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Purpose: To report a case of intraoperative rupture of inferior rectus muscle, which was retrieved and later successfully transposed for management of sixth nerve palsy. Methods: Case report. Results: A 36-year-old woman presented with traumatic right sixth nerve palsy and esotropia following a car accident five years earlier. During the originally planned vertical transposition surgery, the inferior rectus muscle snapped, but was retrieved and resutured to the sclera 3 mm posterior to the original insertion. After a few months, the second attempt of transposition of vertical recti (including the previously snapped and reattached inferior rectus) was successful, and the patient achieved satisfactory postoperative alignment. Conclusions: Intraoperative rupture of an extraocular muscles is a rare and serious complication encountered during strabismus surgery. However, if successfully retrieved, this muscle has still the chance of future re-operation. Keywords: Sixth nerve palsy, Snapped muscle, Vertical transposition

Background: Eight-and-a-half syndrome (EHS) is one-and-a-half syndrome [(conjugated horizontal gaze palsy and internuclear ophthalmoplegia (INO)] plus ipsilateral fascicular seventh cranial nerve palsy. Involvement of lower pontine tegmentum including the abducens nucleus, the ipsilateral medial longitudinal fasciculus (MLF), and the adjacent facial colliculus contribute to the clinical findings of EHS. Recently, nine syndrome with addition of hemiparesis or hemianesthesia to EHS (due to involvement of adjacent corticospinal tract or medial lemniscus) is suggested. Methods: Consecutive patients with presentation of EHS or nine syndrome were reviewed from referral neuro-ophthalmology and strabismus clinics. Results: Three cases of EHS were identified with different etiologies of intracerebral hemorrhage (ICH), demyelination, and neuromyelitis optica spectrum disorder. Moreover, one case of "nine syndrome" due to ICH was described. Brain magnetic resonance imaging (MRI) in all of them revealed lesion in lower tegmentum of pons. Conclusion: Apart from different etiologies, recognition of EHS or nine syndrome allows precise localization of the lesion to lower pontine tegmentum ipsilaterally.

Purpose To compare the outcome of inferior oblique disinsertion and myectomy in patients with unilateral congenital superior oblique palsy. Methods In this prospective study, consecutive patients with superior oblique palsy underwent either myectomy or disinsertion of the inferior oblique muscle. Success was defined as postoperative hypertropia of ≤5Δ in primary position and no hypotropia. In cases with preoperative hypertropia of ≤5Δ, success was defined as improved hypertropia and resolution of abnormal head position (AHP). Results A total of 62 patients were included: 34 underwent myectomy; 28, disinsertion. Preoperative primary position hypertropia was 15.8Δ ± 7.4Δ in the myectomy group and 14.5Δ ± 7.3Δ in the disinsertion (P = 0.756). AHP was present in 85.3% and 85.7% of patients, respectively (P = 1). Mean follow-up was in the myectomy group 7.5 ± 6.7 months and 6.9 ± 3.0 months in the disinsertion group (P = 0.637). Correction of hypertropia in primary position was more pronounced in the myectomy group (14.3Δ ± 7.4Δ vs 10.0Δ ± 5.4Δ; P = 0.013). Success was achieved in 91.2% of myectomy and 60.7% of disinsertion patients (P = 0.006). Persistence of AHP did not differ between groups (8.8% in the myectomy group vs 7.1% in the disinsertion group [P = 1]). Comparison of patients with preoperative hypertropia of ≤15Δ revealed nonsignificant differences between groups in rate of success (100% vs 81.3% [P = 0.226]) and correction of primary position hypertropia (8.8Δ ± 3.2Δ vs 7.6Δ ± 4.0Δ [P = 0.336]). Conclusions In our study cohort, inferior oblique myectomy had a greater effect in reduction of primary position hypertropia; however, disinsertion proved as effective as myectomy if preoperative vertical deviation was ≤15Δ. Both procedures effectively corrected AHP and demonstrated self-adjustment.

Purpose To design software with a novel algorithm, which analyzes the tortuosity and vascular dilatation in fundal images of retinopathy of prematurity (ROP) patients with an acceptable accuracy for detecting plus disease. Methods Eighty-seven well-focused fundal images taken with RetCam were classified to three groups of plus, non-plus, and pre-plus by agreement between three ROP experts. Automated algorithms in this study were designed based on two methods: the curvature measure and distance transform for assessment of tortuosity and vascular dilatation, respectively as two major parameters of plus disease detection. Results Thirty-eight plus, 12 pre-plus, and 37 non-plus images, which were classified by three experts, were tested by an automated algorithm and software evaluated the correct grouping of images in comparison to expert voting with three different classifiers, k-nearest neighbor, support vector machine and multilayer perceptron network. The plus, pre-plus, and non-plus images were analyzed with 72.3%, 83.7%, and 84.4% accuracy, respectively. Conclusions The new automated algorithm used in this pilot scheme for diagnosis and screening of patients with plus ROP has acceptable accuracy. With more improvements, it may become particularly useful, especially in centers without a skilled person in the ROP field.

To evaluate the surgical and functional results of slanted medial rectus resection for treatment intermittent exotropia of the convergence insufficiency type.Fifteen patients with near vision asthenopia and intermittent exotropia of the convergence insufficiency type were included in this prospective study. The upper edge of the MR was resected more than the lower edge. Slanted bilateral or unilateral medial rectus resection was performed. The mean length of follow-up was 14.9 months.Slanted medial rectus resection(s) caused a significant postoperative reduction in the mean distance exodeviation from 11.40 to 4.53 PD, as well as a change in the mean near exodeviation from 23.93 to 10.73 PD. Although mean near-distance difference reduced from 12.53 to 6.2 PD. In final examination, 11 patients showed surgical success rate and recurrent exotropia occurred in 4 cases. On the other hand, 13 cases had experienced significant relief from their symptoms.Slanted medial rectus resection is useful in decreasing the symptoms of intermittent exotropia of the convergence insufficiency type. However, it can result in undercorrection in larger deviations.