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To evaluate the clinical safety and efficacy of the novel Wright hang-back recession with fibrin glue for the treatment of horizontal strabismus.Retrospective, case-controlled clinical study comparing surgical outcomes of the Wright hang-back rectus recession with fibrin glue (WHBG) versus standard fixed suture rectus recession (SFR).Medical records of all patients who underwent strabismus surgery by one strabismus surgeon between 2016 and 2018 for horizontal deviations only, including cases of WHBG (group 1) or SFR (group 2), were reviewed. Good surgical outcome was defined as a postoperative deviation ≤10 prism diopters (PD) at a minimum 2 months of follow-up.32 eyes of 17 patients underwent WHBG and 32 eyes of 17 patients underwent SFR; in each group, 35% had esotropia and 65% had exotropia. Mean preoperative deviations between groups were similar: esotropia 25.5 PD and exotropia 26.6 PD in WHBG; esotropia 28.3 PD and exotropia 23.8 PD in SFR. The mean postoperative deviation was7 PD for both groups. Good surgical outcomes were similar between groups, 16/17 (94%) in WHBG and 15/17 (88%) in SFR, with no complications.WHBG was safe and effective with postoperative results similar to SFR. WHBG has an important advantage, eliminating the complication of retinal perforation that can occur with SFR while avoiding under- or overcorrection that can occur with traditional hang-back recession. This technique increases patient safety without sacrificing surgical outcomes and is especially useful in patients with thin sclera such as patients with high myopia or with difficult posterior exposure.

Mosaic Trisomy 8 is a rare chromosomal abnormality estimated to occur one in 30,000 newborns. The phenotype is highly variable and the severity does not appear to be correlated with the proportion of cells that contain the additional chromosome. Ocular involvement in Trisomy 8 mosaicism has previously been described to include corneal opacities, retinal dystrophy, coloboma, and unilateral microphthalmia. We report a case of severe bilateral microphthalmia in a neonate with Trisomy 8 mosaicism, a previously unrecognized ophthalmic manifestation.

Standard rectus muscle recessions require suturing muscle to sclera posterior to the insertion, which is dangerous as the sclera is thin. Extraocular muscle hang-back recession can avoid the posterior scleral needle pass but has been reported to be unstable. The purpose of this study is to assess the use of N-butyl-2-cyanoacrylate to aid reattachment of rectus muscle to sclera during hang-back recession.2 Phase Study: Phase 1 was a wet lab animal study; Phase 2 was a small case series.Phase 1, 14 frozen bank rabbit heads; Phase 2, 4 human adult patients with myopia and large exotropia.Phase 1: Frozen bank rabbit heads were used to simulate human hang-back rectus muscle recession. Fourteen rectus muscles were recessed by hang-back and glued to sclera with either cyanoacrylate glue alone (group 1) or glue over prolene mesh for greater stability (group 2). Primary outcome was muscle detachment force measured at 20, 30, and 40 seconds. Phase 2: Four patients with myopia and large exotropia who underwent bilateral hang-back lateral rectus recessions with cyanoacrylate glue were retrospectively studied.Phase 1: Group 1 mean detachment force measured at 30 seconds was 172.07 g versus 376.5 g in group 2 (p0.01). Phase 2: All patients had excellent postoperative alignment within 5 PD of orthophoria and no overcorrections. Two patients had unilateral glue extrusion at 1 month requiring in-office removal under topical anaesthesia.Cyanoacrylate glue with or without mesh resulted in adequate muscle-to-sclera adhesion with a detachment force at least 2 times the force of a normal rectus muscle contraction. Patients undergoing hang-back lateral rectus recession with cyanoacrylate glue had excellent stable postoperative alignment; however, half had the complication of late extrusion of glue foreign body.

Retinopathy of prematurity (ROP) is a vasoproliferative disease occurring in premature infants that affects the blood vessels of the developing retina. ROP results in the development of vascular shunts, neovascularization, and in its most severe form tractional retinal detachment. The development of retinal vascular shunts and neovascularization in ROP is related to local ischemia in the immature and incompletely vascularized retina. Understanding the pathophysiology of ROP helps physicians both in the prevention and treatment of ROP and will be discussed in this review article. The role of oxygen in the pathophysiology of ROP will be reviewed with recent studies discussed.

OBJECTIVE Nondepolarizing neuromuscular blocking drugs have been advocated for accurate forced duction testing (FDT) during strabismus surgery. The purpose of this study was to evaluate the literature on use of muscle relaxants (MRs) in strabismus surgery and to evaluate the current practice of pediatric ophthalmologists. DESIGN Systematic review and survey study. PARTICIPANTS Seventy-seven pediatric ophthalmologists. METHODS MEDLINE, EMBASE, CENTRAL, Web of Science, and OpenGrey were searched to August 2019. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Primary studies on depolarizing or nondepolarizing MRs in patients undergoing strabismus surgery were included. Primary outcomes included indications and prevalence of use. A 23-question survey was emailed to pediatric ophthalmologists worldwide to collect practice pattern information involving MRs in strabismus surgery. RESULTS Three studies were included in the systematic review. MRs were used in 34%-45% of patients undergoing strabismus surgery in one 1999 study for FDT. No evidence exists to support the use of MRs for facilitating FDT. Seven of 77 (9.1%) pediatric ophthalmologists requested MRs for FDT. Those who use MRs were more likely to be practicing outside the United States (p < 0.05) and in academic hospitals or private centres rather than in community settings. Drawbacks appeared to outweigh benefits, with the biggest drawback identified as increased turnover time between surgical cases (44%). CONCLUSIONS Inadequate evidence exists in the literature to support the use of nondepolarizing MRs to maintain paralysis of extraocular muscles during strabismus surgery, and this is an uncommon practice among pediatric ophthalmologists.

IMPORTANCE: Allergic conjunctivitis (AC) is one of the most common allergic diseases and is especially problematic in children and adolescents. The course of AC is generally prolonged and often recurs. Understanding the health-related quality of life (QOL) of both children with AC and their parents would be useful. OBJECTIVE: To evaluate the association between AC and health-related QOL in children and their parents. DESIGN, SETTING, AND PARTICIPANTS: A prospective case-control study was conducted at Zhongshan Ophthalmic Center, a single tertiary referral center, from November 16, 2019, through January 20, 2020. Participants comprised 92 children aged 5 to 18 years with AC and their parents and 96 healthy, age-matched children who served as controls and their parents. The 92 children in the AC group were subdivided into cohorts with vernal keratoconjunctivitis (VKC) (23 [25.0%]) or atopic keratoconjunctivitis (AKC) (7 [7.6%]) and seasonal allergic conjunctivitis (SAC) (26 [28.3%]) or perennial allergic conjunctivitis (PAC) (36 [39.1%]). EXPOSURES: Allergic conjunctivitis. MAIN OUTCOMES AND MEASURES: Pediatric Quality of Life Inventory, version 4.0 (PedsQL), scores for children and their parents. Scores range from 0 to 100, with higher scores indicating better health-related QOL and fewer negative aspects. RESULTS: In the AC group, 77 of 92 (83.7%) participants were boys, and 67 (72.8%) of the parents were women. Of the individuals in the control group, 55 of 96 (57.3%) of the children were girls and 76 (79.2%) of the parents were women. Median total PedsQL scores were reduced in both children with AC (69.6 [interquartile range [IQR], 66.3-72.8 vs 96.7; IQR, 92.7-98.9; P

Introduction: Missed appointments are barriers to health care delivery that result in loss of revenue and disruption of physician-patient relationship. There is a paucity of data describing the rate and impact of missed appointments in Pediatric Ophthalmology. Methods: A retrospective review of 3,922 patient appointments for two pediatric ophthalmologists at an academic Canadian institution was conducted over one year. Demographic data included patient age, day and appointment month. Results: There were 720 missed appointments (18.4%), the equivalent of 26.7 full day clinics. New patients were significantly more likely to miss appointments (P < 0.001). There was no difference between patient age (P = 0.46) or day of week (P = 0.16). There was a significant difference between appointment month (P = 0.001), the highest rates were January (26.39%) and February (23.11%). Subset analysis of 1574 patients (one of the providers) revealed surgical strabismus patients were significantly more likely to attend appointments (P < 0.001). Patients were more likely to miss appointments if they previously missed appointment(s) (P < 0.001) or were referred by nurse practitioners (P = 0.027). There was no difference between sex (P = 0.111), distance to clinic (P = 0.073) or appointment time (P = 0.347). The average physician billing loss was estimated at $54,722.46 USD in 1 year. Conclusion/Relevance: This study identifies factors that can be targeted to improve missed appointments. New patients, non-surgical patients and patients referred by nurse practitioners have higher missed appointment rates. Missed appointments cause significant financial loss, physician time wasted, and increase in patient wait times. In the current COVID-19 environment, reduced clinic capacity makes it essential to reduce missed appointments and associated financial loss.

Vitamin D has emerged as a potentially important molecule in ophthalmology. To date, all ophthalmic data pertaining to vitamin D has been restricted primarily to tear and serum analysis in human patients. Considering the isolated nature of the eye, we sought to determine the presence of intraocular vitamin D in ocular disease. Methods 25-Hydroxyvitamin D3 (25(OH)D3) concentrations were measured in the eye and blood of 120 participants undergoing ophthalmic procedures. Ocular localization of the 1,25-dihydroxyvitamin D3-generating (CYP27B1) and deactivating (CYP24A1) hydroxylases was performed by immunohistochemistry. Gene expression of CYP27B1, CYP24A1 and VEGF-A was measured in eyes from patients with and without disease. Results 25(OH)D3 was quantified in 112 ocular samples. In 40 cataract patient samples, the average 25(OH)D3 concentration was 0.057 ng/mL, compared to 72 retinal disease patient samples, average of 0.502 ng/mL (p Conclusions Our data confirms that vitamin D is present in the humours of the human eye and that local synthesis/degradation is possible via the ocular CYP27B1 and CYP24A1. This argues for a functional role for local vitamin D production and signaling in the eye and suggests that vitamin D may be an important intraocular mediator in disease pathogenesis.

Purpose To demonstrate the validity of a new 3D-printed silicone model for practicing strabismus surgery, compared with the rabbit head, in terms of simulator fidelity. Methods In this multicenter study, a validated questionnaire was developed to assess fidelity of the model and rabbit head. Participants were asked to rate overall globe, conjunctiva, muscle, and scleral fidelity using a 5-point scale. The survey instrument was disseminated at three strabismus instruction courses: at two meetings, participants practiced on the model and rabbit head prior to completing the questionnaire; at the third, instructors demonstrated advanced surgical skills using only the model and then completed the questionnaire. Repeated measures analysis of variance compared ratings. Pearson's or Spearman's correlation evaluated correlation between years of experience to participants' responses. Qualitative data were coded into themes. Results A total of 47 participants completed the questionnaire. The model rated 18% higher than rabbit head for anatomical accuracy (mean difference, 0.667; P = 0.001) and 25% higher for position of eyes within the head (mean difference, 0.867; P = 0.006). More experienced participants were more likely to strongly agree that the silicone conjunctiva effectively mimics real conjunctiva (ρ = 0.337; P = 0.036) and that scleral tissue effectively mimics real sclera (ρ = 0.298, P = 0.042). Qualitative data supported the model. Conclusions This study demonstrated the validity of the surgical model in terms of fidelity compared to the rabbit head.

We report the case of an 11-year-old girl with a rare finding of silicone oil migration into the periorbital space surrounding an extraocular muscle, discovered during strabismus surgery for a sensory exotropia that had developed after retinal detachment repair by pars plana vitrectomy with intraocular silicone oil.

Birth-associated ocular trauma is common and often minor, including subconjunctival and retinal haemorrhage and eyelid edema. Significant ocular trauma during birth, usually associated with forceps-assisted delivery, is rarer and can include Descemet's membrane rupture, lid lacerations, hyphema, Purtcher retinopathy, facial nerve palsy, corneal edema, and corneal laceration. We report the first case of ocular birth trauma from forceps presenting as isolated iris heterochromia and a pseudo rubeosis iridis, which completely resolved by 1 month of age with no known adverse ocular sequelae.

Adenoid cystic carcinoma (ACC) of the lacrimal gland is the most common primary malignant tumor of the lacrimal gland. It typically affects patients in the fifth decade of life and presents with rapid progression of pain, ptosis, motility disturbances, and sensory deficits of less than 1 year's duration. ACC is rare in children. Due to early, aggressive perineural and bony spread, there is a high risk of intracranial extension. Additionally, due to frequent hematogenous and lymphatic spread, there is a high rate of distant metastases even after treatment, which can occur late up to a decade or more. The currently accepted treatment for ACC is radical exenteration with orbitotomy and adjuvant chemotherapy and/or radiation therapy. Recently, intra-arterial cytoreductive chemotherapy (IACC) has been investigated as a neoadjuvant treatment modality. It has the advantage of increasing local concentration at the target tissue and decreasing systemic distribution. We report the first known pediatric case of ACC treated with IACC, followed by exenteration, radiation, and adjuvant intravenous chemotherapy. The patient was followed for 4 years, with no recurrence and no known complications.

The clinical features of superior oblique paresis vary widely depending on the type. Common features include an ipsilateral hypertropia that increases on contralateral gaze, and a positive head tilt test with the hypertropia increasing on head tilt to the side of the hypertropia. Congenital superior oblique paresis is commonly associated with ipsilateral inferior oblique overaction and relatively less superior oblique underaction. Acquired superior oblique paresis, on the other hand, has relatively normal versions and minimal inferior oblique overaction, but significant extorsional diplopia. The head tilt test can help to differentiate primary inferior oblique overaction from inferior oblique overaction secondary to superior oblique paresis. A positive head tilt test indicates a superior oblique paresis, and a negative head tilt test suggests primary inferior oblique overaction.

Minimally invasive strabismus surgery provides a valuable option for our strabismus patients with small deviations, and offers an additional or alternative treatment option to the use of prism glasses. The techniques described below can be performed in the office under topical anesthesia, are less invasive than standard strabismus muscle surgeries, and preserve the integrity of the muscle insertion, presumably sparing the anterior ciliary vessels.

The superior oblique tendon can be functionally divided into the anterior one third, which is responsible for intorsion, and the posterior two thirds, which is responsible for depression and abduction (Fig. 18.1). Superior oblique tightening procedures are based on this physiologic division and either tighten the whole tendon (i.e., full tendon tuck) or tighten the anterior tendon fibers (i.e., the Harada-Ito procedure).

Prior to strabismus surgery, an important and seemingly obvious question should be asked: “Why are we operating?” Is our treatment goal to establish binocular fusion, eliminate diplopia, expand the field of binocular vision, correct a compensatory head posture, or simply to improve cosmetic appearance? Establishing the goals prior to surgery helps us clarify indications for surgery, and formulate a logical treatment plan. The plan that is made should be the one that is best for the patient—not just the plan that is best for correcting the angle of deviation.

The faden operation, also termed posterior fixation suture, is used to weaken the rotational force of a rectus muscle when the eye rotates towards the faden muscle. Faden is the German word for suture, so it is inappropriate to call the procedure “faden suture” (i.e., suture-suture).

Transposition surgery is based on changing the location of the muscle insertion so the muscle pulls the eye in a different direction (i.e., changes the vector of forces). Transposition surgeries can be used to treat a rectus muscle paresis, a lost muscle, A and V patterns ( Chap. 15), small vertical tropias ( Chap. 15), and torsion ( Chap. 15). Three transposition procedures are described in this chapter: Knapp, Jensen, and Hummelsheim.

The two most useful rectus muscle tightening procedures are the rectus muscle resection and the rectus muscle plication. Rectus muscle tucking has not proven reliable, as it tends to loosen over time. A tuck is a muscle-to-muscle union. Because the muscle fibers are longitudinal and the transverse fibers are weak, the sutures tend to pull out and slip. The rectus muscle plication, however, involves securing posterior muscle to sclera, and this procedure is as stable as a resection.

Superior oblique tendon weakening procedures are used in the management of various types of strabismus, including superior oblique overaction, inferior oblique palsy, and Brown’s syndrome (see Chap. 7). Most procedures weaken the superior oblique muscle by slackening the tendon. Uncontrolled procedures include tenotomy and tenectomy, in which the tendon is cut and the cut ends are free to widely separate or scar back together. These uncontrolled procedures should not be used in patients with binocular fusion, as the incidence of consecutive superior oblique palsy is more than 50 %.

Historically, inferior oblique surgery was considered extremely difficult and was fraught with complications such as fat adherence, ciliary nerve damage with pupillary dilatation, and intraoperative hemorrhage. More recently, however, the management of inferior oblique overaction has improved substantially. The late Dr. Marshall Parks pioneered meticulous techniques that all but eliminated these complications. Another important advance has been the anteriorization procedure.

This chapter gives a detailed description of the rectus muscle recession procedure. Two conjunctival approaches are presented: fornix and limbal.

Torticollis comes from the Latin word torti, meaning twisted, and collis, meaning neck. Simply speaking, we can consider two types of torticollis: musculoskeletal and ocular. Musculoskeletal torticollis is caused by tight neck muscles (usually the sternocleidomastoid) or a skeletal deformity. With musculoskeletal torticollis, the neck will resist passive flexion with the eyes open or closed, and these patients maintain their head posturing even during sleep. In contrast, ocular torticollis is a compensatory mechanism to achieve optimal vision in patients with nystagmus or incomitant strabismus. A face turn or head tilt is adopted to place the eyes in a position that either reduces nystagmus or improves eye alignment. Ocular torticollis may be horizontal (face turn), vertical (chin up or down), torsional (head tilt right or left), or a combination of the three. The best way to identify the presence of a face turn or chin posturing is by looking at the position of the eyes. A gaze preference indicates a face turn. For example, does the patient in Fig. 6.1 have a face turn?

Vertical transposition of horizontal muscle insertions is an effective means of collapsing an A or V pattern (Fig. 15.1), but only if there is no significant oblique overaction. If oblique overaction is present, appropriate oblique muscle surgery should be performed.

Topical anesthesia strabismus surgery reduces the systemic risk associated with general anesthesia, as well as the postoperative nausea and vomiting. It also eliminates the risk of globe perforation, optic nerve damage, and myotoxicity that is associated with retrobulbar injection. Topical anesthesia can be especially useful in senior citizens who have medical issues that make general anesthesia dangerous.

Adequate surgical exposure is the key to any operation. Good exposure starts with proper positioning of the patient. The top of the head should be positioned at the very end of the surgical table, placing the neck in an extended position so the chin is higher than the forehead (Fig. 10.1). Extending the neck lowers the superior orbital rim and eyebrow, improving exposure of the eye.