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Purpose: The American College of Radiologists (ACR) recognises the value of magnetic resonance imaging (MRI) as the investigation of choice in patients with a clinically suspected scaphoid fracture but normal plain radiographs. The Royal College of Radiologists (RCR) in the UK produces no similar guidelines, as evidenced by the inconsistent management of such cases in hospitals around the UK. In discussion with our musculoskeletal radiologists, we implemented new guidelines to standardise management of our patients and now report our findings.Methods: A consecutive series of 137 patients referred to the orthopaedic department with clinically suspected scaphoid fracture but normal series of plain radiographs were prospectively followed up over a two-year period. We implemented the use of early MRI for these patients and determined its incidence of detected scaphoid injury in addition to other occult injuries. We then prospectively examined results of these findings on patient management.Results: Thirty-seven (27%) MRI examinations were normal with no evidence of a bony or soft-tissue injury. Soft-tissue injury was diagnosed in 59 patients (43.4%). Of those, 46 were triangular fibrocartilage complex (TFCC) tears (33.8%) and 18 were intercarpal ligament injuries (13.2 %). Bone marrow oedema with no distinct fracture was discovered in 55 cases (40.4%). In 17 (12.5%) cases, this involved only the scaphoid. In the remainder, it also involved the other carpal bones or distal radius. Fracture(s) were diagnosed on 30 examinations (22.0%).Conclusions: MRI should be regarded as the gold standard investigation for patients in whom a scaphoid fracture is suspected clinically. It allows the diagnosis of occult bony and soft-tissue injuries that can present clinically as a scaphoid fracture; it also helps exclude patients with no fracture. We believe that there is a need to implement national guidelines for managing occult scaphoid fractures. [ABSTRACT FROM AUTHOR]

Cancers are a heterogeneous mix of cells, some of which exhibit cancer stem cell-like characteristics including ATP-dependent drug efflux and elevated tumorigenic potential. To determine whether aerodigestive squamous cell carcinomas (SCCs) contain a subpopulation of cancer stem cell-like cells, we performed Hoechst dye efflux assays using four independent cell lines. Results revealed the presence of a rare, drug effluxing stem cell-like side population (SP) of cells within all cell lines tested (SCC-SP cells). These cells resembled previously characterised epithelial stem cells, and SCC-SP cell abundance was positively correlated with overall cellular density and individual cell quiescence. Serial SCC-SP fractionation and passaging increased their relative abundance within the total cell population. Purified SCC-SP cells also exhibited increased clonogenic potential in secondary cultures and enhanced tumorigenicity in vivo. Despite this, SCC-SP cells remained chemotherapeutically sensitive upon ATP-dependent transporter inhibition. Overall, these findings suggest that the existence of ATP transporter-dependent cancer stem-like cells may be relatively common, particularly within established tumours. Future chemotherapeutic strategies should therefore consider coupling identification and targeting of this potential stem cell-like population with standard treatment methodologies. [ABSTRACT FROM AUTHOR]

Giant cell tumours of the femoral head and neck treated at the Nuffield Orthopaedic Centre between 1970 and 1982 were reviewed to evaluate the effectiveness of primary treatment by curettage and bone grafting. All 4 cases recurred within two years, necessitating the likelihood of recurrence following curettage and bone grafting, particularly at this anatomical site, is stressed, and the possibility that hip replacement arthroplasty be considered the primary treatment of choice is discussed. [ABSTRACT FROM AUTHOR]

Thirty-two patients who underwent bilateral bicompartmental Oxford Meniscal Knee arthroplasty have been followed up prospectively for a mean period of 51 months from the time of their first operation. Pain relief was obtained in all but one knee; walking ability was improved in more than two-thirds. Overall patient satisfaction with the results was good. Two knees failed. The results demonstrate that bilateral knee arthroplasty can be expected to give good functional results. [ABSTRACT FROM AUTHOR]

Introduction: Congenital enophthalmos is a rare condition characterized by posterior displacement of the globe, often associated with bony orbital anomalies or whole globe development defects. The purpose of this report is to present two unrelated cases of congenital enophthalmos secondary to anomalous accessory orbital bands and to describe characteristics of orbital imaging that differentiate this condition from the other causes., Methods: The case records of two patients who presented with congenital enophthalmos and were discovered to have anomalous accessory orbital extraocular muscle bands were reviewed. The clinical features, initial diagnosis, high resolution magnetic resonance imaging (MRI) findings, and surgical outcomes were noted. A 3-dimensional reconstruction model was used to understand the approach and surgical management in one of the cases., Results: Both patients presented with unilateral severe enophthalmos, globe retraction, and restricted ocular motility in all directions since birth. High-resolution MRI of the orbits revealed a short anomalous band, isointense to the muscle, arising from a rectus muscle belly and attaching to the posteroinferior part of the globe adjacent to the optic nerve. The caliber of the extraocular muscles and ocular motor nerves was normal. In one patient, surgery was not pursued due to the extreme posterior location of the band with proximity to the optic nerve. In the other patient, the deviation did not improve, despite successfully severing the accessory band, due to extensive scarring., Conclusion: Anomalous accessory orbital extraocular muscle bands are a rare and often overlooked cause of congenital enophthalmos when associated with limited ocular motility. Imaging the orbit can aid in diagnosis and help differentiate it from other causes. Safe surgical approaches to address the problem are limited, and available approaches may not be effective. These two cases highlight that the management of accessory extraocular muscle bands causing enophthalmos can be extremely challenging and difficult to improve even with intensive surgical intervention.

Purpose: To evaluate the efficacy of anti-suppression exercises in children with small-angle esotropia in achieving binocular vision., Methods: A retrospective review of patients aged 3-8 years who underwent anti-suppression exercises for either monocular or alternate suppression between January 2016 and December 2021 was conducted. Patients with esotropia less than 15 prism diopters (PD) and visual acuity ≥ 6/12 were included. Patients with previous intra-ocular surgery or less than three-month follow-up were excluded. Success was defined as the development of binocular single vision (BSV) for distance, near, or both (measured clinically with either the 4 prism base out test or Worth four dot test) and maintained at two consecutive visits. Qualified success was defined as the presence of diplopia response for both distance and near. Additionally, improvement in near stereo acuity was measured using the Stereo Fly test., Results: Eighteen patients with a mean age of 5.4 ± 1.38 years (range 3-8 years) at the time of initiation of exercises were included in the study. The male female ratio was 10:8. The mean best corrected visual acuity was 0.18 LogMAR unit(s) and the mean spherical equivalent was +3.8 ± 0.14 diopters (D). The etiology of the esotropia was fully accommodative refractive esotropia (8), microtropia (1), post-operative infantile esotropia (4), partially accommodative esotropia (1), and post-operative partially accommodative esotropia (4). Patients received either office-based, home-based, or both modes of treatment for an average duration of 4.8 months (range 3-8). After therapy, BSV was achieved for either distance or near in 66.6 % of patients (95 % CI = 40.03-93.31 %). Binocular single vision for both distance and near was seen in 50 % of children. Qualified success was observed in 38.46% of patients. Persistence of suppression was observed in one patient (5.5 %). Near stereopsis improved to 200 s of arc or more in 60% of the patients. The mean esotropia reduced from 5.7 ± 4.0 PD for distance and 6.2 ± 4.66 PD for near to 2.7 ± 2.4 PD and 3.38 ± 4.7 PD respectively, at the last follow-up (p-value 0.004 and 0.006). Failure of therapy was noticed after six months of follow-up in the child with infantile esotropia., Conclusion: Anti-suppression exercises may be beneficial to improve binocular vision functions in children with small-angle esotropias of variable etiologies. Recurrence of suppression after cessation of therapy is possible, warranting regular follow up., Competing Interests: Declaration of Competing Interest None of the authors have any conflict of interest., (Copyright © 2023 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. All rights reserved.)

Purpose: To evaluate the prediction error (PE) in pediatric traumatic cataract surgery involving primary or secondary intraocular lens implantation (IOL) and the factors affecting it., Methods: Retrospective data of unilateral traumatic cataract eyes of children aged ≤16 years were collected between February 2019 and March 2022 at a tertiary eye care hospital. Absolute PE was calculated by deducting the target refraction from the observed refraction at 6 weeks postsurgery following suture removal. Simulated PE was calculated in eyes with corneal scar replacing the affected eye keratometry (K) with the K of the fellow eye and standard K (44D) and was then compared with absolute PE., Results: Fifty children with a mean age of 9.5 years (2-16 years) were included. Mean absolute PE was 1.63 ± 1.8D (0 to 9D). Absolute PE was not affected by the age at surgery, method of biometry, duration of injury, type of cataract surgery, position of IOL, and preoperative keratometry. The absolute PE was affected by axial length (AXL) being <1.5D in AXL of 22.73 ± 0.84 mm, <1.5-2D in AXL of 22.07 ± 0.61 mm, and >2D in AXL of 22.01 ± 0.74 mm (P = 0.039) in univariate analysis. In multivariate analysis, none of the factors affected the absolute PE. In 34 eyes with corneal scar, higher variability in PE was observed. The standard K resulted in greater simulated PE as compared to the affected eye average K in eyes with scar involving the visual axis., Conclusion: Absolute PE following pediatric traumatic cataract was studied. It was higher in shorter AXLs. In corneal scar involving the visual axis, using the fellow eye K yielded lesser simulated PE as compared to standard K., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Objective: The objective of this study was to assess the efficacy of low-dose atropine 0.01% in controlling myopia progression among Indian children over a 2-year period., Methods: This retrospective study, conducted across 20 centres in India, monitored the progression of myopia over 2 years after initiating treatment with 0.01% atropine eye drops. This included children between 6 and 14 years with baseline myopia ranging from -0.5 D to -6 D, astigmatism≤-1.5 D, anisometropia ≤ -1 D and documented myopia progression of ≥0.5 D in the year prior to starting atropine. Subjects with any other ocular pathologies were excluded., Results: A total of 732 children were included in the data analysis. The mean age of the subjects was 9.3±2.7 years. The mean myopia progression at baseline (1 year before starting atropine) was -0.75±0.31 D. The rate of myopia progression was higher in younger subjects and those with higher baseline myopic error. After initiating atropine, myopia progression significantly decreased to -0.27±0.14 D at the end of the first year and -0.24±0.15 D at the end of the second year (p < 0.001). Younger children (p<0.001) and higher baseline myopia (p<0.001) was associated with greater myopia progression and poor treatment response (p<0.001 for both)., Conclusion: Low-dose atropine (0.01%) effectively reduces myopia progression over 2 years in Indian children., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Congenital aniridia is a rare genetic eye disorder characterized by the complete or partial absence of the iris from birth. Various theories and animal models have been proposed to understand and explain the pathogenesis of aniridia. In the majority of cases, aniridia is caused by a mutation in the PAX6 gene, which affects multiple structures within the eye. Treating these ocular complications is challenging and carries a high risk of side effects. However, emerging approaches for the treatment of aniridia-associated keratopathy, iris abnormalities, cataract abnormalities, and foveal hypoplasia show promise for improved outcomes. Genetic counseling plays a very important role to make informed choices. We also provide an overview of the newer diagnostic and therapeutic approaches such as next generation sequencing, gene therapy, in vivo silencing, and miRNA modulation., Competing Interests: The authors declare that there are no conflicts of interests of this paper, (Copyright: © 2023 Taiwan J Ophthalmol.)

Purpose : To compare the motor and sensory outcomes of strabismus surgery and the factors affecting surgical success in acquired acute non-accomodative esotropia (ANAET) and partially accommodative refractive esotropia (pARET). Methods : A retrospective chart review of patients with ANAET and pARET who underwent unilateral or bilateral horizontal rectus muscle surgery between January 2020 and December 2021 was conducted. Patients with postoperative follow-up of at least six weeks were included. Patients with pattern deviation, lateral incomitance, and near-distance disparity were excluded. Motor success was defined as a postoperative deviation within eight prism diopters of orthophoria. Sensory success was defined as presence of binocular single vision (BSV) for both distance and near (Worth four dot test). The effect of factors like age at onset, age at surgery, amblyopia before surgery, duration of squint before treatment, presence or absence and magnitude of vertical deviation, preoperative angle of deviation, and spherical equivalent on the motor and sensory success in each group were analyzed and compared. Results : 38 patients with ANAET and 33 patients with pARET were included. The mean age of onset of esotropia was 8.55 ± 4.65 years and 4.39 ± 2.27 years ( p  < .001) and the mean age at surgery was 10.62 ± 4.99 years and 7.89 ± 2.84 years ( p  = .006) in the ANAET and the pARET group respectively. The mean duration of the final follow-up was 38.51 weeks in the ANAET and 48.68 weeks in the pARET group ( p  = .089). Patients were successfully aligned for both distance and near in 81.5% of patients in the ANAET and 78.9% of patients in the pARET group at the final follow-up (p. 0.775). A BSV for both distance and near at the final follow-up was seen in 81.2% vs 66.6% of patients in the ANAET and the pARET group respectively ( p  = .25). A good near stereoacuity (<120 arcsecs) was seen in 60.6% and 41.9% of the ANAET and the pARET groups respectively ( p  = .175). The percentage of patients in the ANAET group who had orthophoria, any esodeviation, and any exodeviation for distance at the final follow-up was 63.1%, 34.2% and, 2.6%. The percentage of patients in the pARET group in similar categories was 36.3%, 42.4% and, 21.2%. None of the demographic and preoperative factors were found to affect the surgical outcomes in the two groups. Conclusions : The motor and sensory outcomes were similar in the two groups. A higher proportion of ANAET patients remained orthophoric during the follow-up. The patients in the pARET group showed a tendency toward exodrift.

Clinical Relevance: Low contrast acuity (LCA) and near stereoacuity (NS) testing are integral to the comprehensive assessment of sensory visual function in children. However, routine ophthalmological evaluations seldom take these measures into consideration. Additionally, there is limited literature regarding the normative values of these parameters in children., Background: This study investigated LCA and NS measures and their variability in children with normal visual acuity. The aim was to provide a benchmark for distinguishing normal measures from abnormal ones., Methods: A prospective observational study was conducted in primary and secondary schools across North India. The participants numbered 240 children, aged between 3 and 15 years. They were split into 12 smaller groups of 20 participants in each age group. Only participants with normal monocular uncorrected visual acuity, no refractive error, normal birth history, and no systemic ailments, were recruited. All the participants underwent a complete ophthalmic examination and non-cycloplegic retinoscopy. LCA was measured, using the low contrast Lea number chart at three metres. NS was measured using the Randot® stereo test at 40 cm., Results: The percentages of males and females, were found to be 55%, and 45%, respectively (p = 0.093). The mean NS was found to be 38.7 ± 11.5 arcsecs in the 3-9-year age group, and 26.7 ± 5.6 arcsecs in the 9-15-year age group ( p -value <0.001). The mean NS showed an increasing trend up to 9 years of age. The mean LCA was 64.4 ± 20.1 in the age group of 3-8 years, and 76.38 ± 11.39 in the age group of 8-15 years ( p -value <0.001). Considerable variability was noted in the LCA in the younger age group ( p -value = 0.000)., Conclusions: LCA and NS mature gradually during childhood. LCA stabilises after the age of 8, while NS stabilises after the age of 9.

Purpose: To evaluate dry eyes in children with vernal kerato-conjunctivitis (VKC) and correlate it with symptoms, clinical findings, and ocular surface analysis (OSA) parameters., Methods: Children with clinically diagnosed VKC underwent complete ophthalmological examination, Schirmer's testing, modified ocular surface disease index (OSDI) scoring, Bonini grading, fluorescein tear-film break-up time (TBUT), VKC - Collaborative Longitudinal Evaluation of Keratoconus (CLEK) scoring, and OSA. Children with a TBUT of < 10 s were defined to have dry eyes. The above-mentioned parameters were compared between dry eye and non-dry eye VKC children., Results: The mean age of the 87 children included in the study was 9.1 ± 2.9 years. Dry eyes were seen in 60.9% [95% confidence interval (CI); 51% to 71%]. The mean TBUT was 13.4 ± 3.8 and 5.9 ± 1.9 s in non-dry and dry eye groups, respectively (P < 0.001). The mean value of Schirmer's test was 25.9 ± 9.8 and 20.8 ± 8.6 mm in the non-dry and dry eye groups, respectively (P = 0.01). The two groups did not differ in their OSDI scores, Bonini grading, and CLEK scores. The OSA parameter of non-invasive break-up time (NIBUT) was 8.3 ± 3.2 s in non-dry eye group and 6.4 ± 2.9 s in dry eye group, P = 0.008. The lower lid Meibomian gland (MG) loss was 7.4% in non-dry eye group and 12.2% in dry eye group, P = 0.028. Other OSA parameters did not differ significantly among the two groups., Conclusion: Dry eyes are seen in two-thirds of pediatric VKC. Evaluation of dry eyes should be incorporated in their clinical evaluation. Among OSA parameters, NIBUT and lower lid MG loss are associated with dry eyes in pediatric VKC patients., Competing Interests: None

Aims: The study aims to detect the underlying genetic defect in two autosomal dominant congenital cataract (ADCC) families., Methods: A detailed family history was collected, pedigrees were drawn, and slit-lamp examination and lens photography were performed. Mutation screening was carried out in the genes for crystallins and connexins by PCR and Sanger sequencing. Ethnically matched controls were tested for the identified variants. Different bioinformatics tools were used to assess the pathogenicity of the observed variants., Results: In an ADCC family with total cataract, a novel change (c.166A > G) (p.Thr56Ala) in GJA8 was identified. In another ADCC family with nuclear cataract, c.134G > C (p.Trp45Ser) in GJA3 has been detected. These variants co-segregated completely in patients in their respective families and were neither observed in unaffected family members nor in ethnically matched 100 controls, excluding them as polymorphisms., Conclusions: The present study identifies a novel variant c.166A > G (p.Thr56Ala) in GJA8 in an ADCC family having total cataract and a previously known mutation c.134G > C (p.Trp45Ser) in GJA3 in another ADCC family. Thr56 in GJA8 seems to be a mutation hotspot, as previously an ADCC Mauritanian family harbored a different substitution (p.Thr56Pro) at the same codon, although for a different phenotype (nuclear cataract). Similarly, Trp45 in GJA3 appears as a mutation hotspot, as p.Trp45Ser has previously been reported for nuclear cataract in a Chinese ADCC family. p.Thr56 (GJA8) and p.Trp45 (GJA3 ) are in the extracellular loop 1 (EL1) in their respective connexin proteins, which, along with EL2, are essential for gap junction formation, hemichannel docking, and regulating the voltage gating of the channels. Hence, residues in these regions seem crucial for maintaining eye lens transparency., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2022 Vanita, Goyal, Tibrewal and Ganesh.)

Infantile nystagmus syndrome (INS) is often characterized by an identifiable null zone. When the null zone is not in the straight-ahead gaze, a compensatory head posture (CHP) is adopted by the patient to achieve best possible vision. Various surgical procedures have been recommended to correct a CHP which is clinically predominant in one dimension of yaw (lateral rotation), pitch (anterior or posterior flexion/extension) or roll (lateral flexion). However, the presence of a complex CHP which is clinically evident in more than one dimension, warrants either a combination of multiple techniques or a stepwise approach. We report the case of a 26-year-old male with INS with an eccentric null and a multi-dimensional complex CHP of 30º left face turn, 20º right head tilt and 10º chin depression. The patient was managed by all four horizontal rectus muscle recession and resection with full tendon vertical transposition to address the face turn and head tilt. He underwent lateral rectus muscle (LR) recession with upward transposition and medial rectus muscle (MR) resection with downward transposition in the right eye. MR recession with upward transposition and LR resection with downward transposition were performed in the left eye. Postoperatively. the head posture improved significantly for both distance and near viewing. The chin depression also reduced after the procedure. He developed transient diplopia due to a small vertical deviation after the surgery, which was managed by prisms and fusional exercises. Thus, horizontal rectus muscle recession and resection combined with vertical transposition may be helpful to simultaneously improve the head tilt associated with the face turn, obviating the need for vertical rectus muscle or oblique muscle surgery.

Competing Interests: None

Congenital aniridia is a pan ocular disorder characterized by partial or total loss of iris tissue as the defining feature. Classic aniridia, however, has a spectrum of ocular findings, including foveal hypoplasia, optic nerve hypoplasia, nystagmus, late-onset cataract, glaucoma, and keratopathy. The latter three are reasons for further visual compromise in such patients. This entity is often due to mutations in the PAX6 (Paired box protein Pax-6) gene. Recently, aniridia-like phenotypes have been reported due to non-PAX6 mutations as in PITX2, FOXC1, FOXD3, TRIM44, and CYP1B1 as well wherein there is an overlap of aniridia, such as iris defects with congenital glaucoma or anterior segment dysgenesis. In this review, we describe the various clinical features of classic aniridia, the comorbidities and their management, the mutation spectrum of the genes involved, genotype-phenotype correlation of PAX6 and non-PAX6 mutations, and the genetic testing plan. The various systemic associations and their implications in screening and genetic testing have been discussed. Finally, the future course of aniridia treatment in the form of drugs (such as ataluren) and targeted gene therapy has been discussed., Competing Interests: None

Congenital superior oblique (SO) palsy is often associated with anomalies of its tendon, increased tendon laxity being the most common. Rarely, the tendon lies in an abnormal location nasal to the superior rectus (SR) muscle, either attaching to the sclera or to Tenon's capsule. We describe a case of a child who presented with abnormal head posture and exotropia. The orthoptic evaluation revealed a left hypertropia and V-pattern exotropia. The motility pattern and the Parks three-step test were suggestive of left-sided SO palsy. Intraoperatively, the left SO tendon was very lax and was absent from its usual insertion. Further exploration revealed it to be inserted entirely to the nasal border of the SR muscle, with no scleral attachment. This tendon was advanced to its normal attachment to the sclera, and 11 mm inferior oblique recession was also performed. Postoperative alignment was satisfactory., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Aim: To report the feasibility and outcomes of muscle transplantation combined with a unilateral recession-resection procedure for primary large-angle [≥60 Prism Diopters (PD)] exotropia., Methods: We retrospectively reviewed medical records of patients from three tertiary eye-care institutes who underwent unilateral recess-resect with muscle transplantation for primary treatment of large angle exotropia between August 2017 and July 2020. Motor and restorative success were defined as alignment ≤10PD of orthotropia and ≤12PD of manifest deviation, respectively, at the final follow-up. Patients with at least 3 months of follow-up were included., Results: Ten patients; six males and four females (median age 26 years) met the study criteria. The median follow-up was 12.89 months. The median preoperative exotropia reduced from 65PD (60 to 90PD) to 10PD (0 to 25PD) at final follow-up ( p = .0019). The median correction obtained for the entire procedure (recession + resection + muscle transplantation) was 3.05 (1.8 to 4.3) PD/mm. Motor and restorative success was achieved in 60% and 70% of the patients, respectively. The median abduction limitation was -1 (0 to -1) at the final follow-up and there were no palpebral fissure changes beyond 6 weeks postoperatively., Conclusions: Unilateral muscle transplantation combined with the recession-resection procedure could be a useful alternative for the management of large-angle exotropia.

Aims: To describe the clinical features, visual acuity and causes of ocular morbidity in children (0-18 years) with microphthalmos, anophthalmos, and coloboma (MAC) from North India., Methods: A retrospective study conducted between October 2017 and September 2018 in three tertiary eye institutes, part of the Bodhya Eye Consortium with consensus led common pro formas. Children with complete clinical data and without syndromic/systemic involvement were included. The clinical phenotype was divided into isolated ocular coloboma (CB), coloboma with microcornea (CBMC), colobomatous microphthalmos (CBMO), non-colobomatous microphthalmos (MO) and anophthalmos (AO)., Results: A total of 532 children with MAC were examined. Seventeen records were excluded due to incomplete data (0.2%). 515 children (845 eyes) were included: 54.4% males and 45.6% females. MAC was unilateral in 36% and bilateral in 64%. CB, CBMC, CBMO, MO and AO were seen in 26.4%, 31%, 22%, 8% and 12.5% of eyes, respectively. Nystagmus was found in 40%, strabismus in 23%, cataract in 18.7% and retinal detachment in 15%. Best-corrected visual acuity (BCVA) of <3/60 was seen in 62.4% eyes. Blindness (BCVA <3/60 in better eye) was seen in 42.8% of bilateral patients. Those with microcornea or microphthalmos with coloboma had worse BCVA (p<0.001). There were regional differences in the type of MAC phenotype presenting to the three institutes., Conclusion: The MAC group of disorders cause significant ocular morbidity. The presence of microcornea or microphthalmos with coloboma predicts worse BCVA. The variation of the MAC phenotype with the district of origin of the patient raises questions of aetiology and is subject to further studies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose : To report outcomes of muscle transplantation for recurrent/residual strabismus. Retrospective, multicentric, observational study.   Methods : We retrospectively reviewed records of all patients operated at three institutes who underwent transplantation of the resected muscle for re-operations for residual/recurrent strabismus from January 1, 2018, to December 31, 2019. Data were collected regarding age, gender, visual acuity, type of strabismus, fixation preference, associated amblyopia, the surgical procedure performed, preoperative and postoperative primary position deviation, limitation of ductions, associated intra-operative and post-operative complications. Surgical success was defined as heterotropia less than or equal to 8 PD, and cosmetic success was defined as manifest deviation ≤12 PD (at 6 weeks follow up). Results : During this period, we identified records of seven patients (5 men: 2 women, median age: 24 years) who underwent muscle transplantation for residual/recurrent strabismus. Six patients underwent extraocular muscle surgery for residual/recurrent exotropia (XT) and one for residual esotropia (ET). In all the patients, median pre-operative primary position deviation reduced from 40 prism diopters (PD) (range: 30 to 55 PD) to 8 PD (range: 6 PD ET to 10 PD XT) at six-weeks follow-up. Four patients had residual exotropia (10-16PD), two had orthotropia and one patient had small-angle esotropia (6PD) at the last follow-up. Excluding two patients who underwent supramaximal re-recession of lateral rectus (≥11 mm from insertion) and re-resection of medial rectus, 3/5 (60%) patients achieved surgical success, and all (100%) achieved cosmetic success at six-weeks-follow-up. There was mild (up to -1) limitation of duction in all patients except one patient (-2 limitation of abduction) who underwent re-recession of lateral rectus to 11 mm from insertion along with medial rectus re-resection and muscle transplant procedure. No intra-operative or post-operative complications were encountered. No patient reported postoperative diplopia. Conclusions : This study describes the feasibility and successful use of muscle transplantation procedure to correct residual/recurrent strabismus, with or without re-recession, especially in patients planned for surgery in one eye. However, larger prospective studies with longer follow-ups will be needed to establish long-term outcomes and correction achieved from this procedure, and comparison with other approaches for reoperations.

Purpose: To report surgical outcomes of patients with exotropic Duane retraction syndrome., Methods: A retrospective review of the medical records from patients with exotropic Duane retraction syndrome who underwent strabismus surgery and had at least 2 months of postoperative follow-up was conducted. Surgical success was defined as a postoperative horizontal deviation within 8 prism diopters (PD), abnormal head posture (AHP) less than 5 degrees, and a two-step decrease in overshoots., Results: Seventy-three patients with exotropic Duane retraction syndrome (38, 52% male, mean age 14 ± 7.9 years) met the study criteria. Unilateral type 3 Duane retraction syndrome was seen in 56 (77%) patients and type 1 in 14 (19%) patients. The mean follow-up period was 22 weeks (range: 8 to 209 weeks). Unilateral and bilateral lateral rectus recession were performed in 48 (65%) and 25 (34%) patients, respectively. In addition to recession, a lateral rectus Y-splitting was performed in 42 (56%) patients. Five patients underwent differential medial rectus and (larger) lateral rectus recession to alleviate severe globe retraction. The mean primary position reduced from 23 PD (CI: 19.6 to 26 PD) preoperatively to 9 PD (CI: 7.02 to 11.02 PD) postoperatively (P < .0001). Postoperatively 50% of patients were orthotropic in the primary position. Surgical success for primary position deviation, AHP, and overshoots were achieved in 74%, 81%, and 71% of patients, respectively., Conclusions: In the current study, type 3 Duane retraction syndrome was the most common subtype necessitating surgery for exotropic Duane retraction syndrome. Good surgical outcomes were obtained for various indications. Unilateral or bilateral lateral rectus recession was successful in improving motor alignment and AHP. The addition of lateral rectus Y-splitting corrected overshoots greater than grade 2 in most patients with exotropic Duane retraction syndrome. [J Pediatr Ophthalmol Strabismus. 2021;58(1):9-16.]., (Copyright 2021, SLACK Incorporated.)

A 43-year-old man developed double vision, esotropia, and abduction limitation after excision of a doubleheaded pterygium. Exploration during strabismus surgery 4 months later revealed a partially severed lateral rectus muscle and extensive conjunctival scarring. Direct injury to the lateral rectus muscle during pterygium surgery is extremely rare. Prevention and management strategies are discussed. [J Pediatr Ophthalmol Strabismus. 2020;57:e96-e99.]., (Copyright 2020, SLACK Incorporated.)

Purpose: To report a case of falsely dampened visual evoked responses in a patient of Usher syndrome after retinal detachment surgery secondary to probable intraocular silicone oil., Methods: Retrospective observational case report., Case Description: A 16-year-old boy with Usher syndrome developed rhegmatogenous retinal detachment in the left eye. He underwent a successful retinal detachment surgery with silicone oil tamponade. On his postoperative follow-up visit, poor vision was noted by our optometrist. A flash stimulus visual evoked response was done, which showed marked delayed latency and reduced amplitude. Marked improvement in the flash stimulus visual evoked response potentials and waveforms was noted after silicone oil removal., Conclusion: Intraocular silicone oil could be responsible for this false delay in the latency and reduction in flash stimulus visual evoked response amplitudes. Assessment of flash stimulus visual evoked responses in the presence of silicone oil after vitreoretinal surgery may produce unreliable responses.

Competing Interests: None

V pattern arises when the eyes diverge more in up-gaze, as compared to down-gaze, leading to vertical gaze incomitance of a horizontal strabismus. In most cases, the magnitude of V pattern is small to moderate, and a single surgical procedure for the same is enough to correct it. We describe a rare case where an extra-large V pattern (>60 Prism Dioptres (PD)) was present along with large exotropia (70 PD). Craniosynostosis or facial asymmetry was not present. The extra-ocular motility evaluation revealed mild over-elevation in adduction and extreme divergence in up-gaze. Examination of the fundus showed ex-cyclotorsion of both the globes. The V pattern was managed by bilateral inferior oblique muscle recession and full thickness upshift of both lateral rectus muscles. The exotropia was treated by bilateral lateral rectus recession and right eye medial rectus resection. Postoperatively, both the exodeviation and V pattern reduced to less than 10PD. The ex-cyclotorsion was also reduced after the surgery. There was restoration of binocularity and the near stereopsis improved to 170 secs of arc. Thus, extra-large V pattern strabismus may need a combination of procedures to achieve a good motor and sensory outcome.

The anterolateral soft tissue envelope of the knee has long been recognised as a key stabilising structure. Once the mainstay of operative management of anterior cruciate ligament (ACL) rupture, interest in the area fell away with the advent of intraarticular arthroscopic reconstruction. Renewed interest in these structures together with cadaveric data evidencing the potential for restoration of near normal knee biomechanics following ACL and anterolateral soft tissue reconstruction has driven current concepts and development of operative techniques. Options for current anterolateral augmentation techniques in primary ACL reconstruction plus patient selection considerations are reviewed, together with an outlook at future research key to development of this area., Competing Interests: None., (Crown Copyright © 2019 All rights reserved.)

Purpose: To evaluate the accuracy of Spot photoscreener (PS) as a noncycloplegic photorefractor in detecting amblyopia risk factors (ARFs) in preschool children in an Indian eye clinic setting. Also, to derive appropriate cutoff values for screening to obtain maximum sensitivity and specificity of the device in detecting ARF., Methods: This was a cross-sectional study conducted in the outpatient pediatric eye clinic at a tertiary eye care institute. A Spot PS was used to screen all the children between the ages of 6 months and 5 years that presented to the eye clinic from August 2018 to October 2018. This screening was followed by a complete eye examination, including cycloplegic refraction by a masked examiner. The 2013 American Association for Pediatric Ophthalmology and Strabismus (AAPOS) guidelines were considered the standard cutoff values for clinically significant refractive error in children younger than 5 years of age., Results: The study comprised of 219 children. The Spot PS diagnosed 135 (61.64%) children with ARF as compared with 124 (56.62%) children detected by clinic examination. For ARF detection, the Spot photoscreeneer had 85.48% sensitivity, 69.47% specificity, 78.52% positive predictive value and 78.57% negative predictive value. The sensitivity for detection of strabismus and hypermetropia was very low (42% and 36%, respectively). The 95% limits of agreement ranged from -5.48 to +5.59 diopters (D) with a bias of 0.06 D for spherical equivalent between noncycloplegic photorefraction and cycloplegic refraction., Conclusion: The Spot PS may be used as a screening tool to detect ARF in children younger than 5 years of age keeping its limitations in consideration. However, the performance can be improved by modifying the cutoff values for the referral., Competing Interests: None