ABSTRACT Purpose: Monocular Elevation Deficiency (MED) is characterized by limited ability to elevate the affected eye in any gaze position, while maintaining normal duction in all other gazes. The type of surgeries described in MED include Knapp’s surgery, vertical muscle recession and resection, contralateral superior rectus recession. Recently, the Nishida’s procedure has also been explored as a treatment for isolated cases of MED. Hence, we conducted this study to evaluate the surgical outcome of Modified Nishida’s procedure in cases of MED in a series of 15 patients. Methods: This prospective interventional study was performed on 15 patients with MED attending the Strabismus Clinic and outpatient department of our tertiary care centre over a period of 1 year from October 2023 to October 2024. In this study, 15 patients of age more than 13 years with Type 2 Congenital MED with negative forced duction test for inferior rectus, hypotropia more than 10 prism diopters and no horizontal deviation were included. Patients with previous history of strabismus surgery or with bleeding diathesis were excluded. Preoperatively, ocular deviation was measured using vertical prisms in terms of prism diopters (PD). Elevation deficit was noted in all the patients on a scale of 0 to -4 with 0 indicating full rotation and -4 indicating severe limitation (not crossing midline). All patients underwent Modified Nishida’s procedure following forced duction test for inferior rectus. Postoperatively, all the measurements were recorded at the end of first week, first month and the final follow up was done at the end of third month. Primary outcome included correction of vertical deviation at 3 months post Modified Nishida’s procedure. Secondary outcome included assessment of elevation deficit. Results: The mean age of the patients was 23.33 ± 15.73 years. There was statistically significant improvement in mean hypotropia from preoperative measurement of vertical deviation of 28.67 ± 9.904 PD to 7.60 ± 10.176 PD (p < 0.001) at the final follow up. There was statistically significant improvement in elevation deficit ranging from mean value of -3.47 ± 0.74 at baseline to -2.73 ± 0.70 postoperatively at final follow up (p < 0.01). Conclusion: The study demonstrated that the Modified Nishida’s procedure is effective in managing MED in terms of improvement of vertical deviation and elevation deficit.

Surgical Dosing for V-Pattern Exotropia.

Impact of Horizontal Strabismus on Mental Health Among Children and Adults in China.

Accuracy and clinical utility of ultrasound biomicroscopy in extraocular muscle imaging: A systematic review and meta-analysis.

Background &amp; objectives: Emergence agitation (EA) is a common incident following sevoflurane anesthesia, especially in children. Various pharmacological agents have been tried to prevent or at least minimize it with variable success. We aimed to evaluate the prophylactic value of oral melatonin versus oral ketamine against the incidence of EA, postoperative sedation, as well as postoperative pain in pediatric patients planned for squint surgery under sevoflurane anesthesia. Methodology: Ninety children aged 3-5 years, of both genders, were randomized to receive either plain honey (control group or Group C), oral ketamine (Group K), or oral melatonin (Group M) before induction of anesthesia. Incidence of EA, parent separation and mask acceptance, postoperative pain scores, as well as total rescue 24 h fentanyl consumption were noted. Results EA incidence was significantly reduced in Groups K and M compared to the control group (16.66% vs. 13.33% vs. 46.66%; P = 0.008). Pairwise comparison revealed a P value of 0.026 between Group C and Group K, and 0.011 between Group C and Group M, with no significant difference detected in the incidence of EA between Group K and Group M. Pain scores remained significantly lower up to 10 min in Groups K and M (P &lt; 0.001), with better parent separation and mask acceptance along with significantly less fentanyl consumption in both groups as compared to the control group (P &lt; 0.05). Conclusions Preemptive oral administration of ketamine or melatonin, both effectively lower the incidence of emergence agitation. Furthermore, it provided better conditions for parent separation and mask acceptance and decreased rescue analgesics requirement in pediatric patients undergoing squint surgery. Abbreviations: EA: emergence agitation, ED: emergence delirium, PSAS: Parent Separation Anxiety Scale, PAED: Pediatric Anesthesia Emergence Delirium, PACU: Post-anesthesia care unit Clinical trial registration number: PACTR202402880294495 Keywords: Child; Ketamine; Emergence Delirium; Melatonin; Squint Citation: Abu Sabaa MA, Shaban SES, Helal RAEF. Effect of oral melatonin versus oral ketamine on the incidence of emergence delirium in children undergoing squint surgery: a prospective randomized controlled trial. Anaesth. pain intensive care 2025;29(4):341-48. DOI: 10.35975/apic.v29i4.2819 Received: May 09, 2024; Revised: October 26, 2024; Accepted: January 01, 2025

To compare surgical outcomes in pediatric patients with superior oblique palsy and exodeviation to those with isolated intermittent exotropia lacking a vertical component, with a focus on the horizontal components in both groups. This was a retrospective analysis of patients undergoing strabismus surgery from January 2010 to September 2022 in a single tertiary hospital's pediatric ophthalmology unit. The superior oblique palsy and exodeviation group was matched with the intermittent exotropia control group. All patients included had an exodeviation of 25 prism diopters (PD) or less. Surgical success was defined by residual horizontal strabismus of 10 PD or less or residual vertical deviation of 4 PD or less, and lack of additional surgery for residual or consecutive strabismus. Among 45 eligible patients, 17 were in the superior oblique palsy and exodeviation group and 28 in the isolated intermittent exotropia group. At follow-up, patients with combined superior oblique palsy and exotropia exhibited significantly lower horizontal measurements at distance (1.8 ± 2.5 vs 6.6 ± 6.6 PD, P = .006) and near (1.9 ± 3.3 vs 7.4 ± 6.8 PD, P = .004). Additional surgery rates were also lower in this group (5.9% vs 21.4%). One patient with superior oblique palsy and exotropia had residual exotropia exceeding 10 PD (5.9%), compared to 21.4% in the intermittent exotropia group. The success rate was higher in the mixed group (88.2% vs 57.1%, P = .045). Multivariate regression analysis demonstrated that the type of strabismus (P = .013) and shorter follow-up (P = .004) emerged as significant predictors of a successful surgical outcome. Patients with small to moderate superior oblique palsy and exodeviation demonstrated superior surgical outcomes for their exodeviation compared to those with small to moderate isolated intermittent exotropia, emphasizing the distinction between these groups and the potential impact on surgical expectations. These findings highlight the need for extended follow-up in intermittent exotropia cases.

Major Complications Following Strabismus Surgery: nine-year data from the IRIS® (Intelligent Research in Sight) Registry

"Navigating risks and benefits"-Parental decision-making experiences and needs in pediatric strabismus surgery: A qualitative study.

Amblyopia prevalence in patients with alternating esotropia.

PurposeWe aimed to examine the effect of strabismus surgery on quality of life levels in children and adolescents.MethodsThe Health-Related Quality of Life Inventory version 4.0 (HRQOL 4.0), consisting of 23 questions and 4 subscales (physical functioning, emotional functioning, social functioning, and school problems), was administered to the children and adolescents who underwent strabismus surgery and their parents between December 2024 and June 2025, at preoperative and postoperative 1st and 3rd months. The postoperative deviation angle of the cases was 10 Prism Diopter (PD) or less. Strabismus surgery was performed by an Ophthalmologist, and the scales were evaluated by a Child and Adolescent Psychiatrist.Results27 cases were included in our study. 17 (62.9%) of the cases were girls and 10 (37.1%) were boys. The average age was 9.0 ± 3.9 (7–17) . In child and adolescents, the change in the physical functionality parameters of the cases was not statistically significant (p >0.05), but the change in the parameters of emotional functionality, social functionality and school-related problems between the preoperative, postoperative 1st month and postoperative 3rd month was statistically significant (p < 0.05). In the parents’ proxy opinion of the child, the change in physical functionality, emotional functionality, social functionality parameters between preoperative, postoperative 1st month and postoperative 3rd month was statistically significant (p < 0.05), but in the parameters of school-related problems, preoperative, postoperative 1st month and postoperative 3rd month were statistically significant. The change between was not statistically significant(p >0.05) (Table 2).ConclusionSuccessful surgery for strabismus results in measurable improvement in the quality of life in children and adolescents and in the parents proxy opinion of the child’s quality of life.

BackgroundPatients with symptomatic esotropia in lateral gaze after lateral rectus recession may not be offered surgery if they are orthophoric in primary gaze due to concern of creating diplopia in primary gaze. There are currently no reports of the surgical management of these cases. The purpose of this study was to report our experience and describe the surgical outcomes for these rare patients.MethodsA comprehensive, retrospective review of all patients undergoing strabismus surgery at Boston Children’s Hospital over an 11-year period identified all cases of orthophoric patients operated on for diplopia in lateral gaze following lateral rectus recession(s). Surgical approach, pre- and post-operative measurements in diagnostic gaze positions, and surgical outcomes were assessed. We developed a new lateral incomitance (LI) score to characterize patient disability before and after surgery. Main outcome measures were improvement in LI score and lateral gaze diplopia, lack of new-onset diplopia in primary gaze, and patient/surgeon satisfaction.ResultsIn all cases, previously recessed lateral rectus muscles were advanced 2–3 mm with an adjustable suture technique despite anticipated exotropia in primary gaze. Early, large-angle, transient sequential exotropia with diplopia was common. All patients had resolution of lateral-gaze diplopia with improvement in LI score by 8–18 PD, and none experienced persistent new-onset diplopia in primary gaze (median follow-up 16 months; range, 8.5–83 months). One patient with a history of surgery for convergence insufficiency developed a well-controlled intermittent exotropia; no other patient had exotropia in primary gaze.ConclusionSmall, adjustable advancements of the lateral rectus muscles provided excellent results in our series of patients with lateral gaze esotropia caused by previous lateral rectus recessions. Despite large, early overcorrections, LI scores improved in all cases, and no patient had recurrence of symptomatic exotropia. The results will support surgical decision-making in the management of these challenging cases.

BackgroundThe oculocardiac reflex (OCR) is the most common complication in pediatric strabismus surgery, and its main clinical manifestation is bradycardia. Esketamine can activate the sympathetic nervous system, leading to an indirect cardiovascular stimulation effect, which results in increased blood pressure and a faster heart rate. The aim of this study is to explore whether a sub-anesthetic dose of esketamine can effectively inhibit the oculocardiac reflex during strabismus surgery.MethodThis prospective, single-center, randomized, double-blinded trial will enroll 204 pediatric patients undergoing strabismus surgery. Participants will be randomly assigned to esketamine (group S) and control groups (group C) in a 1:1 ratio. Esketamine (0.2 mg/kg) or an equal volume of normal saline will be administered after anesthesia induction. The OCR is defined as a sudden decrease in heart rate (HR) of 20% from baseline, and severe OCR will be defined as profound bradycardia (HR < 50 beats per minute). The primary outcome is the incidence of overall OCR during surgery. Secondary outcomes include severe OCR during all stages, the incidence of OCR at various stages of surgery, postoperative agitation, postoperative nausea and vomiting, procedure suspension frequency, and atropine administration requirements.DiscussionThe purpose of this study is to explore whether the administration of a sub-anesthetic dose of esketamine in pediatric strabismus surgery can reduce the incidence of OCR during surgery. The findings of this study may offer a new perspective and direct clinical evidence for the prevention and treatment of OCR during the perioperative period.Trial registration.Chinese Clinical Trial Registry (ChiCTR2400094053). Registered on 16 December 2024, www.chictr.org.cn. Prospectively registered.

This study reveals that children with intermittent exotropia (IXT) demonstrate subtle but measurable impairments in visual motor and visual perceptual skills. Importantly, strabismus surgery may yield functional gains in these domains, providing clinical insights beyond ocular alignment outcomes. To assess visual motor and visual perception skills in children with IXT compared with matched controls, and evaluate post-operative changes after surgical intervention. Prospective longitudinal case-control study. Visual motor and visual perception were evaluated using the Beery Visual Motor Integration 6th ed. and the Test of Visual Perception Skill, 4th ed. A 1-year post-operative follow-up was conducted for the IXT group. A total of 61 children with basic-type IXT (mean age: 9.6 ± 1.9 years; 38 boys) and 40 age-and sex-matched controls (mean age: 9.6 ± 1.7 years; 23 boys) were included. Among the IXT cohort, 27 underwent strabismus surgery and 34 were observed. One-year follow-up was completed by 22 surgical patients, 18 observation patients, and 28 controls. At baseline, children with IXT scored significantly lower than controls on visual motor integration (106.4 ± 11.9 vs. 112.4 ± 9.4, p=0.01), motor coordination (104.8 ± 10.7 vs. 112.4 ± 9.4, p=0.001), and perceptual subtests including form constancy (109.8 ± 12.0 vs. 115.5 ± 11.4, p=0.01) and visual closure (109.1 ± 11.5 vs. 116.6 ± 10.4, p=0.001). At 1-year follow-up, the surgical group showed significant improvements in visual motor integration (mean change: +8.7, p=0.01), motor coordination (+3.7, p=0.04), and form constancy (+6.5, p=0.04), while no changes were observed in the observation or control groups. Analysis of covariance, using the 1-year change from baseline as the outcome, revealed significant group differences in visual motor integration (p=0.02), visual discrimination (p=0.04), and sequential memory (p=0.002), with the surgical group demonstrating greater improvement in visual motor integration compared with the observation group (p=0.03). Children with IXT exhibit functional deficits in the visual motor and perceptual domains. Surgical alignment may lead to improvements in select functions beyond ocular correction, supporting its potential role in enhancing visual cognitive development.

Strabismus, or squint or deviating eyes, is defined as misalignment of the eyes when fixating on an object and is a common problem in ophthalmology. Palsy of the third, fourth or sixth cranial nerve is one of the leading underlying causes for paralytic strabismus, often requiring surgery. However, uncertainty regarding factors influencing surgical success remains. Background/Objectives: The purpose of this study is to review the outcome and influencing factors of strabismus surgery in patients with cranial nerve palsy. Methods: A retrospective study of 57 patients with third cranial nerve (CN3) palsy, fourth cranial nerve (CN4) palsy, sixth cranial nerve (CN6) palsy or combined nerve palsy who underwent strabismus surgery between October 2009 and December 2023 was conducted. Analyzed data included demographic details, type of surgical intervention, etiology of nerve palsy, pre- and postoperative angle of deviation (AOD), vertical deviation (VD), best-corrected visual acuity (BCVA), and refractive error. Results: Mean age was 41.29 ± 23.14 years with a mean follow-up of 10.8 ± 15.38 months. 30 patients (52.63%) had CN6 palsy, 12 patients (21.05%) had CN3 palsy, eight patients (14.04%) had CN4 palsy and seven patients (12.28%) had combined nerve palsy. Brain neoplasm was the most common cause of nerve palsy (33.33%). Mean preoperative AOD improved from 17.54° ± 10.68 to 7.13° ± 8.93 and from 17.21° ± 9.58 to 7.49° ± 9.75 for near and distance, respectively (p < 0.001). Changes in VD, refractive error, and BCVA were not statistically significant. Conclusions: Age, gender, preoperative AOD, subtype and etiology of nerve palsy had no significant influence on surgical outcomes, which are satisfactory in patients with cranial nerve palsy (80.7%).

Background and Objectives: Postoperative nausea and vomiting (PONV) is a common and potentially crucial side effect in pediatric patients. Neuromuscular blockade reversal drugs (NMBRDs) used during surgery have been associated with PONV. This study investigated whether sugammadex, a recently approved NMBRD for children in Korea, induces PONV and possible changes after NMBRD administration in children undergoing strabismus surgery. Materials and Methods: In total, 60 pediatric patients (3–16 years old) undergoing strabismus surgery with general anesthesia were included. They were divided into two groups: sugammadex (group S, n = 30) or pyridostigmine (group P, n = 30). The primary endpoint was the incidence of PONV using the Baxter Animated Retching Faces (BARF) scale at 0.5, 1, 3, and 6 h after NMBRD administration. The secondary endpoints included the recovery time (train-of-four > 0.9) and changes in heart rate following NMBRD administration. Results: There was no significant difference in PONV incidence between the groups according to the BARF scale (13.3% vs. 13.3% at 0.5 h, 6.7% vs. 3.3% at 1 h). Sugammadex demonstrated a significantly faster recovery time than pyridostigmine (p < 0.001). The changes in heart rate were more significant in the sugammadex group than those in the pyridostigmine group after NMBRD administration (p < 0.001); however, the heart rate returned to preoperative levels without any need for rescue medications or anticholinergics during the emergence period. Conclusions: There was no significant difference in PONV incidence between the administration of sugammadex and pyridostigmine in pediatric patients after strabismus surgery. Nevertheless, sugammadex appeared to facilitate faster recovery from the neuromuscular blockade without requiring intervention for the heart rate.

ABSTRACT Purpose Reoperation may be necessary after strabismus surgery. Although different variables have been studied as predispoding to a reoperation, there is no consensus in this issue. In this study, in addition to previously studied parameters, it was aimed to investigate the effects of accommodative convergence/accommodation (AC/A) ratio, near convergence point (NPC), forced duction positivity and optical biometry on reoperation rates in strabismus surgery. Methods Data of patients between 2010 and 2021 with minimum follow-up of 12 months were retrospectively reviewed. The study group (Group 1) included 77 patients who underwent surgery for strabismus for a second time, and the control group (Group 2) included 75 patients. Patients’ surgical outcomes with a deviation of less than 10 prism diopters (PD) were defined as successful. Sex, family history of strabismus, presence of neurological comorbidities, follow-up time, spherical equivalent values, visual acuity, amblyopia, ocular rotations, preoperative and postoperative distance angles of deviation, asymmetric/symmetric surgery, diplopia, fixation preference, AC/A, NPC, stereopsis, forced duction test positivity and ocular biometry values were evaluated. Results Asymmetric surgery, fixation preference, younger age at first surgery, shorter follow-up time, greater preoperative angle of deviation, a more distant NPC and greater lens thickness were found to be statistically significant predictors of reoperation (p < .05). There was no statistically significant difference in AC/A values (p = .92) and forced duction test positivity (p = 1) between the reoperation and control groups. Although amblyopia was more common in the reoperation group than in the control group, the difference was not statistically significant (p = .08). Conclusion Asymmetric surgery, fixation preference, younger age at first surgery, shorter follow-up time, greater preoperative angle of deviation, a more distant NPC and greater lens thickness were found to be statistically significant for reoperation. In this study, convergence insufficiency was more frequent in the reoperation group. There may have been an increase in lens thickness to increase convergence in this group. Also, as optical biometric data changes with age, this may have affected the data results. Accordingly, it would be appropriate to investigate the parameters we studied with larger case series.

Research on strabismus surgery for Thyroid Eye Disease (TED) is limited, with insufficient data on surgical dose-response. This study aimed to assess outcomes and dose-response in initial strabismus surgeries using a large TED sample. A retrospective review of TED patients undergoing initial strabismus surgery (2013-2023) at Zhongshan Ophthalmic Center included data on demographics, ocular deviation, motility, surgical techniques, and outcomes. Surgeries involved rectus recession and tenotomy, with traction sutures (TS) applied for deviations > 35 prism diopters (PD). Success was defined as no diplopia and deviation ≤ 10 PD horizontally, ≤ 5 PD vertically. Dose-response (deviation change per mm rectus recession, DPR) and influencing factors were analyzed. Among 104 patients, rectus recession had a 70.65% success rate, while tenotomy achieved 12.5%. Success was highest for superior rectus (SR) recession (88.00%), followed by inferior rectus (IR) (70.00%) and medial rectus (MR) (38.46%). Two-muscle recessions succeeded in 55.56%. In single rectus recession with TS, DPR for IR, SR, and MR was 6.96 ± 2.18, 5.92 ± 1.14, and 9.78 ± 5.80 PD/mm, respectively, versus 4.26 ± 0.78, 3.95 ± 0.83, and 3.86 ± 0.29 PD/mm without TS. Preoperative deviation significantly affected DPR, especially in IR/SR surgeries (P < 0.001). Simultaneous MR recession did not alter IR/SR DPR in TS (P = 0.266) or non-TS (P = 0.138) groups. However, in non-TS cases, IR/SR recession impacted MR DPR (P = 0.034), but this effect was absent with TS (P = 0.741). Single rectus recession achieves high success for TED vertical strabismus, with TS enhancing correction. Preoperative deviation is key to dose-response, while vertical recession influences horizontal dose-response when deviation is < 35PD.

Measuring the Costs of Strabismus Surgery: A Time-Driven Activity-Based Costing Analysis.

Telemedicine for initial postoperative appointments following strabismus surgery.

Physician reimbursement for strabismus surgery across provinces and territories in Canada.