Cyclic Esotropia: a Case Report

In this case report, two cases with diagnosis of cyclic esotropia are presented. Both patients complained of periodic alternative inside eye deviation with an interval of one day. Para- clinical tests including magnetic resonance imaging (MRI) of the brain and electroretinogram (ERG) were normal and no neurological abnormality or paralysis was detected. Patients were observed in two consecutive days to confirm the diagnosis of cyclic esotropia. Both patients underwent bilateral medial rectus recession surgery as routinely performed for non- cyclic esotropic patients, and the postoperative orthotropia with the best corrected visual acuity (BCVA) of 20/20 was obtained in both cases. In conclusion surgical and non-surgical treatments can be used for cyclic esotropia similar to what is routinely performed for non- cyclic strabismic patients. Successful therapeutic outcomes might be obtained in such patients achieving normal binocular fusion in several days with no ocular deviation. Keywords: Cyclic; Esotropia; Treatment

Acute Acquired Comitant Esotropia in Adults; a Case Report

Purpose:  The aim of this manuscript was to report the clinical characteristics of two patients suffering from acute acquired comitant esotropia presented in adulthood.Case report: Both patients reported intermittent diplopia especially during car driving before their diplopia becoming constant. They had 20/20 uncorrected visual acuity and a cyclorefraction of + 0.50 D with normal extraocular function except very mild lateral rectus underaction (< 1) in their both eyes. In alternate prism cover test, the manifest esotropia of 25 - 30 Δ was measured at both far and near distances. They did not show any signs of neurological disorders such as marked extraocular underaction or different esotropia on lateral gazes compared with esotropia in primary position. No abnormality was found on electromyography, visual field measurements and magnetic resonance imaging for both cases.Conclusion: Based on our clinical assessment, hereditary causes, mild lateral rectus underaction or inability to compensate esotropia due to decreased divergence amplitude and fusion could be considered as the probable risk factors for acute acquired comitant esotropia in adults, although the actual etiology of this disease has not been determined.Keywords: Acquired; Esotropia; Acute; Etiology; Adult; Risk factor

Guidance for Ophthalmologists and Ophthalmology Centers during the COVID-19 Pandemic

This is a Letter to the Editor and does not have an abstract

Is Noncycloplegic Photorefraction Applicable for Screening Refractive Amblyopia Risk Factors?

Purpose: To compare the accuracy of noncycloplegic photorefraction (NCP) with that of cycloplegic refraction (CR) for detecting refractive amblyopia risk factors (RARFs) and to determine cutoff points. Methods: In this diagnostic test study, right eyes of 185 children (aged 1 to 14 years) first underwent NCP using the PlusoptiX SO4 photoscreener followed by CR. Based on CR results, hyperopia (≥ +3.5 D), myopia (≥ -3 D), astigmatism (≥ 1.5 D), and anisometropia (≥ 1.5 D) were set as diagnostic criteria based on AAPOS guidelines. The difference in the detection of RARFs by the two methods was the main outcome measure. Results: RARFs were present in 57 (30.8%) and 52 (28.1%) of cases by CR and NCP, respectively, with an 89.7% agreement. In contrast to myopia and astigmatism, mean spherical power in hyperopic eyes was significantly different based on the two methods (P < 0.001), being higher with CR (+5.96 ± 2.13 D) as compared to NCP (+2.37 ± 1.36 D). Considering CR as the gold standard, specificities for NCP exceeded 93% and sensitivities were also acceptable (≥ 83%) for myopia and astigmatism. Nevertheless, sensitivity of NCP for detecting hyperopia was only 45.4%. Using a cutoff point of +1.87 D, instead of +3.5 D, for hyperopia, sensitivity of NCP was increased to 81.8% with specificity of 84%. Conclusion: NCP is a relatively accurate method for detecting RARFs in myopia and astigmatism. Using an alternative cutoff point in this study, NCP may be considered an acceptable device for detecting hyperopia as well

Long-term visual outcome of congenital cataract at a Tertiary Referral Center from 2004 to 2014

AbstractPurposeTo assess the long-term visual acuity (VA) outcome after congenital cataract surgery at Imam Hossein Medical Center (Tertiary Referral Center) (2004–2014).MethodsIn this descriptive study, records of 120 patients with a history of congenital cataract surgery were studied. Those with traumatic, metabolic cataract, aged <5 years at the last visit who were not able to respond VA testing accurately and follow-up < 6 months were excluded. Cases with incomplete files were recalled and reexamined. Finally, the records of 42 patients (71 eyes) were included.ResultsIn this study, 20 males and 22 females with a mean age of 11.80 ± 6 years at their last visit were studied. Bilateral and unilateral cataract was seen in 69% and 31% of cases, respectively. Posterior and anterior subcapsular opacity was the most common (53.70%) and rarest (1.90%) type of congenital cataract, respectively. The mean age at the time of operation and surgical interval was 65 ± 66.6 (range: 1–200) and 12.9 ± 23.5 (range: 0–96) months, respectively. The most common method of refractive error correction was pseudophakia plus glasses (56.3%) with the mean best corrected visual acuity (BCVA) of 0.29 ± 0.28 LogMAR., The mean BCVA was 0.7 ± 0.53 LogMAR for aphakic patients correcting by glasses. In our study, amblyopia (56%), glaucoma (23.90%), and posterior capsular opacity (16.40%) were observed during their follow-ups on an average of 76 ± 65 months (median: 60, range: 6–240). Unilateral cataract, aphakia, nystagmus, female gender, and strabismus were risk factors of VA loss.ConclusionBased on our results, 56% of cases showed amblyopia. It could be due to late operation (especially in unilateral cases), longer surgical interval between two eyes, and no compliance of amblyopia therapy. Early detection through screening may reduce the rate of amblyopia. Refractive errors, visual acuity, amblyopia, glaucoma, posterior capsular opacity, and compliance of amblyopia therapy should be checked regularly at follow-up visits

Amblyopia Treatment Knowledge Cognition of Iranian Practitioners in 2012.

Background: Amblyopia is considered as one of the most prevalent vision problems in pediatrics age (1-5%). Recently, new methods in amblyopia treatment were reported in Amblyopia Treatment Study (ATS’).The objective of this study was to recognize amblyopia treatment knowledge of Iranian ophthalmologists and optometrists which are responsible for amblyopia treatment in our and other countries.Materials and Methods: This cross sectional study was performed during the Iranian Society of Ophthalmology annual meeting in Tehran in 2012 through questionnaire containing demographic information and 20 closed-answer questions based on ATS results. The questions were classified into seven categories and the sum of correct scores was 100. Optometrists and pediatric ophthalmologists were considered as the group 1 (153 participants), other practitioners (general ophthalmologists and other subspecialists) were regarded as the group 2 (256 participants). Criteria for inadequate, fair and good knowledge were considered by scores of &lt; 50, 50 to 70, and &gt;70 respectively.Results: Overall, 409 out of a total of 600 questionnaires were completed (response rate: 68.1%).  Mean scores of the group 1 were significantly higher than the group 2 in all 7 categories of questions and in 5 of them the differences were statistically significant. The worst and best scores were related to prescription of atropine (12%) and visual acuity improvement with glasses alone (93%), respectively. Scores for other questions were about 50%. There was no relationship between practice status and the number of referral amblyopic cases per week with the level of knowledge. In all categories except prescription of Atropine and recurrence, mean scores of females were more than the male participants.Conclusion: knowledge about amblyopia therapy seems to be overall inadequate and should be improved by more education. We suggest paying more attention to new modified methods of amblyopia treatment and increased discussion of such method in annual and CME meetings

Orthoptic Changes following Photorefractive Keratectomy

Purpose: To report orthoptic changes after photorefractive keratectomy (PRK). Methods: This interventional case series included 297 eyes of 150 patients scheduled for PRK. Complete ophthalmologic evaluations focusing on orthoptic examinations were performed before and 3 months after PRK. Results: Before PRK, 2 (1.3%) patients had esotropia which remained unchanged; 3 (2%) patients had far exotropia which improved after the procedure. Of 12 cases (8%) with initial exotropia at near, 3 (2%) cases became orthophoric, however 6 patients (4%) developed new near exotropia. A significant reduction in convergence and divergence amplitudes (P < 0.001) and a significant increase in near point of convergence (NPC) (P < 0.006) were noticed after PRK. A reduction ≥ 10 PD in convergence amplitude and ≥ 5 PD in divergence amplitude occurred in 10 and 5 patients, respectively. Four patients had initial NPC > 10 cm which remained unchanged after surgery. Out of 9 (6%) patients with baseline stereopsis > 60 seconds of arc, 2 (1.33%) showed an improvement in stereopsis following PRK. No patient developed diplopia postoperatively. Conclusion: Preexisting strabismus may improve or remain unchanged after PRK, and new deviations can develop following the procedure. A decrease in fusional amplitudes, an increase in NPC, and an improvement in stereopsis may also occur after PRK. Preoperative evaluation of orthoptic status for detection of baseline abnormalities and identification of susceptible patients seem advisable

Reoperation in Horizontal Strabismus and its Related Risk Factors

This study was performed to determine the surgical outcomes and the related risk factors of second operation in patients with residual horizontal deviations. In this interventional case series study, a total of 119 patients with a history of reoperation were included (39 exotropia and 80 esotropia). Cases with consecutive strabismus, muscular palsy, systemic disease, lack of ocular fixation, and those, who had vertical deviation and Dissociated Vertical Deviation (DVD)&gt;5 Prism Diopters (pd) were excluded. Medial Rectus (MR) resection in residual Exotropia (XT) and Lateral Rectus (LR) resection in residual Esotropia (ET) were performed. Unilateral or bilateral operations were considered if the preoperative residual deviation was &lt; 20 pd or &gt; 20 pd, respectively. Success of the reoperation was considered if the postoperative angle of deviation was ≤ 10 pd. Unilateral and bilateral MR resection was performed in 26% and 74% of patients with XT, respectively, with greater dose response in unilateral cases (2.8 versus 2.6 mm/pd). Successful surgical outcomes were observed in 94.9% of patients with XT. Unilateral and bilateral LR resection was also performed in patients with residual ET, each in 50% of patients. Unilateral cases showed greater dose-response compared to bilateral ones (2.6 versus 2 mm/pd) and successful surgical outcomes were observed in 83.8% of patients with ET. No variable was found as a risk factor of reoperation in both groups. In conclusion, both LR and MR resection are easy and predictable surgical approaches with high success rate in patients with residual ET and XT. Generally, MR resection is more effective than LR resection. Unilateral operation is less recommended in the residual exotropic group, due to its lower success compared to the bilateral operation. Unfortunately, none of the mentioned variables were found to be the risk factor of reoperation in the sampled patients.Â

Vision Therapy/Orthoptics among Three to Seven Year Old Children

Background: Vision Therapy/Orthoptics(VT/O) is a package of treatments that enables patients to achieve the maximum level of visual performance.The aim was to determine the effect of three months vision therapy/orthoptics on best corrected visual acuity (BCVA), fusion, stereopsis and ocular alignment in 3-7 year old children.Materials and Methods: In this randomized clinical trial study, 80 children with amblyopia and/or non-paralytic horizontal deviations were randomly divided into intervention and control groups. Intervention group was treated by vision therapy/orthoptics for three months. These modalities included patch, red filter, sector patch, over minus lens, prism and synoptophore exercises. Controls were treated by only patching for the same period. Pre and post-treatment BCVA, fusion, stereopsis and alignment were compared. Visual performance was classified as excellent (BCVA≥20/30, deviation≤10pd and stereopsis≤70sec/are), acceptable (BCVA≥20/30, deviation ≤10pd and stereopsis 70 to 3000sec/are) and unsatisfactory (BCVA&lt;20/30, deviation&gt;10pd and no stereopsis).Results: A total of 80 cases (56 girls and 24 boys) with the mean age of 5.6±1.4 years entered the study. Although more improvement of fusion and stereopsis was seen in the intervention group (P&lt;0.001 for both groups), there was no significant differences in BCVA and alignment between two groups. Also the difference of visual performance was not statistically significant between two groups, whereas the improvement was significant in each group (P&lt;0.001, for both groups).Conclusion: Vision therapy/orthoptics treatment can be effective for improving sensory status in 3 to 7 year old children with amblyopia and/or strabismus. Further studies with larger sample sizes and focusing on accommodation and fusional amplitude are warranted