Primary Gaze Research Articles

Effect of distance vision and refractive error on the spontaneous eye blink activity in human subjects in primary eye gaze

PurposeTo evaluate whether visual target character and visibility affects spontaneous eye blink rate (SEBR) in primary eye gaze and silence. MethodsVideo recordings were made of young healthy adults who were either emmetropic (n=32) or who wore spectacles for refractive error (range −4.75D and +4.50D (n=31). Emmetropes had 5min recordings made whilst seated and looking towards a distant whiteboard. For spectacle wearers, recordings were made whilst looking towards the whiteboard with a 35mm sized cross, and repeated after spectacle removal. The average number of eye blinks over 5min was assessed, and its intra-subject variability as the coefficient of variation (COV). ResultsOver 5min without a distance target, an average SEBR of 10.4blinks/min was observed in emmetropes with a of COV=38.1%, and a significant increase in SEBR over the 5th minute to 13.6blinks/min. Hyperopes being asked to look towards a distant target showed the essentially same blinking rate of 11.1/min with or without spectacle wear with the intra-subject variability (COV) being 21.3%. Myopic subjects showed a slightly higher SEBR if looking towards a target without their spectacles (12.4 vs. 11.0blinks/min), with the COV being 18.8%. ConclusionsThe studies indicate that some form of visual target could be useful to promote constancy of spontaneous eye blink activity over time, but that a distance visual target (when provided) does not need to be seen clearly.

Challenging Management of Double Vision After Functional Endoscopic Sinus Surgery—A Series of 6 Cases

To present 6 cases of orbital trauma, diplopia and strabismus after functional endoscopic sinus surgery (FESS). Retrospective observational case series. The medical charts of suitable patients were reviewed for information on medical examination, imaging studies, the type of corrective surgery, and surgical outcomes. All patients with diplopia and strabismus after undergoing FESS who were treated or consulted at our institution between 2008 and 2017 were included. The presence and extent of strabismus and double vision at the end of follow-up. Six patients complained of diplopia after FESS; all of them had proven orbital trauma. In Cases 1-5, patients suffered medial rectus (MR) muscle transection and subsequent exotropia. Their prognosis was guarded despite prompt surgical intervention, and ranged from large exotropia when direct recovery of the MR was attempted, to primary gaze orthotropia but with minimal adduction capacity, during which vertical recti transposition was attempted. Patient 6 sustained transient diplopia, although all of his extraocular muscles appeared intact on imaging. His eye position and movement were completely resolved with conservative measures only. Our experience was that immediate recovery procedures to reattach the muscle in cases with proven transection of the MR muscle are futile, and that definitive corrective strabismus surgery (ie, vertical muscle transposition) has a better chance to achieve favorable results.

Tendon Elongation with Bovine Pericardium in Patients with Severe Esotropia after Decompression in Graves’ Orbitopathy—efficacy and Long-term Stability

ABSTRACTBackground/Aims: We performed a retrospective analysis to examine clinical results, establish a dose-effect coefficient and analyze the long-term efficacy of tendon elongation with bovine pericardium (Tutopatch®) for surgical correction of severe esotropia, occurring after three-wall orbital decompression for dysthyroid optic neuropathy in patients with Graves’ orbitopathy (GO).Methods: Tendon elongation of the medial rectus muscle (MR) was performed in our institution using an interponate of bovine pericardium in 60 patients (27 underwent unilateral and 33 bilateral surgery). Success-rate (total horizontal deviation of 10 prism-diopters (PD) or less and evidence of binocular single vision with or without prism glasses) and horizontal motility were examined 3 months, 1 and >4 years after surgery. A dose-effect coefficient for deviation reduction (PD) per recession distance (mm) was established.Results: Horizontal deviations between 28–80Δ were corrected. Diplopia in primary-gaze disappeared in 65% of the patients after 3 months and in 83% after one year (including 12 patients who underwent subsequent surgery after 3-month follow-up). Patients with deviations ≤40Δ after unilateral and ≤50Δ after bilateral tendon elongation showed higher primary success-rates after 3 months (78% and 72%). Vertical deviations (≤10Δ) were corrected by the procedure in 28% without need of recession of the inferior rectus (IR). Only 3 patients showed overcorrection after one year. One of these underwent revision surgery, in which the interponate was no longer discernible from surrounding fibrotic scar tissue. At >4-year follow-up (4.3–15years) effects were stable and 95% of patients showed fusion in primary gaze. Median dose-effect coefficient was lower after tendon elongation (1.8Δ/mm) compared to conventional medial rectus recession in patients with GO. Horizontal motility was slightly decreased, but much more symmetric around primary gaze.Conclusion: Tendon elongation with a bovine pericardium implant is a safe surgical method, suitable to correct severe esotropia after decompression surgery. A lower dose-effect has to be taken into account. Patients with esotropia ≥42Δ should not be treated with unilateral, but bilateral tendon elongation, to avoid undercorrections. In patients with deviations ≥52Δ it has to be further investigated if the application of even higher elongation distances is viable or if another approach—the recession of more than one rectus muscle has to be performed simultaneously to handle the severe restriction. Generally, a step-by-step approach is advisable, since small vertical deviations could also be corrected in a third of patients with the procedure and the dose-effect was more variable as in medial recessions without tendon elongation.

Clinical Characteristics and Etiology of Bilateral Vestibular Loss in a Cohort from Central Illinois.

Previous series of bilateral vestibular loss (BVL) identified numerous etiologies, but surprisingly, a cause in a significant number of cases remains unknown. In an effort to understand possible etiology and management strategies, a global effort is currently in progress. Here, I contribute my 10-year experience with both acute and chronic BVL during the 2007-2017 decade. This is a retrospective review of the charts and EMR of patients diagnosed with BVL in the last 10 years. Following Institutional IRB approval, we identified 57 patients with a diagnosis of BVL and utilized the current diagnostic criteria listed by the Barany society (1). The inclusion criteria included patients with BVL of any cause, within an age span older than 18 and a neuro-otologic examination supporting the clinical impression of BVL. During the current decade 2007-2017, I identified two broad categories of BVL (acute and chronic) in 57 patients; only 41 of them had records available. The etiology includes: idiopathic: n = 9, Wernicke's encephalopathy n = 11, superficial siderosis n = 3, paraneoplastic syndrome: n = 3, bilateral vestibular neuritis (recurrent AVS lasting days without cochlear symptoms) n = 3, simultaneous ototoxicity of aminoglycoside and chemotherapy toxicity n = 2, MELAS n = 2, Meniere's disease treated with intra-tympanic streptomycin in one ear n = 1, acute phenytoin intoxication: n = 1, combined chronic unilateral tumor-related vestibulopathy and new contralateral vestibular neuritis (this patient presented with Betcherew's phenomenon) n = 1, bilateral AICA stroke n = 1, mixed spinocerebellar ataxia type 3, n = 2 and CANVAS n = 2. This cohort included a 28% overall incidence of acute and subacute BVL; among them, 65% improved with intervention. In the thiamine deficiency group, specifically, the vestibular function improved in 80% of the patients. Even though acute, subacute, or chronic showed slightly asymmetric horizontal-VOR gain loss, it never did cause spontaneous, primary straight gaze horizontal nystagmus. n = 39/41 patients had abnormal manual HIT, n = 26/41 BVL patients tested with video head impulse immediately after manual testing showed decreased VOR gain, including two with covert saccades. Two thiamine patients with positive bedside pretreatment manual HIT, tested after treatment with high-dose thiamine showed improved VOR. In acute thiamine deficiency, the horizontal VOR was abnormal and the vertical was either normal or mildly decreased. This series favored a neurologic cause of BVL. Finally, 20% of the chronic cases were idiopathic.

Rectus Muscle Resection for Vertical Strabismus in Thyroid Eye Disease

ABSTRACTPurpose: Rectus muscle resection in thyroid eye disease (TED) is generally avoided due to the risk of worsening restriction or reactivating inflammation. However, for some patients with large-angle strabismus or diplopia in primary gaze despite maximum recession surgery, rectus muscle resection may be beneficial. We report our surgical experience with rectus muscle resection in the management of vertical strabismus associated with TED.Methods: Retrospective review of eight patients with TED and vertical diplopia who underwent vertical rectus muscle resection by a single surgeon (IBM) at a tertiary referral centre in Liverpool, UK, from 2001 to 2013. The goal of surgery was elimination of diplopia in primary and reading position. Vertical deviations were measured in prism dioptres (∆) before and after surgery at one month, four months and final visit by prism alternate cover testing at ⅓ m and 6 m.Results: The mean ± standard deviation vertical deviation for near and distance reduced significantly from 14.2∆ ± 8.4∆ and 15.8∆ ± 8.8∆ pre-operatively to 5.7∆ ± 4.9∆ and 6.7∆ ± 7∆ at the four-month visit, respectively (p< 0.05). At the four-month follow-up, five (62.5%) patients achieved binocular single vision in primary and reading position with either no prisms or prisms less than 5∆. Further recession surgery, Harada-Ito procedure, or lateral rectus resection were necessary in four (50%) patients with persistent diplopia. No patient developed recurrence of inflammation or increased muscle restriction.Conclusions: Vertical rectus resection could be considered as an additional surgical strategy in the management of TED patients with vertical strabismus without adverse sequelae.

Rehabilitative orbital decompression for Graves' orbitopathy: results of a randomized clinical trial.

Orbital decompression (OD) is a consolidated procedure for the treatment of exophthalmos in Graves' orbitopathy (GO). The efficacy of the various procedures remains unclear due to the variability of the techniques used. To address this issue, we performed a randomized clinical trial to compare the efficacy of two surgical techniques. The primary endpoint was the reduction in proptosis. Secondary aims were the risk of post-operative diplopia (POD) in primary gaze and other surgical complications. 38 patients (76 orbits) affected with GO were enrolled and randomized into single lateral decompression (LD) (n=19) or balanced medial plus lateral wall decompression (MLD) (n=19). Following surgery, patients were seen for a follow-up ophthalmological evaluation at 6months. Pre-operative diplopia in secondary gaze was present in 13/38 patients (34.2%, 8/19 treated with LD and 5/19 treated with MLD). The reduction of exophthalmos was greater in patients treated with MLD (5.1±1.5mm, range 2-8mm) than in those treated with LD (3.5±1.3mm, range 1-6.5mm) (p=0.01). The overall incidence of POD in primary gaze was 5/38 (13.2%) and all of these patients had pre-operative diplopia in secondary gaze (5/13, 38.5%, vs patients with no pre-operative diplopia p=0.005). Two of 19 patients (10.5%) treated with LD and 3/19 (15.8%) treated with MLD, developed POD in primary gaze, with no statistical difference between the two techniques. MLD provides a better result in terms of proptosis reduction compared to LD. The two techniques used here appear to have a similar safety profile in terms of POD. Pre-operative diplopia in the secondary gaze remains a major risk factor for development of POD.

Damage to the inferior oblique muscle branch of the oculomotor nerve: a complication during orbital fat decompression.

To present patients who suffered damage to the inferior oblique muscle branch of the oculomotor nerve during orbital fat decompression. This study was a retrospective chart review of all patients who underwent orbital decompression surgery between April 2009 and June 2016 by the authors. Among 414 sides from 226 consecutive patients who underwent orbital decompression, the inferior oblique muscle branch was injured in two sides (0.5%) of two patients. Both patients showed hypotropia and incyclotropia immediately after surgery. Within 6months of injury, ocular deviation on primary gaze had mostly resolved after conservative treatment. None of the patients underwent strabismus surgery. Postoperative computed tomographic images demonstrated that the affected branch was indistinct 3-4mm posterior to the inferior oblique muscle. This report indicates that injury to the inferior oblique muscle nerve branch can occur at a point posterior to the inferior oblique muscle during orbital fat decompression; however, the resulting ocular deviation improves considerably within 6months of injury.

Combined lateral rectus augmented transposition and inferior rectus recession for monocular elevation deficiency

We report the case of a 21-year-old woman who presented with a drooping right upper eyelid and smaller-appearing right eye, evident since birth. Her visual acuity was 20/30 in the right eye and 20/20 in the left eye. In primary gaze she had a hypotropia of 25Δ, with a marked elevation limitation and associated true upper lid ptosis of 3mm. Under local anesthesia, the lateral rectus muscle was transposed to the superior rectus muscle and was augmented by a nonabsorbable suture attaching the superior rectus muscle and lateral rectus muscle 8mm posterior to the insertion, accompanied by an inferior rectus recession. One year after surgery she was orthophoric in primary position and showed improvement in elevation. The surgical procedure can be performed at the same time as the inferior rectus recession and reduces the risk of anterior segment ischemia.

Change in eyelid parameters after orbital decompression in thyroid-associated orbitopathy

PurposeTo investigate quantitative changes in eyelid parameters after orbital decompression surgery in thyroid-associated orbitopathy using the PC-based program, Eyelid Analysis Software (EAS).MethodsThis study included 202 eyes of 109 thyroid-associated orbitopathy patients. Digital photographs of the patients in primary gaze were taken just before and after orbital decompression surgery, and exophthalmos degree was measured by Hertel exophthalmometry (Hertel Exophthalmometer SKU:52400; Oculus, Arlington, VA, USA). The custom-made PC-based software EAS (Biomedical Research Institute, Seoul, Korea) was used to analyze eyelid parameters. The 11 parameters included pupil to inferior eyebrow distance (PBD), margin reflex distance 1 (MRD1), margin reflex distance 2 (MRD2), palpebral fissure (PF), total lid length, upper and lower lid length, area, medial area, center area, and lateral area.ResultsUnivariate linear regression analysis showed a significant positive association between amount of exophthalmos reduction and the following parameters: area (p = 0.007); MRD2 (p = 0.043); upper lid length (p = 0.045); lower lid length (p = 0.006); medial area (p = 0.045); and lateral area (p = 0.005). Multivariate linear regression analysis showed only two parameters, lower lid length (p = 0.022) and lateral area (p = 0.019) were associated with exophthalmos reduction.ConclusionsA reduction in the inferior lateral part of the eyelid (lateral area + lower lid length) occurred after orbital decompression surgery in patients with thyroid-associated orbitopathy.

Botulinum toxin as an initial therapy for management of sixth nerve palsies caused by nasopharyngeal carcinomas.

PurposeThe purpose of this study is to evaluate the efficacy and safety of botulinum toxin injection as a primary treatment for strabismus in a cohort of patients with nasopharyngeal carcinoma (NPC)-related chronic sixth nerve palsy.Patients and methodsWe retrospectively reviewed all cases of NPC-related sixth nerve palsy receiving botulinum toxin injection in the Hong Kong Eye Hospital between January 2009 and January 2016. Only cases with diplopia for at least 6 months; and failed a trial of Fresnel prism therapy were recruited. We excluded cases with prior strabismus surgery and multiple cranial nerve palsies. Patients were offered botulinum toxin injection as primary treatment for their strabismus and were given further injections or offered surgery if diplopia persisted. Success with botulinum toxin was defined as a final distant orthophoria of <15 PD in primary gaze, no diplopia in primary position, and no head turn, as measured 6 months after the last injection, without requiring a second treatment.ResultsA total of 25 patients were included in the study. All patients received concurrent chemo-radiotherapy for NPC. There was a statistically significant reduction in the mean deviation at distant after the last injection compared to that at presentation (P<0.001, Wilcoxin signed rank test). Overall, 7 patients (28%) achieved clinical success and 15 patients (64%) remained diplopia-free by repeated botulinum toxin injections alone. Nine patients went on to receive definitive surgery and all achieved good ocular alignment after surgery. Transient ptosis or vertical deviation was seen in 7 patients, which resolved within 3 months and no serious complications arose from the treatment in our series.ConclusionsBotulinum toxin injection is a relatively less-invasive alternative to surgery that can be done under a topical anesthesia setting, which improves patient's quality of life via reduction in diplopia. It is a recommendable initial option in patients with chronic nerve palsies who may have higher risks associated with strabismus surgery.

Ultrasound biomicroscopy image patterns in normal upper eyelid and congenital ptosis in the Indian population.

Purpose:To study the features of upper eyelid in healthy individual and different types of congenital ptosis in the Indian population using ultrasound biomicroscopy (UBM).Methods:This was a prospective observational study at a tertiary care center. Eyelid structure of healthy individuals with no eyelid abnormalities (n = 19); simple congenital ptosis (n = 33) cases; Marcus Gunn jaw-winking ptosis (MGJWP, n = 7) cases, and blepharophimosis-ptosis-epicanthus inversus syndrome (BPES, n = 20) cases were studied on a vertical UBM scan using 50-MHz probe. Lid-thickness, tarsal-thickness, orbicularis oculi and levator-Muller-orbital septum-conjunctival (LMSC) complex were measured in primary gaze. Comparison was made between four groups and results were statistically analyzed using ANOVA test. In normal individuals, LMSC measurements were repeated in down-gaze imaging.Results:Skin with subcutaneous tissue, LMSC complex and pre-aponeurotic fat-pad appeared echodense while orbicularis oculi and tarsus appeared echolucent. In primary gaze, mean thickness (± standard deviation) of the eyelid, tarsus, orbicularis oculi and LMSC, respectively, were: 1.612 ± 0.205, 0.907 ± 0.098, 0.336 ± 0.083, and 0.785 ± 0.135 mm in normal individual. LMSC showed 46.64% increase in thickness on down-gaze. The mean eyelid thickness and LMSC were thicker in MGJWP and BPES as compared to normal. In different types of congenital ptosis cases, various patterns of UBM imaging were observed.Conclusion:UBM allows noninvasive imaging of eyelid structures with good anatomical correspondence in normal eyelids and study the structural alterations of eyelids in different types of congenital ptosis. UBM can be used to highlight the anatomical difference in normal eyelids that may help modify the surgery for better cosmetic outcomes. Furthermore, it has the potential to be used in preoperative evaluation and operative planning in certain types of acquired ptosis, which needs to be evaluated.

NUT carcinoma of the sinonasal tract infiltrating the orbit in a man with birdshot chorioretinitis

A 48-year-old man with a history of birdshot chorioretinitis presented with blurry vision, retro-bulbar pain and sinusitis. Though visual acuity was unaffected, he had left optic disc oedema and mild restriction of left eye abduction. His symptoms progressed quickly, with diplopia in primary gaze, epistaxis from his left nostril, and a left relative afferent pupillary defect (RAPD). On computed tomography, there was a mass in the nasal cavity that extended through the left cribriform plate and lamina papyracea and posteriorly into the optic canal.Pathological examination of biopsy specimens revealed sheets of undifferentiated cells with extensive areas of necrosis and islands of squamous differentiation. The tumour cells expressed monokeratin, p63, CD34, and p16. Molecular testing indicated rearrangement of the NUTM1 (15q14) locus and fusion of the NUTM1 and BRD4 (19p13.12) loci, confirming the diagnosis of NUT carcinoma of the sinonasal tract.This is the first reported case of NUT carcinoma in a patient with birdshot chorioretinitis. The onset of chorioretinitis may have been the earliest sign of the effects of the BRD4-NUTM1 fusion protein, resulting in expression of HLA-A29. There is evidence that bromodomain and extra terminal (BET) family proteins play a role in inflammatory marker expression.

Diagnosis and treatment of strabismus caused by nasal endoscopic surgery

Objective: Strabismus with diplopia is the main orbital complication of functional endoscopic sinus surgery (FESS). This study was to analyze clinical findings, treatment and outcomes of such cases. Methods: Retrospective case series. Twenty-three cases were divided into 3 groups based on the disease severity: group A, partial transection of the medial rectus muscle, group B, complete transection of the medical rectus, group C, transection of the medial rectus combined with the other orbital injuries. Complete ophthalmology examinations, including eye alignment, eye motility, force duction test, force generation test, general eye exam, and medical imaging (orbital CT or MRI), were performed for each case. The treatment included botulinum toxin (Botox) injection to the lateral rectus muscle, transposition of the vertical rectus muscle, and orbital surgery if needed. Results: In group A with Botox injection, all the cases achieved single vision in primary position, but still remained some adduction weakness. In group B treated by vertical transposition surgery combined with Botox, 22% of the cases got single vision in primary gaze. In group C, even with more efforts of treatment, the cases with orbital injury can only get cosmetic improvement, and diplopia and adduction dysfunction were found in most cases. Conclusions: Due to the variety of the complications of FESS, force duction test is a crucial exam to detect the direction and severity of synechia in the orbit, which will give solid information to surgery approach as well as prognosis. Botox injection at early stage will minimize the contraction of antagonist lateral rectus, helping to postpone the transposition surgery which may cause anterior segment ischemia when performed right after the medial rectus transection injury. Botox may even reduce the synechia by minimizing the scarring process. Partial vertical rectus transposition combined with muscle resection may effectively correct the eye misalignment in primary gaze and improve eye motility. The prognosis of FESS induced orbital complications is quite related with the severity of the injury. Botox combined with surgery may help medial rectus transection cases to achieve single vision in primary gaze, but when there is any other orbital injury, treatment may only improve cosmetic appearance. (Chin J Ophthalmol, 2017, 53: 917-923).

Clinical features and surgical outcomes of acute acquired comitant esotropia

Objective: To investigate the clinical features and surgical outcomes of patients with acute acquired concomitant esotropia (AACE) type Ⅱ(AACE-Ⅱ) and type Ⅲ (AACE-Ⅲ). Methods: Retrospective case series analysis. Medical records of consecutive patients who underwent strabismus surgery for AACE-Ⅱ and AACE-Ⅲ in Shandong Provincial Hospital affiliated to Shandong University between January 2011 and June 2016 with a minimum follow-up time of 3 months were collected. Each patient underwent a complete ophthalmological and orthoptic examination to exclude esotropia resulting from other reasons, and a systemic assessment to exclude AACE related to intracranial and systemic diseases. Surgical procedures were determined according to the esodeviations measured at distance and near and the different dominant eye of patients. A successful surgical alignment was defined as the distant and near deviation in the primary gaze within 8 prism diopters (PD) of orthophoria and no diplopia. Results: Twenty-nine patients were enrolled in this study, including 17 males and 12 females. The mean age of the patients was 22.14±15.13 years (range, 5-63 years). The median corrected visual acuity (LogMAR) of patients with AACE-Ⅱwas 0 (range, 0.22 to 0), and that of patients with AACE-Ⅲ was 0 (range, 0.10 to 0). The median esodeviation of patients with AACE-Ⅱ at distance was 35 PD (range, 10 to 55 PD), and that at near was 35 PD (range, 20 to 60 PD). The median esodeviation of patients with AACE-Ⅲ at distance was 30 PD (range, 12 to 50 PD), and that at near was 30 PD (range, 6 to 50 PD). When tested with the red filter test preoperatively, all the patients had an uncrossed horizontal diplopia with the same distance in left and right lateral fixations. With a mean follow-up time of 12.0±12.6 months, of all the 29 patients, 24 patients (83%) achieved successful surgical alignment after one surgery, and 5 patients (17%) were undercorrected or had recurrence, in whom 4 were successfully aligned after repeated surgery (performed at a mean of 3.5 months after the first surgery) and 1 was treated with the Fresnel press-on prism. At the last follow-up, of all the 28 patients successfully aligned, 20 (71%) regained bifoveal fusion, 8 (29%) regained peripheral fusion, 17 (61%) regained normal stereopsis (stereoacuity ≤60"), and 11 regained a certain degree of stereopsis (stereoacuity 80"-400"). The constituent ratio of biocular central fusion and peripheral fusion in patients with AACE-Ⅱ had no significant difference from patients with AACE-Ⅲ (χ(2)=0.235, P>0.05), and the constituent ratio of central stereopsis, macular stereopsis, and peripheral stereopsis in patients with AACE-Ⅱ had no significant difference from patients with AACE-Ⅲ (χ(2)=0.762, P>0.05). Conclusions: All patients exhibited the typical features of AACE, which included an acute onset of diplopia and comitant esotropia, a wide range of onset age of the patients, normal corrected visual acuity and ocular movements, a mean moderate level of esodeviation with a wide range, and a good binocular potential. According to the esodeviations measured at distance and near and the different dominant eye of patients, good oculomotor alignment and perceptual outcomes may be obtained in patients with AACE-Ⅱand AACE-Ⅲ. (Chin J Ophthalmol, 2017, 53: 908-916).

Use of A-scan Ultrasound and Optical Coherence Tomography to Differentiate Papilledema From Pseudopapilledema.

Differentiating papilledema from pseudopapilledema reflecting tilted/crowded optic discs or disc drusen is critical but can be challenging. Our study suggests that spectral-domain optical coherence tomography (OCT) peripapillary retinal nerve fiber layer thickness and retrobulbar optic nerve sheath diameter (ONSD) measured by A-scan ultrasound provide useful information when differentiating the two conditions. To evaluate the use of A-scan ultrasound and spectral-domain OCT retinal nerve fiber layer thickness (RNFLT) in differentiating papilledema associated with idiopathic intracranial hypertension from pseudopapilledema. Retrospective cross-sectional analysis included 23 papilledema and 28 pseudopapilledema patients. Ultrasound-measured ONSD at primary gaze, percent change in ONSD at lateral gaze (30° test), and peripapillary RNFLT were analyzed. Receiver operating characteristic curves were constructed using one eye from each subject. Compared with pseudopapilledema, papilledema eyes showed larger mean ONSD (5.4 ± 0.6 vs. 4.0 ± 0.3 mm, P < .0001), greater change of ONSD at lateral gaze (22.4 ± 8.4% vs. 2.8 ± 4.8%, P < .0001), and thicker retinal nerve fiber layer (219.1 ± 104.6 vs. 102.4 ± 20.1 μm, P < .0001). Optic nerve sheath diameter and 30° test had the greatest area under the receiver operating characteristic curve, 0.98 and 0.97, respectively; followed by inferior quadrant (0.90) and average RNFLT (0.87). All papilledema eyes with Frisén scale greater than grade II were accurately diagnosed by ONSD, 30° test, or OCT. In mild papilledema (Frisén scale grades I and II, n = 15), area under the receiver operating characteristic curve remained high for ONSD (0.95) and 30° test (0.93) but decreased to 0.61 to 0.71 for RNFLT. At 95% specificity, sensitivities for ONSD, 30° test, and RNFLT were 91.3%, 91.3%, and 56.5%, respectively, for the entire papilledema group and 80.0%, 86.7%, and 13.3% for the mild papilledema subgroup. Retinal nerve fiber layer thickness can potentially be used to detect moderate to severe papilledema. A-scan may further assist differentiation of mild papilledema from pseudopapilledema.

Surgical interventions for vertical strabismus in superior oblique palsy.

Superior oblique palsy is a common cause of vertical strabismus in adults and children. Patients may be symptomatic from binocular vertical diplopia or compensatory head tilt required to maintain single vision. Most patients who are symptomatic elect to undergo strabismus surgery, but the optimal surgical treatment for vertical strabismus in people with superior oblique palsy is unknown. To assess the relative effects of surgical treatments compared with another surgical intervention, non-surgical intervention, or observation for vertical strabismus in people with superior oblique palsy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), MEDLINE Ovid (1946 to 13 December 2016), Embase Ovid (1947 to 13 December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 13 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 13 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 13 December 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 13 December 2016. We did not use any date or language restrictions in the electronic searches for trials. We included randomized trials that compared at least one type of surgical intervention to another surgical or non-surgical intervention or observation. Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. We identified two randomized trials comparing four different surgical treatments for this condition, two methods in each trial. The studies included a total of 45 children and adults. The surgical treatments were all procedures to weaken the ipsilateral inferior oblique muscle. One study compared inferior oblique myectomy to recession of 10 mm; the other study compared inferior oblique disinsertion to anterior transposition (2 mm anterior to the temporal border of the inferior rectus insertion).We judged both studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Neither study reported data on the primary outcome of this review, which was the proportion of participants with postoperative surgical success, defined as hypertropia less than 3 prism diopters (PD) in primary gaze. However, both studies reported the average reduction in hypertropia in primary gaze. One study found that at 12 months' postoperatively the average decrease in hypertropia was higher in participants who underwent inferior oblique myectomy than in those who underwent recession, however data were not available for statistical comparison. The other trial found that after at least six months of follow-up, the mean decrease in primary position hypertropia was lower in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (mean difference (MD) -5.20 PD, 95% confidence interval (CI) -7.76 to -2.64; moderate-quality evidence).Both trials also reported the average postoperative reduction in vertical deviation in adduction. One study reported that the average reduction in hypertropia in adduction was greater in participants who underwent inferior oblique myectomy than in those who underwent recession, but data were not available for statistical comparison. The other study found a lower decrease in hypertropia in contralateral gaze in participants who underwent inferior oblique disinsertion than in those who underwent anterior transposition (MD -7.10 PD, 95% CI -13.85 to -0.35; moderate-quality evidence).Secondary outcomes with sufficient data for analysis included proportion of participants with preoperative head tilt that resolved postoperatively and proportion of participants who underwent a second surgery. These outcomes were assessed in the trial comparing inferior oblique anterior transposition to disinsertion; both outcomes favored anterior transposition (risk ratio 7.00, 95% CI 0.40 to 121.39 for both outcomes; very low-quality evidence). None of the participants who underwent inferior oblique anterior transposition or disinsertion developed postoperative hypotropia or reversal of the vertical deviation. All participants who underwent inferior oblique anterior transposition developed elevation deficiency, which the authors deemed to be clinically insignificant in all cases, whereas no participants who underwent inferior oblique disinsertion experienced this complication. Additionally, the trial comparing inferior oblique myectomy to recession reported that no participant in either group required another strabismus surgery during the postoperative period. The two trials included in this review evaluated four inferior oblique weakening procedures for surgical treatment of superior oblique palsy. We found no trials comparing other types of surgical procedures for this disorder. Both studies had enrolled a small number of participants and provided low-quality evidence due to limitations in completeness and applicability. We therefore found no high-quality evidence to support recommendations for optimal surgical treatment of superior oblique palsy. Rigorously designed, conducted, and reported randomized trials are needed to identify the optimal surgical treatment for vertical strabismus in this disorder.

Predictive factors for corrective effect of inferior rectus recession for congenital superior oblique palsy.

To identify preoperative factors associated with the surgical corrective effect of contralateral inferior rectus recession (IRR) for vertical deviation in patients with congenital superior oblique palsy (SOP). This retrospective study included 20 treatment-naïve patients with unilateral congenital SOP (age range, 6-79years) who underwent contralateral IRR according to our basic policy to select IRR for paretic eye fixation. The corrective effect (°/mm) of IRR was defined as the difference in the vertical deviation at the primary gaze position between before and 6-18months after surgery per distance of recession. We also measured the preoperative vertical deviation at primary and secondary gaze positions, and vertical deviation with head-tilting, and calculated the difference in vertical deviation between these positions. We analyzed the correlation between the corrective effect of IRR and these study parameters. The mean corrective effect of IRR was 2.4±1.6°/mm, which had a significant correlation with preoperative differences in vertical deviation between the primary gaze position and the downward (P=0.004, r=-0.61) and contralateral gaze positions (P=0.03, r=-0.48); and the presence of preoperative stereopsis (P=0.02, r=-0.51). After excluding a statistical outlier, the correlation between the corrective effect and the difference between the primary and contralateral gaze positions was no longer significant (P=0.07), while the other two relationships remained significant. Our findings suggest that preoperative differences in vertical deviation between the primary and downward gaze positions and the presence of preoperative stereopsis are important considerations prior to performing IRR for congenital SOP, particularly with paretic eye fixation.

Centration and Decentration of Contact Lenses during Peripheral Gaze.

Varying amounts of peripheral defocus reported in previous studies are likely due to whether peripheral defocus is measured while turning the eyes or the head. Contact lenses (CLs) lag when viewing objects in peripheral gaze, so future studies ought to measure peripheral defocus while turning the head to measure defocus through the peripheral add power. Soft multifocal CL peripheral defocus studies report varying results. To determine whether soft multifocal CL lag when turning the eyes could affect the measurement of peripheral defocus, we measured how much CLs move when looking in different gazes. The distance between limbus and CL edge was measured with a slit-lamp reticle magnifier. Centration was measured as the distance between CL edge and limbus at the superior, inferior, nasal, and temporal location of the CL while in primary gaze. Decentration of the CL equals the difference of the distance between the CL edge and limbus while looking centrally and 20 degrees in each direction. All measurements were performed while subjects wore habitual and Proclear Multifocal CL. The average ± SD age of the 40 subjects was 27.8 ± 8.4 years, 65% were female, and SE refractive error was -4.43 ± 2.05 diopters. The soft multifocal CLs decentered 0.09 ± 0.03 mm temporal (P = .006). The soft multifocal CLs lagged 0.49 ± 0.28 mm while looking down (P < .001), 0.24 ± 0.36 mm while looking up (P = .008), 0.58 ± 0.20 mm while looking nasal (P < .001), and 0.35 ± 0.21 mm while looking temporal (P < .001). Soft multifocal CLs center temporally in primary gaze, and they lag significantly while looking in every direction, but 0.50 mm or more when looking down or nasal, which could affect measurement of peripheral defocus when subjects turn their eyes instead of their head.

Validity of a new comprehensive pterygia grading scale for use in clinical research and clinical trial.

To determine the reliability and agreement of a new comprehensive pterygium grading scale for use in clinical research and clinical trials. Thirty eyes with pterygia were enrolled in this study. Primary gaze position and lateral gaze position images were taken of each eye with a modified single-lens reflex camera system. Our grading scale includes five parameters: two hyperemia parameters of pterygia on two different gaze position images and three size parameters, quantifying length, width, and area of the cornea encroachment of pterygium, using ImageJ software. All images were graded on the five parameters by two masked, certified reading center graders. Two graders independently graded all the images to determine inter-grader reliability. One grader regraded the images after 3days to determine intra-grader reliability. Intraclass correlation coefficient (ICC) and inter-rater agreement statistic (κ) calculations were performed. The intra-grader reliability for hyperemia grading was high on both primary and lateral gazing positions (κ value is 0.93 and 0.96). The inter-grader reliability for hyperemia grading was also good (κ value is 0.85 and 0.87). The mean value of width, length, and area of the cornea encroachment of pterygium was 4.31±2.04mm, 2.08±1.43mm, and 7.84±7.62mm2, respectively. The intra-grader agreement on width, length, and area were excellent, with ICCs of 0.98 (95% CI 0.96-0.99), 0.99 (95% CI 0.98-1.0), and 0.97 (95% CI 0.94-0.99), respectively. The inter-grader agreement on width, length, and area were also excellent, with ICCs of 0.96 (95% CI 0.90-0.98), 0.99 (95% CI 0.98-0.99), and 0.99 (95% CI 0.97-0.99), respectively. There was excellent intra- and inter-observer reproducibility with the new comprehensive grading scale. This scale could lead to the development of standardized grading assessments and quantification of pterygia that would be valid in clinical research and clinical trials.

Inferior Oblique Belly Transposition for Small Angle Hypertropia With Inferior Oblique Overaction: A Pilot Study.

To evaluate the efficacy of transposition of the belly of the inferior oblique muscle in treating inferior oblique overaction with small angle hypertropia. The medical records of 10 patients who underwent inferior oblique belly transposition from March 2014 to July 2016 were reviewed. Transposition of the inferior oblique muscle belly consisted of suturing the entire body of the muscle to the sclera 5 mm posterior to the temporal insertion of the inferior rectus muscle. All patients had small hypertropias (< 5 prism diopters) in the primary gaze position with associated inferior oblique overaction. Deviations in both primary and lateral gazes, compensatory face turns or head tilts, and the degree of inferior oblique overaction were evaluated preoperatively and postoperatively. Nine of the 10 patients had a complete resolution of inferior oblique overaction. In the remaining patient, the inferior oblique overaction improved from +3 to +1. None of the patients had any residual vertical deviation. There was elimination of compensatory head tilting in 5 patients and correction of compensatory face turns in 4 patients. One patient with mild up drifting of the involved eye also improved after the procedure. All patients expressed subjective satisfaction with the surgical outcome. Transposition of the inferior oblique muscle belly effectively weakened mild to moderate inferior oblique overaction and corrected small primary position hypertropias. This procedure may be a useful addition to surgical treatment options in patients with small hypertropias associated with inferior oblique overaction. [J Pediatr Ophthalmol Strabismus. 2018;55(1):43-46.].