Search

Myasthenia gravis (MG) has been described as a great mimicker of other neurologic and ocular motility disorders, including centrally mediated ophthalmoplegia. For example, ocular myasthenia gravis (ocular MG) may cause impaired binocular visual acuity for near vision due to reduced accommodation or for distance vision due to accommodative excess. Notably, accommodative excess due to ocular MG is rare, but may occur with exotropia, with or without diplopia. We report 2 cases of ocular MG: First, a 32-year-old man with exotropia, bilateral hypometric and slowed adducting saccades with dissociated abducting nystagmus, miosis, and decreased distance vision in his right eye; second, a 45-year-old man with similar ocular motor deficits, miosis, and myopia. Both patients showed ocular motor deficits which appeared to localize to the pons but were instead due to ocular MG. Ocular MG should be considered in patients who present with reduced visual acuities due to any disruption in accommodation. Any ocular motor deficit, even if appearing to be centrally mediated or occurring without ptosis, may be caused by ocular MG.

Obesity is now a significant global public health issue. Limited understanding exists regarding the association between obesity and concomitant exotropia. Our objective was to identify the causal relationship between lifecourse obesity, including birth weight, childhood body mass index (BMI), and adult BMI, and the risk of concomitant exotropia. We used a two-sample Mendelian randomization (MR) strategy to examine the causal relationship with inverse-variance weighted method as the primary MR analysis. We carried out sensitivity analyses to evaluate the accuracy and robustness of our findings. Also, we performed reverse-direction MR analysis to eliminate the possibility of reverse causality. Childhood BMI, as opposed to birth weight or adult BMI, had a significant impact on the risk of concomitant exotropia (odds ratio = 1.40, 95% confidence interval (CI): 1.08-1.81, P = .01). This significance persisted even after accounting for birth weight and adult BMI using multivariable MR analysis (odds ratio = 1.35, 95% CI: 1.04-1.75, P = .02). There was no significant heterogeneity or pleiotropy observed in sensitivity analyses (P > .05). Multivariable MR analysis further confirmed the absence of pleiotropic effects of some risk factors including prematurity, maternal smoking around birth and refractive error. Reverse causality did not affect the causal relationship (beta = -0.0244, 95% CI: -0.0545 to 0.0056, P = .11). Genetic predisposition to higher childhood BMI was found to be causally linked to an increased risk of concomitant exotropia., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Accurate diagnosis of efferent visual system disease in neuro-ophthalmology involves the classification of clinical signs as prenuclear, nuclear, or infranuclear in origin. Over many years, I have come to recognize ocular torsional instability as a clinical sign of prenuclear disease., Methods: Retrospective chart review of patients in whom ocular torsional instability was diagnosed using indirect ophthalmoscopy., Results: Twenty patients were diagnosed as having ocular torsional instability (OTI). Eight had neuro-ophthalmologic disease caused by structural injury to prenuclear ocular motor areas. Six of these had structural lesions primarily involving the cerebellum, one had a midbrain glioma, and one had traumatic encephalomalacia. Eight additional patients had infantile strabismus (esotropia in 7, exotropia in 1) associated with various combinations of monocular nasotemporal optokinetic asymmetry, latent nystagmus, and dissociated vertical divergence (DVD), indicating prenuclear involvement of subcortical visuovestibular pathways within the brain. Three additional patients presented with intermittent exotropia with DVD signifying early onset, while 2 had acquired esotropia that was noninfantile in origin. One had partially accommodative esotropia with bilateral inferior oblique overaction, and one presented with acquired esotropia followed by spontaneous secondary exotropia., Conclusions: OTI provides a useful clinical sign of prenuclear ocular motor dysfunction. When detected in patients without any signs of infantile or early-onset strabismus, OTI signifies the need for neuroimaging to rule out neurovestibular or cerebellar causes of prenuclear disease., Competing Interests: The author reports no conflicts of interest., (Copyright © 2023 by North American Neuro-Ophthalmology Society.)

Rationale: Pulled-in-two syndrome is one of the significant complications of strabismus surgery. This study aimed to report a case of pulled-in-two syndrome of the contractured medial rectus muscle (MR) that occurred during strabismus surgery for strabismus fixus due to high myopia, and to describe a rescue of this complication., Patient Concerns: A woman in her 60s presented to our Ophthalmology Department with the main complaint of unilateral high myopia and severe myopic strabismus fixus. Esotropia exceeded 45° and hypotropia exceeded 15° in her right eye in the Hirschberg test. Right eye duction was markedly limited in every gaze direction. Orbital magnetic resonance images showed rupture of the superior rectus to lateral rectus band ligament and lengthening of the distance between the SR and LR muscles in the right eye., Diagnosis: Due to the patient's ophthalmic examination and imaging results, she was diagnosed with high myopic strabismus fixus., Interventions: We performed MR recession and Yokoyama surgery to correct right eye hypoesotropia. In the MR recession procedure, pulled-in-two syndrome (MR muscle tear) occurred. Thus, no additional procedure was performed on the MR. After the surgery, she presented 45 prism diopter exotropia and 18 prism diopter residual right hypotropia in a Krimsky test. We performed a second surgery, combining MR muscle advancement and inferior rectus (IR) muscle recession, 3 months after the first surgery., Outcomes: One and a half years after the second surgery, she presented exotropia of 14 prism diopters without hypotropia in the Krimsky test and was satisfied with her ocular position and improved motility., Lessons: We experienced pulled-in-two syndrome in a case with severe myopic strabismus fixus and achieved a good outcome by performing additional surgery 3 months later, in which the lost MR muscle was advanced. This case underscores that, if the lost muscle cannot be found during surgery, one should maintain composure and perform a reoperation a few months after the initial surgery, if necessary. This case report can aid in making rescue treatment decisions when pulled-in-two syndrome occurs., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The objective is to observe the changes in aberrations before and after surgery in patients with common horizontal strabismus and to analyze the possible reasons for the changes., Methods: Forty eyes of 40 cases with concomitant exotropia who underwent strabismus correction at the Ophthalmology Department of Nantong University Hospital from October 2020 to July 2021 were included in this study, all of whom underwent unilateral lateral rectus recession combined with a medial rectus resection in the same eye. Aberration parameters were measured 1 day before surgery and 1 week, 1 month, 3 months, and 6 months after surgery. Differences in the indicators at each time period were compared by analysis of variance (ANOVA) of repeated measures data for a single factor, and data were analyzed using SPSS 25.0 statistical application software., Results: 5 mm pupil diameter: the preoperative and postoperative RMS of total aberration showed statistically significant difference ( P < 0.01). Postoperation test (Bonferroni method) and preoperative comparison at each period after surgery showed statistically significant differences between 6 months after surgery ( P =0.002) and preoperative comparison. The preoperative and postoperative comparison of RMS in LOAs was statistically significant ( P < 0.01); postoperative test (Bonferroni method) and preoperative comparison showed that there were statistically significant differences between 1 week ( P =0.033) and 6 months ( P =0.002) after operation. The difference of RMS of defocus before and after operation was statistically significant ( P < 0.01); postoperation test (Bonferroni method) and preoperative comparison showed that there was statistically significant difference between 6 months after operation ( P =0.007) and preoperative comparison. There was statistically significant difference in preoperative and postoperative RMS of HOAs ( P =0.013). Postoperative test (Bonferroni method) and preoperative comparison showed that there was statistically significant difference 6 months after surgery ( P =0.03). The RMS of secondary astigmatism showed a statistically significant difference before and after operation ( P =0.001), and the postoperation test (Bonferroni method) showed a statistically significant difference 6 months after operation ( P =0.002). In 5 mm pupil diameter, the preoperative and postoperative RMS of total aberration showed statistically significant difference ( P < 0.01), postoperative test (Bonferroni method) was used to compare each period after surgery with that before surgery, and there were statistically significant differences between 1 week after surgery ( P =0.034), 3 months after surgery ( P =0.033), and 6 months after surgery ( P =0.003). The preoperative and postoperative comparison of RMS in LOAs was statistically significant ( P < 0.01), postoperative test (Bonferroni method) was used to compare each period after surgery with that before surgery, and there were statistically significant differences between 1 week after surgery ( P =0.04), 3 months after surgery ( P =0.034), and 6 months after surgery ( P =0.004). The difference of RMS of defocus before and after surgery was statistically significant ( P =0.002), and the comparison between postoperation test (Bonferroni method) and preoperation showed that the difference was statistically significant 6 months after surgery ( P =0.027). The RMS of astigmatism showed statistically significant difference before and after operation ( P =0.002), and the postoperation test (Bonferroni method) showed statistically significant difference between 6 months after operation ( P =0.009) and before operation., Conclusion: We found that horizontal rectus surgery had a transient effect on LOAs and almost no effect on HOAs. Long-term follow-up is recommended after strabismus surgery to observe eye position and binocular visual function. Because of the high prevalence of strabismus in adolescents, long-term observation of the eye axis and aberration is recommended., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Xixi Zhang et al.)

Exotropia (XT) in internuclear ophthalmoplegia (INO) is a difficult problem to treat. The purpose of this study is to describe surgical approaches in treating INO and glean insight into various pre-operative factors that may affect outcomes for XT in INO. We conducted a retrospective review from 1 January 1995 - 5 January 2021 and identified seven patients with INO who underwent strabismus surgery for XT. Patient age, sex, etiology of INO, pre-operative alignment and sensorimotor exam, presence of diplopia, surgery performed, subsequent surgeries, use of adjustable sutures, post-operative alignment, presence of post-operative diplopia, presence of post-operative diplopia with use of prism correction, and length of follow-up were all collected. Initial surgeries undertaken included unilateral medial rectus (MR) plication and lateral rectus (LR) recession, bilateral medial rectus (MR) plications or resections, or bilateral MR plications combined with either unilateral or bilateral LR recessions. Chart review yielded ten charts, however two were excluded due to manifest esotropia (ET), and one was excluded due to incomplete records. Seven total patients were used in final analysis. The cohort age range was from 29 to 79 years. Pre-operative horizontal distance alignment ranged from 35 to 95 XT with an average exodeviation of 67.8 ± 22.6 prism diopters (PD). Horizontal adduction deficit ranged from -1 to -4 and was present bilaterally in all patients. A variety of initial surgical approaches were undertaken. After two muscle surgeries, distance deviation had an average change of 57.3 PD. After three muscle surgeries, distance deviation had an average change of 75 PD. After four muscle surgeries, distance deviation had an average change of 60 PD. Three patients required additional surgery for XT. Time to follow-up ranged from 1 to 58 months. Horizontal distance alignment in primary gaze at latest follow-up ranged from 30 ET to 30 XT with an average of 0 (orthotropia) ± 16.0 PD. One patient had a consecutive esotropia of 30 PD, one had a persistent exotropia of 30 PD, and five patients were orthotropic at distance. All patients reported relief of diplopia in primary gaze at near and distance either with or without use of prism. Horizontal ductions improved to some degree in all patients. Horizontal rectus surgery can treat many cases of XT in INO. Surgeons should consider INO etiology and concomitant vertical deviations when considering surgery. The degree of pre-operative adduction limitation is another important factor, though did not always dictate final motor and sensory outcomes.

Competing Interests: The authors report no conflicts of interest.

The aim of this prospective study was to compare surgical outcomes of slanted bilateral lateral rectus (LR) recession for intermittent exotropia (IXT) with convergence insufficiency (CI) according to their response to preoperative monocular occlusion. This prospective study included 55 children who underwent slanted bilateral LR recession for IXT with CI. Patients were divided into two groups according to their response to preoperative monocular occlusion for 2 hours. The True CI group was defined as having near-distance differences of ≥10 PD before and after occlusion; the Masked CI group as having near-distance differences of <10 PD and ≥10 PD prior to and after occlusion. Slanted procedure reduced distance and near exodeviations from 32.1 PD and 43.0 PD to 3.5 PD and 4.4 PD, and collapsed near-distance differences from 10.9 PD to 1.0 PD at 3 years postoperatively. Cumulative probabilities of surgical success were 76%, and the mean recurrence was 50 months at 3 years postoperatively; the True CI and Masked CI groups showed cumulative success rates of 89% and 55%, respectively (p = 0.0052). Patients in the True CI group demonstrated surgical outcomes superior to those demonstrated by patients in the Masked CI group after slanted bilateral LR recession.

Rationale: Angelman syndrome (AS) is an uncommon genetic disease characterized as serious retarded mental development and ocular abnormality., Patient Concerns: This report aims to present the ophthalmological features, and identify the diagnosis and outcomes of strabismus surgery in AS patients., Diagnosis: Three children with exotropia were diagnosed with AS based on their typical clinical features., Interventions: All patients underwent multiplex ligation-dependent probe amplification (MLPA) analysis and accepted lateral rectus recession surgery with the assistance of intravenous combined inhalation anesthesia., Outcomes: The maternal heritage deletion of chromosome 15q11.2-q13 was verified in all patients by MLPA. All patients with strabismus could not cooperate during the vision test, and had astigmatism. The strabismus type of AS patients was horizontal exotropia, and no vertical strabismus was found. One of these patients was combined with high myopia. The hypopigmentation on the hair and iris was ubiquitous. However, retina pigmentation was normal. After different degrees of lateral rectus recession, the exotropia was significantly relieved, and the surgical effects were stable postoperatively., Lessons: Horizontal exotropia is the major strabismus type. Severe intellectual disability, hyperactivity, and speech impairment are the common characteristics of AS children. Its examination and operation design remains challenging. Thus, repeated examinations and intelligence rehabilitation are essential.

Recent work has implicated one type of horizontal strabismus (exotropia) as a risk factor for schizophrenia. This new insight raises questions about a potential common developmental origin of the two diseases. Seasonality of births is well established for schizophrenia. Seasonal factors such as light exposure affect eye growth and can cause vision abnormalities, but little is known about seasonality of births in strabismus. We examined birth seasonality in people with horizontal strabismus in a retrospective study in Washoe County, Nevada, and re-examined similar previously obtained data from Osaka, Japan. We then compared seasonal patterns of births between strabismus, refractive error, schizophrenia and congenital toxoplasmosis. Patients with esotropia had a significant seasonality of births, with a deficit in March, then increasing to an excess in September, while patients with exotropia had a distinctly different pattern, with an excess of births in July, gradually decreasing to a deficit in November. These seasonalities were statistically significant with either χ2 or Kolmogorov-Smirnov-type statistics. The birth seasonality of esotropia resembled that for hyperopia, with an increase in amplitude, while the seasonality for myopia involved a phase-shift. There was no correlation between seasonality of births between strabismus and congenital toxoplasmosis. The pattern of an excess of summer births for people with exotropia was remarkably similar to the well-established birth seasonality of one schizophrenia subtype, the deficit syndrome, but not schizophrenia as a whole. This suggests a testable hypothesis: that exotropia may be a risk factor primarily for the deficit type of schizophrenia.

A young girl with constant exotropia was planned for surgery. Thorough preoperative workup was done and the patient underwent strabismus surgery. The girl developed preseptal haematoma on the third postoperative day with marked chemosis and oozing of blood from the conjunctival cul-de-sac. A history of factor XIII (FXIII) deficiency was later revealed by the caretakers. The patient was admitted and fresh frozen plasma was transfused for 5 days along with intravenous tranexamic acid. Orbital ultrasound and CT scan were done to confirm the location of the haematoma. The child improved significantly after 5 days and the proptosis subsided. FXIII deficiency is a rare form of bleeding disorder that is not revealed on routine coagulation profile tests. Fresh frozen plasma and recombinant FXIII are now available for treatment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/objectives: To analyze the surgical and sensory outcomes of intermittent exotropia according to refractive errors and the factors associated with surgical success., Subjects/methods: A total of 326 children were divided into three groups according to preoperative refractive error; hyperopic eyes with SE ≥+2D (hyperopic group), eyes with SE between -1D and +2D (emmetropic group), and myopic eyes with SE ≤-1D (myopic group). The surgical outcomes and the sensory outcomes measured by near and distant stereoacuity were compared among the three groups., Results: The surgical success rate in hyperopic group was significantly lower compared to myopic group at last follow-up (P = 0.012). Preoperative near stereopsis was not different among three groups, however, the distance stereopsis was significantly deteriorated in the hyperopic group compared to the other two groups (Titmus; P = 0.168, FD2; P < 0.001, DR; P = 0.048). There was postoperative improvement in both near and distant stereopsis in all three groups (Titmus; P = 0.009, FD2; P = 0.021, DR; P = 0.036) and no significant difference was found in the postoperative distant stereopsis among the three groups., Conclusions: Preoperative refractive error is a prognostic factor of surgical success in patients with intermittent exotropia. Patients with hyperopia achieved less favorable surgical outcome compared to myopic patients. The preoperative distant stereoacuity was decreased in hyperopic patients compared to myopic patients, which eventually improved after surgery and showed no significant difference at postoperative measurements.

We evaluated changes in ocular axial length (AL), anterior chamber depth (ACD), and intraocular pressure (IOP) after strabismus surgery by comparing the operated and fellow eyes in patients undergoing unilateral strabismus surgery.This was a prospective study including patients who underwent unilateral strabismus surgery for exotropia alone or exotropia with unilateral superior oblique palsy. The AL and ACD using IOLMaster biometer and the IOP using non-contact tonometry were measured 1 day prior to surgery and 1 week, 1 month, and 3 months postoperatively.Fourteen female and 22 male patients (mean age: 8.2 years) were included in the study. In the operated eye, the mean AL increased significantly from 23.99 mm preoperatively to 24.08 mm 1 week postoperatively (P < .001), and although the mean ACD decreased in this time, the decrease was not statistically significant. The mean IOP of the operated eye increased from 17.08 mmHg preoperatively to 20.31 mmHg at 1 week postoperatively (P = .01), as did the IOP of the fellow eye (P = .03). However, the AL and IOP of the operated eyes decreased by 1 month postoperatively. There were no significant differences in the AL, ACD, and IOP between operated and fellow eyes by 3 months postoperatively.Strabismus surgery caused significant AL elongation in the operated eye and IOP elevation in both the operated and fellow eyes immediately after surgery. However, both ocular changes were transient. The AL, ACD, and IOP did not exhibit any significant differences between operated and fellow eyes 3 months postoperatively.

Objective: To investigate the changes of life quality in children with intermittent exotropia (IXT) and their parents 1 year after surgical treatment. Methods: Retrospective study. The scores of Chinese version of the intermittent exotropia questionnaire (CIXTQ) and follow-up visits at 1 week preoperatively and 3 months, 12 months postoperatively were collected from 122 IXT children with successful eye positions 3 months postoperatively and their parents in Department of Ophthalmology, the First Affiliated Hospital of Nanjing Medical University from December 2015 to July 2016. The CIXTQ scores of children with different eye positions 1 year postoperatively, the impact of parent CIXTQ scores and 1-year postoperative eye positions on children's CIXTQ scores and parents' proxy CIXTQ scores, were analyzed. Repeated measures anova was used for the analysis. Results: A total of 122 IXT children were collected in this study, there were 64 boys and 58 girls, age (2-15) years, mean (7±3) year. The eye positions of 88 (72.1%) children were successful 1 year postoperatively, and 34 (27.9%) were undercorrected 1 year postoperatively. The CIXTQ scores of children with different eye positions 1 year postoperatively were significantly higher than that at 1 week preoperatively and at 3 months postoperatively(scores of all children, 83.27±9.49 vs . 57.30±8.37 and 69.19±7.95; successful children, 84.12±8.80 vs . 57.36±8.16 and 69.99±7.85; undercorrected children, 81.07±10.95 vs . 57.14±9.04 and 67.10±7.98), with statistical significance (compared with 1 week preoperatively, t= 22.44, 22.13, 8.73; compared with 3 months postoperatively, t= 12.42, 11.40, 5.49; all P< 0.001). However, the parent' CIXTQ scores of children with recurrent strabismus showed no significant differences when compared to those at 3 months postoperatively ( P> 0.05). The CIXTQ scores of parents and eye positions 1 year postoperatively showed no impact on children's CIXTQ and parents' proxy CIXTQ scores (all P> 0.05). Conclusion: The orthodontic surgery can effectively improve the life quality of children with IXT and their parents 1 year after surgical treatment, and there is no correlation between the life quality of children and their parents. (Chin J Ophthalmol, 2019, 55:31-36) .

Purpose: Although less frequent than consecutive exotropia, consecutive esotropia is a well-known type of strabismus when it follows the surgical correction of an exotropia. Spontaneous conversion from initial constant, large-angle exotropia beyond the age of 3 months to esotropia or orthophoria, however, is not common. We describe a series of infants who presented a spontaneous evolution from a large-angle infantile exotropia to either an orthophoria or a spontaneously consecutive esotropia., Methods: Cases of infants examined in the pediatric neuro-ophthalmology clinic of a tertiary ophthalmology department between 2009 and 2015, and having presented an early large-angle exotropia that spontaneously converted into an esotropia or orthophoria-i.e., without any previous surgery or botulinum toxin injection-were studied., Results: Ten cases (6 M:4 F) were followed up. Median age at first exotropia assessment was 3.88 months (SD = 6.35). Median age at spontaneous conversion to esotropia or orthophoria was 7.23 months (SD = 14.73). Six patients suffered from severe neurologic or metabolic diseases, three had neonatal respiratory distress syndrome, and one was healthy., Conclusion: Spontaneous conversion from initial large-angle exotropia to esotropia or orthophoria can be encountered. The cerebral maturation of visual structures probably accounts for this uncommon strabismus sequence.

The Xq28 duplication involving the MECP2 gene ( MECP2 duplication) has been mainly described in male patients with severe developmental delay (DD) associated with spasticity, stereotypic movements and recurrent infections. Nevertheless, only a few series have been published. We aimed to better describe the phenotype of this condition, with a focus on morphological and neurological features. Through a national collaborative study, we report a large French series of 59 affected males with interstitial MECP2 duplication. Most of the patients (93%) shared similar facial features, which evolved with age (midface hypoplasia, narrow and prominent nasal bridge, thick lower lip, large prominent ears), thick hair, livedo of the limbs, tapered fingers, small feet and vasomotor troubles. Early hypotonia and global DD were constant, with 21% of patients unable to walk. In patients able to stand, lower limbs weakness and spasticity led to a singular standing habitus: flexion of the knees, broad-based stance with pseudo-ataxic gait. Scoliosis was frequent (53%), such as divergent strabismus (76%) and hypermetropia (54%), stereotypic movements (89%), without obvious social withdrawal and decreased pain sensitivity (78%). Most of the patients did not develop expressive language, 35% saying few words. Epilepsy was frequent (59%), with a mean onset around 7.4 years of age, and often (62%) drug-resistant. Other medical issues were frequent: constipation (78%), and recurrent infections (89%), mainly lung. We delineate the clinical phenotype of MECP2 duplication syndrome in a large series of 59 males. Pulmonary hypertension appeared as a cause of early death in these patients, advocating its screening early in life., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: To determine surgical responses and outcomes of bilateral lateral rectus (BLR) recession in exotropes with cerebral palsy (CP) and to compare the results with exotropes without CP., Methods: Forty-one exotropes with CP and 82 age- and type (intermittent or constant)-matched exotropes without CP who underwent BLR recession by one surgeon (J-M.H.) were evaluated. Main outcome measures were surgical responses, factors affecting surgical response, success rates, cumulative probabilities of success and recurrence, and drifts of ocular alignment towards exodeviation after surgery (exodrift)., Results: The surgical responses of BLR recession were not significantly different between both groups (p = 0.136). After a mean follow-up period of 2 years, success rates showed no significant difference between the two groups (p = 1.000). The cumulative probabilities of success and recurrence were not significantly different between the two groups (p = 0.770 and 0.754, respectively). The rate of recurrence per person-year during follow-up was 16.7% in patients with CP and 20.2% in patients without CP. The amount of exodrift showed no significant difference between both groups (p = 0.118)., Conclusions: Exotropes with CP showed a similar surgical response, an amount of exodrift, cumulative success and recurrence rates after BLR recession compared to exotropes without CP., (© 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Objective: To determine the preoperative variables affecting early and late favorable outcomes of bilateral lateral rectus recession surgery for concomitant exotropia., Material and Method: A retrospective study of 65 patients with concomitant exotropia (constant and intermittent) who had bilateral lateral rectus recession was conducted. The follow-up period was more than 1 year in all patients. Preoperative parameters were obtained and evaluated using univariate analysis., Results: Sixty-five patients with concomitant exotropia who underwent bilateral lateral rectus recession were included. In the early and late postoperative outcome, 78% and 82% of the patients were in the success group, respectively. Meanwhile, 22% and 18% were in the failure group, respectively. There was no association between postoperative outcome and preoperative variables i.e. age at onset (p = 0.841, 0.591), age at surgery (p = 0.564, 0.634), interval between onset and surgery (p = 0.506, 0.753), preoperative deviation (p = 0.278, 0.211), refractive error (p = 0.217, 0.136), anisometropia (p = 0.946, 0.946), phase of exotropia (p = 0.741, 0.013), A-V pattern (p = 1.000, 1.000), stereopsis (p = 0.841, 0.268) and amblyopia (p = 0.569, 0.567)., Conclusion: Preoperative variables could not be used to predict the early and late postoperative outcome.

Introduction: Frontonasal dysplasia is a rare condition of congenital structure malformations of the midface. Ophthalmologic abnormalities have been estimated to occur in 87% of cases of frontonasal dysplasia., Case Report: We report a case of type I frontonsal dysplasia in a 15-year old boy after the correction of severe hypertelorism, median nasal cleft w~ith a broad nasal root and associated decompensated intermittent exotropia with overaction. of the inferior oblique muscles and V pattern. He underwent bilateral lateral rectus recessions of 6.0 mm for intermittent exotropia when he was six years old. The correction of hypertelorism was performed with orbital rotation surgery when he was thirteen years old. For some time after strabismus surgery, the ocular alignment improved, but it deteriorated gradually. The ocular alignment improved after the hipertelorismus correction; however, intermittent exotropia deteriorated gradually again six to seven months later. On the last ophthalmologic examination, he had the ocular alignment on the level of small angle exotropia and associated hypertropia and occasionally even.small angle esotropiaat near. There was bilateral overelevation in addiction and V pattern, which remained unchanged after extensive facial bones surgical procedures., Conclusion: The high incidence of ocular abnormalities, particularly exodeviations, indicates that the early assessment by an ophthalmologist should be a part of the initial evaluation of patients with frontonasal dysplasia to detect treatable visual or ocular problems.

Objective: To discuss the application of disparity discriminating accuracy test in evaluating the stereopsis of postoperative intermittent exotropia., Methods: Patients with intermittent exotropia who underwent surgery during July 2011 to June 2013 were followed up. The stereoacuity was examined by Titmus Stereotest, Randot Stereotest and Frisby Stereotest. Twenty adult cases whose stereoacuity reached normal were chosen as experimental group. Twenty healthy adults were selected as normal control group. Both groups were examined with disparity discriminating accuracy test. Discriminating accuracy of the two groups were analyzed with Two-Way ANOVA method. Test-retest reliability was analyzed with Intraclass Correlation Coefficient analysis., Results: The test-retest reliability of disparity discriminating accuracy test is excellent (ICC=0.99, P<0.01) . Discriminating accuracy under different disparities in experimental group were 0.56±0.09, 0.67±0.14, 0.77±0.15, 0.82±0.14, 0.85±0.11, 0.85±0.14, 0.87±0.10, 0.84±0.16, while those in control group were 0.77±0.09, 0.88±0.09, 0.93±0.08, 0.91±0.09, 0.95±0.08, 0.96±0.05, 0.97±0.06, 0.96±0.04. There were statistically significant differences between them (F=38.06, P<0.01) . The discriminating ability of group grating in both groups was affected by the size of disparity. Under situation of small disparity, a large difference was found between the experimental group (0.67±0.12)and control group(0.86±0.07) (F=4.84, P<0.05)., Conclusions: Stereoscopic function can be evaluated comprehensively with disparity discriminating accuracy test. Use this test, a certain degree of dysfunction in stereopsis can still be found in postoperative intermittent exotropic patients who reached normal stereoacuity examined with traditional stereotests. (Chin J Ophthalmol, 2016, 52: 584-588).

Background and Objective: Weakening of the lateral rectus muscle to correct exotropia can be achieved by using a conventional or a hang-back recession. This study was conducted to compare the results of these techniques and to analyze the dose-response curve and complication rates., Study Design and Methods: Patients who underwent a lateral rectus muscle recession for exotropia were included in this retrospective study. The recession was performed conventionally with direct scleral fixation at the desired point or with a hang-back recession, each combined with a plication of the ipsilateral medial rectus muscle. The study analyzed ocular alignment and motility preoperatively as well as 1 day and 3 months postoperatively. Intraoperative and postoperative complications were compared., Results: A total of 50 patients (age 4-75 years) met the inclusion criteria for this study. A conventional recession of the lateral rectus muscle was performed in 30 patients and a hang-back recession in 20. Preoperative ocular alignment with distance fixation was - 33.8 ± 14.4 prism diopters (PD) in the conventional group and - 30.6 ± 11.8 PD (mean ± standard deviation) in the hang-back group (where negative values constitute exotropia and positive values are esotropia). Preoperative ocular alignment with near fixation was - 40 ± 15.2 PD and - 36 ± 14.7 PD for conventional and hang-back recession, respectively. Ocular alignment with distance fixation 3 months postoperatively was - 10 ± 14.1 PD in the conventional group and - 11.1 ± 13.2 PD in the hang-back group and with near fixation it was - 15.4 ± 13.9 PD and - 11.5 ± 13.9 PD, respectively. In the conventional group 1 mm of combined surgery corrected 2.03 ± 0.88 PD (- 0.31-4.15 PD/mm) of exotropia with distance fixation and 2.13 ± 0.87 PD (0.89-3.85 PD/mm) with near fixation. In the hang-back group, it corrected 1.83 ± 0.89 PD (0.42-2.95 PD/mm) and 2.32 ± 1.25 PD (0.17-4.76 PD/mm), respectively. Differences between groups were not statistically significant. Intraoperative complications, such as scleral perforation were not observed. Postoperative complications, particularly slipped or lost muscles or induced vertical strabismus were not documented in either group., Conclusion: The hang-back recession is an effective and safe alternative to conventional recession of the lateral rectus muscle for exotropia. Larger studies with longer follow-up would be desirable to prospectively compare these two techniques.

Background: In psychomotor retardation there is an abnormal development of mental, sensory and motor skills associated with ocular manifestations. There are biological and psychosocial risk factors that predispose an individual to neurological damage. From 50% to 80% of patients with strabismus retardation have special features that differentiate it from the rest of strabismus in healthy patients., Objective: To determine the most common type of strabismus in patients with psychomotor retardation and their clinical features., Material and Methods: Patients with psychomotor retardation and strabismus were included. An ophthalmological examination was performed, as well as an evaluation of the characteristics of strabismus, including perinatal and post-natal history., Results: Esotropia was the most frequent squint with 65.3%, followed by exotropia with 32.7%. The variability in the squint magnitude was 60% in both types, and 6 patients had dissociated vertical deviation. Most of the patients started to present strabismus since they were born. The most frequent perinatal risk factors were threatened miscarriage, pre-eclampsia, foetal distress, and hypoxia., Conclusions: Esotropia is the most common type of strabismus in psychomotor retardation. The variability of squint magnitude is a characteristic in these patients. The moderate variability is the most frequent in both esotropia and exotropia. The most common refractive error is hyperopic astigmatism in esotropia and the myopic kind in exotropia., (Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.)

Objective: To summarized the clinical features of thyroid associated ophthalmopathy patients with myasthenia gravis., Methods: This is a retrospective case series study. The clinical data of 12 thyroid associated ophthalmopathy patients with myasthenia gravis were collected in the 416 Hospital of Nuclear Industry from Oct. 2012 to Feb. 2014. All patients had a detailed medical history including symptoms of onset, the best corrected visual acuity, anterior and posterior segment examination, the exophthalmos, eyelid position, eye movement, diplopia, strabismus, systemic symptoms, concurrent fatigue test, neostigmine test, thyroid function and orbital CT scan. One patient underwent CT examination of thymus., Results: In all 12 patients, there were 8 females and 4 males with age from 13.0 to 44.0 years (the median age of 26.5 years), 11 cases had difficulties to open their eyes which was least severe in the morning and worsened in the evening. All of cases did not have general symptoms. Ptosis was observed in 9 cases, 3 cases were bilateral, and 6 cases were unilateral. Abnormal extra ocular muscle function was observed in 8 cases, all of them were bilateral. In these 16 eyes, the limitation of downward gaze were observed in 15 eyes, the limitation of upward, outward and inward gaze were observed in 14 eyes, eye fixation occurred in 4 eyes. Four cases had diplopia, 3 cases had strabismus, and 2 of them were exotropia. Orbital CT demonstrated extraocular muscle thickening in 6 cases. Thickening of inferior rectus were observed in all 12 eyes, superior rectus and medial rectus were found thickened in 6 eyes, and thickening of lateral rectus muscle was found in 3 eyes., Conclusions: The clinical features of thyroid associated ophthalmopathy patients with myasthenia gravis were complex. When ptosis and eye movement disorders were not consistent with TAO severity, associating with exotropia and systemic muscle paralysis, myasthenia gravis should be considered.

Aims: To compare the surgical outcomes of exotropia patients with cerebral palsy (CP) and controls without CP., Methods: 30 patients with exotropia and CP and 60 age-matched controls without CP who underwent bilateral lateral rectus (BLR) recession were retrospectively enrolled. All patients underwent BLR recession according to Parks' method. Surgical success was defined by esotropia deviation ≤5 PD (prism diopters) and exotropia deviation ≤10 PD. Success rate, cumulative probabilities of success, and postoperative change of angle deviations using a linear mixed model were evaluated., Results: Mean postoperative follow-up times were 21.60±8.62 months for the CP group and 25.60±10.82 months for the control group (p=0.081). Mean preoperative deviation was 30.97±10.54 PD in the CP group and 29.75±7.52 PD in the control group (p=0.530), which was reduced to 4.44±7.13 PD and 7.43±7.59 PD, respectively (p=0.093) after BLR recession. Using linear mixed model analysis, the estimated mean postoperative deviation of both groups was in the success range at all times tested. At the final visit, successful surgical outcomes were achieved in 76.7% of the CP group and 56.7% of the control group (p=0.179). Differences in the cumulative probability of surgical success were not statistically significant between the two groups (p=0.106, log rank test)., Conclusions: CP patients with exotropia showed successful ocular alignment comparable to that of controls after BLR recession of at least 2 years., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose: To investigate the association between concomitant esotropia or concomitant exotropia and refractive error in preschool children., Methods: A population-based sample of 5831 children aged 3 to 6 years was selected from all kindergartens in a representative county (Yuhuatai District, Nanjing, Jiangsu Province) of Nanjing, China. Clinical examinations including ocular alignment, ocular motility, visual acuity, optometry, stereopsis screening, slit lamp examination and fundus examination were performed by trained ophthalmologists and optometrists. Odd ratios (OR) and 95% confidence intervals (95% CI) were calculated to evaluate the association of refractive error with concomitant esotropia and concomitant exotropia., Results: In multivariate logistic regression analysis, concomitant esotropia was associated independently with spherical equivalent anisometropia (OR, 3.15 for 0.50 to <1.00 diopter (D) of anisometropia, and 7.41 for > = 1.00 D of anisometropia) and hyperopia. There was a severity-dependent association of hyperopia with the development of concomitant esotropia, with ORs increasing from 9.3 for 2.00 to <3.00 D of hyperopia, to 180.82 for > = 5.00 D of hyperopia. Concomitant exotropia was associated with astigmatism (OR, 3.56 for 0.50 to 1.00 D of astigmatism, and 1.9 for <0.00 D of astigmatism), myopia (OR, 40.54 for -1.00 to <0.00 D of myopia, and 18.93 for <-1.00 D of myopia), and hyperopia (OR, 67.78 for 1.00 to <2.00 D of hyperopia, 23.13 for 2.00 to <3.00 D of hyperopia, 25.57 for 3.00 to <4.00 D of hyperopia, and 8.36 for 4.00 to <5.00 D of hyperopia)., Conclusions: This study highlights the close associations between refractive error and the prevalence of concomitant esotropia and concomitant exotropia, which should be considered when managing childhood refractive error.

Purpose: To screen mutations in the fibrillin-1 (FBN1) gene in a Chinese family with autosomal dominant Marfan syndrome (MFS)., Methods: Patients and unaffected family members were given ophthalmic, cardiovascular, and physical examinations with a 5-year follow-up. Genomic DNA was extracted from the leukocytes of venous blood from all patients and their relatives. The entire coding region of the FBN1gene was screened with an ABI 9700 GeneAmp PCR System. The mutation identified was screened in 100 healthy and ethnically unrelated Chinese individuals., Results: Mutation screening in FBN1 identified a T>G transition at position c.1786 in exon 14, leading to substitution of cysteine for glycine at codon 596 (C596G) in this four-generation Chinese family. The C596G mutation was associated with the disease phenotypes in all six patients but not found in 14 unaffected family members or the 100 ethnically unrelated and healthy controls., Conclusions: A C596G mutation in FBN1 was identified in a Chinese family with MFS. Our results expand the spectrum of FBN1 mutations and contribute to the understanding of the role of FBN1 in the pathogenesis of Marfan syndrome.

We describe two cases with complaints of atypical headache who were initially diagnosed as having psychiatric problems, but who, after careful evaluation, were found to have an underlying eye disorder. Both patients were known to have an ophthalmic history. Patient A, a 21-year-old female, presented with severe headache, which was so disabling that she was declared unfit for work. A diagnosis of tension headache was made and she received psychological treatment with neurofeedback, homeopathy and acupuncture, which had no effect. Patient B, a 26-year-old male, complained of extreme photophobia, nausea and dizziness. The patient was diagnosed as having a conversion disorder and was admitted to a psychiatric clinic and given psychotropic treatment. Careful ophthalmological examination revealed that an ocular deviation was causing the symptoms in both patients and could be treated appropriately with strabismus surgery. These cases emphasise the importance of a thorough general medical and ophthalmic history and proper examination at all times without putting a psychiatric stigma on the patient.

Aim: To investigate the relationship between myopic progression and intermittent exotropia, and the impact of surgery for exotropia on myopic progression in early school-aged children (from 7 years to 12 years of age)., Methods: Medical records of early school-aged patients with myopia were reviewed. Patients were divided into three groups; (A) Patients with intermittent exotropia and myopia at presentation and who underwent bilateral lateral rectus muscle recession for exotropia when 7-12 years old; (B) Patients with intermittent exotropia and myopia at presentation and who were merely observed for exotropia; and (C) Patients with myopia and straight ocular alignment. Main outcome measurements were the simple rate of myopic progression per year, the preoperative and postoperative rates of refractive growth with regards to the logarithmic age model in Group A, and the rate of high myopia development at the end of the early school period., Results: The rates of myopic progression were -0.43±0.14 dioptre (D) per year in Group A, -0.49±0.17 D/year in Group B and -0.42±0.24 D/year in Group C. There was no significant difference in the rate of myopic progression among three groups. There was no significant intergroup difference in the preoperative and postoperative rates of refractive growth in Group A. There were no significant intergroup differences in the rates of high myopia development among three groups., Conclusions: Whether patients with intermittent exotropia underwent surgical correction for intermittent exotropia did not influence the rate of myopic progression. There was no significant difference in the rate of myopic progression between patients with accompanying intermittent exotropia and myopia and those with myopia alone., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To investigate AC/A ratio and coexisting ametropia in intermittent exotropia. To discuss the relation between AC/A ratio and the development of intermittent exotropia., Methods: The medical records of 135 patients who had an exotropia were retrospectively reviewed. Patients were divided into 3 groups based on the type of ametropia: exotropia without ametropia (-0.50-+3.00 D between the age of 3-6 years old, -0.50-+2.00 D between the age of 7-40 years old) , exotropia coexisting with myopia (-0.50-7.75 D) and exotropia coexisting with hypermetropia ( ≥ + 3.00 D of 3-6 years old , ≥ + 2.00 D of 7 ∼ 40 years old). AC/A ratios of all patients were assessed using synoptophore method. Distance and near deviations were assessed using prism cover test. AC/A ratios and deviation angles of 3 groups were compared. The relationship between AC/A ratios and ametropia/age were investigated., Results: There were obvious differences in AC/A ratios(2.686 ± 1.372, 1.773 ± 1.110, 4.581 ± 1.552, F = 36.323, P < 0.001) and in near deviation angles (44.473(Δ) ± 19.008(Δ), 53.621(Δ) ± 20.749(Δ), 34.455(Δ) ± 13.292(Δ), F = 8.762, P = < 0.001) between 3 groups of patients, no obvious differences were seen in distance deviation angles (40.333(Δ) ± 19.474(Δ), 44.052(Δ) ± 23.722(Δ), 35.590(Δ) ± 11.143(Δ), F = 1.444, P = 0.24). AC/A ratios were negative linear correlated with refractive powers for patients of intermittent extropia coexisting with myopia or with hypermetropia (r = 0.320, P = -0.469 and r = -0.046, P = 0.036, respectively) . A trend of decline with age was found for AC/A ratios only in patients of intermittent extropia without ametropia (r = -0.320, P = 0.019; r = -0.023, P = 0.865; r = 0.246, P = 0.296 for the other 2 groups, respectively)., Conclusions: Myopia and hypermetropia, when coexisting with abnormally low or high AC/A ratio, can destroy the balance between extraocular muscles and induce exophoria to be manifest.

Purpose: To report factors associated with preoperative squinting, defined as transient eye closure in bright light, and photophobia and the factors affecting improvement of these symptoms postoperatively in intermittent exotropia., Methods: In this retrospective study, patients (N = 99) were divided into groups according to the presence (n = 54) or absence (n = 45) of preoperative squinting and the presence (n = 64) or absence (n = 35) of photophobia. Clinical characteristics, including overaction or underaction of the oblique muscle and fundus intorsion and extorsion, were compared between the two groups. The squinting and photophobia groups were further categorized into two subgroups each according to postoperative improvement. The extended list of characteristics, including the duration from onset to surgery, postoperative angle of deviation, and fusion, was compared between the two subgroups., Results: Preoperatively, 54 (54.5%) and 64 (64.6%) patients had squinting and photophobia, respectively. The coincidence of squinting and photophobia was marginally significant (p = 0.05). Postoperatively, squinting and photophobia disappeared in 64.8 and 59.4% of the patients, respectively. The photophobia group had a younger onset age of strabismus than the nonphotophobia group (39.3 vs. 56.4 months; p = 0.03). Good fusional status at the near range was more common in the nonsquinting group than in the squinting group (74.3 vs. 47.6%; p = 0.02). Superior oblique overaction was significantly more common in the squinting group than in the nonsquinting group (11.1 vs. 0%; p = 0.03). Early surgical correction and successful outcomes were associated with squinting improvement (p = 0.001 and p = 0.02, respectively)., Conclusions: More than 50% of patients with intermittent exotropia had squinting or photophobia, and approximately 60% of symptomatic patients experienced improvement postoperatively. The onset of strabismus, near fusion, superior oblique overaction, and fundus intorsion were related to these symptoms. Early surgery and successful eye position realignment were beneficial for improving squinting postoperatively.

Purpose: To determine etiology, characteristics, and stability of the monofixation syndrome (MFS) in a chart review of 63 consecutive patients in a private practice of pediatric ophthalmology., Design: Retrospective, consecutive chart review., Methods: The charts of 63 consecutive patients with MFS, encountered from 2007-2012 followed for a minimum of 3 years were included. Best visual acuity, motor angle deviation at near, fusion, and stereoacuity as recorded on the most recent visit during the follow-up period were examined. Stability of the MFS was determined by comparing the dates of diagnosis with the last examination for those patients who remained stable. Decompensated patients were also studied for characteristics and results of secondary surgery., Results: The etiology of the MFS was esotropia in 58 (92.1%), anisometropia in 2 (3.2%), and exotropia in 3 patients (4.8%). The majority of patients, 57 of 63 (92%), had stable MFS for a mean of 13.9 years. Six esotropic patients decompensated after a mean of 6 years; 5 of these patients were restored to MFS by secondary surgery and 1 spontaneously recovered. Five patients were found to have improved stereoacuity to 60 arc seconds or better by the end of the study., Conclusions: The MFS is a relatively stable binocular status during the first 2 decades of follow-up. A small percentage of patients decompensated, requiring secondary surgery to restore the MFS binocular status. A similar small percentage of MFS patients developed a higher grade of stereoacuity when followed for a sufficient interval of time., (Copyright © 2014. Published by Elsevier Inc.)

Two patients were assessed for acute onset of diplopia. Clinical examination revealed upbeat nystagmus, exotropia, and internuclear ophthalmoplegia (INO). Both patients had vascular risk factors; acute ischemic stroke affecting ponto-mesencephalic junction was suspected. Magnetic resonance imaging confirmed strategic location of the acute infarct affecting the medial longitudinal fasciculus, adjacent occulomotor nuclei, and paramedian tract. We propose that constellation of acute onset of upbeat nystagmus, INO, and exotropia in patients with vascular risk factors might be unequivocal manifestation of the ponto-mesencephalic stroke., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Purpose: To present a case of sensory strabismus due to keratoconus with an ipsilateral nodular lesion of the bulbar con-junctiva., Case Presentation: The patient is a 17 year-old-boy. The fixing eye was the right eye and keratoconus in this eye was late onset. Vision in the left eye was poor and keratoconus was advanced in this eye. Due to longstanding of keratoconus and occurrence in the sensitive period, sensory exotropia had developed in the left eye. A nodular lesion of the bulbar conjunctiva was also present in the ipsilateral eye., Conclusion: Sensory exotropia is not unusual but to be due to longstanding keratoconus is not a usual strabismus. If keratoconus develops before 7 years of age, sensory strabismus can develop. We reported and reviewed literature that keratoconus seldom begins in the sensitive period where abnormal visual experience affects visual development and may induce sensory exotropia.

Purpose: To evaluate the changes of refractive astigmatism after horizontal rectus muscle surgery in intermittent exotropic children., Methods: Sixty-nine exotropic patients were retrospectively reviewed. Of those, 35 patients received unilateral lateral rectus recession (BLR group, 35 eyes) and 34 patients received unilateral lateral rectus recession and medial rectus resection (R&R group, 34 eyes). Non-cycloplegic refractions were measured until 6 months postoperatively. Spherical equivalent (SE), J0 and J45 using power vectors were calculated to determine and compare the changes of refractive astigmatism and axis in both groups., Results: SE significantly decreased after surgery for the first week and did not changed thereafter in both groups (p = 0.000 and p = 0.018, respectively). In BLR group, J0 showed significant changes at the first week and 1 month after surgery (p = 0.005 and p = 0.016, respectively), but in R&R group, J0 changed significantly between 1 week and 3 months postoperatively (p = 0.023 and p = 0.016, respectively). J45 did not change significantly as time passed in both groups (all p > 0.05). There was no statistically significant difference in the magnitude of changes in SE, J0 and J45 between the two groups after the 6-month follow-up (p = 0.500, p = 0.244 and p = 0.202, respectively)., Conclusions: Horizontal rectus muscle surgery in intermittent exotropic children tends to induce a statistically significant change in astigmatism in the with-the-rule direction and myopic shift in SE. This astigmatism change seems to occur within the first 3 months after surgery. Thus, astigmatism induced by surgery should be checked and corrected at least 3 months after horizontal strabismus surgery.

Purpose: To describe the clinical characteristics, treatment, and subsequent clinical course of children with exotropia and high hyperopia., Methods: The medical records of 26 patients seen between 1990 and 2009 who had an exotropia and ≥4.00 D of hyperopia were retrospectively reviewed. We analyzed the clinical characteristics, treatments, and subsequent alignment outcomes., Results: A total of 26 patients between the ages of 2.5 months and 9 years were included. Of these, 15 had associated medical conditions or developmental delay. Of 22 patients with measured visual acuities, 19 had amblyopia (10 unilateral, 9 bilateral). None of the patients demonstrated fine stereoacuity. Twenty-three exotropic children were treated with spectacles: 15 were fully corrected, 10 of whose exotropia improved; 8 received partial correction of their hyperopia, 3 of whose exotropia improved. Six patients who presented with large, poorly controlled exotropia and did not improve with spectacle correction required strabismus surgery., Conclusions: Children with high hyperopia and exotropia are likely to have developmental delay or other systemic diseases, amblyopia, and poor stereopsis. Treatment of high hyperopia in exotropic children with their full cycloplegic refraction can result in excellent alignment., (Copyright © 2012 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To assess the rate of development of esotropia following the diagnosis of pseudoesotropia among young children., Methods: Retrospective records review of children diagnosed during an eye examination with pseudoesotropia prior to age 5 years with a reassessment for strabismus completed after age 5 years., Results: Thirty-one patients met the inclusion criteria. The median age at diagnosis of pseudoesotropia was 1.3 years. Fourteen were boys (45%). Six (19.4%) children were subsequently diagnosed with esotropia (95% confidence interval: 7.5 to 37.5%)., Conclusion: Even when experienced examiners find no misalignment in young children, a small number will later be found with esotropia. Serial examinations and parent education about this possibility need to be considered.

Background: Intermittent exotropia (IXT) is an exodeviation intermittently controlled by fusional mechanisms. Patients with IXT may present with asthenopic symptoms, blurred vision, headaches, diplopia or visual confusion and reading difficulties; especially after prolonged periods of near work., Objective: To report the presentation and management of a young adult with intractable accommodative spasm secondary to long standing intermittent exotropia., Case: The patient was found to have bilateral accommodative spasm with high pseudomyopia and severe impairment of vision. There was a tendency for recurrence with discontinuation of cycloplegics., Conclusion: A total relief of symptoms was noticed after strabismus surgery was undertaken for the exotropia. A detailed orthoptic evaluation with emphasis on recognizing accommodative spasm as an unusual presentation of IXT, could aid in appropriate diagnosis and treatment of such cases., (© NEPjOPH.)

Purpose: To suggest a surgical normogram for lateral rectus recession in exotropia associated with unilateral or bilateral superior oblique muscle palsy (SOP)., Methods: We retrospectively reviewed the charts of 71 patients with exotropia who were successfully corrected over one year. Each patient had undergone unilateral or bilateral rectus recession associated with uni- or bilateral inferior oblique (IO) 14 mm recession, using a modified surgical normogram for lateral rectus (LR) recession, which resulted in 1 to 2 mm of reduction of LR recession. We divided all patients into 2 groups, the 34 patients who had undergone LR recession with unilateral IO (UIO) recession group and the remaining 37 patients who had undergone LR recession with bilateral IO (BIO) recession group. Lateral incomitancy was defined when the exoangle was reduced by more than 20% compared to the primary gaze angle. The surgical effects (prism diopters [PD]/mm) of LR recession were compared between the two groups using the previous surgical normogram as a reference (Parks' normogram)., Results: The mean preoperative exodeviation was 20.4 PD in the UIO group and 26.4 PD in the BIO group. The recession amount of the lateral rectus muscle ranged from 4 to 8.5 mm in the UIO group and 5 to 9 mm in the BIO group. Lateral incomitancy was noted as 36.4% and 70.3% in both groups, respectively (p = 0.02). The effect of LR recession was 3.23 ± 0.84 PD/mm in the UIO group and 2.98 ± 0.62 PD/mm in the BIO group and there was no statistically significant difference between two the groups (p = 0.15)., Conclusions: Reduction of the LR recession by about 1 to 2 mm was successful and safe to prevent overcorrection when using on IO weakening procedure, irrespective of the laterality of SOP.

Purpose: To compare the results of penetrating keratoplasty (PK) in a series of congenital hereditary endothelial dystrophy (CHED) patients operated at amblyogenic years and at later ages., Methods: Records of 65 eyes of 35 CHED patients who underwent PK were reviewed retrospectively. Visual results and graft clarity rates were compared between patients operated after (group 1) and before (group 2) 12 years of age. Results were also compared between eyes with and without nystagmus., Results: Group 1 consisted of 47 eyes (24 patients), whereas group 2 consisted of 18 eyes (11 patients). Thirteen patients (54%) in group 1 and 10 patients (91%) in group 2 had nystagmus. Mean ages at surgery were 26.4 and 7.6 years in group 1 and group 2, respectively. Mean follow-up period was 101.0 months in group 1 and 59.7 months in group 2. Group 1 cases had better graft clarity rates than group 2 cases (P = 0.023). Postoperative best-corrected visual acuities (BCVAs) were 20/80 or better in 39 eyes of group 1 (83%) and in 5 eyes of group 2 (28%). Visual outcomes were found significantly better in group 1 cases (P < 0.001). In group 1, 76% of eyes with nystagmus and 91% of eyes without nystagmus had BCVAs of 20/80 or better. In group 1, both preoperative and postoperative BCVAs were found significantly better in eyes without nystagmus (P < 0.001 and P = 0.002, respectively)., Conclusions: Delayed keratoplasty seems to offer better graft outcomes and visual prognosis to CHED patients, even in the presence of nystagmus.

Purpose: To describe the long-term surgical outcomes of bilateral lateral rectus recession in patients with intermittent exotropia., Methods: Retrospective review of 18 patients diagnosed with intermittent exotropia between 1995 and 2005 who underwent surgical treatment in the Ramon y Cajal Hospital., Results: Of the 18 patients with intermittent exotropia, 50% were basic subtype. All of them underwent bilateral lateral rectus recession, associated with a previous failed botulinum toxin injection in 8 of them. Satisfactory results (less than 10 PD orthophoria) were obtained in 68.2% of the patients after a 4.5-year follow-up period., Conclusions: Bilateral lateral rectus recession is an effective and stable surgical procedure in the long-term motor control of intermittent exotropia, especially in basic subtype. Previous injection of botulinum toxin did not affect the results., (2010 Sociedad Española de Oftalmología. Published by Elsevier Espana. All rights reserved.)

Comitant infantile exotropia is a rare entity and is far less common than infantile esotropia. It has been shown to be highly correlated with intracranial pathology. We report a case of a medulloblastoma in a child in whom it presented as an incomitant esotropia after surgical correction for comitant infantile exotropia., (Copyright © 2011 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)