Microtropia Research Articles

Opinions on Amblyopia Treatment in Microtropia – A Questionnaire Study of Orthoptists in Scandinavia

Background: Microtropia is a small angle strabismus of less than or equal to ten prism diopters. It often co-exists with anisometropia, and patients may require amblyopia treatment. Diplopia following amblyopia treatment is considered rare, but older literature can advise caution when treating amblyopia in microtropia. This study aimed to explore orthoptists’ opinions on amblyopia treatment in microtropia. Methods: Orthoptists working in Scandinavia were invited to complete an online questionnaire regarding their views on amblyopia treatment. They were presented with three different clinical scenarios: 1) patient with anisometropia; 2) patient with anisometropia and microtropia with identity; and 3) patient with anisometropia and microtropia without identity. Results: The questionnaire received responses from 30 orthoptists, which were analysed. The results showed a significantly higher concern for diplopia in patients with microtropia undergoing amblyopia treatment than in patients with anisometropia. They responded that to prevent diplopia, it is more important to stop amblyopia treatment before equal visual acuity (VA) is reached in microtropia compared to anisometropia. Thus, amblyopia treatment was stopped more often in microtropia, even if VA was improving and diplopia was absent. Equal VA was perceived to be more difficult to achieve in microtropia, both with and without identity, compared to anisometropia. Conclusion: Despite more recent evidence that diplopia following amblyopia treatment is extremely rare, orthoptists working in Scandinavia reported more concerns about diplopia when treating amblyopia in microtropia than in anisometropia. Stopping amblyopia treatment in microtropia before equal VA was achieved was considered somewhat important to prevent diplopia. Orthoptists also reported that equal VA was difficult to achieve in patients with microtropia, both with and without identity. Further research would help improve the evidence and inform clinical decisions about microtropia and amblyopia treatment in microtropia.

Factors affecting outcome of acquired comitant esotropia with restricted use of digital devices: ACEDD Study 3.

The objective of this study is to investigate factors associated with outcomes after 3 months of instructed usage of hand-held digital devices (DD) in patients with acquired comitant esotropia (ACE). This prospective multicentre observational study included patients with ACE, aged 5-35 years, who used DD within 1 year of onset and were followed up for clinical findings and instructed use of DD. The outcomes were classified into four groups: cured, improved, unchanged and worsened. After the analysis of group differences in the clinical and DD use-related factors by univariate analysis, we used ordinal logistic regression models to identify factors associated with favourable outcomes. Of 156 patients (mean age (SD): 16.4 (7.4) years), 10 (6%), 58 (37%), 67 (43%) and 21 (14%) were classified into the cured, improved, unchanged, and worsened, respectively. In the univariate analysis, consultation within 3 months of onset, small-angle strabismus at distance and good stereoacuity were associated with good outcomes. Ordinal logistic regression analysis on adjusting for age with stereoacuity or successful DD-use time halving showed that small-angle strabismus at distance (OR: 1.02, 95% CI 1.00 to 1.03, p=0.023), good stereoacuity (OR: 1.31; 95% CI 1.10 to 1.56; p=0.003) and successful halving of DD-use time (OR: 0.63; 95% CI 0.43 to 0.92; p=0.016) influenced favourable outcomes. Patients with small-angle esotropia, good stereoacuity on consultation and success in halving DD-use time had a higher chance of recovery through instructional DD usage. Further studies using objectively measurable systems are needed to ensure the accuracy of DD-use time.

High-Adherence Dichoptic Treatment Versus Patching in Anisometropic and Small Angle Strabismus Amblyopia: A Randomized Controlled Trial

PurposeTo compare the effectiveness and safety of a novel binocular eye-tracking-based-home-treatment (CureSight) to patching for the treatment of amblyopia. DesignProspective, masked, randomized controlled noninferiority trial. SettingMulticenter, multinational, home treatment. ParticipantsOne hundred forty-nine children 4 to < 9 years with anisometropic, small-angle strabismic, or mixed-mechanism amblyopia were randomized to either binocular treatment (n=75) or patching (n=74). InterventionsThe binocular treatment group used the CureSight system for 90 min/day, 5 days/week for 16 weeks (120 hours). The patching group received 2-hour patching 7 days/week (224 hours). Main outcome measuresThe primary outcome was the mean improvement from baseline in amblyopic eye visual acuity (VA) to week 16 in both study groups (non-inferiority of ≤0.10 logarithm of the minimum angle of resolution [logMAR]). Other outcomes included changes in stereoacuity and binocular VA from baseline to week 16. ResultsThe mean improvement from baseline at week 16 in the binocular treatment group was noninferior to patching group improvement in the modified intent-to-treat (mITT) dataset (LS mean difference between groups in improvement from baseline: 0.034 logMAR (95% CI -0.009 to 0.076)). In the per-protocol (PP) dataset, the mean improvement from baseline at week 16 in the binocular treatment group was superior to patching group improvement (LS mean difference between groups in improvement from baseline: 0.05 logMAR ([95% CI; 0.007 to 0.097]). At week 16, both groups showed significant median improvement in stereoacuity, with no significant between-group difference in the magnitude of improvement in both the mITT and the PP datasets. Binocular VA was also improved in both groups (p<0.0001). Median adherence in the mITT binocular treatment group (94.0%) was also significantly higher than in the patching group (83.9%; p=0.0038). ConclusionsBinocular, eye-tracking-based amblyopia home treatment is at least as effective as patching.

Small-angle strabismus detection by telemedicine in an experimental model

To evaluate the ability of observers to accurately detect strabismus using an alternate cover testing approach via telemedicine and to assess the effect of various factors related to video conditions on the accuracy rate. Videos were made by the authors in which different angles of strabismus, up to 12Δ, were induced by prism and recorded using alternate cover testing. The videos were made under a variety of conditions that incorporated various head postures, lighting, fixation target position and motion, and viewing angle. The videos were shown to observers of varying levels of expertise. The accuracy of detecting the deviation was assessed and analyzed for statistical significance. The overall rate of detection was significantly affected by the angle of deviation, with 12Δ being correctly detected with 94% accuracy, 8Δ with 72% accuracy, and 4Δ with <50% accuracy. Esotropia and hypertropia were more accurately detected than exotropia for all angles tested. The level of training of the observer did not correlate with detection accuracy. However, accuracy was negatively affected by backlighting and movement of the fixation target during cover testing. Our data demonstrate that detection of even relatively small angles of strabismus can be accomplished with a high level of accuracy using telemedicine and an alternate cover testing strategy. For optimal results, it is important to consider conditions related to the fixation target and lighting.

Comparison between bupivacaine injection and mini-tenotomy in the management of horizontal small angle strabismus in children

ABSTRACT Purpose To compare the outcome of bupivacaine (BUP) injection vs mini-tenotomy of extra-ocular muscles in treating small angle horizontal strabismus in children. Methods A prospective comparative study that included a total of 40 patients. Twenty patients received 3 ml of 0.75% Bupivacaine (BUP) injection in both medial recti in case of exotropia and in both lateral recti in case of esotropia. MRI orbit was performed before and 30–60 days’ post injection of bupivacaine to estimate changes in muscle size. Mini-tenotomy was done in the other 20 patients, performed on both lateral recti in case of exotropia and on both medial recti in case of esotropia. Results Mean change of alignment at the end of 6 months in exotropic patients in bupivacaine group was 5.50 ± 4.10 PD and in esotropia patients 4.00 ± 3.38 PD with an average increase in muscle thickness of 0.12 mm ± 0.08 and 0.13 mm ± 0.09 in exotropia and esotropia, respectively. There was an average increase in volume 23 mm3 ± 17.3 and 17.00 mm3 ± 9.50 in exotropia and esotropia, respectively, as measured with MRI. The mean change of alignment in mini-tenotomy was 5.33 ± 4.12 PD, 5.75 ± 4.95 PD in exotropia and esotropia, respectively. Conclusion Bupivacaine and mini-tenotomy are safe and effective alternative treatment, that improved eye alignment in 65% of patients with small angle horizontal deviation.

Extraocular Rectus Muscle Stretching as a Weakening Procedure.

Anterior segment ischemia may occur when three or more rectus muscles are operated in the same eye. Our purpose was to investigate the efficacy of rectus muscle stretching as a vessel-sparing weakening technique, in comparison with a retrospectively collected series of patients. Non-operated patients with an indication of medial rectus muscle weakening surgery (deviation up to 20PD, prism diopters) who could cooperate with topical or sub-Tenon's anesthesia. Clinical workup included routine complete ophthalmological evaluation. One double-needle 6/0 Mersilene suture was used on each side of the muscle at 4mm distance of the insertion and pulled/stretched to insert in the sclera 3-5mm posterior to the muscle locking passes. Main outcome measure was distance deviation at 2months after surgery (alternate prism and cover test). Seven patients with esotropia of 12-20PD, recruited in a 20-month period, were included. Preoperative median deviation was 20PD, whereas postoperative median deviation was 4PD (range 0-8PD). On a visual pain scale (1-10) median pain score was 3 (range 2-5). Remarkable postoperative complications did not occur. Significant differences with a retrospectively collected series of patients' data, treated with standard medial rectus recession, were not observed. Preliminary data indicate that stretching of a rectus muscle has some weakening effect, that could be useful to correct small-angle strabismus, and may be suggested as a vessel-sparing technique when two rectus muscles have previously been operated in the same eye. ClinicalTrials.gov NCT05778565.

Presence and development of strabismus in children with telecanthus, epicanthus and hypertelorism.

To study the presence and development of strabismus in children with telecanthus, epicanthus, and hypertelorism. This is a prospective, longitudinal, and observational study. Sixty children aged between 6 months and 18 years with telecanthus, epicanthus, and hypertelorism in isolation or in combination were recruited. A detailed analysis of the history, determination of best corrected visual acuity, complete evaluation of strabismus, and ocular examination were carried out. The presence of telecanthus, epicanthus, and hypertelorism and associated strabismus, if any, was noted. All children were followed up for a minimum and maximum period of 12 and 18 months, respectively, to analyze the strabismus (previously present) and for detection of strabismus in those who did not have. The data were analyzed descriptively with mean and standard deviation. Chi square test and Fishers exact test were used to analyze the data between the groups. A P value less than 0.05 was considered to be statistically significant. Telecanthus was the most common lid feature (55%). At baseline, ten (16.66%) children had strabismus (six: esotropia; four: exotropia). Two (3.33%) children underwent surgery. One child developed exotropia at the third follow-up (18 months). At the end of the study, 11 (18.33%) children had strabismus. No significant association was seen between lid characteristics and the type of strabismus. Children with telecanthus, epicanthus, and hypertelorism in isolation or in combination may or may not have associated strabismus. These features can pose difficulty in strabismus diagnosis, which mandates a careful examination, especially in younger age groups and small-angle strabismus. On the other hand, children without strabismus need longer follow-up to detect the development of strabismus and to initiate further management at the earliest.

Application of Soft Directional Prismatic Contact Lenses to Correct Diplopia.

To verify whether diplopia due to a small-angle strabismus within 8 prism diopters (PD) could be corrected by applying soft directional prismatic contact lenses, obtaining higher comfort and quality of vision for the patients. A prospective study was undertaken by enrolling consecutive patients affected by vertical and/or horizontal diplopia and small-angle strabismus within 8 PD. The patients were tested for best corrected visual acuity, refraction, cover test for near and for distance, ocular motility test, prismatic fit test, corneal topography, tear film evaluation, binocular vision test, head position evaluation, retinography, and optical coherence tomography of the posterior and anterior segment. Custom soft contact lenses, made in Benz G5X material, were designed and developed for this study. All patients were first corrected with prismatic glasses according to their degree of strabismus and ametropia. Then they were asked to wear custom-made directional prismatic contact lenses with appropriate simultaneous correction of strabismus and ametropia. The patients were then asked to answer whether the comfort and quality of vision was higher with directional prismatic contact lenses or prismatic glasses. Eight patients were enrolled with different causes of diplopia caused by a strabismus of 8 PD or less. The soft directional prismatic contact lenses could resolve diplopia in 100% of patients. All patients reported greater comfort and quality of vision with directional prismatic contact lenses. The study demonstrated that diplopia resulting from an angle of strabismus within 8 PD can be corrected through the use of soft directional prismatic contact lenses, obtaining greater quality of vision free of aberrations. [J Pediatr Ophthalmol Strabismus. 2023;60(4):248-252.].

Clinical Management of Monofixation Syndrome due to Microtropia

BACKGROUND: Monofixation syndrome is a binocular vision disorder characterized by peripheral fusion with a central suppression of one eye due to smallangle strabismus (microtropia) or anisometropic amblyopia. Reduced stereopsis and acuity are noted in the non-fixating eye. Although often left untreated due to good cosmetic appearance, central suppression and reduced stereopsis can affect visual performance, comfort, and depth perception. CASE REPORT: EJ, a 17-year-old Caucasian female was previously treated for amblyopia of the left eye (OS) with glasses and patching since age 8 with no improvement to vision. EJ experienced the following symptoms: blurred vision at near when reading, blurred vision at far distances, eye pain and fatigue, difficulty copying from the board, difficulty seeing at night while driving, and poor depth perception. Entering uncorrected visual acuity was 20/20-2 OD and 20/50-2 OS with Snellen Letter Chart. Near uncorrected acuity was 20/20 OD and 20/200 OS with a reduced Snellen chart at 40 cm. Microtropia of 2 to 12 prism diopters of esotropia, eccentric fixation on visuoscopy, and central suppression on various tests were measured. EJ was diagnosed with monofixation syndrome, monocular esotropia of the left eye, strabismic amblyopia of the left eye, suppression of binocular vision (OS), and fusion with defective stereopsis. The patient completed 19 sessions of in-office vision therapy with the practice of home reinforcement activities between therapy sessions. Visual performance was reassessed after 10 and 19 sessions of vision training with improvements noted in acuity, accommodation, oculomotor accuracy and speed, eye alignment, fusional vergence skills, and stereopsis. CONCLUSION: Optometric vision therapy can decrease suppression, improve central fusional ability, visual acuity, accommodative accuracy, and stereopsis in a patient with monofixation syndrome.

Strabismus as a Presenting Sign in Retinoblastoma.

To report the presenting signs of retinoblastoma in a large cohort of patients who underwent orthoptic assessment at presentation. A retrospective medical chart review was conducted on 131 patients with retinoblastoma who presented consecutively to a single institution during a 6-year period. The main outcome measure was the presenting sign(s) of the disease. Of 131 patients with retinoblastoma, 88 presented with unilateral disease and 43 presented with bilateral disease (mean ages: 22.7 and 14.8 months, respectively). Leukocoria was the presenting sign in 56% of patients, leukocoria and strabismus in 18%, strabismus in 13%, inflammation in 8%, and "other" signs in 5%. The fovea was affected by the retinoblastoma tumor or its sequelae in 75% of patients. Patients who presented with strabismus were significantly more likely to have foveal involvement than patients who presented with leukocoria alone (P = .001). Thirty-one percent of patients had strabismus as a component of their presentation; 63% had exotropia, 23% had esotropia, and 14% had variable strabismus. The percentage of patients with strabismus increased to 66% when small angle and variable strabismus were also considered. Patients with inflammation had worse ocular survival (P < .05). This study assessed the combination of leukocoria and strabismus as presenting features of retinoblastoma. Foveal involvement is common in patients who have strabismus and may influence decision-making regarding globe salvage. The authors confirmed that exotropia is more common than esotropia in retinoblastoma in the largest cohort to have undergone an orthoptic assessment. [J Pediatr Ophthalmol Strabismus. 2021;58(5):324-330.].

Management of patients with small-angle esotropia and subnormal stereopsis using Fresnel prism.

Monofixation syndrome (MFS) is a specific subnormal binocular vision status, either with or without a small deviation. Patients with MFS have a tendency to maintain stable ocular alignment. Correction of refractive errors and occlusion are considered as treatment option for amblyopia, and the status of MFS could be changed with long-term follow-up. The purpose of this study is to evaluate whether a Fresnel prism affected the visual acuity, angle of deviation, and sensory status in small-angle esotropia with subnormal stereopsis presenting with MFS features. Patients with small-angle esotropia within 8 prism diopters (PD) on the simultaneous prism and cover test from 2010 to 2019 were reviewed. Patients with subnormal stereopsis defined as more than 100 s of arc (arcsec) and with the central suppression with peripheral fusion were only included. A Fresnel prism was applied to the dominant eye, and the minimum follow-up period after Fresnel prism treatment was 24months. We assessed patient clinical characteristics, course and response to therapy including visual acuity, angle of deviation, and stereopsis. Twenty patients with a mean age of 5.5 ± 1.4years were included. The mean duration of Fresnel prism treatment was 15.3 ± 10.3months. After 50.7 ± 17.2months of follow-up, VA of the non-dominant eye was changed from 0.26 ± 0.20 logMAR to 0.07 ± 0.17 logMAR (P < .001). The initial stereoacuities were 3.54 ± 0.27 log arcsec, ranged from 6000 to 400 arcsec. After the treatment with Fresnel prism, the final stereoacuities were 3.09 ± 0.58 log arcsec, ranged from 6000 to 100 arcsec (P = .001); nine patients (45%) improved stereoacuity more than two octaves. No changes in the angle of deviation or a change of fixation were observed. After use of Fresnel prism, there was some improvement in visual acuity and stereopsis in patients with MFS features. Following occlusion and refractive correction, management using Fresnel prism could be attempted in small-angle esotropic patients with amblyopia or subnormal stereopsis.

Augmented Lateral Rectus Recession for Consecutive Exotropia

ABSTRACT Purpose: To evaluate the efficacy of augmented bilateral lateral rectus recession in the treatment of consecutive exotropia. Methods: We retrospectively reviewed records of nine patients who underwent augmented bilateral lateral rectus recession for consecutive exotropia with minimal adduction deficits. Our normal surgical dosing tables for bilateral lateral rectus recession were augmented by adding 1.5–2 mm. All patients had been measured preoperatively using prism and alternate cover testing (PACT), except for one patient in whom Krimsky measurements were performed because of amblyopia. Surgery was deemed successful if postoperative alignment fell within a potential monofixation range of ±10 prism diopters (PD) by PACT at the final postoperative examination. Results: Eight out of nine patients (89%) had a successful outcome. One patient was surgically undercorrected. Despite successful realignment to a state of monofixation syndrome in most patients, there was no significant restoration of stereopsis following strabismus surgery. Conclusions: Surgical augmentation of bilateral lateral rectus recession standard dosing by 1.5–2 mm is efficacious for restoring binocular alignment for both distance and near fixation. This surgical approach may be preferable to bimedial advancements in patients with minimal preoperative adduction deficits who show no significant increase in exotropia during near fixation.

Time and Factors Affecting the Direction of Re-drift in Essential Infantile Esotropia.

To investigate the development pattern and related factors of postoperative re-drift in infantile esotropia. A total of 112 patients with infantile esotropia who underwent surgery before 3 years of age were included. Surgical outcomes were divided into (1) consecutive exotropia: more than 8 prism diopters (PD) of exodeviation; (2) recurrent esotropia: more than 8 PD of esodeviation; and (3) monofixation syndrome: maintenance of deviations within 8 PD. The occurrence rate, time of onset, and associated factors of the re-drift were evaluated. At a mean follow-up of 9.5 years, consecutive exotropia developed in 37 patients (33.0%) and recurrent esotropia in 43 patients (38.4%). Whereas 76.7% of total recurrent esotropia cases were identified within postoperative 1 year, consecutive exotropia occurred constantly over 10 years postoperatively. The mean time to consecutive exotropia development from surgery was 78.6 months, greater than that of recurrent esotropia development (8.9 months) (P < 0.001). In multinomial logistic regression using monofixation syndrome as the reference category, fixation preference before surgery (odds ratio [OR]: 6.64, 95% confidence interval [CI]: 2.07 to 21.32) and the rate of myopic progression (OR: 15.07 per -1.00 D/year, 95% CI: 1.23 to 184.86) were associated with consecutive exotropia, whereas increase in the angle of esodeviation on postoperative day 1 (OR: 1.15, 95% CI: 1.04 to 1.26) was correlated with recurrent esotropia. This study demonstrates a difference between the development pattern of exotropic and esotropic drift after infantile esotropia surgery. Detailed preoperative assessment and close postoperative observation of deviations and refractive status will help to determine surgical outcomes of infantile esotropia. [J Pediatr Ophthalmol Strabismus. 2018;55(2):128-134.].

Long-term Surgical Outcomes in the Sagging Eye Syndrome

ABSTRACTBackground/aims: Strabismus due to sagging eye syndrome (SES) caused by age-related connective tissue involution is now an established cause of diplopia in older people. High suspicion of the condition results in early recognition, often obviating extensive neurological investigations and enabling surgical correction of the strabismus.Methods:This retrospective study reviewed surgical results in 93 patients (40 males) of average age 68 ± 12 years, who had small-angle strabismus due to SES, during the 20-year period 1994–2014.Results: In central gaze, mean distance pre-operative esotropia was 4.2 ± 7.5Δ (mean, SD), while mean hypertropia was 4.7 ± 5.9Δ. Surgeries comprised medial rectus (MR) recession; lateral rectus (LR) resection; plication, imbrication, and superior transposition of the LR to the superior rectus (SR) for esotropia; and graded vertical rectus tenotomy (GVRT) or vertical muscle recession for hypertropia. Mean post-operative immediate and long-term deviation after 316 ± 265 months average follow-up was 0.2 ± 1.2Δ and 1.1 ± 2.7Δ esotropia (both distance), respectively, and 0.00Δ and 1.1 ± 2.7Δ, respectively, for hypertropia. Strabismus recurred in 19 cases.Conclusions: Progressive connective tissue involution in SES may occasionally result in symptomatic recurrences of the small-angle strabismus in about 20% of patients, irrespective of surgical procedures performed, possibly because of progressive involutional changes. This risk should be disclosed pre-operatively.

Prism under cover test in alternate fixation horizontal strabismus

ABSTRACTPurpose: To evaluate the applicability of the prism under cover test (PUCT) to quantify manifest deviation in horizontal strabismus with alternate fixation when simultaneous prism and cover test (SPCT) is not feasible.Methods: Children aged 4–11 years, with alternate fixation horizontal strabismus and alternate prism and cover test (APCT) distance deviation (DD) up to 25 PD were eligible. In group 1 of the study, SPCT was not feasible (n = 18), whereas in group 2, it was feasible (n = 24). Refraction, PUCT, APCT, central/peripheral fusion, and stereoacuity were measured. Repeatability of PUCT, agreement between PUCT and SPCT, and Pearson correlations between variables were studied.Results: In group 1, mean DD was 15.6 and 9.5 PD using APCT and PUCT, respectively (intraclass correlation, ICC: 0.90). Mean stereoacuity was 201.1 arc seconds. PUCT was better correlated with stereoacuity than APCT, but not significantly (p = 0.12). Coefficient of repeatability for PUCT was 3.4 PD. In group 2, mean DD was 17.6, 14.1, and 12.5 PD using APCT, PUCT, and SPCT, respectively. Mean stereoacuity was 285.9 arc seconds. Correlations APCT-PUCT (0.87), APCT-SPCT (0.82), and SPCT-PUCT (0.95) were significant. APCT did not show as good correlation with stereoacuity (0.58) as SPCT and PUCT (0.74 and 0.78, respectively). Concordance correlation coefficient between SPCT and PUCT was 0.91, and Bland Altman agreement between the two variables was also good.Conclusions: PUCT is a procedure with good repeatability, of interest in children to estimate manifest deviation when SPCT is not feasible, and in support of the diagnosis of monofixation syndrome.

Botulinum toxin for the treatment of strabismus.

Botulinum toxin for the treatment of strabismus.

Development of Monofixation Syndrome After Extraction of Dense Cataracts.

If the interruption of macular fusion for an extended period of time is the key event that results in the development of monofixation syndrome, then the decreased macular input caused by dense cataracts may cause monofixation syndrome in adults. This study was designed to test this hypothesis. The study design was a retrospective chart review that identified patients with unilateral cataracts at two southern Louisiana medical centers. Patients were assigned to the dense cataract group if a unilateral cataract had been present for at least 3 months and led to a visual acuity of worse than 20/200. Patients in the control group had a unilateral cataract for more than 3 months and visual acuity better than 20/200 in the affected eye. Stereoacuity was assessed using the Titmus or Randot stereo test. A Worth 4-dot test viewed at a distance of 20 feet was used to assess the presence of a macular scotoma. The criteria for monofixation syndrome were met if stereoacuity was less than 60 seconds and the Worth 4-dot test demonstrated central macular scotoma at 20 feet. The dense cataract group's association with monofixation syndrome was statistically significant when compared to the control group (P < .0001). This study adds dense adult-onset cataracts to the list of causes of monofixation syndrome and reduced stereoacuity. A delay in treating dense lens opacities can result in good visual outcome but an inferior binocular visual outcome (poor stereoacuity). [J Pediatr Ophthalmol Strabismus. 2017;54(1):39-42.].

Acute acquired concomitant esotropia and decompensated monofixation syndrome: a sensory-motor status assessment

ObjectiveTo assess and compare sensory-motor status and clinical features of type I and type II acute acquired concomitant esotropia (group A) and decompensated monofixation syndrome (group B). MethodsIn a retrospective, comparative study, 26 patients with a confirmed postoperative diagnosis of type I and II acute acquired concomitant esotropia and monofixation syndrome were enrolled. The 2-tailed unpaired t test and 2-tailed χ2 test were performed to compare angle of deviation and sensory-motor status under the environmental conditions and after prismatic adaptation test and progressive prism test of 2 groups. ResultsAll of the patients of group A and 4 patients (33%) of group B experienced diplopia under viewing conditions in the Worth’s 4 dot and Bagolini striated glass tests. The TNO stereo test showed the total absence of stereopsis in 6 patients in group B and a significantly lower stereoacuity in group A in the remaining 6 patients (p < 0.0001). The prismatic adaptation test was positive in all of the patients in group B and in 10 patients (71%) in group A (p = 0.39). The value of the angle of deviation after the progressive prism test was significantly higher in group B than in group A (p = 0.02). At the end of the progressive prism test, all of the patients in group A and only 2 patients in group B were orthotropic (p = 0.01). ConclusionsBagolini striated glass and Worth’s 4 dot tests under viewing conditions and responses under prisms allow for the differentiation of the 2 forms and lead to an accurate aesthetic and functional prognosis.

Iatrogenic Injury to Medial Rectus After Endoscopic Sinus Surgery.

Endoscopic sinus surgery (ESS) is the mainstay of the treatment in sinus disorders, to re-establish the drainage of the affected sinus. The close proximity of the orbital structures to paranasal sinuses makes them vulnerable to inadvertent injury during the sinus surgery. Medial rectus (MR) muscle is the most commonly injured extraocular muscle during ESS due to its anatomic proximity to the thin medial wall of the orbit. This is a non-comparative, retrospective, interventional case series of six patients presenting with MR injury after ESS. We discuss the management, outcome and review the published literature. Atotalof six patients met the inclusion criteria. The presenting complaints were diplopia, squinting and limitation of ocular movements. Two patients underwent surgical exploration of the MR muscle and reattachment of the muscle along with injection botulinum to the antagonist lateral rectus muscle. Two patients who had small angle strabismus and who were able to fuse were advised orthoptic exercises and prisms as management. Remaining two patients were advised surgical intervention to correct strabismus but they declined further surgical intervention. Management of MR injury following ESS is complex, often resulting in suboptimal outcomes. Since early intervention is associated with better outcomes, early referral by otolaryngologists to ophthalmologists would result in better outcome.

Acute acquired comitant esotropia of childhood: a classification based on 48 children.

To identify characteristics of pediatric patients who develop acute acquired comitant esotropia (AACE) with and without intracranial disease. We reviewed the charts of 48 children consecutively referred to the hospital with AACE during a 13-year period. Inclusion criteria were acute onset of comitant esotropia, available data on ophthalmologic, orthoptic and neurologic examinations. Children with neurological signs, AACE recurrence or hyperopia <+3 dioptres (D) underwent brain computed tomography or magnetic resonance imaging. Patients without imaging were followed. In all, 48 cases were recorded. The mean age at onset was 4.7 years, being significantly higher among children with intracranial disease. Seven cause-specific types of AACE in childhood were identified: The acute accommodative (n = 15, 31%), decompensated monofixation syndrome or esophoria (n = 13, 27%), idiopathic (n = 9, 19%), intracranial disease (n = 3, 6%), occlusion related (n = 3, 6%), AACE secondary to different aetiologic disease (n = 3, 6%) and cyclic AACE (n = 2, 4%). Intracranial disease included hydrocephalus, pontine and thalamic glioma. Of the children with intracranial disease, 2 of 3 had no obvious neurological signs at onset. Four significant risk factors for intracranial disease were identified as follows: larger esodeviation at distance, recurrence of AACE, neuro signs (papilledema) and older age at onset (>6 years). In a large case series of children with AACE and by review of literature, we identified seven cause-specific types of AACE. Intracranial disease was present in 6%, and four risk factors were identified to guide clinicians when to perform brain imaging. Findings suggest AACE of childhood to be differentiated from AACE of adulthood.