Ocular Misalignment Research Articles

Deep Learning Model for Static Ocular Torsion Detection Using Synthetically Generated Fundus Images.

The objective of the study is to develop deep learning models using synthetic fundus images to assess the direction (intorsion versus extorsion) and amount (physiologic versus pathologic) of static ocular torsion. Static ocular torsion assessment is an important clinical tool for classifying vertical ocular misalignment; however, current methods are time-intensive with steep learning curves for frontline providers. We used a dataset (n = 276) of right eye fundus images. The disc-foveal angle was calculated using ImageJ to generate synthetic images via image rotation. Using synthetic datasets (n = 12,740 images per model) and transfer learning (the reuse of a pretrained deep learning model on a new task), we developed a binary classifier (intorsion versus extorsion) and a multiclass classifier (physiologic versus pathologic intorsion and extorsion). Model performance was evaluated on unseen synthetic and nonsynthetic data. On the synthetic dataset, the binary classifier had an accuracy and area under the receiver operating characteristic curve (AUROC) of 0.92 and 0.98, respectively, whereas the multiclass classifier had an accuracy and AUROC of 0.77 and 0.94, respectively. The binary classifier generalized well on the nonsynthetic data (accuracy = 0.94; AUROC = 1.00). The direction of static ocular torsion can be detected from synthetic fundus images using deep learning methods, which is key to differentiate between vestibular misalignment (skew deviation) and ocular muscle misalignment (superior oblique palsies). Given the robust performance of our models on real fundus images, similar strategies can be adopted for deep learning research in rare neuro-ophthalmologic diseases with limited datasets.

Strategies for managing strabismus from oculomotor nerve palsy

Addressing ocular misalignment secondary to partial and complete oculomotor nerve palsy presents a special challenge to the strabismus surgeon, particularly when treating patients with binocular diplopia. We review the reported surgical options and, through illustrative cases, provide our own perspective on managing this disorder.

VERBAL AND VISUAL INTERPRETATION OF PICTURES EMBEDDED WITH RELEVANT SIGNS AND SYMPTOMS OF EYE PROBLEMS

There is a recognised need for a questionnaire playing a crucial role in eye care. Substantial research has been undertaken on the role of a questionnaire assessing the vision-related quality of life. However, the need for pictures to be embedded as a part of the questionnaires has not been recognised. This study investigated the verbal and visual interpretation of pictures about signs and symptoms of eye problems. 60 subjects aged 18 to 40 years old were recruited using convenient sampling in this cross-sectional study. Sixteen pictures representing three domains (physical signs, behavioural signs and visual- related activity) were included. The verbal interpretation was recorded for each picture. The visual interpretation was recorded as fixation count and duration using a heat map for three pictures representing each domain. All pictures (100%) under the physical signs category provided a high percentage (more than 80%) of correct verbal responses. A significant difference in the verbal responses was found between gender and two different levels of education for behavioural signs and visual-related activity pictures (p<0.05). Significantly longer fixation duration was found among respondents who provided incorrect verbal responses compared to correct verbal responses (p<0.05). A simple picture with direct information like ocular misalignment was more interpretable than a picture with abstract information like ‘glare’ and ‘writing up and downhill’. Both verbal and visual interpretations of the picture are closely correlated. Therefore, selecting pictures of eye care questionnaires for the general population should consider a minimum cognitive load to improve interpretability.

Automated Detection of Horizontal Strabismus and Home Control Evaluation Using a Mobile Phone App

Purpose: To evaluate the reliability, validity, and usability of a mobile phone app that captures facial images to identify strabismus.Methods: We enrolled patients who visited our pediatric strabismus clinic and provided consent for participation in the study. The facial photographs of the patients were automatically captured by the app. The app used the photographs to identify ocular misalignment based on the comparison of the positions of the corneal reflex and limbus of both eyes. The results from the app were compared to the physician’s diagnosis. Intraclass correlation coefficients were used to assess the test-retest and interrater reliability of the app. Additionally, the guardians captured photographs of the patients through this app for 1 month at home to evaluate the frequency of manifest exotropia at home. And the results were compared to those of other strabismus control scales.Results: A total of 103 patients were enrolled and 10 patients were enrolled for the home control test. Based on the physician’s diagnosis, the sensitivity, specificity, positive predictive value, and negative predictive value of the app were 74.6%, 87.5%, 90.4%, and 68.6%, respectively. The interclass correlation coefficients for inter-rater and test-retest reliability were 0.801 (<i>p</i> = 0.011) and 0.828 (<i>p</i> < 0.001), respectively. The frequency of intermittent exotropia recorded by the app at home showed a strong positive correlation with other control scales (rho > 0.770, <i>p</i> = 0.009).Conclusions: This mobile phone app is easily accessible and useful for the rapid determination and recording of strabismus, particularly in uncooperative patients. Also, this app may be used as a reliable indicator of the frequency of manifest strabismus at home.

PREVALENCE OF STRABISMUS IN CHILDREN ATTENDING A TERTIARY CARE HOSPITAL IN KASHMIR

Background: Strabismus is an ocular condition wherein the visual axis of two eyes do not meet at an object of regard, with esotropia being the most common pattern of strabismus. Aim: To nd the prevalence of strabismus in children between 5-20 years of age attending the OPD of Department of Ophthalmology, Government Medical College, Srinagar. Methods: This was a cross-sectional study wherein 3000 patients between the age group of 5-20 years attending the OPD of a tertiary care centre from august 2019 to august 2021 were taken into consideration. Proper birth history and family history was taken from these patients. Proper ophthalmological examination was done which included uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA). Ocular misalignment was diagnosed by cover uncover test and angle of deviation was measured by prism bar test. Results: Out of 3000 patients, only 60 patients were found to have strabismus with overall prevalence of strabismus in our study being 2%. In our study, 66.7% cases were girls and 33.3% cases were boys. Esotropia was most prevalent form of strabismus accounting for 60% of cases followed by exotropia accounting for 40% cases Conclusion: Our study indicated the prevalence of strabismus as 2%. Proper screening, early detection and adequate management of ocular misalignment can help in reducing the burden of strabismus in the population

Vision characteristics of Special Olympics athletes seen at the United States National Games 2010-2018.

Special Olympics International (SOI) has provided eye assessments at no cost to athletes participating in competitions through the Special Olympics Lions Clubs International Foundation Opening Eyes (OE) programme. Access to vision services is crucial given the high rates of eye abnormalities found in studies collected at OE programmes in other countries. As of 2022, no studies covering vision data have been published on SOI athletes specifically from the USA. Therefore, this multiple cross-sectional study hopes to investigate the vision profile of US athletes over three national games, detecting any changes in vision and ocular health outcomes over an 8-year period. Vision assessments were conducted in the US national games of 2010, 2014 and 2018. Demographic and clinical data from 1427 vision assessments were used in this study. Prevalence of vision and ocular health abnormalities were compared across national games. In our cohort of 1427 assessments with athletes' mean age±SD of 29.8±11.5years, 85.3% (n=1170) had an abnormal vision result with at least one of the following findings: decreased visual acuity of 20/40 or worse (31.0%, n=442), refractive error including myopia (52.8%, n=754), hypermetropia (15.7%, n=224), and astigmatism (35.0%, n=499), ocular misalignment distant (16.2%, n=224) or near (17.2%, n=239), or ocular abnormality (19.1%, n=273). This study demonstrates the burden of vision defects and ocular disease in US SOI athletes over the past decade. While continued effort must be made to train eye providers in caring for patients with ID to increase eyecare accessibility outside of SOI, vision assessments at national games can continue providing opportunities for improved ocular health in children and adults with ID.

Concomitant Unilateral Duane Retraction Syndrome and Contralateral Brown’s Syndrome

ABSTRACT A 10-year-old boy was introduced with a chief complaint of ocular misalignment from birth. Ocular examination indicated right Brown and left Duane retraction syndrome in a non-familial pattern. We suspect that a teratogenic damage or genetic mutation may be responsible for this combination.

Superior rectus recession for vertical strabismus with limitation of depression in abduction

Ocular misalignment can occur from a tight vertical rectus muscle, as is seen with thyroid eye disease. Hypertropia from a tight superior rectus is less common, but would show an increase in vertical deviation in the field of action opposite the involved muscle. We report outcomes of superior rectus recession for hypertropia increasing in downgaze.

Nystagmus in Down Syndrome - a Retrospective Notes Review.

Introduction:Nystagmus has been reported in up to 30% of people with Down Syndrome (DS), and yet is still not well understood. Our study aims to characterise the clinical features of patients with DS and nystagmus.Methods:A retrospective medical-records review was conducted of all patients with a diagnosis of DS and nystagmus seen at Moorfields Eye Hospital over a ten-year period.Results:Fifty-one subjects were identified, with complete data in 48. The mean age at presentation was 5.1 years (range 0–26 years). The mean binocular LogMAR visual acuity was 0.55(95%CI 0.53–0.57), mean refractive error was –1.8 Dioptre Sphere, DS (95% CI – 5.251.63) with –1.2 Dioptre Cylinder, DC (95% CI – 1.6–0.7). Ocular misalignment was found in 50% of patients. A diagnosis of Fusion Maldevelopment Nystagmus Syndrome (FMNS) was made in 6.3%, Infantile Nystagmus Syndrome (INS) in 8.4% and ABducting nystagmus/Inter-Nuclear Ophthalmoplegia (INO) in 2.1%. The descriptive term ‘Manifest Horizontal Nystagmus’(MNH) was used in the majority, highlighting the difficulties in clinically differentiating the subtypes of nystagmus in DS. Eleven patients had associated cataract. Additional diagnoses unrelated to DS were made in 10.4%.Conclusions:The most frequent type of nystagmus in our cohort was ‘presumed’ INS. This study highlights the importance of differentiating between FMNS and INS (with a latent component), so that further investigations can be performed as appropriate. Almost 25% had associated cataract, and a further 10% other diagnoses un-associated to DS. Despite INS being known to be associated with DS, further investigations may be required in a small subset with true INS after careful clinical assessment and use of eye movement recordings (where available).

Strabismus and Its Management - A Commentary

Purpose: The main purpose of this review is to find and educate oneself about ocular misalignment and its preventive and curable measures of treatment. Methods: An extensive literature search was conducted in PubMed, google scholar, Cochrane search engines for the articles on strabismus and their new strategies of treatment. As a result, five articles were found to be fit into the criteria. Those articles were gathered and put-up as a commentary. Results: As a result, we could able to find out the immense need for educating and creating awareness to parents of children who have squint and various ways of treating it. Conclusions: Educating ourselves as practitioners and patients can help in eradicating the treatable misalignment and that can improve the quality of life mainly among children who are in their early stage. Always informing the parents and educating them helps to reduce further damage to the patient. Mainly in kids who can’t even explain their symptoms will be benefitted. Keywords: strabismus, misalignment, psychosocial factors, binocular vision, misalignment .

Contribution of the retinal contour to the peripheral optics of human eye

Understanding the relationship between the retinal contour and peripheral aberrations is fundamental for exploring the mechanism of myopia progression. Not much has been known about how the retinal expansion can affect peripheral aberrations across the two-dimensional visual field. This study aims to quantify and analyze the changes in the lower- and higher-order aberrations across the visual field induced by retinal expansion, and to understand how this relationship can be influenced by axial astigmatism and the misalignments in the ocular components. Retinal expansion was represented by translating retinal points along the chief rays in the vitreous humor. A realistic eye model was constructed incorporating astigmatism, misalignments and other irregular features based on measurement data. Three-dimensional ray tracing was performed on this model and its two symmetric versions to analyze the changes of axial and peripheral aberrations induced by retinal expansion. The results show that spherical equivalent refraction changes the most during retinal expansion with the rate of −4 to −3 D/mm, which is around 10 times larger than the plus cylinder power. Axial astigmatism determines the retinal impacts on peripheral astigmatism, and unique patterns were found near the two peripheral field locations with zero cylinder power. Ocular misalignments mainly affect higher-order aberrations, especially third-order coma. For most optical features, the impacts of retinal expansion are stronger for larger eccentricity. The impacts of retinal expansion on the lower- and higher-order aberrations have been systematically characterized for the two-dimensional visual field, showing unique patterns in the presence of astigmatism and ocular misalignments.

How to Manage a Strabismus Clinic During the COVID-19 Pandemic; What is Really Urgent, What is Not?: A Single-Center Case Series from Turkey

Objectives:To evaluate the management of the pediatric ophthalmology and strabismus clinic when strict quarantine conditions were adopted during the coronavirus disease 2019 (COVID-19) pandemic in Turkey.Materials and Methods:The study presents a review of the patients examined during the quarantine period. All patients were assessed with the highest possible level of personal protection.Results:Ten patients (6 girls, 4 boys) with a mean age of 9 years (range: 2-16) were evaluated. The patients presented 3-20 days after symptom onset. Ocular misalignment and diplopia were the main symptoms. Four of the 10 patients were diagnosed with sixth cranial nerve palsy and three patients were diagnosed with acute-onset comitant esotropia. Six patients had significant cranial magnetic resonance imaging findings.Conclusion:Acute-onset neurological conditions are more common during the COVID-19 pandemic. These reports will contribute to global experience and understanding of COVID-19.

Ocular Manifestations of Loeys–Dietz Syndrome

Loeys–Dietz syndrome (LDS) is caused by connective tissue mutations; the resulting defective connective tissue in organs such as the eye may be related to ocular symptoms in patients with LDS. The aim of this study was to review different ocular manifestations in LDS. A literature review of articles published within the past 5 years was performed using Web of Science™ and PubMed to search for ‘Loeys–Dietz’ with the terms ‘ocular’ and ‘ophthalmology.’ Additional search terms were generated from the initial literature assessment, and 32 articles were ultimately reviewed. Reported ocular symptoms in LDS included hypertelorism, ocular misalignment, refractive errors, and more. For LDS, the most reported findings were hypertelorism (n=111), astigmatism (n=25), down slanting palpebral fissures (n=20), myopia (n=9), and strabismus (n=8). However, more research on ocular symptoms in LDS is needed.

Binocular Alignment Changes Between Sitting and Supine Positions in Patients with Dizziness.

Vertical and torsional ocular misalignment can occur from mild traumatic brain injuryor inner ear pathology, which may vary depending on head position. Here, we evaluate differences in a behavioral measure of binocular alignment in both upright and supine head position. Ocular perception of vertical and torsional alignment was measured using the torsional and vertical alignment nulling (TAN, VAN) task in N = 52 veterans with dizziness (N = 38 with traumatic brain injury), N = 41 civilians with vestibular schwannoma resection (UVD), and N = 33 healthy controls for both positions. The interquartile range within each group, regardless of head position, was greater for torsional compared to vertical misalignment. We use generalized estimating equations to compare average TAN (torsional) scores and VAN (vertical) scores between groups and test position. Compared to the healthy controls, TAN was significantly increased by + 0.4186° in veterans (P = 0.030) and by + 0.5747° in UVD (P = 0.010), but there was no difference with head position. For VAN, no difference was found between the three groups, but the misalignment did worsen by 0.0888° (P = 0.0070) as the head position moved from upright to supine. Head position had negligible effects on this behavioral measure of vertical and torsional binocular misalignment, and torsional misalignments were worse than controls in both veterans with dizziness and patients with vestibular nerve resection although neither reported torsional diplopia. Our data suggests that the tolerance for roll misalignment may be abnormally large in patients with dizziness. Alternatively, perceptual roll misalignments may be a manifest cause for dizziness, and therefore a useful proxy for distinguishing differences in putative otolith function in veterans with dizziness.

Undetected ophthalmological disorders in Parkinson’s disease

BackgroundOphthalmological disorders are common and frequently disabling for people with Parkinson’s disease (PD). However, details on the prevalence, severity and impact of ophthalmological disorders thus far lacking. We aimed to identify PD patients with undetected ophthalmological disorders in a large cross-sectional, observational study.MethodsWe previously delivered a screening questionnaire to detect ophthalmological symptoms (Visual impairment in PD questionnaire; VIPD-Q) to 848 patients. Here, we report on a subgroup of 102 patients who received complete ophthalmological assessment aimed at identifying clinically relevant ophthalmological diseases, which were classified as either vison-threatening or not. Impact on daily life functioning was measured using the visual functioning-25 questionnaire (VFQ-25) and fall frequency.ResultsAlmost all patients (92%) had one or more clinically relevant ophthalmological disorders. Of those, 77% had a potentially vision-threatening disease, while 34% had a potentially treatable ophthalmological disease which impacted on quality of life. The most prevalent ophthalmological disorders were dry eyes (86%), ocular misalignment (50%) and convergence insufficiency (41%). We found a weak but significant association between clinically relevant ophthalmological diseases and both fall frequency (R2 = 0.15, p = 0.037) and VFQ-25 score (R2 = 0.15, p = 0.02). The VIPD-Q could not correctly identify patients with relevant ophthalmological disorders.ConclusionsSurprisingly, in our study sample, many participants manifested previously undetected ophthalmological diseases, most of which threatened vision, impacted on daily life functioning and were amenable to treatment. Screening for these ophthalmological disorders using a questionnaire asking about symptoms seems insufficient. Instead, episodic ophthalmological assessments should be considered for PD patients, aiming to identify vision-threatening yet treatable diseases.Trial registrationDutch Trial Registration, NL7421.

Evaluation of Diplopia by Emergency Medicine Physicians and Consulting Neurologists.

Appropriate evaluation of diplopia requires separating serious from benign causes. If providers are not adept in this task, diagnosis of critical conditions may be delayed and unnecessary testing may result. We studied the records of 100 consecutive patients who presented to an emergency department between 2010 and 2020 with diplopia as a prominent symptom. We rated the performance of emergency medicine physicians (EMPs) and consulting neurologists (CNs) in the examination, diagnosis, and ordering of diagnostic tests according to standards based on neuro-ophthalmologic consultation and the neuro-ophthalmologic literature. EMPs made no diagnosis or an incorrect diagnosis in 88 (88%) of 100 encounters. They ordered 14 unindicated and 12 incorrect studies, mostly noncontrast computed tomography scans. CNs made an incorrect diagnosis in 13 (31%) encounters. They ordered 6 unindicated and 2 incorrect studies. The total charge for unindicated and incorrect studies ordered by EMPs and CNs was $119,950. EMPs and CNs made frequent errors in the examination, diagnosis, and ordering of diagnostic studies, leading to inefficient care and unnecessary testing. EMPs largely delegated the evaluation of diplopia to their consultants. If such consultative support were not available, the care of diplopic patients would be delayed. CNs performed more complete examinations, but rarely enough to allow appreciation of the pattern of ocular misalignment, contributing to misdiagnoses and ordering errors. The identification of these provider errors allows for more targeted teaching in the evaluation of diplopia.

Trends in Etiologies, Demographics, and Neuroimaging in New-Onset Adult Strabismus at an Ophthalmic Emergency Department.

To evaluate new-onset strabismus in adults presenting to an ophthalmic emergency department, and to identify which patients require neuroimaging. This was a retrospective review of electronic medical records of patients 18 years and older who presented to an ophthalmic emergency department between January 1, 2019 and December 31, 2020 with new-onset strabismus. Data regarding demographics, causes, neuroimaging, and resolution were recorded and analyzed. Of the 557 patients in the current study, 54.8% were men and the mean age was 57.3 ± 16.7 years (range: 18 to 92 years). Most patients (72.4%) presented with diplopia. Esotropia was the most common ocular misalignment (43.6%) and was more common in women than men (51.6% vs 37.0%, respectively) (P = .001). The most common diagnoses were cranial nerve palsies (66.8%) for both sexes and all age groups, with the most common etiology being microvascular (48.1%) for patients 50 years and older and idiopathic (20.1%) for patients between 18 and 49 years old. The incidence of cranial nerve palsies was significantly higher in older patients (P < .001). Neuroimaging was performed in 58% of patients (n = 323), of whom 37.2% (n = 120) had abnormal findings. The most common abnormal neuroimaging finding was mass for all age groups and sexes (19.2%). Patients with cranial nerve palsy and microvascular etiology had a significantly lower proportion of abnormal neuroimaging findings (P < .001). Most cases of new-onset strabismus in adults presenting to the emergency department were due to cranial nerve palsy, particularly in older patients. Despite high rates of neuroimaging, patients with cranial nerve palsy had mostly normal findings. The current study supports the belief that neuroimaging may be deferred in patients older than 50 years with micro-vascular risk factors. [J Pediatr Ophthalmol Strabismus. 2022;59(4):269-273.].

Etiology-based strabismus classification scheme for pediatricians.

Pediatricians are regularly involved in the initial examination of children presenting with strabismus, a common ocular condition occurring in 3% of children. The objective of this review was to gain insight into pediatric residents, fellows and attendings` understanding of strabismus, and to propose an etiology-based strabismus classification scheme to aid this understanding. A survey was conducted in a single Department of Pediatrics in a university academic institution in order to assess the degree of understanding of the classification, etiology and nomenclature of strabismus. A targeted literature review, pertinent to our classification scheme for strabismus in the pediatric age group, is provided to clarify the various underlying etiological conditions for pediatricians. The surveyed cohort (n=26) consisted of 10 (38.5%) attendings and 16 (61.5%) pediatricians-in-training. Although 69% of survey participants felt comfortable performing an ocular motility evaluation, only 19% had a clear understanding of the underlying etiology of strabismus, 8% had a clear understanding of strabismus nomenclature and none of the participants had clear knowledge of a classification scheme of strabismus. We propose an etiologic-based strabismus classification scheme with streamlined nomenclature geared towards Pediatricians to facilitate the management of pediatric patients with various ocular misalignments. Eight major categories of this classification scheme include (1) physiologic, (2) comitant, (3) paralytic, (4) sensory, (5) syndromic, (6) orbital, (7) supranuclear and (8) pseudostrabismus. Pediatricians at all levels of professional experience have a limited command of strabismus. An etiology-based classification scheme of strabismus may assist in understanding the underlying causes and facilitate the management of strabismus in the pediatrician`s office.

A COMPREHENSIVE APPROACH INTO STEREOSCOPIC VISION

Stereopsis (or stereoscopic) vision is the ability to see depth of perception, which is created by the difference in angle of view between both eyes. The first process is known as simultaneous perception. Objects will fall on each corresponding retina and there will be a process of fusion of the two images into one. Then, the brain initiates three-dimensional perception in visual cortex, creating stereoscopic vision. Stereoscopic vision will rapidly develop, especially at the age of 6-8 months of life. Stereoscopic is important in daily activities. There are many stereoacuity tests to evaluate stereoscopic vision. Stereoscopic examinations are based on the principle of haploscope, anaglyph, or polaroid vectograph. There are qualitative and quantitative examination methods to assess stereoscopic vision. Qualitative examinations such as Horizontal Lang Two Pencil test and Synoptophore. Quantitative examination including Contour stereopsis test and Clinical random dot stereopsis test. The inability of the eye to see stereoscopic can be called stereoblindness. This can be affected by amblyopia, decreased visual acuity, or the presence of ocular misalignment. Inability to achieve stereoscopic vision will impact an individual to perform some daily life activities, and lead to an increase in difficulty interacting in the world.

An Interdisciplinary Approach to Improve Head Tilt in Pediatric Torticollis Patients with the Use of Prism Glasses

Background: Infants with head tilts are most often diagnosed with torticollis and are referred to a pediatric physical therapist for evaluation and treatment. Determining if the head position is muscular or non-muscular when assessing these infants is key in making the appropriate referrals to other specialists and determining the best treatment approach. Most pediatric physical therapists treat patients with head tilts with manual therapy (i.e. massage, myofascial release, and passive/active range of motion). Many physical therapists only consider a visual etiology as a possibility after other treatment options have been exhausted and the head tilt persists. Although the incidence of torticollis has increased, based on the author’s experience, the number of cases of non-muscular etiology has also increased. There is a lack of current research on the use of prism glasses for treating head tilts in young children and infants carrying a diagnosis of torticollis, especially those presenting without any active/passive motion limitations. Traditionally, these patients undergo years of treatment without resolution of the head tilt. Case Report: A two-year-old patient initially presented with a diagnosis of torticollis with an intermittent and alternating head tilt for physical therapy. After several months of manual therapy, with little improvement in her head posture, the patient’s physical therapist referred her to a behavioral optometrist for a comprehensive vision examination and to pursue alternative treatment options. The optometric evaluation revealed ocular misalignment causing poor depth perception skills and prism glasses were prescribed full-time with the recommendation of continuing physical therapy for gross motor development. Conclusion: Prism glasses are an appropriate treatment consideration for some pediatric patients with persistent head tilts because they can provide immediate improvement in head position and depth perception. It is important to include optometrists in the multi-disciplinary team when working with patients with head tilts. Pediatric physical therapists would benefit from training on how to properly screen visual skills when evaluating children with head tilts. With such training, an appropriate optometric referral could be initiated early on in treatment.