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BACKGROUND Lid fatigability test (LFT), Cogan lid twitch (CLT), and forced eyelids closure test (FECT) are simple clinical screening tests for ocular myasthenia gravis (OMG). However, these tests are subjectively interpreted. We thus evaluated the interobserver and intra-observer reliability of each test. METHODS The 3 eyelid tests were performed in ptotic patients associated with various conditions, including OMG and others. Video clips of all tests were recorded using smartphone with built-in camera in the following order; LFT, CLT, and FECT. All video clips were distributed to 3 neuro-ophthalmologists and 3 general ophthalmologists, who were trained to evaluate the tests using a single standard instruction. After 3 months, all video clips were re-organized for the second evaluation. Interobserver and intra-observer reliability were calculated using Cohens' Kappa coefficient and Fleiss Kappa statistic. RESULTS The 3 eyelid tests were performed and recorded in 35 patients, which included the diagnosis of OMG, levator muscle dehiscence, partial oculomotor nerve palsy, and Horner syndrome. CLT received moderate-to-substantial interobserver reliability in neuro-ophthalmologist group (Fleiss Kappa 0.77 [95% CI 0.60-0.94] and 0.66 [95% CI 0.46-0.85] in first and second evaluation respectively), but the results varied in general ophthalmologist group (Fleiss Kappa 0.58 [95% CI 0.37-0.79] and 0.54 [95% CI 0.33-0.76] in first and second evaluation respectively). FECT and LFT received lower interobserver reliability in both groups. CLT also received moderate-to-almost perfect intra-observer reliability in neuro-ophthalmologist group (Cohen Kappa 0.55, 0.58, and 0.92), whereas FECT and LFT received lower intra-observer reliability. The intra-observer reliability varied among general ophthalmologists for all 3 eyelid tests. CONCLUSIONS CLT is the most reliable test among the 3 eyelid tests. However, all tests should be interpreted with caution by general ophthalmologists.

Supharat Jariyakosol,1,2 Lita Uthaithammarat,1,2 Nattakarn Chatwichaikul,1,2 Ngamjit Kasetsuwan,1– 3 Yuda Chongpison4 1Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 2Ophthalmology Department, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; 3Center of Excellence for Cornea and Stem Cell Transplantation, Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 4Biostatistic Excellence Center, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, ThailandCorrespondence: Supharat Jariyakosol 1873 Rama IV Road, Pathumwan, Bangkok, 10330, ThailandTel +662-2564142Email jsupharat@gmail.comPurpose: To assess the impact of botulinum toxin type A (BTX-A) on signs and symptoms of dry eye (DE) in affected eye of hemifacial spasm (HFS) patients and to compare the prevalence of DE between affected and non-affected eye in HFS patients.Patients and Methods: This prospective study included participants with unilateral HFS, who received BTX-A injection as a treatment. The eyes ipsilateral to the spasm side were used as studied eyes and the contralateral eyes were used as controls. The Ocular Surface Disease Index (OSDI) score, tear break-up time (TBUT), corneal fluorescein staining, and Schirmer I test were measured at baseline, 1 and 3 months after BTX-A injection. Fluorescein clearance test (FCT) was evaluated at baseline and at 1 month after BTX-A injection.Results: Thirty-one participants (6 males and 25 females; mean age 61± 10 years) were included. The prevalence of DE according to the Asia Dry Eye Society was not significantly different between affected (37.93%) and non-affected eyes (27.6%); P=0.083. At baseline, there was no significant difference in TBUT, Schirmer test, basal tear secretion, presence of delayed tear clearance, and presence of reflex tear secretion between affected and non-affected eyes, while significant difference in Oxford scheme grade was observed (P=0.031). OSDI score, TBUT, Oxford scheme grade, and Schirmer test at 1 month (P=0.817, 0.796, 0.534, 0.556), and 3 months (P=0.803, 0.904, 0.936, 0.684) after BTX-A injection did not significantly change from baseline in affected eyes. FCT results were not significantly different between baseline and at 1-month follow-up in both groups. All findings were corresponding in both naïve and long-term botulinum toxin injection groups.Conclusion: We found no significant effect of BTX-A on signs and symptoms of DE in patients with HFS. Moreover, there was no significant association between HFS and DE. However, we found significant corneal surface damage in the affected eyes, which emphasized importance of ocular surface evaluation and prompt treatment in HFS patients.Keywords: hemifacial spasm, botulinum toxin, dry eye, fluorescein clearance test, prevalence of dry eye

Purpose To evaluate the associated factors of conversion of ocular myasthenia gravis (OMG) to generalized myasthenia gravis (GMG) among patients with seropositive acetylcholine receptor antibody (AchR Ab). Design Retrospective cohort study. Methods Setting : Retrospective chart review. Patient : Seventy-one OMG patients with seropositive AchR Ab presented during July 2009 and December 2016. The exclusion criteria were patients who (1) first presented with GMG, (2) were unable to identify the time of onset of OMG or GMG, (3) were unable to provide information about previous treatments before the onset of GMG, and (4) had incomplete or lost medical records. Observation procedure : We collected demographic and clinical characteristics, including onset of OMG and GMG, presence of other autoimmune disorders, history of smoking, presence of thymic abnormalities, and medications received. Main outcome measures : Conversion to GMG and time to conversion. Results Thirty-six patients experienced conversion to GMG. Overall incidence of GMG was 14 (95% confidence interval [CI] 10.09-19.4) per 100 patient-years. Probability of conversion at 2 years was .37 (95% CI .27-.49). Overall median conversion time was 4.97 years. Cox proportional hazard model showed that risk factors were female sex (HR 2.52, 95% CI 1.04-6.10), history of smoking (HR 3.42, 95% CI 1.40-8.45), and thymic abnormalities (HR 1.82, 95% CI 0.91-3.67). Protective factors against conversion to GMG were receiving immunosuppressive agents (HR 0.42, 95% CI 0.19-0.97) and pyridostigmine (HR 0.37, 95% CI 0.14-0.93). Conclusions OMG patients with seropositive AchR Ab should be informed that taking pyridostigmine and/or immunosuppressive agents as well as smoking cessation might prevent conversion to GMG.

Purpose To evaluate the success rate and long-term motor and sensory outcomes of the full tendon vertical rectus transposition (VRT) with Foster suture for unilateral complete sixth cranial nerve palsy. Patients and methods We reviewed the medical records of patients with unilateral acquired sixth cranial nerve palsy who underwent unilateral full tendon VRT with Foster suture between 2005 and 2016 and had a follow-up of ≥2 years. Data on pre- and postoperative diplopia, face turn, ocular deviation, and limitation of abduction were collected. A successful outcome was defined as a horizontal deviation ≤10 prism diopter (PD) of ortho in a primary position at distance and absence of diplopia. Results A total of 20 patients were included in this study. Median (IQR) preoperative deviation was esotropia 65 (40-130) PD, which improved to 10 (-4 to 45) PD postoperatively. Median (IQR) improvement of esotropia was 54 (30-76) PD (P

Pituitary adenoma invasion into the orbit is a rare phenomenon with only 22 cases, including the present case, in the literature. Our case is a 31-year-old man who presented with biopsy-proven atypical pituitary adenoma invading the right orbit after a prior resection. We compare his clinical course with previous cases and discuss clinical features, radiological features, management considerations, histologic features, and prognosis. Cases are organized by specific pituitary tumor type to aid in determining appropriate management. Early surgical intervention is the key, especially in the setting of pathologic features indicating aggressive tumor behavior or worsening visual function but is generally not indicated in prolactin-secreting adenomas that may respond to medical therapy. The role of radiation therapy is not fully established; however, it should be strongly considered in conjunction with or after surgery, especially in cases where complete resection is not achieved or histological and molecular analyses indicate a high likelihood of recurrence. More uniform and comprehensive data about management and outcomes are needed to determine the optimal treatment approach for this rare entity.

Background: Progressive outer retinal necrosis (PORN) is a necrotizing chorioretinopathy caused by herpes simplex virus, varicella-zoster virus, or cytomegalovirus. Objective: To describe the clinical morphology of PORN presenting with asymmetrical isolated bilateral retrobulbar optic neuropathy. Method: The medical records of a 45-year-old human immunodeficiency virus infected patient presenting with bilateral visual loss at King Chulalongkorn Memorial Hospital were reviewed with respect for the privacy of patient. Result: Gradual visual loss progressed to no light perception in the right eye and 20/200 in the left eye within 1 month. The patient was initially diagnosed with retrobulbar optic neuritis in both eyes. The investigations included MRI, vitreous tapping, lumbar puncture, and serological testing. MRI elicited enhancement around both optic nerves, which suggested optic neuritis. Thereafter, multifocal areas of retinal necrosis developed with rapid progression and additional cutaneous zoster lesions were established. These findings led to a diagnosis of PORN. The patient was promptly treated with intravenous ganciclovir, anti-retroviral therapy, and vitrectomy with endophotocoagulation and silicone injection. Unfortunately, his visual prognosis in the left eye was still poor Conclusion: PORN was uncommonly present with bilateral isolated optic neuropathy before retinal lesions developed. Retrobulbar optic neuropathy from herpetic infection in immunocompromised patients should be considered despite a normal fundus at initial presentation. Early diagnosis and prompt intervention may preserve vision. This case demonstrates the importance of careful physical examination and follow up of retinal lesions.

Background: Bilateral lateral rectus recession is the most common surgical treatment of intermittent exotropia in children. Success rates in previous studies differ because longer follow-up periods may change success rate as the eyes drift out with time. Initial overcorrection was thought to be appropriate management, but the preferred initial postoperative deviation has not been well quantified. Objective: To study long-term outcomes (≥3 years) of bilateral lateral rectus recession for intermittent exotropia and to evaluate factors influencing long-term success. Methods: This retrospective descriptive study reviews patients with intermittent exotropia who underwent bilateral lateral rectus recession with a minimum follow up of 3 years. Long-term motor outcome was classified as good (within 8 prism diopters (PD) of esodeviation and 10 PD of exodeviation), acceptable (exodeviation 11-20 PD), and poor (esotropia >8 PD or exotropia >20 PD). Stereoacuity testing pre- and postoperatively was used to evaluate sensory outcome. Correlation between long-term outcome and various pre- and postoperative factors were analyzed. Results: A total of 59 patients met the selective inclusion criteria. The mean age at time of surgery was 7.1 years with a mean follow-up time of 4.5 years. At the time of the last visit, 69% (41 patients) had good outcomes, 24% (14 patients) had acceptable outcomes, and 7% (4 patients) had poor outcomes. Initial postoperative ocular deviation significantly correlated with long-term outcome (P < 0.05). Mean initial postoperative ocular deviation of patients with good outcome was esodeviation 12.7 PD (range ortho to esodeviation 25 PD). In 45 patients whose stereoacuity could be assessed, 58% (26 patients) had stereoacuity improvement. Conclusion: Good long-term motor outcome can be achieved in 69% of patients following bilateral lateral rectus recession for intermittent exotropia. Initial postoperative ocular deviation correlated with long-term motor success.

Brain tumors are the leading cause of death from childhood cancer. Overall survival has improved due to earlier detection, better therapies, and improved posttreatment surveillance. Permanent sequelae of the tumor and its treatment may cause severe impairment and decreased quality of life (QoL). Pediatric primary brain tumor patients' vision can be severely affected, even when the tumor location does not primarily involve the visual pathway. Visual dysfunction and impaired vision-related QoL may not be detected or screened for in children with primary brain tumors for many reasons, including examination difficulty and lack of awareness. The authors review the ophthalmic presenting symptoms, effects on vision, and quality of life in pediatric patients with primary brain tumors. They also describe and emphasize the importance of systematic neuro-ophthalmologic examinations in this population, which may improve long-term visual and QoL outcomes through earlier interventions.

Purpose To evaluate motor and sensory outcomes of 3 or 4 horizontal muscles surgery for the treatment of large-angle exotropia and to evaluate factors influencing the success rate and the relationship between initial postoperative and final motor outcomes. Design A retrospective analytical study. Methods Medical records of patients with primary large-angle exotropia [>50 prism diopters (PD)] who had 3 or 4 horizontal muscles surgery were reviewed. Motor outcomes were categorized as successful (esotropia 1-8 PD, orthotropia or exotropia 1-10 PD), acceptable (exotropia 11-20 PD), and poor (esotropia >8 PD or exotropia >20 PD). Results were evaluated only at the last follow-up visit if patients were followed up for less than 2 years. Those who were followed up for more than 2 years were evaluated at both the 2-year and final follow-up visits. Factors influencing the success rate and the relationship between initial postoperative and final motor outcomes were analyzed. Results A total of 36 patients were enrolled in this study. The median follow-up time was 18 months (range, 3-60 months). The success rate was 69% at the last follow-up and 75% at the follow-up at 2 years, respectively. Stereopsis improved in 43% at the last follow-up and 56% at 2 years. Initial postoperative deviation was found to correlate with the success rate at the last follow-up (P = 0.018). Initial postoperative overcorrection of 8 to 14 PD had the highest possibility of gaining successful final motor outcomes. Conclusions Three or 4 horizontal muscles surgery in large-angle exotropia can achieve successful motor outcomes and improve stereopsis. Surgeons should aim for initial overcorrection in order to maximize long-term success.

PURPOSE This study aimed to observe the prevalence and associated factors of neurovascular contact hemifacial spasm (HFS). DESIGN This was a cross-sectional analytical study. METHODS Medical records of patients with HFS in a neuro-ophthalmology clinic in Thailand between June 2008 and June 2012 were reviewed. A positive magnetic resonance imaging finding was defined as an adjacent variant vessel that directly compressed or placed pressure on the affected facial nerve. Prevalence and associated factors were analyzed. RESULTS A total of 60 participants were enrolled, composed of 12 male patients and 48 female patients with a median age of 54 years [interquartile range (IQR), 44.0-64.75] and a disease duration ranging from 4 months to 16 years (median, 2 years; IQR, 1.0-6.0). The prevalence of neurovascular contact HFS was 41.7%. Neurovascular contact HFS was more prevalent among women, with an overall ratio of 3.33. In age group analysis, the prevalence was higher among older patients. In univariate analysis, right-sided symptoms and diabetes mellitus were statistically significant in their association with neurovascular contact HFS (P = 0.040 and P = 0.029, respectively). Right-sided symptoms were significant in a multiple logistic regression analysis (P = 0.038), with an odds ratio of 3.30 [95% confidence interval (CI), 1.07-10.15]. Diabetes mellitus was not statistically significant (P = 0.051), with an odds ratio of 9.99 (95% CI 0.99-96.34). CONCLUSIONS The prevalence of neurovascular contact in patients with HFS was 41.7%. Right-sided symptoms were significantly associated with this condition.