Journal Information
ISSN / EISSN : 0927-3972 / 1744-5132
Published by: Informa UK Limited (10.1080)
Total articles ≅ 1,017
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, Jason H. Peragallo
Published: 3 April 2022
Strabismus, Volume 30, pp 65-71;

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.
, Svetlana Rychkova, Ron Lehnert, Evelyn Heim, Felix Muchamedjarow
Published: 3 April 2022
Strabismus, Volume 30, pp 99-110;

The aim of the present work was to investigate the effect of a novel therapy based on pleoptic exercises combined with standard occlusion in patients with meridional amblyopia. The exercising system itself, termed focal ambient visual acuity stimulation (FAVAS), consists of sinusoidally modulated circular gratings, which were implemented as a background pattern in computer games binding the children's attention. For the assessment of therapeutic effects, we tested for the development of best-corrected visual acuity (BCVA) in patients trained with a gaming field background of moving gratings (Moving) compared to patients treated with stationary gratings (Stationary). Patients with amblyopia (caused by strabismus, refraction, or both) and astigmatism were randomly allocated to two groups, all of whom received a standard occlusion regimen. In combination with occlusion, using a crossover design, the first group (Moving-Stationary group) was alternately exercised for 10 days with a series of Moving followed by 10 days with Stationary and the second group (Stationary-Moving group) vice versa. The treatment-dependent training effect on BCVA was measured with respect to the alignment of the least vs. the most ametropic meridian in both groups. BCVA was examined using a meridionally direction-sensitive visual test inventory, and we estimated the monocular BCVA in all patients along four meridians: 0°, 45°, 90°, and 135° before and after Moving as compared to Stationary treatments. The Moving-Stationary group consisted of 17 children (34 eyes) aged 10 to 13 (average 11.6 ± 0.3) years. The Stationary-Moving group consisted of 20 children (40 eyes) aged 9 to 14 (average 12.5 ± 0.4). In both groups, visual acuity increased significantly only with Moving combined with occlusion. Thereby, the visual acuity (logMAR) along different meridians showed a statistically significant improvement induced by Moving if testing was coincident with alignment of the directional optical characters close to the most ametropic meridian in the Moving-Stationary group (0.73 ± 0.32 to 0.41 ± 0.22, p < 0.01) and also in the Stationary-Moving group (0.48 ± 0.27 to 0.33 ± 0.18, p < 0.01). Significant improvement was also induced by Moving if tested in alignment with the perpendicular orientation close to the least ametropic meridian, although with a smaller amount, in the Moving-Stationary group (0.49 ± 0.23 to 0.37 ± 0.21, p < 0.01) as well as in the Stationary-Moving group (0.33 ± 0.18 to 0.28 ± 0.16, p < 0.01). After Stationary combined with occlusion, however, there was no statistically significant improvement, regardless of the meridian. Visual training of patients with meridional amblyopia by a series of online exercises using attention-binding computer games which contained moving gratings as a background stimulus (Moving) resulted in a statistically significant improvement in visual acuity in the most refractive meridian, and to a lesser extent, in the least refractive meridian. No statistically significant improvement was achieved after the respective exercising series in the sham condition with stationary gratings (Stationary).
Published: 31 March 2022
Strabismus, Volume 30, pp 72-77;

Age-related distance esotropia (ARDE) is thought to be caused by sagging eye syndrome. Sagging of the lateral rectus derives from the naturally occurring aging process and induces excyclotorsion of the eye. To date, no study has compared the cyclodeviation in ARDE with that in the age-matched individuals without strabismus. This study aimed to measure the objective cyclotorsion on fundus photographs of ARDE patients and compare the findings with those for normal age-matched individuals. Objective cyclotorsion was measured by determining the disc-to-fovea angle (DFA) on fundus photographs, which were obtained from two groups: 38 consecutive patients with ARDE (age, 74.1 ± 7.9 years), 76 normal age-matched controls (age, 73.9 ± 8.1 years). DFA in ARDE patients was not different from that in the control group (Welch’s t-test: ARDE vs Control, right eye; 7.7° ± 2.9° vs 6.8° ± 3.9°, p = .18. Left eye; 10.0° ± 4.5° vs 9.4° ± 3.6°, p = .54. Sum of both eyes; 17.6° ± 5.8° vs 16.2° ± 4.7°, p = .21). These findings suggest sagging of the lateral rectus is not the sole cause of ARDE. Another aging-related factor, such as decreased phoria adaptation, might also be responsible for ARDE.
, Liesbet Beelen, Ivo De Clerck, Louise Petit, Irina Balikova, Ingele Casteels, Maria Dieltiëns, Catherine Cassiman
Published: 15 March 2022
Strabismus, Volume 30, pp 59-64;

We investigated a possible association between the acute onset of esotropia and tablet or smartphone use in children. We characterized the clinical aspects of esotropia associated with tablet or smartphone use. The medical records of 10 children aged between 5 and 15 years old with presumably tablet or smartphone associated esotropia were reviewed regarding orthoptic examination and cycloplegic refraction. Legal guardians of the children were asked to fill in a questionnaire regarding tablet and smartphone use of their child. This questionnaire was also conducted in a control group of age-matched children. The results of this questionnaire were compared to search for possible determinants of tablet or smartphone associated esotropia. All 10 patients presented with a comitant esotropia ranging from 8 to 45 prism diopters with no significant difference between near and far. The mean age of onset was 9.8 years. Cycloplegic refraction showed a mild hyperopia in eight patients, a mild myopia in one patient and emmetropia in the other patient. All patients had near full refractive correction at the onset of esotropia. Diplopia was reduced after visual hygiene recommendations, however in six patients, strabismus surgery was needed. The working distance was significantly shorter in the 10 cases compared to the controls. In children with acute acquired esotropia, we found a statistically significant association with a smaller working distance during tablet or smartphone use compared to age-matched controls. We hypothesize that intensive near viewing can be a precipitating factor in this type of esotropia.
, Leah Walsh
Published: 8 March 2022
Strabismus, Volume 30, pp 78-89;

This study aimed to calculate the dose–response relationship and predictors of visual acuity (VA) improvement following occlusion therapy at the IWK Health Center Eye Clinic and to add to amblyopia therapy dose–response relationship literature. A retrospective chart review was performed, considering patients who reached an occlusion therapy outcome at the IWK Eye Clinic between 2012 and 2019. The treatment outcome was defined as equal VA or stable VA for three consecutive clinical visits despite reported compliance. Subjective patching hours from parental reports, not prescribed hours, were used for statistical analyses. One hundred and thirty-four patients (66 females and 68 males) ages 2–11 years were included. Results showed a dose–response relationship of 224 hours/0.1logMAR increase in VA and total dose of 1344 hours for full-time occlusion and 504 hours for part-time occlusion was required to reach outcome VA. The fastest VA improvement occurred with younger age at treatment initiation, during the first 4 weeks of treatment, and in patients with strabismic and/or severe amblyopia. Classification of amblyopia, age, VA chart, initial distance VA (amblyopic eye), and treatment dose predicted the hour dose–response relationship. Dose–response relationship was faster in younger participants, in participants with strabismic and severe amblyopia, and during the first month of occlusion. Additionally, by creating a GLM model of dose–response relationship, relationship calculations can be performed. Therefore, an estimated timeline can be developed to allow allocation of clinical resources and to prepare patients for the treatment duration required and possibly increase treatment compliance.
, S. K. Sharma
Published: 2 January 2022
Strabismus, Volume 30, pp 38-41;

A 20-year-old male presented with esotropia in both the eyes with limitation of abduction and elevation. He also had low vision in both the eyes since childhood. Radiological imaging demonstrated a nasally deviated superior rectus and inferiorly displaced lateral rectus. He was diagnosed to be a case of bilateral myopic strabismus fixus. Silicone band-assisted myopexy of superior and lateral rectus was done along with passing the band through the scleral tunnel. The patient had satisfactory alignment postoperatively and did not require any intervention over 1-year follow-up. Scleral fixation has an advantage as it prevents migration of band, and passing the scleral band through the scleral tunnel lowers the risk of scleral perforation as it does not require the need for passing suture needle through the sclera once the tunnel is made.
, Joe Smith, Krishan Parmar
Published: 2 January 2022
Strabismus, Volume 30, pp 42-47;

Introduction: Bupivacaine (BPX) is a widely used local anesthetic. Ophthalmologists have found a unique use of BPX to alter the elasticity and contractile properties of extraocular muscles to straighten strabismus. The utilization of BPX to treat strabismus has been well documented. The purpose of this review is to examine the overall efficacy of BPX when used in isolation for the treatment of strabismus, based on the published literature. Methodology: A literature search was carried out to identify papers published between the years 1980 and 2021, which examined the impact of BPX as a stand-alone treatment for strabismus. Results: Eight articles were identified as matching the inclusion criteria. The authors reported that volumes of ≤1.00 mL are unlikely to be significant enough to improve ocular alignment and increasing volume strength is associated with greater changes in ocular alignment. The overall change in ocular alignment varied from 0–16PD between the different studies included, with similar effects being noted for deviations between 10 and 20PD and deviations as large as 55PD. It has been documented that there is no significant difference in the outcomes of BPX treatment for esotropia and exotropias, but some clinical differences have been noted with esotropia (or the lateral rectus) responding better to BPX. Bupivacaine has been demonstrated to be less effective in patients with chronic nerve palsies. All but one author documented increases in the injected muscle’s volume and maximum cross-sectional area from month one to three followed thereafter by a gradual decrease in both measurements. It was noted that despite the reduction in both measurements, the change in ocular alignment continued to show improvements. No sight-threatening or persistent complications were reported within any of the studies or case reports included within this review. In the interest of patient experience, the majority of patients reported that BPX improved their eye alignment, while a third reported feelings of discomfort during the procedure. Conclusion: Bupivacaine is a viable option for the treatment of small angle deviations and is not recommended for use in long-standing cranial nerve palsies or those associated with atrophy. Care is needed in determining the required dose to avoid the need for re-injection and impacting patient experience.
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