Visual Axis Research Articles

Complications, Visual Acuity, and Refractive Error 3 Years after Secondary Intraocular Lens Implantation for Pediatric Aphakia

To report the cumulative incidence of complications and describe refractive error and visual acuity (VA) outcomes in children undergoing secondary intraocular lens (IOL) implantation following previous surgery for non-traumatic cataract. Pediatric cataract registry. 80 children (108 eyes: 60 bilateral, 48 unilateral) undergoing lensectomy at <13 years of age, followed by secondary IOL implantation at median age (range) of 2.7 (0.6 to 5.0) years for bilateral and 2.1 (0.5 to 6.4) for unilateral cases. Annual data collection from medical record review through 5 years following lensectomy. Cumulative incidence of newly emergent complications following secondary IOL implantation; refractive error and VA by 5 years after lensectomy. Median (interquartile range [IQR]) follow-up following secondary IOL implantation was 2.5 years (0.8 to 3.3 years). A common complication following secondary IOL implantation was a glaucoma-related adverse event (GRAE: glaucoma or glaucoma suspect); the cumulative incidence was 17% (95% CI: 3%-29%) in bilateral and 12% (95% CI: 0%-23%) in unilateral cases. The cumulative incidence of surgery for visual axis opacification was 2% (95% CI: 0%-7%) for bilateral and 4% (95% CI: 0%-10%) for unilateral cases. Median prediction error (IQR) within 90 days of implantation was 0.88 D (-0.50 D to +3.00 D) less hyperopic than intended among 21 eyes for bilateral cases and 1.50 D (-0.25 D to +2.38 D) less among 19 unilateral cases. Median (IQR) spherical equivalent refractive error at 5 years (median 5.1 years of age) in eyes receiving a secondary IOL was +0.50 D (-2.38 D to +2.94 D) for 48 bilateral and +0.06 D (-2.25 D to +0.75 D) for 22 unilateral cases. Median (IQR) monocular VA at 5 years was 20/63 (20/50-20/100) for bilateral (n=42) and 20/400 (20/160-20/800) for unilateral (n=33) cases. Eyes with secondary IOL implantation have an ongoing risk of new glaucoma-related adverse events. Five years after lensectomy (approximately 2.5 years after secondary IOL implantation), average refractive error was less hyperopic than desired given the anticipated further myopic shift before refraction stabilizes.

Unilateral Congenital Cataracts: Best Practices and Case Studies for Effective Management

Congenital cataract is a clouding of the eye lens in children, which contributes to blindness in 5% to 20% of children throughout the world. Cataracts can occur unilaterally or bilaterally and can vary in size, morphology, and degree of opacification. This report aims to comprehensively diagnose and treat unilateral cataracts and provide optical rehabilitation. A 3-month-old baby boy was brought by his family with complaints of a white spot on the right eye, which the family had known about since the patient was one month old. The patient was diagnosed with a congenital cataract and underwent surgery, which included aspiration irrigation, primary posterior capsulotomy, and anterior vitrectomy under general anesthesia. The use of glasses is chosen as optical rehabilitation. Collaborative management is also done with pediatric specialists, ENT, and pediatric cardiology. It was concluded that congenital cataract management aims to prevent amblyopia by clearing it as soon as possible (Clear Visual Axis) and optical rehabilitation (Clear Retinal Image) to improve the vision prognosis.

Cataract surgery outcomes in children and adolescents with type 1 diabetes mellitus

PurposeTo report the outcomes of cataract surgery in children and adolescents with type 1diabetes mellitus. MethodsThe medical records of all pediatric patients (<18 years of age) with a diagnosis of type 1 diabetes mellitus who had undergone surgery for cataract between January 2000 and December 2019 at a tertiary care center were reviewed retrospectively. ResultsA total of 27 eyes of 15 patients who met the inclusion criteria were included. Median age at cataract surgery was 13 (IQR, 9.5-16) years, and median follow-up was 3.8 (IQR, 1.25-7.2) years, with 11 eyes followed for more than 5 years. Visual acuity improved from a median preoperative value of 0.8 (IQR, 0.55-1.3) logMAR to 0.15 (IQR, 0-0.45) logMAR at final follow-up. Posterior capsular visual axis opacification in 40.7% and diabetic retinopathy in 14.8% were the common complications requiring additional intervention, including laser capsulotomy and panretinal photocoagulation, respectively. ConclusionsCataract surgery in children and adolescents with type 1 diabetes leads to improvement in visual acuity. Proliferative diabetic retinopathy can lead to poor visual outcomes in these children. Visual axis opacification occurs at similar rates with or without primary posterior capsulorhexis.

Longitudinal study of microphthalmia in connexin 50 knockout mice using spectral-domain optical coherence tomography.

Connexin 50 (Cx50) mediated signaling is essential for controlling the lens growth and size. Cx50 mutations cause microphthalmia, smaller lenses, and cataracts in humans and animals. These ocular defects have never been investigated in live Cx50 mutant mice by using non-invasive imaging techniques. Here, we report a longitudinal study of the ocular defects in Cx50 knockout (Cx50KO) mice from the ages of 3 weeks to 12 months by using spectral-domain optical coherence tomography (SD-OCT). The anterior chamber depth (ACD), lens thickness (LT), vitreous chamber depth (VCD), and axial length (AL) were measured along the visual axis and adjusted with corresponding refractive indices. The SD-OCT image data confirm age-related reductions of LT and AL in live Cx50KO mice compared to age-matched wild-type (WT) controls, and the reduction values are comparable to the in vitro measurements of Cx50KO eyeballs and lenses reported previously. Moreover, reductions of ACD were observed in Cx50KO mice at all ages studied while VCD changes are statistically insignificant in comparison to the WT controls. Therefore, Cx50KO's microphthalmia with small lens is selectively associated with delayed ACD development but not the vitreous formation. This work supports the notion that lens size and/or growth is important for anterior chamber development.

Intraoperative trypan blue central landmark and its use in capsulotomy and capsulorhexis centration.

To compare 3 capsulotomy centration methods. Private clinic, Zlin, Czech Republic. Prospective, consecutive case series. 180 eyes undergoing cataract surgery had anterior capsule staining with microfiltered 0.4% trypan blue solution before selective laser capsulotomy. The first 60 eyes (Group 1) had mydriatic dilated pupil centered capsulotomies. The next 60 eyes (Group 2) were centered on the trypan blue central landmark (TCL). The final 60 capsulotomies (Group 3) were centered on the patient fixated coaxial Purkinje reflex (CPR). Measurements between key anatomical landmarks and the TCL, CPR capsulotomies, and implanted intraocular lens (IOL) center were made. The TCL, observed in >94% of eyes in the study, coincided with the CPR with a displacement of <0.1 ± 0.1 mm. Group 1 capsulotomies were noticeably decentered on the IOLs by 0.3 ± 0.2 mm. The Group 2 symmetrical IOL relationship was maintained with a decentration of 0.15 ± 0.1 mm. Group 3 had a similar decentration with the IOLs with 0.15 ± 0.1 mm. Verification with IOLMaster 700 data and CALLISTO Eye System showed that the CPR and the TCL were coincident with the measured visual axis. The clearly visible TCL served as an alternate landmark to the patient fixated CPR, and being on the anterior capsule was not sensitive to tilt. Further patient compliance was not required. Both were superior to dilated pupil centration, to achieve symmetric IOL coverage. This has application for both capsulotomies and capsulorhexes.

Complement regulation in the eye: implications for age-related macular degeneration.

Careful regulation of the complement system is critical for enabling complement proteins to titrate immune defense while also preventing collateral tissue damage from poorly controlled inflammation. In the eye, this balance between complement activity and inhibition is crucial, as a low level of basal complement activity is necessary to support ocular immune privilege, a prerequisite for maintaining vision. Dysregulated complement activation contributes to parainflammation, a low level of inflammation triggered by cellular damage that functions to reestablish homeostasis, or outright inflammation that disrupts the visual axis. Complement dysregulation has been implicated in many ocular diseases, including glaucoma, diabetic retinopathy, and age-related macular degeneration (AMD). In the last two decades, complement activity has been the focus of intense investigation in AMD pathogenesis, leading to the development of novel therapeutics for the treatment of atrophic AMD. This Review outlines recent advances and challenges, highlighting therapeutic approaches that have advanced to clinical trials, as well as providing a general overview of the complement system in the posterior segment of the eye and selected ocular diseases.

Next-Generation Exoscopic Surgery Featuring a Head-Mounted 3-Dimensional Display for Carotid Endarterectomy: 2-Dimensional Operative Video.

Recent advancements in medical equipment have led to the use of exoscopes in neurosurgery, thereby replacing conventional operating microscopes.1,2 These devices enable surgeons to work comfortably, even in situations requiring a tilted visual axis, and their effectiveness in carotid endarterectomy (CEA) for carotid artery stenosis has been reported.3,4 However, the placement of 3-dimensional (3D) monitoring devices is challenging.3,4 To address this issue, we present a case in which CEA was performed using ORBEYE with a 3D head-mounted display. This device allows continuous 3D observation of the surgical field on the preocular screen. Case: A 79-year-old man who had undergone chemoradiotherapy for left maxillary cancer 5 years earlier was referred to our department to undergo treatment for left internal carotid artery stenosis. Computed tomography angiography revealed severe left internal carotid artery stenosis with hypoechoic vulnerable plaques on carotid ultrasound. Carotid artery stenting was considered to be a better option than CEA. However, CEA yields better outcomes, especially in patients with vulnerable soft plaques.5 Left CEA was performed using ORBEYE with a 3D head-mounted display (HOGY Medical Co., Ltd.). The procedure was successfully performed under the observation of the head-mounted display, from skin incision to closure. Postoperatively, the patient had no neurological deficits but experienced transient hoarseness. Using an exoscope under the guidance of a head-mounted display represents a next-generation surgical technique that overcomes the limitations of traditional exoscopic surgery. The patient consented to the procedure, and the participants and any identifiable individuals consented to publication of his/her image. Our institutional review board approved this publication (#B230184).

Mechanisms for Positive Bielschowsky Head Tilt Testing in Horizontal Strabismus

ABSTRACT Purpose To elucidate the induced effects of horizontal strabismus on the Bielschowsky Head Tilt Test (BHTT). Design Prospective clinical study. Methods Prospective analysis of BHTT testing in 85 patients with exotropia and 71 patients with esotropia who were examined in a strabismus clinic. Results Eighty-four of 85 patients with exotropia (98.82%) showed a positive BHTT with an induced hyperdeviation on the side of the tilt (to both sides in 67% and to one side in 32%). Fifty-seven of 71 patients with esotropia (80.2%) showed a positive BHTT with an induced hypodeviation on the side of the tilt (to both sides in 57.7% and to one side in 22.5%). These induced vertical deviations were greater in patients with larger horizontal deviations and in those with constant rather than intermittent deviations; however, they were not influenced by the presence or absence of associated primary oblique muscle overaction. Conclusions Exotropia and esotropia produce hyperdeviations during BHTT testing, with a hyperdeviation on the side of the tilt observed in patients with exotropia, and hypotropia on the side of the tilt observed in patients with esotropia. These diametrical results are not attributable to any preexistent alteration of neurologic output inherent to these two forms of horizontal strabismus or to associated torsion. Rather, they arise directly from the altered anatomical positions of the two eyes, which cause the eyes to approximate their visual axes more closely to the vertical rectus muscles (in exotropia) and the oblique muscles (in esotropia), enabling the vertical actions of specific cyclovertical muscles to predominate in response to altered utricular output generated by the BHTT.

Intraocular lens power calculation: angle κ and ocular biomechanics

Purpose: To study the effect of ocular biomechanics on the prediction error of intraocular lens (IOL) power calculation. Setting: Centro Hospitalar Universitário do Porto, Porto, Portugal. Design: Prospective longitudinal study. Methods: This study included 67 subjects. Before cataract surgery subjects underwent biometry with IOLMaster 700 and biomechanical analysis with Corvis Scheimpflug technology. The targeted spherical equivalent was calculated with SRK-T and Barrett Universal II. Associations between prediction error (PE), absolute prediction error (AE), and biometric and biomechanical parameters were performed with stepwise multivariate linear correlation analysis. Results: Using the SRKT formula, there was association between PE and Corvis Biomechanical Index (CBI, B = −0.531, P = .011) and between AE and the horizontal offset between the center of the pupil and the visual axis (angle κ, B = −0.274, P = .007). Considering the Barret Universal II formula, PE was independently associated with anterior chamber depth (B = −0.279, P = .021) and CBI (B = −0.520, P = .013) and AE was associated with angle κ (B = −0.370, P = .007). Conclusions: A large angle κ may reduce the predictability of IOL power calculation. Ocular biomechanics likely influence the refractive outcomes after IOL implantation. This study showed that eyes with softer corneal biomechanics had more myopic PE. This may relate to anteriorization of the effective lens position. Dynamic measurements may be the way to progress into future formulas.

Neonatal Macular Hemorrhage in a Term Healthy Infant: 18-Year Follow-up.

Unobstructed binocular vision is required during the critical period of vision development to obtain optimal visual acuity in each eye and binocular stereopsis. In this article, we report 18-year follow-up of a full-term, otherwise healthy infant noted to have dense premacular hemorrhage occluding the visual axis in the left eye on retinal imaging performed 48 hours after birth. Serial examinations by the retina service were performed weekly for 10 weeks as the hemorrhage resolved spontaneously. Shortly thereafter, visual acuity revealed fixation was present, but the mother noted intermittent left eye esodeviation. At 90 days of life, the infant was seen by pediatric ophthalmology and started on 1 to 2 hours patching of the right eye daily for the esotropia, which was maintained through 24 months. At 18 years of age, the patient had orthophoria alignment, no spectacle correction, vision of 20/20 in the right eye and 20/25 in the left eye, and normal binocularity and stereopsis. Intermittent esodeviation on the left eye was observed when the patient was fatigued. Early identification of a visual axis occlusion led to prompt referral for the esotropia and initiation of patching therapy. This patient ultimately achieved a very favorable visual functional outcome that may not have been possible without early detection and management. This case report describes the longest-term published follow-up of a neonatal macular hemorrhage. [Ophthalmic Surg Lasers Imaging Retina 2024;55:354-357.].

Traumatic flap dehiscence 15 years after LASIK: case report and review of the literature

Introduction: Corneal flap trauma rarely occurs years after laser in situ keratomileusis (LASIK), and management is not standardized. The authors report a case of LASIK flap dehiscence 15 years postoperatively with a review of the literature describing clinical characteristics, management, and outcomes of similar cases occurring at least 6 years postoperatively. Patient and Clinical Findings: A 55-year-old man with a history of LASIK surgery 15 years prior presented with flap dehiscence after trauma with a tree branch. His right eye uncorrected distance visual acuity (UDVA) at presentation was counting fingers. On slitlamp examination, the medial flap edge was folded underneath the temporal aspect. Diagnosis, Intervention, and Outcomes: The flap was unfolded, irrigated, repositioned, and instilled with topical antibiotics. The patient was started on prednisolone acetate 1% and moxifloxacin. On postoperative day 1, his UDVA improved to 20/50 and the flap remained centered and clear. His vision stabilized at 20/30 after 7 months. Peripheral epithelial ingrowth was noted without visual axis obscuration. Conclusions: This case, along with 20 reported instances of late traumatic flap dehiscence, highlights that early recognition with prompt intervention can optimize visual outcomes. Comparison of injury mechanisms, treatments, and complications may guide surgeons in patient counseling and care.

Ten-year outcomes of congenital cataract surgery performed within the first six months of life.

To investigate the long-term outcomes of congenital cataract surgery performed within the first 6 months of life. 11 ophthalmic surgical sites in Japan. Retrospective chart review. Medical charts were retrospectively reviewed for 216 eyes of 121 patients. The age at surgery was 2.9 ± 1.7 months, with follow-up duration 13.0 ± 2.3 years. The cohort consisted of 83 cases with bilateral aphakia, 12 with bilateral pseudophakia, 20 with unilateral aphakia, and 6 with unilateral pseudophakia. Surgical intervention within the critical period of visual system development (10 weeks for bilateral and 6 weeks for unilateral cases) led to significantly better final visual acuity than surgery conducted after this time frame. The incidence of secondary glaucoma was similar between groups while the occurrence of visual axis opacification was more frequent with earlier surgery. A forward stepwise multiple regression analysis revealed that the final visual acuity was significantly associated with laterality of cataract (better outcomes in bilateral cases), phakic status (with pseudophakia outperforming aphakia), presence of systemic and ocular comorbidities, and development of secondary glaucoma. Secondary glaucoma was significantly more prevalent in aphakic eyes than pseudophakic eyes. In patients with genuine congenital cataract, surgery within the critical period of visual development results in better final visual acuity, albeit with an increased risk of visual axis opacification. The use of IOL with sophisticated surgical techniques shows promise even in congenital cataract surgery.

Factors affecting the visual outcome of paediatric cataract surgery: A hospital based prospective study in tertiary eye care

The aim of this study is to evaluate the various factors affecting the visual outcome of paediatric cataract surgery. Paediatric cataract is a huge problem of the world specially for developing and poor countries. Without treatment cataract can damage connection between brain and eye. So importance of early diagnosis and treatment can prevent permanent vision loss in children.Cataract in children can appear in variety of forms, each presenting in differencing in different way depending on the time. Sometime cataract associated with other ocular disease like coloboma, nystagmus, microphthalmos. These conditions are associated with poor prognosis. So proper visual rehabilitation of neuro- ophthalmic axis is crucial for good visual prognosis. All patients from 2 - 14 years of age who underwent cataract surgery in Department of Ophthalmology at BRLSABVMM College Rajnandgaon during 1- year period were included in the study. Detail history of patient, preoperative examination, ocular and systemic co-morbidity, intraoperative complications and post-operative outcome were documented and analysed. 25 patients underwent cataract surgery during this period.16 were male (64%) and 9 females (36%). Most common presenting symptom is diminution of vision in some cases nystagmus and strabismus also present. In some patient there is history of trauma also present. There was significant improvement in best corrected visual acuity following surgery in approx. 70% of patients. Visual axis opacification is most common complication after that fibrin reaction is other complication.: Improvement in vision in post operative paediatric cataract surgery due to early detection by parents and raise awareness by health workers of rural and urban area. Good visual outcome is depended on good infrastructure for operation theatre, advance microscope with instrument, advance cataract surgery with posterior capsulotomy and anterior vitrectomy, post-operative management and visual rehabilitation.

Visual axis opacification after pediatric cataract surgery - An analysis of morphology and etiology.

To investigate the morphological types and delineate the clinical and surgical variables associated with VAO in children undergoing pediatric cataract surgery. We included 33 eyes of 28 children who developed clinically significant visual axis opacification (VAO) after congenital or developmental cataract surgery. All eyes underwent a comprehensive examination under anesthesia followed by a membranectomy to clear the visual axis. We classified VAO into three subgroups: fibrotic, proliferative, and combined morphologies. We reviewed and analyzed the retrospective data and the findings during membranectomy to identify the etiological variables associated with various morphologies of VAO. The median age at primary surgery was 7 (2-96) months. The median interval from primary surgery to the first documentation of VAO was 6 (1-22) months. Younger children developed VAO sooner than older children. VAO was fibrotic in 11 eyes (33%), proliferative in 18 eyes (54.5%), and combined in four eyes (12.12%). Most children with fibrotic VAO belonged to economically disadvantaged sections of society ( P = 0.04). Lower age at primary surgery was the predominant risk factor for the development of VAO. Besides primary posterior capsulotomy and adequate anterior vitrectomy, a strict adherence to anti- inflammatory measures and follow up in necessary to prevent the occurrence of VAO. A close follow-up facilitates early detection and management, which can prevent the onset of visually impairing amblyopia.

Pupil versus 1st Purkinje capsulotomy centration with femtosecond laser: Long term outcomes with a sinusoidal trifocal lens.

To assess the role of femtosecond laser-assisted capsulotomy centration in the long-term intraocular positioning of a multifocal intraocular lens. Prospective comparative study. A total of 60 eyes of 30 patients underwent femtosecond laser-assisted Refractive Lens Exchange (RLE). For every patient, capsulotomy centration was randomly performed according to pupil centre (PC) in one eye and first Purkinje reflex (FPR) in the other. The intraocular lens (IOL) positioning, visual acuities, spherical equivalent, internal aberrometry and quality of vision were assessed and compared at 3 years' follow-up between groups (PC and FPR). Intraocular lens positioning showed a statistically significant difference between groups, with a closer centration to the visual axis in the FPR patients (p < 0.001). Internal aberrometry showed higher values in the PC capsulotomy centration group (p < 0.01). FPR centered capsulotomy is associated to a closer centration of the IOL to the visual axis.

Parafoveal vision reveals qualitative differences between fusiform face area and parahippocampal place area.

The center-periphery visual field axis guides early visual system organization with enhanced resources devoted to central vision leading to reduced peripheral performance relative to that of central vision (i.e., behavioral eccentricity effect) for many visual functions. The center-periphery organization extends to high-order visual cortex where, for example, the well-studied face-sensitive fusiform face area (FFA) shows sensitivity to central vision and the place-sensitive parahippocampal place area (PPA) shows sensitivity to peripheral vision. As we have recently found that face perception is more sensitive to eccentricity than place perception, here we examined whether these behavioral findings reflect differences in FFA's and PPA's sensitivities to eccentricity. We assumed FFA would show higher sensitivity to eccentricity than PPA would, but that both regions' modulation by eccentricity would be invariant to the viewed category. We parametrically investigated (fMRI, n = 32) how FFA's and PPA's activations are modulated by eccentricity (≤8°) and category (upright/inverted faces/houses) while keeping stimulus size constant. As expected, FFA showed an overall higher sensitivity to eccentricity than PPA. However, both regions' activation modulations by eccentricity were dependent on the viewed category. In FFA, a reduction of activation with growing eccentricity ("BOLD eccentricity effect") was found (with different amplitudes) for all categories. In PPA however, qualitatively different BOLD eccentricity effect modulations were found (e.g., at 8° mild BOLD eccentricity effect for houses but a reverse BOLD eccentricity effect for faces and no modulation for inverted faces). Our results emphasize that peripheral vision investigations are critical to further our understanding of visual processing.

Did the metal object hit the cornea? A case report of penetrating ocular injury with embedded foreign body

Introduction : Penetrating ocular injury with IOFBs may cause severe ocular damage. We demonstrate the diagnostic and treatment approach in a case of scleral laceration with a large IOFB.&#x0D; Case Illustration : A-24-year-old male presented with a rusty segment of fence wire, sized 15x11 mm, embedded near the nasal corneal margin of the right eye. Upon initial examination the vision was 6/9 with normal IOP. The object obstructed the view of the entry site, therefore corneal wound was suspected. CT scan showed penetrating metal object without posterior segment involvement. Anti-tetanus injection, topical and oral levofloxacin were given. He underwent exploration, foreign body removal and repair surgery. During surgery, the wound was revealed as a scleral laceration, 4 mm from nasal limbus. One day post-operative, vision was 6/20. A 0.1 mm hypopyon was found, along with fibrin at nasal vitreous. Oral and topical corticosteroids were given, and hypopyon disappeared the next day. One week after surgery, vision improved to 6/7.5, with clear vitreous and normal retina.&#x0D; Discussion : Ocular injuries with large IOFBs can hinder clinical examination. Corneal entry wound should be ruled out, due to potential permanent damage to visual axis. CT scan was helpful in assessing the depth of object penetration. The object was removed successfully, with no damage to the cornea and retina. Anti-tetanus, antibiotics and corticosteroids were able to control infection and inflammation.&#x0D; Conclusion : Large IOFBs which do not affect the visual axis, can be managed with successful outcome, by prompt removal and repair of the entry wound, and control of infection and inflammation.

DIFFERENT CONJUNCTIVAL AUTOGRAFT TECHNIQUES FOR PTERYGIUM SURGICAL EXCISION, A CASE SERIES

Abstract&#x0D; Introduction : Pterygium is a wing shaped fibrovascular growth that extends from the conjunctiva onto the cornea. There are many techniques available for pterygium removal, from simple excision to excision and repair of the defect with modified techniques.&#x0D; Case Illustration : 1. A 50-year-old woman presented with a grade II pterygium in both of her eyes. She was undergone sliding flap pterygium excision for her right eye. Case 2. A 32-year-old man presented with a grade II pterygium in his left eye. He was then undergone rotational flap pterygium excision for his left eye. Case 3 A-55-year-old woman presented with a grade II-III double head pterygium. She was later undergone modified conjunctival autograft double head pterygium excision for his left eye.&#x0D; Discussion : Surgical management is the gold standard for pterygium treatment. Indications for pterygium excision include decreased visual acuity due to astigmatism, obstruction of visual axis, repeated irritation and cosmetics. Surgical techniques for excision of the pterygium include bare sclera excision, tissue grafting using conjunctival graft, membrane transplantation amnion and limbal- conjunctival autograft. There are several choices of conjunctival graft techniques after pterygium excision, such as conjunctival sliding flap, conjunctival rotational flap, and modified conjunctival autograft. Modified conjunctival autograft technique was performed for double head pterygium management. The technique consisting of horizontally modified conjunctival autograft and vertically modified conjunctival autograft.&#x0D; Conclusion : The choices of surgical excision techniques for pterygium depends on the grades of the pterygium and operator’s preference.

Anterior Segment Dysgenesis in A Child, A Rare Case Report: What Should We Do?

Introduction : Anterior segment dysgenesis affects a various range of ocular structure, including: cornea, iris, ciliary body, anterior chamber, and lens associated with approximate 50% of glaucoma&#x0D; Case Illustration : A 20 month-old boy presented with bilateral corneal opacity. VA was 6/480 on both eye. Examination revealed bilateral central corneal opacity with keratolenticular adhesions, anterior lens dislocation and opacification, aniridia, and posterior segment were difficult to evaluate. The IOP were 17.3 mmHg and 14.6 mmHg in the right and left eye respectively. The aforementioned feature contributed to the diagnosis of Type II Peters Anomaly (PA). Lens aspiration combined with adhesiolysis on the LE was performed. Patient was given topical antibiotic, corticosteroid, and anti- glaucoma medication post-operatively. Postoperative course showed no complication and the corneal opacity diminished&#x0D; Discussion : Lens aspiration in combination with adhesiolysis was performed because the presence of cataract interfered the visual axis and increased the risk of corneal decompensation due to keratolenticular adhesions. We considered to perform the surgery on the LE first because the corneal opacity was milder than the RE. Glaucoma is an almost ineluctable issue and medical therapy are necessary. Further evaluation was required to determine if a similar procedure is needed for the fellow eye and whether the IOL implantation was going to enhance the visual prognosis in the future&#x0D; Conclusion : The keratolenticular adhesions and corneal opacity in type II PA make the surgical approach more challenging. Cautious manipulation can prevent further corneal decompensation. In addition, parents should receive extensive counseling regarding the complications and prognosis

Thyroid Eye Disease and Rare Manifestations of Severe Restrictive Strabismus with Large Hypertropia: A Case Report and Treatment Considerations

Introduction : Restrictive strabismus with large hypertropia is an infrequent manifestation of thyroid eye disease that arises due to severe thickening of the superior rectus muscle. This condition can lead to losing the visual axis in the primary gaze position, and prompt management is essential.&#x0D; Case Illustration : A Forty-seven-year-old man came to the hospital and presented with misalignment in both eyes, known for five months before admission. Ophthalmology examination revealed visual acuity for both eyes was 0.4—Large hypertropia with 50 prism diopters and exotropia with 20 prism diopters, and down shoot restrictions were found in both eyes. The patient had a history of hyperthyroidism since eight months ago and regularly took PTU medication. CT scan of the orbit showed hypertrophy on the extraocular muscle.&#x0D; Discussion : Continued fibroblast stimulation results in collagen deposition and subsequent fibrosis, ultimately leading to restrictive strabismus in TED patients. For patients with large hypertropia, the primary surgical approach remains recession of the involved restricted muscles, with or without tendon elongation surgery. Vertical rectus muscle resection is preferred for its low inflammation and restriction risk, while hemi hang-back is another suitable option.&#x0D; Conclusion : The recession of restricted muscles and tendon elongation, preferably vertical rectus muscle resection, is necessary for patients with rare manifestations of restrictive strabismus and large hypertropia in thyroid eye disease.