CASE REPORT

Introduction : Severe DVD is one of the indications for surgery. There are guidelines recommended for management based on grading of severity and the surgeon’s preference. Large recession of superior rectus muscle and prismatic glasses yield good result in unilateral DVD reported in this paper.&#x0D; Case Illustration : A 21 year-old student stated difficulty in working with his microscope since 2 years ago. He had a history of double vision since childhood. The visual acuity in both eyes were 5/5. Qualitative strabismus examination resulted in hypertropia RE and intermittent exotropia. When the occluder was removed from RE, a non fixating eye would appear elevated and did not correspond with the contralateral eye hypotropia. Krimsky test revealed RE hypertropia 30? PD, exotropia 10? PD. Sensory evaluation using WFDT was normal in near and crossed diplopia in distance. Patient diagnosed with unilateral DVD then underwent superior rectus recession in 10 mm. The following month, patient was still experiencing vertical diplopia. The patient was given 3 PD prismatic glasses. Consequently, diplopia was absent and stereoacuity test using TNO was 480 seconds of arch&#x0D; Discussion : DVD can’t be fully corrected by surgery due to central cortical innervational problem. The residual symptom can be corrected by conservative management. Large SR recession in combination with prismatic glasses was found to improve vertical deviation and reduce diplopia.&#x0D; Conclusion : While large superior rectus recession can significantly improve vertical deviation, it can not completely remove binocular symptom

Surgical Strategies for Divergence Excess: A Comparison of True Divergence Excess and Pseudo-Divergence Excess Cases

Introduction : True divergence excess (True DE) intermitent exotropia (IXT) is characterized by a greater deviation at distance than near ?10 prism diopters, while pseudo-divergence excess (Pseudo-DE) has greater deviation at distance than near but the difference becomes minimal after patching. Bilateral Lateral Recess (BLR) and Monocular Recess Resect (MRR) are commonly chosen for surgical planning.&#x0D; Case Illustration : Case 1, a 4-year-old female presented with squint since 1 year old. Hirschberg test showed XT 15° in near (N) and 30° in distance (D). Prism alternate cover test (PACT) result was 30 ?D (N) and 60 ?D (D). Case 2, a 4-year-old female presented with squint since 6 months old. Hirschberg test showed XT 30° (N) and 45° (D) and dominant right eye. PACT result was 70 ?D (N) and 80 ?D (D). Poor fusion was found in both cases. Both patients underwent monocular patching for 30 minutes. We diagnosed patient 1 with True DE and BLR was done, while patient 2 with IXT dominant right eye Pseudo-DE and MRR was done on the left eye.&#x0D; Discussion : First case was a patient with True DE who underwent 8-mm BLR, while second case was Pseudo-DE with dominant right eye who underwent monocular recess 11 mm and resection 8 mm on the left eye. Orthophoria was found after surgical correction in both cases.&#x0D; Conclusion : Surgery management in True DE and Pseudo-DE are challenging, especially in determining the amount of surgery dosage and it depends on surgeon's experience. Both cases achieved successful outcomes with surgical correction resulted in orthophoria.

Frequency of Strabismus with Down Syndrome

Background: To assess the frequency of deviation in eyes in Down Syndrome patients and also to determine the type of deviation in each eye.&#x0D; Objective(s): The purpose of this study was how frequent the strabismus is among the Down Syndrome patients.&#x0D; Methodology: The related study was carried out at Shadaab Special School, Lahore. A self-designed Performa was used to gather the data that mainly includes the type of strabismus, findings of the Hirschberg test and cover uncover test. Strabismus was assessed with the pen torch used to determine the findings of cover test, Hirschberg test and cover uncover test. Then we used IBM SPSS Version for entering and analysing the data.&#x0D; Results: A total of 60 patients took part in this research with a gender split of 36 male and 24 female varying in age from 2-18y.These are categorized into 4 age groups. The patients with DS had high prevalence in age group of teens (13-18 years) 51.70%. 41.70% of deviation was in school going children (6-12 years). Pre-school children (3.5-5 years) and toddlers (2-3 years) had 3.3% of misalignment. Strabismus was found in 36 (60%) males and 24 (24%) females. Esotropic deviation was assessed in 25 (67.57%) and exotropia deviation in 9 (24.32%) in RE. In LE esotropic deviation was found in 14 (60.86%) and exotropic deviation in 7 (30.43%).&#x0D; Conclusion(s): This study showed that strabismus in DS Patients were more prevalent in males as compared to females. Esodeviation was the commonest type in DS Patients.

A new method based on deep learning and image processing for detection of strabismus with the Hirschberg test

Strabismus is a condition in which one or both eyes do not work in parallel or in harmony. People with strabismus have one eye looking straight ahead while the other eye looks inwards, outwards, upwards or downwards. This condition can affect both eyes. Strabismus is a common eye condition that affects about 4 % of the world's population. Tests such as Hirschberg, Cover and Krimsky are used to detect strabismus. In the Hirschberg test, a light source is held at a distance of 50 cm so that it falls on the centre of each eye. The horizontal and vertical distance between the centre of gravity of the light reflected from the cornea and the centre of the pupil indicates the degree of strabismus. In this study, deep learning and image processing algorithms are used to detect the eye, corneal reflection, iris and pupil on a patient's facial image. Based on the Hirschberg test, the horizontal and vertical shifts for both eyes were measured to determine the patient's degree of strabismus. In this way, the Hirschberg test used in strabismus screening was performed automatically by software. The correct detection of the pupil and the light reflected from the cornea by the algorithm means that the eye has been measured correctly. The software was tested on the facial images of 88 strabismic patients of different sexes and ages. 91 % of the 88 patients, or 80 patients, had their left eye measured correctly. 90 % of the 88 patients, or 79 patients, had their right eye measured correctly. The results for each eye obtained from the correct measurements were found to have an error of maximum ± 2°. This error is due to the fact that a real eye is in three-dimensional space, while the digital eye image is in two-dimensional space, and was only observed in the test results of some patients. This algorithm can be tested on patients of all ages and is not affected by morphological differences in the patients' faces. Successful results have been observed experimentally that this newly proposed method can be used in strabismus screening.

Modelling a vision screening module in a sample population of non-eye care practitioner in MSU Shah Alam, Selangor (A Pilot Study)

Purpose: To investigate the reliability of new model of vision screening module in one sample population in MSU, Shah Alam. Methods: This is cross sectional study with ten subjects who were non-eye care practitioner which were MSU students, aged 19 to 21 years old. They were divided into two groups, first group were participated in training and the other group were not be trained. The subjects required to perform the vision screening based on provided module. Result: There are no significant different on the finding between trained and non-trained non eye care practitioner for all three tests (visual acuity test, colour blindness test, Hirschberg test). However, the time taken for trained eye care practitioner to do the vision screening is no significant difference comparing to non-trained non-eye care practitioner. Conclusion: This study provide initial evidence that new model of vision screening module are reliable to be used by non-eye care practitioner. Furthermore, a standardized vision screening module will be benefited to the community especially to the underserved community as they have difficulty in accessing the health care services.

SUCCESSFUL MANAGEMENT OF HYPERTROPIA RELATED THYROID EYE DISEASE WITH HEMI HANG-BACK PROCEDURE

Introduction: Hypertropia in thyroid eye disease (TED) is uncommon condition which may cause visual and aesthetical problem with quality of life disturbance. Case Illustration: A 44-year-old woman presented with a squint on the right eye with bilateral diplopia for 18 months. She had history of hyperthyroidism for two years which had been treated with thiamazole and propanolol for 1 year and methylprednisolone for 6 months. Visual acuity of both eyes was 20/20 with no sign of active inflammation and optic neuropathy. Ocular motility showed restriction in lateral and down gaze. Inferior restriction was found in forced duction test. Hypertropia of 40 prism diopters was remarkably seen in Krimsky test. We performed strabismus surgery after patient was in inactive stage and reach euthyroid state without treatment for 6 months. During surgery we found muscle enlargement and fibrous tissue of superior rectus muscle. Superior rectus recession for six milimeters with additional hemi-hang back procedure for two milimeters had been performed with significant improvement of diplopia. Ocular motility exercise was suggested to reach binocular vision. Discussion: Hypertropia in TED was caused by extraocular muscle fibrosis due to inflammation and lymphocytic infiltration. Strabismus surgery was aimed at diplopia correction in primary position. Surgical procedure, extra ocular muscles in which surgery must be done and its surgical dosage should be considered carefully. Conclusion: This case showed restrictive hypertropia in TED with distressing symptoms and challenging management. Hemi hang-back procedure is should be considered in difficult case.

Rescue of exotropia subsequent to pulled-in-two syndrome of the medial rectus muscle occurring during surgery for high myopic strabismus fixus: A case report

Pulled-in-two syndrome is one of the significant complications of strabismus surgery. This study aimed to report a case of pulled-in-two syndrome of the contractured medial rectus muscle (MR) that occurred during strabismus surgery for strabismus fixus due to high myopia, and to describe a rescue of this complication. A woman in her 60s presented to our Ophthalmology Department with the main complaint of unilateral high myopia and severe myopic strabismus fixus. Esotropia exceeded 45° and hypotropia exceeded 15° in her right eye in the Hirschberg test. Right eye duction was markedly limited in every gaze direction. Orbital magnetic resonance images showed rupture of the superior rectus to lateral rectus band ligament and lengthening of the distance between the SR and LR muscles in the right eye. Due to the patient's ophthalmic examination and imaging results, she was diagnosed with high myopic strabismus fixus. We performed MR recession and Yokoyama surgery to correct right eye hypoesotropia. In the MR recession procedure, pulled-in-two syndrome (MR muscle tear) occurred. Thus, no additional procedure was performed on the MR. After the surgery, she presented 45 prism diopter exotropia and 18 prism diopter residual right hypotropia in a Krimsky test. We performed a second surgery, combining MR muscle advancement and inferior rectus (IR) muscle recession, 3 months after the first surgery. One and a half years after the second surgery, she presented exotropia of 14 prism diopters without hypotropia in the Krimsky test and was satisfied with her ocular position and improved motility. We experienced pulled-in-two syndrome in a case with severe myopic strabismus fixus and achieved a good outcome by performing additional surgery 3 months later, in which the lost MR muscle was advanced. This case underscores that, if the lost muscle cannot be found during surgery, one should maintain composure and perform a reoperation a few months after the initial surgery, if necessary. This case report can aid in making rescue treatment decisions when pulled-in-two syndrome occurs.

The role of elimination of functional scotoma in the treatment of comitant strabismus (clinic case)

INTRODUCTION. Long-term strabismus causes various complications, one of which is functional scotoma or binocular haploscopic suppression. PURPOSE: The main purpose of this article is to show that the elimination of a functional scotoma caused by a complication of strabismus is very important for the elimination of strabismus. MATERIAL AND METODS: A 15-year-old schoolboy with complaints of internal strabismus came to our clinic for surgical correction of strabismus. The patient underwent standard eye examinations and was checked whether or not have movement restrictions in the muscles that move the eyeball. The degree of deviation was measured by Hirschberg's test, alternating prismatic cover test according to generally accepted rules. The examination of the objective angle of strabismus was carried out in the synoptophore. The subjective angle of strabismus, as well as the presence of haploscopic binocular vision, was examined both in the synoptophore and in the "Klinok" computer program. In order to prepare for the operation, appropriate therapeutic exercises were prescribed in the synoptophore and in a special computer program to restore haploscopic binocular vision.RESULTS: BCVA OD=0.9; OS=0.8; EZO 30PD without correction, 15PD with correction. Binocular haploscopic suppression was found. After a 10-day course of orthooptic treatment, haploscopic binocular vision was restored. Deviation angles decreased both without correction and with correction. After a course of diploptic treatment, carried out after a 1-month break, normal binocular vision with correction was achieved. CONCLUSION: Elimination of functional scotoma and restoration of haploscopic binocular vision facilitates the subsequent stages of strabismus treatment, sometimes allowing to obtain normal binocular vision and achieve orthotropy even without surgical operation.

The effects of hydroxyapatite implantation with the autogenous sclera cap: A cohort study

We performed a novel hydroxyapatite (HA) prosthesis implantation method in which an HA implant was implanted into the scleral shell with an autogenous scleral cap.Twenty-six patients who had undergone the novel HA prosthesis implantation method and 32 patients who had undergone traditional HA prosthesis implantation were retrospectively reviewed. The postoperative activity of the artificial eye was measured by the Hirschberg test combined with arc perimetry. The visual analog score (VAS) was used to evaluate 2-month postoperative pain and 2-month postoperative discomfort. HA implant vascularization was measured with enhanced magnetic resonance imaging (MRI) 2 and 6 months after the operation. The enhancement volume (VE) and the volume of the HA implant (VHA) were measured. All cases were followed up for 2 years. Measurement data were processed using SAS 6.12.There was a statistically significant difference (P = .016) between the percentages of excellent grade in the two groups. Two months after implantation, the median pain scores of the study and control groups were 2 and 2.5, respectively, and there was a statistically significant difference (W = 585.0, P = .004); there was a statistically significant difference (W = 535.5, P = .000) between the median discomfort scores of the study group (score = 1) and control group (score = 2); the mean VE/VHA values of the study and control groups were 0.3075 and 0.1535, respectively, and there was a statistically significant difference (t = −8.196, P = .000). Six months after implantation, the VE/VHA values of the study and control groups were 0.9686 and 0.5934, respectively, and there was a statistically significant difference (W = 549.0, P = .000). Within 2 years of postoperative follow-up, there were no serious complications in the study group.In the study group, in which the hydroxyapatite implant was implanted into a preserved scleral shell with unaltered muscles and covered with an autogenous scleral cap, postoperative activity and the fibrovascularization of the HA implant were significantly increased, and postoperative pain and discomfort were significantly reduced.

Tolosa-Hunt Syndrome with Multiple Orbital Myositis in a Patient with Crohn’s Disease

Purpose: We report a case of Tolosa-Hunt syndrome with multiple orbital myositis identified via orbital magnetic resonance imaging in a patient with Crohn's disease who developed right eye pain and binocular horizontal diplopia.Case summary: A 46-year-old woman visited our clinic with a 2-month history of right eye pain and migraine, as well as a 3-day history of acute horizontal diplopia. She had previously been diagnosed with Crohn's disease and was taking immunosuppressive drugs. In the eye movement test, esotropia and an abduction limitation of -3.0 in the right eye were observed on the Krimsky test. There were no specific findings in anterior segment and fundus examinations. Orbital magnetic resonance imaging showed multiple extraocular muscle enhancement in the right eye and multiple extraocular muscle hypertrophy in the left eye. The patient was diagnosed with binocular multiple orbital myositis and right Tolosa-Hunt syndrome; she was treated with high-dose steroids for 3 days followed by lower dose oral medications. During the first week of treatment, the right eye pain disappeared and the right eye abduction limitation showed slight improvement. After 3 months of treatment, the right eye abduction limitation and esotropia completely disappeared.Conclusions: Orbital myositis and Tolosa-Hunt syndrome are idiopathic, nonspecific chronic granulomatous diseases with painful ophthalmoplegia. We describe a rare case in which the two diseases appear together.

Validity of vision screening program conducted by preschool teachers: An interventional study.

Clear vision is crucial for effective learning among preschool children. Hence, early detection of vision impairment and prompt treatment are required to improve prognosis. Currently, limited information is available, and no program exists to screen for vision impairment among preschoolers in Bangladesh. This study aimed to validate the KieVision™ Preschool Vision Screening Kit, translated into the Bengali language, to improve vision impairment detection among preschool children. In this prospective case-control study, 60 preschool teachers from Chittagong were randomly selected. The study group was trained to conduct vision screening among preschool children using the translated kit, whereas the control group was trained using the Chittagong Eye Infirmary and Training Complex (CEITC) School Teachers' Training Module. Fifteen preschool children aged 4-6 years were screened by each preschool teacher and again by the optometrist. Sixty preschool teachers screened 900 children. The results showed a higher validity of vision screening findings by the preschool teachers in the study group (sensitivity, 68.00%; specificity, 92.75%) than in the control group (sensitivity 47.37%, specificity 70.39%). The level of agreement between the preschool teachers and optometrists was high for all tests (first-order agreement coefficient [AC1] ≥ 0.80 in the study group). The sensitivity and specificity of the visual acuity test for the study group were 59.65% and 94.15%, respectively, while in the control group it was 13.33% and 62.54%, respectively. A similar trend was noted in the general observation component and Hirschberg's test. The Bengali Language KieVision™ Preschool Vision Screening Kit can be used effectively by preschool teachers in vision screening programs to improve the identification of vision impairment among preschool children in Bangladesh.

Побочные эффекты при лечении косоглазия у детей ботулиническим токсином типа А

Background: the use of botulinum toxin type A (BTA) in ophthalmology for extraocular disorders in children and adults became possible was pioneered by A. Scott in the 1980s. Lack of experience and understudied risks of this treatment modality in Russia prevent the introduction of chemodenervation into daily ophthalmic practice. In addition, several adverse reactions of BTA were reported. Therefore, these adverse reactions should be considered when choosing this treatment in adults and children. Aim: to assess the efficiency and adverse reactions of BTA when treating strabismus in children. Patients and Methods: 212 children (424 eyes) aged seven months to 15 years with estab-lished strabismus were enrolled. Visual fixation and acuity were measured before BTA injection. BTA was injected in horizontal extraocular muscles (average dose 3.40 U). Results: the average angle of strabismus was 33.28±12.96°, the average angle of eso-tropia was 33.69±12.86°, the average angle of exotropia was 31.50±13.41°. Neutralization of strabismus angle was achieved in 92.2%, a reduction in strabismus angle was reported in 7.8%. In total, 288 procedures were performed. 76 patients (35.85%) required re-surgeries. In most cases, re-chemodenervation was performed in children with a strabismus angle &gt;25° (Hirschberg test). Adverse reactions of chemodenervation were blepharoptosis (2.83%), hypereffect (17.45%), conjunctival redness, and edema at the injection sites. These adverse reactions were self-limited, no specific treatment was needed. Conclusion: chemodenervation by BTA injection in hyperfunctional extraocular muscles is a highly effective, non-traumatic, and safe treatment for strabismus in children. All adverse reactions identified by our study were transient. Keywords: botulinum toxin type A, postoperative complications, strabismus, nystagmus, extraocular disorders, chemodenervation. For citation: Sidorenko E.E., Ostanina I.A., Rosel’o K.N.M. et al. Adverse reactions of botulinum toxin type A for treating strabismus in children. Russian Journal of Clinical Ophthalmology. 2022;22(2):145–148 (in Russ.). DOI: 10.32364/2311-7729-2022-22-2-145-148.

Myopia and Myopic Astigmatism in school-children

Worldwide, there is an epidemic increase in myopia. In children, the evidence points to a lack of ex posure to natural light. In Chile, the population situation of myopia in children is unknown. Objec tive: To estimate the tendency of myopia and myopic astigmatism in 1st- and 6th-grade students from the public education system in Chile. Ecological study based on diagnostic confirmations of the JUNAEB Medical Services Program, between 2012 and 2018. Annual country prevalence of myopia and astigmatism was estimated by region and sex. The screening evaluation included visual acuity using Snellen Eye Abbreviated chart, red reflex, Hirschberg test, Titmus test, Cover test, ocular motility, and anterior segment examination. Chi2 and logistic regression were used to assess differences and linear regression to estimate average annual change. Between 2012 and 2018, myopia and myopic astigmatism had a heterogeneous geographical presentation. Myopia and myopic astigmatism ≥ 3 dioptres increased by an annual average of 0.11% (R2 0.67) and 1.21% (R2 0.90), respectively, in 1st-grade children and by 0.2% (R2 0.65) and 8.7% (R2 0.79), respectively, in 6th-grade children. Myopia < 3 dioptres decreased by 0.13% annual average (R2 0.45) in 1st-grade children and myopic astigmatism < 3 dioptres by 0.5% (R2 0.53) in 6th-grade children. High myopic astigmatism affected men more than women and myopia < 3 dioptres affected more 6th-grade females. In schoolchildren of the public education system, myopia and myopic astigmatism > 3 dioptres tend to increase. The protective effect of natural light against myopia has been demonstrated in longitudinal and experimental studies. This evidence is to be considered in promoting children's time spent outdoors.