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Purpose To quantify the effectiveness of superior oblique tuck (SOT) surgery in patients with a hyperdeviation secondary to superior oblique paresis (SOP). Surgical outcomes were compared in patients undergoing SOT surgery as a primary procedure with those who had previously undergone ipsilateral inferior oblique weakening surgery. Methods This retrospective study assessed surgical outcomes from all patients undergoing SOT surgery for SOP between 2012 and 2021 across 2 hospitals. The effectiveness of SOT surgery in reducing the hyperdeviation was assessed in the primary position (PP) and in contralateral elevation and depression. Results were compared between those undergoing primary SOT surgery with those who had previously undergone ipsilateral inferior oblique weakening surgery. Results A total of 60 SOT procedures were performed between 2012 and 2021. 7 were removed due to incomplete data. The remaining 53 cases experienced a mean reduction in hyperdeviation of 6.5 prism dioptres (PD), 6.7PD and 12.0PD in the PP, contralateral elevation and contralateral depression respectively. In eyes with previous IO weakening, the reduction of hyperdeviation was larger than in those eyes with no previous IO weakening surgery, with mean reductions of 8.0PD vs 5.2PD, 7.4PD vs 6.2PD and 12.4PD vs 11.6PD in the PP, contralateral elevation and contralateral depression respectively. Conclusion SOT surgery is a safe and effective procedure with high patient satisfaction and resolution of symptoms in those patients with troublesome diplopia in downgaze secondary to SOP. This is true in both unoperated eyes and in those who have previously undergone inferior oblique weakening surgery.

A 69 year old woman was referred by her primary care doctor to the eye emergency department with a dilated left pupil and ptosis of her right upper lid. She had visited her primary care doctor because of an upper respiratory tract infection and was unconcerned about her unequal pupil size (anisocoria), stating that she “has had odd pupils and a droopy right lid since being a teenager.” She had no ocular or medical history and was not taking any oral or topical medication. She denied any history of trauma, neck pain, weight loss, diplopia, or anhydrosis. On examination she had a partial right upper lid ptosis (fig 1⇓) and her right pupil, which was the abnormal one, was constricted and showed a dilatation lag. Both pupils constricted to light and accommodation and there was no relative afferent pupillary defect. Iris colour was equal on both sides. Visual acuity was 6/9 in both eyes and intraocular pressures were 12 mm Hg and 14 mm Hg in the right and left, respectively. Ocular motility was full and funduscopy showed healthy optic discs. She had no other neurological signs. One drop of apraclonidine 1% was applied to both eyes. After one hour there was dilation of the constricted pupil and improvement in the ptosis. Fig 1 Photograph of patient in room light and distance fixation showing right upper lid ptosis ( A ) and right miosis ( B ) ### Short answer Right Horner’s syndrome. …

A 62 year old woman presented to eye casualty with a 10 day history of a left sided headache. Two days after her headache started she developed a painful and pruritic left sided rash. During the 24 hours before presentation, her left eye had become injected, painful, and photophobic. On examination she had a well demarcated, unilateral area of erythematous and mildly oedematous skin, which extended from her left upper lid up across her forehead. Within this area were discrete tender scabbed lesions, which extended back into her hairline (fig 1⇓). She had no lesions on the tip of her nose or in her auditory canal. No lesions crossed the midline to the right side of her forehead or scalp. Fig 1 Left side scabbed skin lesions respecting the midline with associated left lid swelling and conjunctival injection Ocular examination showed an unaided visual acuity of 6/6 in the right eye and 6/9 in the left eye. Ocular motility was full. Intraocular pressures were 10 mm Hg in the right eye and 12 mm Hg in the left. Her left cornea was clear and did not stain with fluorescein, while her conjunctiva was diffusely injected. Slit lamp examination of her left anterior chamber showed 1+ for cells and flare. Dilated funduscopy showed a clear vitreous and healthy fundus. Her right ocular examination was normal. 1. What is the most likely diagnosis? 2. How is the diagnosis confirmed? 3. How is the condition managed? 4. What complications might occur? ### 1. What is the most likely diagnosis? #### Short answer Left herpes zoster ophthalmicus (HZO) with associated anterior uveitis. #### Discussion HZO occurs when latent varicella zoster virus (VZV), residing in the ganglion of the trigeminal nerve, reactivates and affects the ophthalmic nerve (V1). Primary infection with VZV commonly occurs in childhood as chickenpox. Anterior uveitis occurs in 40-50% of all cases of HZO.1 The …

Purpose To investigate the use of MultiColor Scanning Laser Imaging as an adjunct to traditional imaging modalities in the assessment of children with suspected disk swelling. Methods In this study of 20 consecutive children with suspected papilledema, MultiColor imaging was performed on all patients in addition to fundus examination, fundus autofluorescence, disk spectral domain optical coherence tomography (SD-OCT), and disk retinal nerve fiber layer thickness (RNFL) measurement. Diagnoses were determined in all 20 patients, and all images were evaluated by a medical retina specialist. Results Of the 20 cases (average age 11 years [range, 5-16 years]; 10 males), papilledema was confirmed in 11 (55%) and pseudopapilledema diagnosed in 9 (45%). Of pseudopapilledema cases, there were 4 cases of optic disk drusen, 2 hypermetropic disks, 2 “crowded disks,” and 1 anomalous disk. In patients with true papilledema, on the combined MultiColor image, a green shift in the form of an elevated green ring was seen consistently. This ring was also hyperreflective on the blue and green images and surrounded a central “shadow,” which was seen best on near infrared reflectance (NIR). The disk margins and vasculature were obscured on the combined, green, blue, and NIR images. These changes were not present in the pseudopapilledema cases. Conclusions MultiColor imaging of disks with papilledema shows characteristic changes that may prove useful in differentiating true papilledema from pseudopapilledema. It is therefore a useful adjunct to traditional disk imaging modalities in assessing children with suspected disk swelling.