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Purpose: To determine whether the clinical features of intermittent exotropia (IXT) needing muscle surgery were different in the ophthalmologist-detected and non-specialist-detected groups (including parents).Methods: Medical records of 218 children (mean age: 5.9 ± 1.4 years) with IXT of ≥ 20 prism diopters (PD) were reviewed retrospectively. The angles of deviation were measured using the prism and alternate cover test and assessed by two ophthalmologists using photographs with a translucent occluder (photographic angle). The IXT subtype, fusional control, stereopsis, suppression, and spherical equivalent (SE) were compared between the ophthalmologist-detected and non-specialist-detected groups.Results: Mean 25.8 ± 6.8 PD of distant angle of IXT was first detected by the ophthalmologist in 41 patients (18.8%) and the non-specialists in 177 patients (81.2%). The deviated eye was more myopic in the ophthalmologist-detected than non-specialist- detected group (-0.77 ± 1.59 diopters [D] vs. -0.19 ± 1.48 D, p = 0.03). There were no other differences between the two groups. A comparison of 39 age- and non-dominant eye SE-matched pairs demonstrated that the measured angles for distant and near fixation were smaller in the ophthalmologist-detected than non-specialist-detected group (24.0 ± 6.8 PD vs. 28.5 ± 6.4 PD and 26.9 ± 6.6 PD vs. 31.0 ± 6.4 PD, respectively, p < 0.01), while the remaining characteristics, including the photographic angle, were similar.Conclusions: In cases with small angles of deviation or myopia, IXT with angles requiring surgical correction were commonly first detected by ophthalmologists during examinations.

Purpose: To evaluate the validity of the photographic assessment with a translucent cover that is clinically available for the evaluation of intermittent exotropia. Methods: Photographs of 270 patients who cooperated for the prism and alternate cover test (PACT) were reviewed. Full-face images were obtained with a digital camera while a translucent cover was placed in front of either eye. The change in distance from the medial canthus to the nasal limbus with occlusion was measured and the photographic angle was estimated by three independent ophthalmologists based on representative photographs. These two measurements were correlated with the angle measured using the PACT, and clinical features related to the discrepancy between the photographic angle and the angle measured with the PACT were determined. Results: Patients with intermittent exotropia of 27.0 ± 6.1 prism diopters (PD) showed a 4.5 ± 3.3 mm exodrift and an estimated angle of 29.0 ± 4.3 PD on the photographs with occlusion. The exodrift distance and photographic angle were positively correlated with the angle of PACT ( r = 0.256, P < .001 and r = 0.546, P < .001, respectively). Of the 47 patients with a discrepancy of greater than 8 PD, 38 patients (80.9%) were regarded as having a photographic angle that was larger than the angle of PACT, which was more common in older patients, in those with a small distance angle, and when taking off the spectacles. Conclusions: Photographs with a translucent cover can reveal the latent components of intermittent exotropia. However, the photographic angle might differ from the real angle, particularly in older patients with a small angle and with the spectacles off. [ J Pediatr Ophthalmol Strabismus . 2021;58(5):331–338.]

Ametropia is reported as a common ophthalmic manifestation in craniosynostosis. We retrospectively compared childhood refractive error and ocular biometric features of fibroblast growth factor receptor (FGFR)-related syndromic craniosynostosis patients with those of non-syndromic craniosynostosis and control subjects. Thirty-six eyes (18 patients) with FGFR-related syndromic craniosynostosis, 76 eyes (38 patients) with non-syndromic craniosynostosis, and 114 eyes (57 patients) of intermittent exotropes were included in the analysis. Mean age at examination was 7.82 ± 2.51 (range, 4–16) years and mean spherical equivalent was -0.09 ± 1.46 Diopter. Mean age and refractive error were not different between groups, but syndromic craniosynostosis patients had significantly longer axial length, lower corneal power, and lower lens power than other groups (p p p

To quantify a passive range of cyclorotation using a smartphone application and evaluate its associations with fundus torsion and rectus muscle cyclorotation in superior oblique palsy (SOP) and V-pattern strabismus. Fifty-two patients showing overelevation in adduction (30 with congenital SOP and 22 with V-pattern strabismus) underwent forced cyclorotation on the photographs. A photograph of the globe was taken in maximally excyclorotated and incyclorotated positions after marking at the 6 and 12 o’clock limbus under general anaesthesia, and the rotational alignment of these markings was read using the toriCAM application. The degrees of forced cyclorotation were compared between the two groups. Disc-fovea angle on fundus photographs and rectus muscle cyclorotation in the coronal view on orbital computed tomography were correlated with the range of forced excyclorotation. The range of forced excyclorotation was greater in V-pattern strabismus than that in SOP (58.5° vs. 46.8°, p

Background To determine whether there is an asymmetry in bilateral sternocleidomastoid muscle (SCM) thickness in patients with unilateral congenital superior oblique palsy (SOP) and its association with surgical results. Methods The medical records of 186 patients with head tilt secondary to unilateral SOP, who were evaluated for the status of the SCM with neck ultrasound or magnetic resonance imaging, were reviewed. The SCM asymmetry index was calculated as a bilateral difference in the maximal muscle thickness divided by each tilted-side SCM thickness. The presence of SCM asymmetry, defined as an index of >10%, and its relationship to residual torticollis ≥5° after SOP surgery were assessed. Results Of 186 patients with a median age of 1.2 years, SCM asymmetry was present in 102 (54.8%) patients (6.8 ± 1.9 mm for the SOP side vs. 6.6 ± 2.1 mm for the tilted side). The SCM asymmetry did not differ according to age, amount of head tilt or hypertropia. In the patients with SCM asymmetry, more patients (87.3%) underwent physiotherapy than those without asymmetry (61.9%) (P = 0.021). In 99 patients who underwent surgery for SOP, the resolution of torticollis was not significantly different between patients with and without SCM asymmetry (87.2% vs. 76.9%, P = 0.184). Conclusions Nearly half of the patients with congenital SOP had SCM thickness asymmetry that was already determined at a young age. However, the surgical results did not differ significantly with respect to SCM asymmetry when physiotherapy was combined. Thus, SOP surgery can be considered despite preoperative SCM asymmetry.

Orthokeratology is a procedure involving the use of reverse-geometry lenses to temporarily correct refractive errors. Switching from spectacles to orthokeratology lenses may influence binocular visual function and accommodation. This is the first report of orthokeratology lens–associated acquired esotropia, a form of distance esotropia, in an adolescent with myopic anisometropia. [ J Pediatr Ophthalmol Strabismus . 2022;59(1):e7–e10.]

Municipal wastewater provides a representative sample of human fecal waste across a catchment area and contains a wide diversity of microbes. Sequencing wastewater samples provides information about human-associated and medically-important microbial populations, and may be useful to assay disease prevalence and antimicrobial resistance (AMR).Here, we present a study in which we used untargeted metatranscriptomic sequencing on RNA extracted from 275 sewage influent samples obtained from eight wastewater treatment plants (WTPs) representing approximately 16 million people in Southern California between August 2020 – August 2021. We characterized bacterial and viral transcripts, assessed metabolic pathway activity, and identified over 2,000 AMR genes/variants across all samples. Because we did not deplete ribosomal RNA, we have a unique window into AMR carried as ribosomal mutants. We show that AMR diversity varied between WTPs and that the relative abundance of many individual AMR genes/variants increased over time and may be connected to antibiotic use during the COVID-19 pandemic. Similarly, we detected transcripts mapping to human pathogenic bacteria and viruses suggesting RNA sequencing is a powerful tool for wastewater-based epidemiology and that there are geographical signatures to microbial transcription. We captured the transcription of gene pathways common to bacterial cell processes, including central carbon metabolism, nucleotide synthesis/salvage, and amino acid biosynthesis. We also posit that due to the ubiquity of many viruses and bacteria in wastewater, new biological targets for microbial water quality assessment can be developed.To the best of our knowledge, our study provides the most complete longitudinal metatranscriptomic analysis of a large population’s wastewater to date and demonstrates our ability to monitor the presence and activity of microbes in complex samples. By sequencing RNA, we can track the relative abundance of expressed AMR genes/variants and metabolic pathways, increasing our understanding of AMR activity across large human populations and sewer sheds.

The authors found the changes of myelinated retinal nerve fibers in one pair of identical twins with nonsyndromic craniosynostosis and two patients with Crouzon syndrome, who were at risk for impaired lamina cribrosa barrier function. This is the first report of progressive and presumed acquired myelinated retinal nerve fibers in craniosynostosis. [ J Pediatr Ophthalmol Strabismus . 2021;58(6):e40–e43.]

PURPOSE We previously reported costs and outcomes of the Children's Eye Care Adherence Program (CECAP1), a social worker intervention designed to improve adherence to eye care for underserved children in urban Philadelphia. Using cost findings from CECAP1, we revised the intervention to reduce costs. The aim of this study was to evaluate costs and effectiveness of the revised intervention (CECAP2). DESIGN Retrospective cohort study. METHODS Records of children needing ophthalmic follow-up after 2 community-based vision screening programs were reviewed. We modified CECAP1 to prioritize children more likely to visit, decreased phone calls and scheduling attempts, better documented children already followed by other doctors, and constricted our geographic catchment area for better accessibility. Cost was calculated using time spent executing CECAP2 by our salaried social worker. Effectiveness was defined as the percentage of patients completing at least 1 follow-up visit within the recommended time frame. RESULTS Of 462 children referred to CECAP2 from our in-school and on-campus screening programs, 242 (52.4%) completed subsequent recommended eye examinations, a proportion identical to our prior report (52.3%). Social worker time per patient was 0.8 hours; a significant reduction from the previous 2.6 hours (P < .01). Cost per patient was $32.73; a significant reduction compared to the previous $77.20 (P < .01). CONCLUSIONS Programmatic changes to reduce social worker intervention time and target potential patients by likelihood to attend along with constriction of the catchment area led to reduced costs by more than 50%, without impairing CECAP effectiveness.

To determine whether there is asymmetry in the lateral rectus (LR) muscle attachment between both eyes in patients with intermittent exotropia (IXT) with a non-dominant eye, but without amblyopia or anisometropia. In total, 109 patients who underwent bilateral lateral rectus recession for IXT were included, 81 with and 28 without eye dominance. The limbus-insertion distance and tendon width of the LR muscle were measured intraoperatively using callipers. The insertion-equator distance (presumed arc of contact), area of contact (arc of contact × tendon width), and torque value (radius of globe × arc of contact) of the LR muscle were calculated based on intraoperative measurements and axial length measured using a partial interferometer. Parameters regarding LR muscle attachment were compared between fellow eyes and between groups. Mean measurements in all parameters related to LR muscle attachments other than tendon width were not different between the two eyes or between groups. The mean tendon width of the non-dominant eye was 9.2 ± 0.7 mm, narrower than the 9.4 ± 0.5 mm width in either eye of patients without dominance (p = 0.020). However, there was no difference in all parameters in 21 pairs of patients after matching. The proportion of patients who showed binocular discrepancies in attachment measurements beyond that attributable to potential measuring errors did not differ between the two groups. Structural parameters related to LR muscle attachments did not differ based on eye dominance, suggesting that the anatomic structure of LR muscle attachments is not responsible for eye dominance in IXT.

Purpose To assess the relationship between eye position and anesthesia depth using the bispectral index (BIS) value, a parameter derived from electroencephalography data. Methods We investigated the relationship between BIS value and eye position in 32 children who underwent surgery for epiblepharon under general anesthesia. BIS values were recorded continuously throughout the procedure (from induction to awakening). Eye positions were video-recorded and analyzed after surgery. The vertical position of each eye was scored according to its height in relation to the medial canthus. An eye position in which the upper eyelid covered one-third of the cornea was defined as a significant ocular elevation. Results The BIS value correlated inversely with the end-tidal concentration of each anesthetic agent, whereas it correlated positively with the eye elevation score (eye position = 0.014 × BIS + 0.699, p = 0.011). The mean eye position score was significantly greater in patients whose BIS values were over 65. Eleven patients (34.4%) had significant ocular elevation; their mean concurrent BIS value was 61.6. Two of these patients had elevation during surgery and 9 had elevation during emergence from anesthesia. Conclusions We found that high BIS values were correlated with low levels of anesthetic concentration and high eye position, suggesting that BIS monitoring may be useful for predicting eye position during anesthesia. Particular attention must be given to eye position during ophthalmic surgery. Anesthesia depth can be maintained by assuring that the BIS value remains below 65.

Ocular complications of adenotonsillectomy are rare. The authors describe a 6-year-old boy who developed mydrasis and limitations of supraduction and infraduction after adenotonsillectomy. This was attributed to the hemorrhagic compression of the nerve in the cavernous sinus. This is the first report of pupil-involving oculomotor nerve palsy following adenotonsillectomy. [ J Pediatr Ophthalmol Strabismus . 2019;56:e76–e78.]

We sought to determine whether the myopic progression of patients with central precocious puberty (CPP) who were undergoing treatment differed from that of their healthy peers with normal pubertal onset and progression. Eighteen girls with CPP and 14 age-matched controls who underwent regular ophthalmic examinations for at least 1 year were included. All the CPP patients received a 3.75 mg leuprolide acetate depot subcutaneously every 28 days. The spherical equivalent (SE) and axial length (AL) for myopia progression and the pubertal parameters (height, body weight, body mass index, Tanner stage, and bone age) were compared between the two groups. Of 32 subjects with a mean age of 8.6 ± 0.7 years, the SEs and ALs did not differ at baseline between the two groups, which had similar weight and similar body mass index. After 1 year, both the CPP patients and controls showed myopic progression, with an average myopic shift of −0.73 ± 0.48 diopters (D) and AL elongation with a mean change of 0.44 ± 0.61 mm. The SE and AL changes over 1 year were greater in the controls than those in the CPP patients, which was not statistically significant (–0.85 ± 0.55 D vs. –0.64 ± 0.41 D and 0.55 ± 0.89 mm vs. 0.35 ± 0.22 mm, respectively). The change in AL correlated significantly with the change in the height (β = 0.691, p = 0.039). In this 1-year study, the CPP patients with treatments trended to show less myopic progression than the controls.

Childhood abducens nerve palsy can occur as a result of trauma, tumour, vasculopathic disease, elevated intracranial pressure, infection, inflammation, and congenital or idiopathic causes. The authors present two cases of unilateral abduction deficit secondary to a recent trans-sutural distraction osteogenesis (TSuDO) operation for craniosynostosis. After distractor removal, the problem resolved spontaneously over 2–4 months in both cases. This is a first reported case of sixth nerve palsy as a complication of TSuDO operation.

To evaluate the impact of myopic keratorefractive surgery on ocular alignment. This prospective study included 194 eyes of 97 myopic patients undergoing laser refractive surgery. All patients received a complete ophthalmic examination with particular attention to ocular alignment before and 3 months after surgery. Patients with a mean age of 26.6 years and a mean refractive error of −4.83 diopters (D) myopia were treated. Asymptomatic ocular misalignment was present preoperatively in 46 (47%) patients: a small-angle heterophoria (1–8 prism diopters, PD) in 36%; and a large-angle heterophoria (>8 PD)/heterotropia in 11%. Postoperatively, the change in angles of 10 PD or greater occurred in 3% for distance and 6% for near fixation: in 7% of the patients with orthophoria, in 3% of those with a small-angle heterophoria, and in 18% of those with a large-angle heterophoria/heterotropia. No patient developed diplopia. The preoperative magnitude of myopia or postoperative refractive status was not related to the change in ocular alignment. The higher anisometropia was associated with a decrease in deviation (P=0.041 for distance and P=0.002 for near fixation), whereas the further near point of convergence tended to be related with an increase in near deviation (P=0.055). Myopic refractive surgery may cause a change in ocular alignment, especially in cases with a large-angle heterophoria/heterotropia. There is also a chance of improvement of misalignment in patients with anisometropia.

Purpose: To determine whether changes in ocular alignment following general anesthesia, as measured by interpupillary distance, can be used as a predictor for surgical outcomes in children with intermittent exotropia. Methods: The authors obtained digital photographs of 40 children with exotropia and 20 children with epiblepharon (control group) before and immediately after induction of general anesthesia in the primary supine position. Differences in the anatomic interpupillary distance (aIPD) for each patient were measured and compared with the preoperative angles of deviation. They were also correlated with surgical outcomes on the first day and 1 year after surgery. Results: All 60 patients demonstrated an increase in aIPD following general anesthesia. The mean change in aIPD in patients with exotropia was similar to that in patients with epiblepharon (3.78% ± 2.53% and 3.15% ± 1.05%, respectively). In patients with exotropia, there was a significant positive linear correlation between the preoperative distance deviation (P) and the change in eye position (A): A = 0.362 P – 4.488, r 2 = 0.476 ( P < .001). Five (71%) of seven patients whose changes were outside the 80% confidence interval for expected values had poor surgical outcomes on the first postoperative day and four had unsatisfactory results 1 year after surgery. Conclusions: Changes in aIPD following general anesthesia were strongly correlated with preoperative angle of deviation. Therefore, they may be a useful predictor of surgical outcomes in children with exotropia.

Nonrefractive accommodative esotropia is a condition that is diagnosed when an emmetropically corrected patient with a high accommodative convergence to accommodation (AC/A) ratio shows orthotropia at distance fixation but displays more than 10 prism diopters of esotropia at near fixation which can be corrected with a +3.00 diopter add lens. The AC/A ratio is the amount of induced convergence that occurs when accommodation is exerted. In normal eyes, the ratio is thought to remain stable without change until presbyopia, after which the AC/A ratio increases [1-3]. However, the change of the AC/A ratio with age in nonrefractive accommodative esotropia has not yet been studied. Nonrefractive accommodative esotropia can be treated with bifocal lenses or miotics [4-9]. Miotics pharmacologically decrease accommodative convergence and correct esotropia at near fixation. Long term effects of miotics have been studied in detail and reports of iris cysts, cataracts, retinal detachment, iridocyclitis and punctal occlusion are abundant in the literature and thus are used only for diagnostic purposes or for short term correction. Bifocal lenses horizontally divide the visual field with a +2.50 - +3.00 diopters add lens in the lower portion and uses the upper and lower portions for distance and near fixation, respectively. Bifocal glasses induce orthotropia for both far and near vision and decrease chances of amblyopia with appropriate development of stereopsis. As patients grow older, some can discontinue the use of bifocal lenses due to spontaneous normalization of the AC/A ratio [10], but others need to keep their bifocal lenses or undergo strabismus surgery in an attempt to eliminate the need for bifocals [11-13]. Surgical options include augmented recession, slanted recession, and recession with posterior fixation suture of the medial rectus muscles [12,14,15]. The AC/A ratio can be calculated in several ways, among which only the lens gradient method gives a true estimate of the ratio. In the lens gradient method, the change in stimulus to accommodation is produced by means of an ophthalmic lens, not a change in viewing distance. Franceschetti and Burian [16] reported that the normal range of the AC/A ratio by the lens gradient method is lower than that by the heterophoria method. The heterophoria method does not account for proximal convergence, which is kept constant in the lens gradient method by performing both measurements at the same distance [17]. Previous studies did not evaluate the AC/A ratio by the lens gradient method, but by heterophoria methods [9,18]. However, in this study we computed the AC/A ratio by the lens gradient method.

Purpose: To evaluate changes in the angle of deviation after spectacle correction in patients who had hyperopia and intermittent exotropia (X(T)) and to determine whether the changes and surgical outcomes differ when compared with those of myopic and emmetropic X(T). Methods: One hundred fourteen patients with X(T) were recruited and allocated into three groups: X(T) with hyperopia (group I; 38 patients), X(T) with emmetropia (group II; 35 patients), and X(T) with myopia (group III; 41 patients). After at least 6 months wearing spectacles, changes in exodeviation were compared. The results of surgery based on the spectacle-corrected distance angle and the ratios of accommodative convergence over accommodation (AC/A) were also assessed. Results: With spectacle correction, the mean exodeviation increased significantly in group I, but did not change in groups II or III. Thirteen patients in group I (34%) showed a more than 10 prism diopters (PD) exotropic shift after wearing spectacles. The mean AC/A ratio in group I was 2.63 (PD/D), whereas in groups II and III the ratios were 4.03 and 4.06, respectively. There was no difference in surgical results among the three groups. Conclusion: Although hyperopic correction in patients with X(T) resulted in a limited increase in exodeviation with a subnormal AC/A ratio, one-third of the patients experienced a significant increase in exodeviation. A spectacle correction trial should be considered before surgery in patients with hyperopia and X(T).

Purpose: To analyze the practical aspects and advantages of one-stage adjustable surgery under topical anesthesia in concomitant horizontal strabismus. Methods: A retrospective review of 363 patients was completed to assess (1) the frequency of need to perform adjustment, (2) the amount and pattern of adjustment, and (3) the final alignment at least 6 months after surgery. Intraoperative adjustment was performed strictly toward the aim of orthophoria or slight overcorrection (heterophoria < 6 prism diopters [PD]) while avoiding diplopia. Results: Of the 363 patients, 261 (72%) required intraoperative adjustment. Of these, 85% of exotropes underwent a decreased amount of surgery compared with the standard amount, whereas 58% of esotropes underwent an increased amount of surgery. Forty-two patients underwent a one-muscle surgery instead of the scheduled two-muscle surgery, and all had less than 35 PD preoperative angle of deviation. Success rates were 83% in all patients with one-stage adjustable sutures and 87% in patients who underwent adjustment. In 42 patients with one-muscle surgery instead of two-muscle surgery, 32 (76%) obtained successful results. Conclusion: Intraoperative adjustment was effective in concomitant horizontal strabismus surgery and can provide the opportunity to avoid a large overcorrection, especially in cases with moderate angle horizontal muscle surgery.

PURPOSETo evaluate epithelial healing time, postoperative pain, corneal haze, and visual and refractive outcomes following the application of cultured sheets of human allogeneic epidermal keratinocyte (CEAK) onlays on the photorefractive keratectomy (PRK) -ablated corneal surface as dressing material. METHODSIn total, 204 eyes from 103 patients with myopia or myopic astigmatism were prospectively evaluated for 6 months after PRK. The ablated cornea was dressed in three different ways. Specifically, CEAK onlays were placed in 80 eyes (CEAK group), CEAK with amniotic membrane (AM) strips in 63 eyes (CEAK with AM group), and therapeutic contact lenses only in 61 eyes (control group). All eyes were covered with bandage contact lens after the operation. Contact lens removal time, intensity of postoperative pain score on postoperative day 2, corneal haze, Snellen visual acuity, and remaining refractive errors were measured. RESULTSThe mean contact lens removal time was shorter in the CEAK with AM group (1.84±0.72 days) compared to the control (2.77±1.59 days) and CEAK only (2.24±0.79 days) groups (P CONCLUSIONSThe CEAK onlay with AM facilitates epithelial healing, and is thus a good candidate dressing material to decrease the epithelial healing time after PRK. However, this onlay method did not affect the intensity of postoperative pain or final visual outcomes after surgery. [J Refract Surg. 2008;24:826-832.] ABOUT THE AUTHORS From the Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine (Chung, E.K. Kim, Ryu, Lee); and Balgeunsesang Ophthalmology Clinic (J.K. Kim), Seoul, Korea. This study is supported by a faculty research grant of Yonsei University Research Fund of 6-2004-1036. The authors have no commercial or proprietary interest in the materials presented herein. Correspondence: Hyung Keun Lee, MD, PhD, Institute of Vision Research, Dept of Ophthalmology, Yonsei University College of Medicine, Yongdong Severance Hospital, 146-92 Dogok-Dong, Kangnam-Ku, Seoul, Korea. Tel: 82 2 3497 3440; Fax: 82 2 3463 1049; E-mail: shadik@yumc.yonsei.ac.kr Received: January 15, 2007 Accepted: November 7, 2007 Posted online: March 31, 2008

The ocular and systemic abnormalities of nonsyndromic craniosynostosis are often considered to be less severe than those of syndromic craniosynostosis and are less well described. The purpose of this article was to describe the frequency and nature of ophthalmic abnormalities in children treated for nonsyndromic craniosynostosis by expansion cranioplasty. A retrospective review identified 88 consecutive children with nonsyndromic craniosynostosis who underwent expansion cranioplasty with distraction osteogenesis. Assessment of presence and type of strabismus, refractive error, and amblyopia before and 6 months after surgery was recorded. Children with a mean age of 24.4 months were treated for nonsyndromic craniosynostosis (27 with coronal and 61 with sagittal and/or lambdoid). One-fourth of the patients had a fixation preference. Significant refractive errors were found in 45 (51%) of the 88 patients: hyperopia in 27%, myopia in 5%, and astigmatism in 35%. Anisometropia was present in 20%. Of the 85 patients who completed orthoptic examination, 48 (56%) had strabismus: exodeviation in 26%, esodeviation in 14%, and vertical deviation in 5%. Fourteen patients (16%) had abnormal head posture. Significant refractive error and strabismus were more likely to occur in cases with coronal synostosis. The procedures used for cranial vault expansion improved the abnormal head posture but did not affect the refractive error or ocular misalignment. Of children with nonsyndromic craniosynostosis who need neurosurgical correction, more than half were found to have significant refractive error and strabismus. Our findings support the importance of ophthalmic evaluation in these children.

Purpose: To report a case of monocular elevation deficiency as the presenting manifestation of systemic lupus erythematosus (SLE). Case summary: A 23-year-old, otherwise healthy female presented with a 3-day history of vertical diplopia and headache. She had a left hypotropia, which worsened in adduction and supra-duction and a profound inferior oblique underaction (-3). Magnetic resonance imaging showed an enhancement around the left superior oblique muscle and multiple infarctions in the left midbrain. On repetitive serological tests, anemia, lymphopenia, and anti-phospholipid antibody were positive. A presumptive diagnosis was a myositis of left superior oblique muscle and hyper-coagulation related with anti-phospholipid antibody. Two months after high-dose steroid treatment, the vertical diplopia was resolved. Five months later, the left hypotropia recurred as a more severe form with the inability to elevate the left eye in all directions. In addition, the infarction associated with vasculitis recurred in the left midbrain. As the treatment with high-dose steroid failed to relieve her ocular symptoms, recession of the left inferior rectus was performed 8 months later. One month after the surgery, she developed multiple lesions of erythematous nodosa with tenderness. Skin biopsy of the lesion in the fingers showed the histological findings consistent with lupus. Conclusions: Eye movement abnormality can be an initial manifestation of SLE, which should be considered as a differential diagnosis especially in young female patients. J Korean Ophthalmol Soc 2016;57(1):161-166

Purpose: To evaluate the effect of patching on ocular alignment in children with unilateral amblyopia. Methods: We evaluated the change in ocular alignment during and after patching in patients who had started amblyopia treatment with patching, and analyzed the aspects of change according to the cause and severity of amblyopia, type and magnitude of deviation, type of refractive error, and age at initiation. A change of eight prism diopters (PD) or more in horizontal deviation, or two PD or more in vertical deviation was considered significant. Results: A total of 209 patients were enrolled; 135 had amblyopia associated with anisometropia, 50 with strabismus, 19 with combined cause, and 5 with deprivation. After patching, there was no change in distant deviation in 177 patients (84.7%), while a decrease was noted in 23 patients (11.0%) and an increase in nine patients (4.3%). The angle of deviation decreased in 7.4% of anisometropic amblyopia, 20.0% of strabismic amblyopia, 10.5% of combined amblyopia, and 20.0% of deprivation amblyopia. The angle of deviation increased in 4.4% of anisometropic amblyopia, 5.3% of combined amblyopia, and 40.0% of deprivation amblyopia. The angle of deviation decreased in 24.2% of exodeviation, and 21.6% of esodeviation, but there was no change in vertical deviation among the studied patients. The angle of deviation decreased in 31.9% of patients with deviation greater than 8 PD. The change did not differ according to severity of amblyopia, type of refractive error, or age. Among the successes, decrease in deviation was more common until they achieved equal visual acuity between both eyes, while the increase during tapering of patching. Conclusions: Change in ocular alignment may occur after patching in some patients with amblyopia, and seems to be more frequent in cases associated with horizontal deviation greater than 8 PD. J Korean Ophthalmol Soc 2016;57(2):302-309

To assess the presence and extent of photophobia in children with intermittent exotropia (X[T]) using the contrast sensitivity test. Fifty-eight children with X(T) and 34 normal controls were studied with the functional acuity contrast test. Each participant viewed the stimuli of contrast monocularly and binocularly under photopic and mesopic conditions, performed with and without glare. Photophobia was defined as a reduction of contrast sensitivity caused by glare light. We compared the photophobia of children with X(T) to that of normal controls, and to the photophobia 3 months after muscle surgery. With stimuli of glare, the contrast sensitivity of children with X(T) was suppressed at intermediate spatial frequencies under mesopic condition (p = 0.006 for 6 cycles per degree [cpd], p = 0.027 for 12 cpd), whereas that of normal controls showed no difference. It occurred when X(T) patients viewed targets binocularly, and significantly improved after strabismus surgery (p = 0.003 at 6 cpd). The measured photophobia of X(T) was strongly correlated to the photophobia symptoms reported by parents (p = 0.002). The mesopic contrast sensitivity with glare can represent the photophobia of children with X(T). Contrast sensitivity may be a useful measure for monitoring symptoms related to X(T).

To report the incidence of, and change in ocular misalignment following topical anesthetic cataract surgery.Prospectively, 160 consecutive patients who were scheduled for cataract surgery under topical anesthesia were evaluated. All patients had a complete ophthalmic examination, including ocular alignment evaluation, just before and 1 day, 1 week, 3 weeks, and 2 months after cataract surgery.Preoperatively, 26 patients had ocular misalignment. Mean deviation in these preexisting misalignment was 7.2 +/- 6.8 prism diopters (PD). Postoperatively, the angle of deviation improved to 5.4 +/- 7.4 PD. Acquired ocular misalignment after cataract surgery occurred in 12 of 160 patients (8%) at 1 day, and seven of 131 (5%) at 2 months. None of these seven patients sought medical attention for the diplopia.The overall incidence of topical anesthesia-related change in ocular alignment after uneventful cataract surgery was 5%. However, no patients had symptomatic diplopia. Topical anesthetic cataract surgery could abolish the risk of postoperative diplopia and improve the heterophoric status of preexisting misalignment.

Purpose: To report two patients with positive ice tests who had diplopia and blepharoptosis caused by something other than ocular myasthenia gravis. Case summary: A 35-year-old female presented with a one-week history of inability to adduct the left eye and left blepharoptosis. Although the ice test was positive, serum anti-acetylcholine receptor binding antibody and the repetitive nerve stimulation test were negative. Brain angiography showed an aneurysm of the left posterior communicating artery, leading to the diagnosis of left pupil-sparing oculomotor nerve palsy. A 25-year-old female presented with an 8-month history of intermittent horizontal diplopia and blepharoptosis in the right eye. The ice test was positive, however serum anti-acetylcholine receptor binding antibody and the repetitive nerve stimulation test were negative. Anti-nuclear antibody was positive (titer 1:160). Conclusions: The ice test is a useful screening test for myasthenia gravis. However, a series of differential diagnoses including blepharoptosis and ocular motility disorder should be considered because these conditions also show a positive result in the ice test. J Korean Ophthalmol Soc 2015;56(2):309-315

Purpose: Nystagmus is not considered a good indication for laser refractive surgery. However, we report 2 cases with congenital nystagmus that underwent a safe procedure due to improvement of laser firing rate and eye tracker. Case summary: Two myopic patients with congenital nystagmus underwent transepithelial photorefractive keratectomy with the Schwind Amaris laser platform using an eye tracker. The laser ablations were performed under topical anesthesia without any mechanical eyeball fixation. A 30-year-old man with a history of muscle surgery at 11 years of age had a conjugate, 4 Hz right beating jerk nystagmus. His preoperative refractive error was -8.50 D sph = –0.50 D cyl x 160 x 20/30) in the right eye, and –6.00 D sph = –0.75 D cyl x 30 x 20/25) in the left eye. A 19-year-old man had a conjugate, 3 Hz pendular nystagmus. His refractive error was –5.25 D sph = –2.50 cyl x 175 x 20/30) in the right eye, and –4.25 D sph = –2.50 D cyl x 180 x 20/30) in the left eye. Both patients underwent a well-centered laser ablation without any problems. Six months after surgery, uncorrected visual acuity was 20/25 or better, and refractive error was within ±0.50 D in all 4 eyes. In addition, the 19-year-old man showed decreased nystagmus amplitude. Conclusions: In some patients with congenital nystagmus, laser refractive surgery may be safely and accurately performed under topical anesthesia using an active tracking system. The best uncorrected visual acuity may improve in certain patients postoperatively. J Korean Ophthalmol Soc 2015;56(12):1991-1996