Ahmed Awadein

To compare the outcomes of patching to dichoptic stimulation using virtual reality (VR) in moderate and severe amblyopia. This study was conducted on 86 subjects with unilateral anisometropic and mixed amblyopia. The subjects were randomized to the VR or patching group. The VR group received treatment using the Vivid Vision software (Vivid Vision Inc., San Francisco, USA) with each subject receiving weekly 2 h-sessions for 10 weeks. The patching group was prescribed patching for 10 weeks. Best-corrected visual acuity (BCVA) was measured using a single crowded letter in an ETDRS chart before, after 10 weeks of treatment, and after another 10 weeks of cessation of treatment. Near stereoacuity was measured using the TNO test. Forty-two patients were randomized to the patching group and 44 to the VR group. The median age of the subjects was 12.0 (range 6.0 to 37.0) years. In the VR group, mean amblyopic eye BCVA showed statistically significant improvement by 0.89 line (95% confidence interval {CI}, 0.73 to 1.35 lines;  < 0.001) after 10 weeks of therapy, and after another 10 weeks of follow-up by 1.32 lines from baseline (95% CI, 1.15 to 1.7 lines;  < 0.001). Regarding the patching group, mean BCVA showed statistically significant improvement after 10 weeks by 1.38 lines (95% CI, 0.82 to 1.8 lines;  < 0.001), and after another 10 weeks by 1 line from baseline (95% CI, 0.06-0.147; 0.6 to 1.47 lines;  < 0.001). There was no significant difference between both groups at any time-point ( values >0.05). No serious adverse events were noted. Adults and severe amblyopes in the VR group showed more significant VA improvement than their counterparts in the patching group. Amblyopes treated using VR dichoptic treatment demonstrated statistically significant VA improvement after 10 and 20 weeks of follow-up that is comparable to patching.

PURPOSE: To describe and report the results of a zip-up modification for loop myopexy for facilitating a muscle union procedure in heavy eye syndrome.

METHODS: A retrospective chart review was conducted on patients with heavy eye syndrome in whom the modified surgical technique was performed. Superior and lateral rectus muscle bellies were approximated using a suture 4 to 5 mm from the muscle insertion. Muscles were then zipped together by 5-0 polyester sutures placed in an anteroposterior direction using a hand-over-hand technique. Details of the surgical technique were reported. Ductions, versions, and angles of strabismus were evaluated before and after surgery. Complications were reported.

RESULTS: A total of 8 patients were identified (mean age: 60.8 ± 7 years). Mean axial length was 33.2 ± 1.2 mm. Mean preoperative horizontal and vertical angles of deviation were 78 ± 20 prism diopters (PD) (range: 50 to 120 PD) and 34 ± 4 PD (range: 30 to 40 PD), respectively. Preoperative limitation of abduction and elevation was -4 to -5 in all patients. An average of seven to eight sutures were used. No intraoperative complications were reported. In 7 patients, both vertical and horizontal angles of deviation were reduced to within 8 PD from orthophoria and limitation of ductions was reduced to null or -1 after surgery. Undercorrection occurred in 1 patient with bilateral heavy eye syndrome who had unilateral surgery. No recurrences developed over a median of 6 months of follow-up.

CONCLUSIONS: A zip-up modification for loop myopexy can facilitate the surgical procedure to achieve a satisfactory outcome in heavy eye syndrome. .

Convergence excess esotropia is a condition characterized by an esotropia which is greater for near fixation than for distance fixation after full hypermetropic correction with a single focus lens. Convergence excess esotropia may be classified according to the AC/A ratio into two subtypes: accommodative type and non-accommodative type. Bifocal glasses are a suitable option for the management of patients with a high AC/A ratio and for the hypoaccommodative type. However, the overall success rate with bifocals is still low even in selected patients. Surgery is often eventually needed for most patients with convergence excess esotropia. Surgical options that do not directly address the variability of the angle of deviation entail medial rectus recession with the target angle based on the distance deviation, the near deviation, an augmented formula based on an intermediate angle, or on a prism adaptation test. Surgical options that directly address the variability of the angle include partial myotomy, medial rectus muscle posterior scleral fixation with or without recession, pulley fixation, slanting recession, Y-splitting, or combined recession-resection of the medial rectus muscle. The review article summarizes the surgical outcome of these strategies and suggests an algorithm for the management of patients with convergence excess esotropia.

PURPOSE: To evaluate the visual outcome of intraocular lens (IOL) exchange for the management of myopic shift in pseudophakic children.

METHODS: The medical records of children who underwent IOL exchange for myopic shift were examined. The preoperative data, operative details and the postoperative outcome were analyzed.

RESULTS: Twenty-one eyes (16 patients) were identified. Mean age at cataract extraction was 20 ± 26 months (range, 2-84 months). Twelve patients (6 unilateral, 6 bilateral) had primary IOL implantation. Mean age at IOL exchange was 7.3 ± 3.2 years. Mean spherical equivalent (SE) at IOL exchange was -14 ± 5 D (range, -7 to -21 D): Mean SE at IOL exchange was -13.64± 4.99 D, -12 ± 1.53 D, and -15.5 ± 4.7 D in unilaterally pseudophakic cases (8 patients), in the eye that underwent unilateral IOL exchange (3 patients) in bilaterally pseudophakic cases, and in bilateral IOL exchange cases (5 patients), respectively. Mean axial length at IOL exchange was 24 ± 1.3 mm (range, 23 to 27 mm). Following IOL exchange, mean SE was reduced to -2 ± 1.8 D (range, -4 to +2.5 D). An average of three logMAR line improvement in the best-corrected visual acuity was observed in 12/16 eyes of patients for whom pre- and post-exchange visual acuity were available, while visual acuity remained unchanged in 4 eyes. Mean logMAR visual acuity improvement was 0.35 and 0.49 in unilateral and bilateral pseudophakic cases, respectively.

CONCLUSIONS: IOL exchange is a safe procedure that should be considered to improve visual rehabilitation in pseudophakic patients with myopic shift.

PURPOSE: To report a series of cases, who developed consecutive exodeviation after vertical muscle transposition (VRT) performed for sixth nerve palsy, describe their management and analyse their outcome.

DESIGN: Retrospective case series.

METHODS: This is an institutional study on patients who developed consecutive exotropia following VRT for sixth nerve palsy in two different centres. The age, gender, cause, and time to surgery were reviewed. Ductions, versions and angles of misalignment were analysed. In those who developed an exotropia >10 PD after surgery, a second surgery was performed. The time to the second surgery, intra-operative findings, surgical procedure and outcome were studied.

RESULTS: A total of 164 cases of VRT for sixth nerve palsy were identified. Nine patients developed consecutive exotropia >10 PD (5.5%). There were no significant differences in the characteristics of those who developed overcorrection compared to those who did not. Five patients had full-tendon muscle transposition, three patients had Hummelsheim procedure and one patient had Jensen procedure. The average angle of consecutive exotropia was 26 ± 9 Δ (range 10-40 Δ). After the second surgery, angle of exotropia decreased to 21 ± 15 PD. Seven patients still had residual exotropia ≥10Δ and the exotropia was corrected in the remaining two patients. The time to second surgery in those two patients was much shorter than the other seven patients.

CONCLUSIONS: Patients who undergo VRT should be followed up in the early post-operative period and revisiting the transposition should be done immediately in case of consecutive exotropia to avoid permanent overcorrection.

Duane retraction syndrome (DRS) is a congenital cranial dysinnervation disorder that is characterized by paradoxical lateral rectus muscle innervation of the affected eye by axons meant to innervate the ipsilateral medial rectus muscle, with resultant varying degrees of co-contraction. It is characterized by severe abduction deficiency, variable limitation of adduction, globe retraction with narrowing of the palpebral fissure, and oblique elevation or depression on adduction. A total of 16 patients with unilateral DRS were identified. The mean age was 13 ± 8 years (range: 6 to 28 years). There were 5 males and 11 females. The cohort included 8 patients with DRS type I, 3 patients with DRS type II, 4 patients with DRS type III, and 1 patient with synergistic divergence (DRS type IV). The mean width of the palpebral fissure in primary gaze was 9.95 ± 0.25 mm, increased in abduction to 11.11 ± 1.16 mm, and changed on adduction to 10.03 ± 1.19 mm. The mean reduction in the size of the palpebral fissure on adduction was 11.7 ± 10.2% (range: 0 to 30%). The difference in the palpebral fissure width between adduction and abduction was statistically significant ( = .0018). Of the 16 patients, 8 (50%) showed narrowing of the palpebral fissure of the contralateral eye on adduction compared to abduction of more than 10%. In this case series of unilateral Duane retraction syndrome, there was a common association between widening of the palpebral fissure of the unaffected eye and adduction of the eyes with DRS in DRS types II, III, and IV and DRS type I with upshoot or downshoot. .

PURPOSE: To evaluate differences in the subjective aniseikonia and stereoacuity in patients with axial anisometropia after full correction of the refractive error with spectacles, contact lenses, and refractive surgery.

METHODS: A prospective study was performed in Cairo University Hospitals on 20 patients with axial anisometropia caused by unilateral myopia > 5 D with > 4 D inter-ocular difference in spherical equivalent who were suitable candidates for excimer laser ablation (LASIK) or implantable collamer lens implantation (ICL). All patients had measurement of best-corrected visual acuity (BCVA), fusion, stereoacuity, and magnitude of aniseikonia with spectacles, contact lenses, and after surgery.

RESULTS: The mean age at time of surgery was 25.7 ± 3.1 years. There were no statistically significant differences in the BCVA or stereoacuity with spectacles, contact lenses, or after refractive surgery. Microkonia < 5%) was perceived with spectacles in 8 patients (40%) and remained unchanged in 7 of these 8 patients with contact lenses. Following LASIK (n = 11), there was an induced macrokonia < 2% in 4 patients (36%), persistent microkonia of 3% in 1 patient (9%), and no change in image size in 6 (55%) patients. Following ICL implantation (n = 9), there was a perceived macrokonia of 2% in 4 patients (44%), disappearance of microkonia in 1 patient (11%) and no change in 4 patients (44%).

CONCLUSIONS: Differences in BCVA, stereoacuity, and aniseikonia after correction of anisometropia by glasses, contact lens and surgery are both clinically and statistically insignificant. Retinal or neural adaptation might have a role in correction for differences in image size.

PURPOSE: To compare the postoperative alignment, degree of improvement of abduction, and complications of the Hummelsheim procedure to the Jensen procedure in chronic sixth nerve palsy, and to calculate the dose-response of both procedures.

METHODS: A retrospective study was done on patients who either had Hummelsheim or Jensen procedure for chronic sixth nerve palsy. Demographic characteristics, details of surgical procedure, ductions, versions, and angles of misalignment before and after surgery were analyzed.

RESULTS: A total of 79 patients were identified: 38 Jensen and 41 Hummelsheim. There were no statistically significant differences in baseline characteristics of both groups. Medial rectus recession was performed in 35 patients in the Jensen group and in 30 patients in the Hummelsheim group. Success defined as orthotropia within 8 PD was achieved in 25 (66%) patients in the Jensen group and in 24 (59%) patients in the Hummelsheim group (P = 0.51). The mean improvement in the angle of deviation in the primary position was 42 ± 12 PD in the Jensen group and 42 ± 16 PD in the Hummelsheim group (P = 0.89). The mean improvement in abduction was slightly better in the Hummelsheim group (1.8 vs 1.5, P = 0.32). A new vertical deviation occurred in three patients in the Jensen group and in 4 patients in the Hummelsheim group. Anterior segment ischemia occurred in one patient in the Jensen group.

CONCLUSIONS: There was no difference in the success rate between the Hummelsheim and Jensen procedures in cases of chronic sixth nerve palsy. Strabismus surgeons can choose between the two procedures according to their preference.

BACKGROUND: Adjustable sutures increase the success rate of strabismus surgery. However, the optimal timing of postoperative suture adjustment remains controversial. This trial was aimed at comparing the surgical outcomes and pain scores of early or 2 - 4 h and delayed or 24 h postoperative suture adjustment in adult patients undergoing strabismus surgery.

METHODS: An open-label, prospective, randomized, comparative interventional study was performed in consecutive adult patients scheduled for eye muscle surgery. Patients were randomized into two groups: the early group, with suture adjustment 2 - 4 h postoperatively, and the delayed group, with suture adjustment 24 h postoperatively. Subjective pain scores during the adjustment were also analyzed. The angles of misalignment at 1 and 3 months and the success rate at 3 months postoperatively were compared.

RESULTS: Forty-five (90%) patients completed the follow-up, including 23 (92%) in the early adjustment group and 22 (88%) in the delayed adjustment group, with a mean (standard deviation) age of 25.6 (9.5) years and a male-to-female ratio of 46.7:53.3. Thirty patients (66.7%) had exotropia, and 15 (33.3%) patients had esotropia. Both groups had comparable baseline characteristics (all P > 0.05). The mean pain scores during adjustment did not differ significantly between groups ( > 0.05). The postoperative angles of alignment were comparable between the groups before suture adjustment and at the 1- and 3-month follow-ups (all > 0.05). The success rate in the early adjustment group was slightly higher (87.0% versus 63.6%), but the difference was not statistically significant ( > 0.05). The success rate was comparable between the groups in patients with esotropia or exotropia (both > 0.05).

CONCLUSIONS: Although the early adjustment group had a slightly higher success rate, the difference was not significant. Both groups had comparable subjective pain scores during adjustment, final motor alignment, or success rate. Future clinical trials should be performed different time intervals for postoperative suture adjustment, and subjective and objective outcomes, such as diplopia and stereopsis, should be compared between patients with a first strabismus surgery and those who underwent reoperation. This could better resolve the persistent controversy related to the optimal time for suture adjustment.

PURPOSE: To evaluate the outcome of fenestration of the vertical rectus muscles in correcting vertical deviations.

MATERIAL AND METHODS: A retrospective chart review was conducted on patients who underwent fenestration surgery on the superior rectus (SR) or inferior rectus (IR) muscles. Ductions, versions, angle of deviations before and after surgery, and surgical details were analyzed Success was defined as vertical alignment within 4 PD of orthophoria.

RESULTS: Nineteen patients were identified. The mean age of the patients was 19.3 ± 13.1 (range; 4 to 48) years. The mean follow-up was 6.5 ± 2.7 (range, 3 to 12) months. Eleven patients presented with dissociated vertical deviation (DVD), 2 patients with sensory hypertropia, and 6 patients with sensory hypotropia. Fourteen patients had concomitant horizontal muscle surgery. The mean change of the angle of deviation was 13 ± 3 (range, 8 to 20) PD after SR fenestration. and 12 ± 2 (range; 10 to 15) PD after IR fenestration. There was a significant improvement in the post operative angle of deviation in both groups (P value <0.001). Success was achieved in 10 (77%) of patients who underwent SR fenestration and in all patients underwent ir fenestration. Only one patient in the IR group developed a 1-mm lower lid retraction.

CONCLUSION: Fenestration of the vertical rectus muscles is an effective and safe method for correcting vertical deviations. We recommend increasing the amount of fenstration in DVD to further improve the outcome.

BACKGROUND: Anomalous ocular muscle insertions are a rare cause of ocular motility disturbances.

METHODS: We report the clinical presentation and the intraoperative findings of two cases with an abnormally nasally inserted superior oblique tendons presenting with a Brown syndrome-like clinical picture.

RESULTS: Case no 1 was a 5-year-old girl presenting with a chin up position. There was bilateral limitation of elevation in adduction, -4 on the right side and -3 on the left side with +1 downshoot on adduction on either side Patient was orthotropic in down-gaze with small V-pattern exotropia. Case no 2 was a 4-year-old boy presenting with an esotropia of 35Δ that was partially corrected with his spectacles to 20Δ. Ductions showed -4 defective elevation in adduction of the right eye. Surgical exploration in both cases revealed abnormal nasal insertion of the superior oblique tendons. The line of insertion had a convexity facing superonasally. The posterior fibers were inserted 7-8 mm posterior and just nasal to the nasal border of the superior rectus insertion, while the anterior fibers were shorter and inserted 5 mm nasal and 4 mm posterior to the nasal edge of superior rectus insertion. In both cases, there was an improvement in the elevation on adduction after superior oblique lengthening.

CONCLUSIONS: Abnormal nasal insertion of the superior oblique muscle enhances the depressor effect of the muscle and can create a Brown-like picture.

PRECIS: Anterior chamber angle (ACA) narrowing continues to occur for at least 2 years after congenital cataract surgery. Risk factors for intraocular pressure (IOP) elevation after congenital cataract surgery were higher central corneal thickness (CCT) and surgery at <2 months.

PURPOSE: The purpose of this study was to study the changes in IOP and in the ACA during the first 2 years after pediatric cataract surgery and to determine risk factors for such changes.

PATIENTS AND METHODS: A retrospective observational study was done on infants who underwent pediatric cataract surgery in Cairo University Hospitals and completed a 1-year follow-up. Demographic and clinical characteristics were recorded including age at surgery, sex, corneal diameter, CCT pupil diameter, IOP, gonioscopic findings, presence of persistent hyperplastic primary vitreous, surgical approach, primary intraocular lens implantation, and perioperative subconjunctival steroid injection. Changes in IOP and in the ACA were recorded, and the risk factors for such changes were analyzed.

RESULTS: Postoperative IOP elevation >18 mm Hg occurred in 23 eyes of 206 eyes (11%), who completed Year 1 and in 9 (13%) of 86 eyes who completed Year 2. Risk factors for IOP elevation were larger preoperative CCT (P=0.01) in Year 1, and younger age at surgery (P=0.01), and aphakia (P=0.05) in Year 2. In multivariate analysis only younger age at surgery was a risk factor for IOP elevation in Year 2. ACA narrowing occurred in 49% and in 21% of the examined eyes in Years 1 and 2, respectively. Aphakia was not a significant risk factor of angle narrowing in Years 1 and 2 (P=0.17 and 0.42, respectively).

CONCLUSIONS: Higher preoperative CCT was a risk factor for early-onset IOP elevation. Surgery at >2 months was associated with lower susceptibility to late-onset IOP elevation.

PURPOSE: To report the results of contralateral recession-resection of the horizontal muscles in oculomotor nerve palsy with aberrant regeneration to correct both the strabismus and the ptosis in one procedure.

DESIGN: Retrospective case series.

METHODS: This is an institutional study on patients with oculomotor nerve palsy with aberrant innervation who had contralateral eye muscle surgery in 2 different centers. Patients were included if they have both exotropia and aberrant regeneration with a ptosis that improved on adduction. All patients had contralateral lateral rectus recession and medial rectus resection. Ductions, versions, angle of misalignment, and degree of ptosis were evaluated before surgery and at last follow-up.

RESULTS: Eleven patients were identified. The mean age at surgery was 15.0 ± 9.2 years. Five patients were male (45%). Trauma was the cause in 8 (72%) cases. The mean angle of exotropia was 42 ± 14 prism diopters. The mean degree of ptosis was 3.9 ± 1.6 mm. The mean lateral rectus recession was 8.2 ± 1.1 mm, and the mean medial rectus muscle resection was 6.7 ± 0.9 mm. The mean follow-up was 6.4 ± 2.5 months. After surgery, none of the patients had residual exotropia >10 prism diopters. The mean degree of ptosis after surgery was 0.9 ± 0.8 mm. None of the patients required further surgery for ptosis or strabismus.

CONCLUSION: Contralateral eye muscle in third nerve palsy with aberrant innervation offers the advantage of simultaneous correction of both strabismus and ptosis through a single procedure.

PURPOSE: To report ocular motility patterns that mimic, but do not fulfil the full clinical picture of Duane retraction syndrome (DRS) and to describe their clinical features and surgical management.

METHODS: This is a retrospective case series study conducted on patients with DRS, mimicking non-comitant exotropia or esotropia and a face turn. Patients were included only if they lacked either globe retraction on adduction (sine retraction) or limitation of adduction or abduction on ductions (sine limitation not >0.5). Any overshoots or pattern strabismus was recorded. The ocular motility and alignment, details of surgery and their surgical outcomes were analysed.

RESULTS: Twenty-one patients were identified; 13 in the sine retraction and 8 in the sine limitation group. All patients presented with a compensatory face turn. Overshoots were present in 10 (77%) and 7 patients (88%) in the sine retraction and sine limitation groups, respectively. Forced duction test showed tightness of the ipsilateral medial and the ipsilateral lateral rectus muscle in esotropic (n = 3) and exotropic patients (n = 18), respectively. Orthotropia was achieved in 82% of patients following ipsilateral medial or lateral rectus muscle recession.

CONCLUSIONS: There is a subset of patients who present with motility pattern similar to DRS but lack its complete diagnostic criteria. The presence of a face turn, overshoots on adduction or an ipsilateral tightness of the affected muscle should make one consider DRS sine retraction/sine limitation. The patients in our study responded well to lines of management similar to those of DRS.

PURPOSE: To investigate the agreement between the intraocular pressure (IOP) measurements in the awake condition and under different stages of general inhalational anesthesia using sevoflurane in both glaucomatous and normal children.

METHODS: A prospective study was performed on 43 glaucomatous children and 30 age-matched controls. Baseline IOP of one eye was measured immediately before general anesthesia using Perkins tonometer and then re-measured under light, intermediate, and deep anesthesia, and then after intubation. Depth of anesthesia was determined using bispectral index pediatric sensor. The agreement between the IOP measurements before and during different stages of anesthesia was analyzed using Bland-Altman plots. Systematic and proportionate deviations between the IOP measurements were analyzed.

RESULTS: The mean age was 58.6 ± 41.99 months. The mean IOP was significantly lower at all stages of anesthesia in both groups. The coefficient of variation was over 20% in all measurements under anesthesia. For all IOP measurements during anesthesia, the limits of agreement were > 7 mmHg difference in the control group and > 20 mmHg in the glaucomatous group. The best agreement was with the IOP measurement after intubation (mean limit of agreement of -1.4 mmHg, 1.96 s range, -8.8-6 mm Hg) in the control group and with the IOP measurement under intermediate anesthesia (mean limit of agreement of -4.2 mmHg, 1.96 s range, -15.1-6.8 mm Hg) in the glaucomatous group.

CONCLUSIONS: Inhalational anesthesia has variable effects on IOP measurement at all stages of anesthesia. Caution should be taken when extrapolating the true IOP from these measurements.

PURPOSE: Cushingoid features are occasionally encountered in infants after pediatric cataract surgery. The aim of this study is to evaluate whether the use of topical glucocorticoids (GCs) following congenital cataract surgery can result in endogenous adrenal suppression and/or systemic side effects similar to those seen with systemic steroids.

METHODS: A prospective study was performed on 20 infants with bilateral congenital cataract. All infants received a single subconjunctival betamethasone injection of 1 mg at the end of surgery in addition to topical dexamethasone eye drops 1 mg/ml for 6 weeks. All infants had anthropometric measurements and blood pressure measurements, serum cortisol, and ACTH level measurements before surgery and 2 months after. In addition, the total administered glucocorticoid adjusted per weight was calculated.

RESULTS: The mean age of the infants was 4.93 ± 2.58 months. Thirteen were males (65%). The total administered glucocorticoid dose was 18.7 mg and the mean cumulative dexamethasone equivalent dose administered was 2.75 ± 1.31 mg/kg. There was a statistically significant increase in the adjusted weight percentile for age (P = 0.009). Both the systolic and diastolic blood pressure were significantly elevated (P = 0.005 and P = 0.025 respectively). There was a statistically significant reduction in both the morning and afternoon serum ACTH levels (P = 0.023 and P = 0.014). The reduction in serum cortisol levels was statistically non-significant.

CONCLUSIONS: Topical steroids following pediatric cataract surgery can result in both subclinical and clinical changes in the hypothalamic-pituitary-adrenal axis that can be easily overlooked and need careful attention and follow-up.

PURPOSE: To compare the postoperative alignment after medial rectus muscle posterior scleral fixation versus augmented recession in children with partially accommodative esotropia (PAET) without convergence excess.

METHODS: In this prospective study, 60 children with PAET without convergence excess were randomly assigned to either augmented medial rectus recession, based on the average of distance angle with correction and near angle without correction, or medial rectus recession, based on distance angle with correction, combined with posterior scleral fixation. The ductions, versions, angles of deviation, and difference between angles were analyzed before and 6 months after surgery. Complete success was defined as orthotropia to within 8 of esophoria/tropia for both distance and near, with spectacle correction, at 6 months. Patients who developed any exophoria/tropia with their original spectacles and needed reduction of their hyperopic correction to achieve successful outcome were defined as qualified successes.

RESULTS: Of the 60 children, 25 in the augmented group and 28 in the posterior fixation group completed follow-up. The mean age at surgery was 4.90 ± 2.34 years. The complete success rate was 48% and 64% in the augmented and posterior fixation groups, respectively (P = 0.15); the qualified success rate was 80% and 92.9%, respectively (P = 0.17). Success rate was significantly higher (P = 0.04) in the posterior fixation group (56%) than in the augmented group (18%) when the preoperative angle disparity was ≥20.

CONCLUSIONS: Medial rectus posterior scleral fixation can improve the success rate in PAET with large angle disparity.

PURPOSE: To report ocular motility patterns that mimic, but do not fulfil the full clinical picture of Duane retraction syndrome (DRS) and to describe their clinical features and surgical management.

METHODS: This is a retrospective case series study conducted on patients with DRS, mimicking non-comitant exotropia or esotropia and a face turn. Patients were included only if they lacked either globe retraction on adduction (sine retraction) or limitation of adduction or abduction on ductions (sine limitation not >0.5). Any overshoots or pattern strabismus was recorded. The ocular motility and alignment, details of surgery and their surgical outcomes were analysed.

RESULTS: Twenty-one patients were identified; 13 in the sine retraction and 8 in the sine limitation group. All patients presented with a compensatory face turn. Overshoots were present in 10 (77%) and 7 patients (88%) in the sine retraction and sine limitation groups, respectively. Forced duction test showed tightness of the ipsilateral medial and the ipsilateral lateral rectus muscle in esotropic (n = 3) and exotropic patients (n = 18), respectively. Orthotropia was achieved in 82% of patients following ipsilateral medial or lateral rectus muscle recession.

CONCLUSIONS: There is a subset of patients who present with motility pattern similar to DRS but lack its complete diagnostic criteria. The presence of a face turn, overshoots on adduction or an ipsilateral tightness of the affected muscle should make one consider DRS sine retraction/sine limitation. The patients in our study responded well to lines of management similar to those of DRS.

PURPOSE: To describe a pattern of combined exotropia and hypotropia in patients with unilateral high myopia and to suggest a surgical approach for their management.

METHODS: In this observational study of 13 patients presenting with unilateral combined exotropia and hypotropia with high axial myopia in the deviating amblyopic eye, cycloplegic refraction, visual acuity, ocular motility, and orbital imaging findings were evaluated. For patients who had undergone surgery, the intraoperative findings and their surgical outcome were also analyzed.

RESULTS: Median age at presentation was 27 ± 14.6 years. In the deviated eyes, mean spherical equivalent was -13.6 ± 9 D; mean axial length, 28.3 ± 1.7 mm. The mean preoperative horizontal and vertical angles of deviation in primary gaze were 46.5 ± 12.1 (range, 25-60) and 21.1 ± 6.5 (range, 15-35), respectively. All patients had a V pattern, with limitation of elevation in abduction. Magnetic resonance imaging revealed no evident displacement of the lateral rectus muscles in all cases. Six patients (46%) had surgical intervention. In 5 cases, the lateral rectus was displaced inferiorly by a mean of 2.5 mm (range, 2-4 mm) and was recessed and transposed 8 mm upward. The muscle was then fixated to the sclera with a nonabsorbable polyester suture 2-4 mm behind its new insertion. Successful surgical outcome was achieved in 5 cases (83%).

CONCLUSIONS: Combined exotropia and hypotropia associated with high myopia shows an overlap in the clinical presentation of the heavy eye syndrome. Although not evident radiologically, downward displacement of lateral rectus muscle was documented intraoperatively.

PURPOSE: To analyze the risk factors associated with early and late failure after goniotomy for primary pediatric glaucoma.

METHODS: A retrospective study was done on infants who underwent goniotomy as the initial surgical procedure for primary pediatric glaucoma, and had a follow-up period ⩾48 months after surgery. Early and late failures were defined as intraocular pressure ⩾18 mmHg or signs of glaucoma progression before and after the end of first year, respectively.

RESULTS: A total of 81 eyes of 47 children were included. The mean age at the time of surgery was 6.1 ± 6.7 months, 34 children (72.3%) were bilateral. The mean follow-up was 5.9 ± 2.8 years. Of the included eyes, 41 eyes (50.6%) showed success, 25 eyes (30.9%) showed an early failure, and 15 eyes (18.5%) showed a late failure. The mean survival time was 43 months. However, only surgery before the end of the first month and positive consanguinity of the parents (P < 0.01 for both) were independent risk factors for early and late failure of goniotomy for primary pediatric glaucoma. Patients with late failure showed a statistically significant lower preoperative intraocular pressure (P = 0.02). A larger preoperative corneal diameter and a male gender were associated with higher but statistically insignificant failure rates. There were no differences in the early or late failure rates between unilateral and bilateral cases.

CONCLUSION: A positive consanguinity of the parents and surgery before the end of the first month are the major predictors of failure of goniotomy.

PURPOSE: After bilateral lateral rectus recession for intermittent exotropia, children can develop V- or A-pattern esodeviation and adopt a chin-down or chin-up position to facilitate fusion. The aim of this study was to discuss possible causes and management of this pattern.

METHODS: The medical records of children who developed consecutive esodeviation with V- or A-pattern strabismus after surgery for intermittent exotropia but with no pre- or postoperative oblique muscle dysfunction were reviewed retrospectively. Ductions, versions, angles of deviation, and fundus torsion were evaluated before and after surgery. Patient management and outcomes were analyzed.

RESULTS: A total of 37 patients were identified (mean age, 5.7 ± 1.5 years), with a mean preoperative deviation of 30.6 ± 5.2; no patient had a preoperative pattern strabismus. Mean bilateral lateral rectus recession was 6.2 ± 0.9 mm. Of the 37, 34 (89%) returned postoperatively with V pattern, 2 with an A pattern, and 1 with an hourglass-like pattern. No patient showed oblique muscle dysfunction or fundus torsion. Reoperation for the consecutive deviation was performed in 19 patients, in all of whom the lateral rectus muscles were not vertically displaced. The pattern disappeared completely after reoperation and reestablishment of adequate alignment in the primary position.

CONCLUSIONS: In our patient cohort, pattern strabismus after bilateral lateral rectus recession was successfully reversed by correction of the consecutive esodeviation.

PURPOSE: To compare the results of augmented superior rectus transposition (with or without medial rectus recession) with simple medial rectus recession in the treatment of patients with esotropic Duane retraction syndrome.

METHODS: This was a prospective, randomized, and interventional comparative study of 20 patients with esotropic type 1 Duane retraction syndrome. Patients were randomly divided into two groups. In the first group (superior rectus transposition group), superior rectus transposition with or without medial rectus recession was performed. In the second group (non-superior rectus transposition group), unilateral medial rectus recession was performed.

RESULTS: Each group included 10 patients. Esotropia improved from 20.4 prism diopters (PD) preoperatively to 0.6 PD postoperatively in the superior rectus transposition group and from 22.5 PD preoperatively to 0.9 PD postoperatively in the non-superior rectus transposition group. Face turn improved from 11.5° preoperatively to 0.5° postoperatively in the superior rectus transposition group and from 12° preoperatively to 1.5° postoperatively in the non-superior rectus transposition group. Abduction improved in the superior rectus transposition group from -3.9 preoperatively to -3.1 postoperatively and from -3.9 preoperatively to -3.6 postoperatively in the non-superior rectus transposition group. Vertical deviation developed in two cases in the superior rectus transposition group.

CONCLUSIONS: Both superior rectus transposition and medial rectus recession are effective in the elimination of esotropia and face turn in patients with esotropic Duane retraction syndrome. Superior rectus transposition is more effective in improving abduction, but it can be complicated by vertical deviation. [J Pediatr Ophthalmol Strabismus. 2020;57(5):309-318.].