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Intermittent exotropia (IXT) is known to relapse after surgery. No factors to predict or prevent recurrence are known with certainty. This study investigated surgical outcome, potential influencing factors, and reoperation rate in patients with IXT. Medical records of 537 patients who underwent surgery for IXT from 2000 to 2022 with preoperative angles of exodeviation of 6 to 50 prism diopters (PD) were retrospectively studied. Multivariate regression analyses of factors influencing surgical outcome on postoperative day 1 (POD1) and reoperation rate were performed. A Kaplan-Meier analysis was performed to illustrate the reoperation rate. After the first surgery, 83.8% of patients had a successful surgical outcome on POD1 (esodeviation ≤ 5 PD or exodeviation ≤ 10 PD). Logistic regression analysis revealed that small preoperative angles of exodeviation increased the probability for surgical success. Follow-up data at different times (4 days-20 years) after surgery were available for 176 patients: 40 patients were still in the range of surgical success, 133 patients had exotropia > 10 PD. Of the follow-up patients, 65 (12.1%) underwent reoperation. A total of 8.5% had their reoperation within one year after the first surgery, 52.9% within five years. Cox regression analysis revealed that large preoperative angles of exodeviation, far/near incomitance and alphabet pattern strabismus increased the risk of reoperation. Most patients achieved surgical success on POD1, yet the squint angles often increased after surgery, resulting in reoperation in some patients. Prospective studies are needed for a better assessment of pre-, peri- and postoperative factors for surgical success in IXT.

Background: Due to the long life expectancy, retinal detachment is a special threat to visual acuity in children and adolescents. This study presents the clinical features of retinal detachment in childhood and adolescence up to the age of 20 years., Patients and Methods: A cohort was selected comprising 259 patients who suffered from unilateral or bilateral retinal detachment, were not older than 20 years of age at the first diagnosis of the first or only affected eye and had undergone surgery at least once at the Department of Ophthalmology of the University Medical Center of Munich during a period of 18 years (1980-1998). This patient collective was retrospectively analyzed with respect to the clinical features of the first retinal detachment. The group consisting of only one affected eye or the first affected eye (259 eyes) was included. The fellow eyes affected later were excluded (19 eyes)., Results: The time period between the first visual symptoms and the diagnosis of retinal detachment was on average 9.6 weeks and the most commonly manifested symptom was loss of vision (36.3% of patients). In 40.2% of the patients the detachment was discovered fortuitously. The most frequent presentation (34.0%) was a 2-quadrant retinal detachment and was (sub)total in 27.0% of eyes. Macular detachment was found in 154 eyes (59.5%). The commonest type of retinal break was a tear near the ora serrata (36.1% of all breaks). Giant tears (12.8% of all breaks) occurred preferentially in the area of the ora serrata, round atrophic holes were identified especially in the area of the equator, often in the form of a chain of holes. Breaks most frequently occurred in the inferior temporal quadrant. In 22.4% of retinal detachments no break was found even intraoperatively. A primary proliferative vitreoretinopathy (PVR) of at least stage C was involved in 25.5% of detachments., Conclusion: In childhood and adolescence a characteristic delay of diagnosis enables a large sized expansion of the retinal detachment with frequent macular involvement and a high proportion with (sub)total detachment and severe primary PVR. Tears in the ora serrata area, giant tears, multiple round atrophic holes in the area of the equator and a high rate of undetectable breaks are the intrinsic characteristics of juvenile retinal detachment.

Clinical Features: The congenital Brown syndrome is characterized by a mechanical limitation of elevation in adduction, with an orthophoria in down gaze. Brown postulated a shortened superior oblique tendon sheath as the cause of the limitation but this was disproved by Parks et al. in 1975 and the origin of Brown syndrome remains unclear. In recent years, a congenital dysinnervation has been discussed; however, this does not explain the full spectrum of abnormalities and especially contradicts the unlimited depression in adduction seen in Brown syndrome., Origin: Surgical exploration in Brown true typical cases reveals a fibrotic strand, typically located at the posterior margin of the superior oblique tendon. This strand originates from the trochlear area and has a common insertion with the superior oblique tendon posterior to the equator into the globe. It may represent an atavistic superior oblique muscle as described by Fink in various animals. They do not have a trochlea but a superior oblique muscle originating in the anterior superior nasal orbit., Atypical Brown Syndrome: A fibrotic strand was also surgically revealed in two cases of atypical Brown syndrome. In the first case an elevation deficit-as in Brown true atypical cases-also present in abduction could be explained by an unusual insertion of the fibrotic strand anterior to the equator. The second case showed a fibrotic strand which was completely separated from the superior oblique tendon and inserted far posterior to the equator nasal to the superior rectus muscle. This finding had not been previously described and explained the total elevation restriction which was suddenly in > 30° adduction and the Y‑pattern exotropia which increased in adduction and decreased in abduction., Treatment and Follow-Up: A 10 mm excision of the fibrotic strand from the insertion gives the best results from all procedures. The residual limitation of active elevation in adduction improved with gaze exercises mostly after more than 1 year., Conclusion: The fibrotic strand, an atavistic superior oblique muscle, not only explains the typical Brown syndrome but also-by its variable insertion-different patterns of elevation deficits seen in atypical Brown syndrome. A 10 mm excision of the strand gives good functional results of abnormal head position (immediate in most cases) and even elevation in adduction (after 1 year in most cases).

Palisade endings are located at the myotendinous junction of extraocular muscles in most mammals. Irrespective of their unclarified function as motor or sensory nerve endings, a specialized role in convergence is proposed, based on their high number in the medial rectus muscle (MR). Further support comes from a study in monkey demonstrating that only the MR and inferior rectus muscle (IR) contain an additional population of palisade endings that express the calcium-binding protein calretinin (CR) in addition to choline acetyltransferase (ChAT). Here we studied, whether CR-positive palisade endings are present in human as well and confined to extraocular muscles most active during convergence. The systematic analysis of all eye muscles of 17 human specimen revealed that only the MR and IR contain an additional population of CR-positive palisade endings and multiple en-grappe endings, which target non-twitch muscle fibers along their whole length. Approximately 80% of all palisade endings in the MR expressed CR. Furthermore, the intrafusal muscle fibers of some muscle spindles in the MR were innervated by CR-positive annulospiral nerve endings that transmit the signals of muscle length changes to the brain. All extraocular muscles contained few thin CR-positive, but ChAT-negative nerve fibers, possibly representing free sensory or autonomic endings arising from the trigeminal ganglion. As in monkey, in the medial periphery of the human oculomotor nucleus ChAT-positive neurons were found to co-express CR. Therefore these neurons most likely represent the cell bodies of CR-positive palisade endings in the MR. Unlike in monkey, these neurons do not lie within a compact cell group, but are more scattered. In conclusion, the MR and IR in human contain two histochemically different populations of palisade and multiple endings that may contribute to ocular alignment and convergence in a different way., (© 2019 Elsevier B.V. All rights reserved.)