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Purpose: Thyroid eye disease (TED) is the most common orbital disease in adults. Ocular motility restriction is the primary complaint of patients, while its evaluation is quite difficult. The present study aimed to introduce an artificial intelligence (AI) model based on orbital computed tomography (CT) images for ocular motility score. Methods: A total of 410 sets of CT images and clinical data were obtained from the hospital. To build a triple classification predictive model for ocular motility score, multiple deep learning models were employed to extract features of images and clinical data. Subgroup analyses based on pertinent clinical features were performed to test the efficacy of models. Results: The ResNet-34 network outperformed Alex-Net and VGG16-Net in prediction of ocular motility score, with the optimal accuracy (ACC) of 0.907, 0.870, and 0.890, respectively. Subgroup analyses indicated no significant difference in ACC between active or inactive phase, functional visual field diplopia or peripheral visual field diplopia (p > 0.05). However, in the gender subgroup, the prediction model performed more accurately in female patients than males (p = 0.02). Conclusion: In conclusion, the AI model based on CT images and clinical data successfully realized automatic scoring of ocular motility in TED patients. This approach potentially enhanced the efficiency and accuracy of ocular motility evaluation, thus facilitating clinical application. [ABSTRACT FROM AUTHOR]

The symptoms and syndromes associated with visual impairment that occur in acute cerebrovascular accident (OMNA) of various parts of the brain are quite characteristic, can develop with circulatory disorders in various arteries of the brain and depend on the severity of damage to brain tissues. Disorders of vision and oculomotor functions, including decreased central vision, impaired peripheral vision, limited eye mobility and impaired visual perception, are widespread among patients who have suffered a cerebral stroke. This article is the first part of a two-part review devoted to the problem of visual impairment in patients with acute cerebral circulatory disorders. In the first part, we examined the prevalence and diversity of such violations. The second part will provide an overview of the methods of rehabilitation of patients in this category. Main content of the rewiew. The data of the analysis of the prevalence of various types of visual impairments in patients who have undergone ONMC are presented, based on publications in international and domestic databases OpenAlex, Scilit, Lens, PubMed, Cyberleninka and eLibrary.ru available for analysis by August 15, 2024, with a search depth of mostly 15 years. As a result of the search, 52 articles on a given topic were reviewed. In addition, 5 sources dated from an earlier period (1989–2000) were used, as they contain the necessary information within the framework of this review. Conclusion. Visual impairment entails a significant decrease in the quality of life of such a category of patients. To obtain a complete picture of the patient’s condition after a cerebral stroke, it is necessary to conduct a thorough targeted screening of visual impairment. This will allow you to take timely measures to restore visual functions, which may have a beneficial effect on further rehabilitation.

Currently, there is no established system for quantifying patterns of ocular ductions. This poses challenges in tracking the onset and evolution of ocular motility disorders, as current clinical methodologies rely on subjective observations of individual movements. We propose a protocol that integrates image processing, a statistical framework of summary indices, and criteria for evaluating both cross-sectional and longitudinal differences in ductions to address this methodological gap. We demonstrate that our protocol reliably transforms objective estimates of ocular rotations into normative patterns of total movement area and movement symmetry. This is a critical step towards clinical application in which our protocol could first diagnose and then track the progression and resolution of ocular motility disorders over time. [ABSTRACT FROM AUTHOR]

Currently, there is no established system for quantifying patterns of ocular ductions. This poses challenges in tracking the onset and evolution of ocular motility disorders, as current clinical methodologies rely on subjective observations of individual movements. We propose a protocol that integrates image processing, a statistical framework of summary indices, and criteria for evaluating both cross-sectional and longitudinal differences in ductions to address this methodological gap. We demonstrate that our protocol reliably transforms objective estimates of ocular rotations into normative patterns of total movement area and movement symmetry. This is a critical step towards clinical application in which our protocol could first diagnose and then track the progression and resolution of ocular motility disorders over time.

Purpose: To measure the ocular motility parameters of the Developmental Eye Movement (DEM) test objectively, with an eye tracker in subjects with intellectual disability (ID). Methods: The DEM test was performed on 45 subjects with ID, while their eye movements were recorded with an eye tracker. Some objective parameters of ocular motility were obtained through each subtest (A, B, and C) of the full DEM test. Results: There was a significant positive correlation between the saccadic speed (cc: 0.537; p = 0.001) and length (cc: 0.368; p = 0.030) of both eyes for the same subject. People with a higher percentage of ID exhibited a greater number of fixations, saccades, and errors, and took longer to perform the DEM test than those with a lower ID percentage, who had greater numbers of these parameters than subjects without ID. Subjects without ID exhibited faster saccades, with a higher amplitude, than subjects with ID. Conclusions: The eye tracker quantifies ocular motility parameters involved in the DEM test in subjects with ID. Both eyes' movements in subjects with ID were conjugated, exhibiting saccades of the same length and speed. All parameters were different in subjects with ID compared to those in subjects without ID, so normative tables specifically for subjects with ID are necessary. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the prevalence of reduced visual acuity (VA), refractive errors (RE), reduced contrast sensitivity and strabismus in developmentally delayed (DD) patients. Methods: This descriptive cross sectional study was carried out in Ophthalmology Departments of Mayo Hospital, Lahore, The Children's Hospital, Lahore and The Children's Hospital, Multan from June 2019 to December 2019. We recruited 257 patients of either gender, between the ages of 06-16 years having intelligence quotient (IQ) ≤ 80 by Wechsler Intelligence Scale for Children (WISC) from the out-patient departments. Detailed systemic and ophthalmic history was taken and through anterior and posterior segment examination was carried out. VA was assessed with age matched VA charts. Cycloplegic refraction with 1% cyclopentolate was carried out. Contrast sensitivity was measured with hiding Heidi charts. Strabismus was assessed with Hirschberg and covers /uncover tests. Results: The mean age of the patients was 8.88 years with standard deviation (SD) of ± 2.70. The prevalence of reduced VA, RE, strabismus and reduced contrast sensitivity in these children were 43.58%, 52.92%, 52.14% and 32.7% respectively. Out of these 52.92% RE, 56 (21.79%) were myopic, 66 (25.68%) were hyperopic and 14 (05.45%) were astigmatic. The percentage of esotropia was 72 (28.02%) and exotropia was 62 (24.12%). Conclusion: The results of our study in DD children have shown that a significant number of children have reduced VA, RE, strabismus and reduced contrast sensitivity. Apart from general management of DD children by a pediatrician, the ophthalmic management of these problems must be carried out by a pediatric ophthalmologist to improve their quality of life. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate ocular motility (OM) abnormalities associated with Ehlers-Danlos Syndrome (EDS). Materials and methods: In this cross-sectional observational study, patients with EDS underwent a complete orthoptic examination. The following orthoptic tests were performed: corneal light reflex test, stereoscopic test, cover test, OM assessment, evaluation of eye pain in different gaze positions and red filter test for diplopia. Results: The corneal light reflex test at 33 cm showed an intermittent divergent deviation in 31.7% of patients and an intermittent horizontal deviation associated with a vertical deviation in 4.9% of patients. A manifest strabismus was observed in 2.4% of patients, whereas 2.4% of patients showed a microstrabismus. The corneal light reflex test at 5 m revealed microstrabismus in 9.8% and manifest strabismus in 2.4% of our patients. Moreover, intermittent exotropia was observed in 2.4% of cases. No significant alterations involving the inferior rectus and the superior oblique muscles were observed. Significant associations were observed between medial rectus muscle deficit of both eyes with pain (p = 0.020) and diplopia (p = 0.014). Furthermore, a significant association between lateral rectus muscle alteration of both eyes and pain was observed (p = 0.004). Conclusions: Our results show various OM alterations in patients with EDS, specifically superior and medial rectus muscle hypofunction. A full orthoptic evaluation in these patients is recommendable to detect OM involvement and possible ligamentous laxity changes over time through an accurate OM assessment. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate ocular motility in normal young adults when performing the Developmental Eye Movement (DEM) test using an infrared eye-tracker in a sample of young subjects without visual dysfunctions. Methods: An optometric evaluation was carried out on 52 participants with a mean age of 21.00 ± 3.22 years to verify they did not have any binocular dysfunction, by completing a computerized version of the DEM test while their eye movements were recorded with an eye-tracker. A custom-written software was developed to analyse some specific parameters of ocular motility while performing each subtest (Test A, Test B and Test C) of the complete DEM test. Results: The mean duration of the fixations was shorter in Test C (243.56 ± 46.18 s) than in Test A (493.52 ± 171.41 s) and Test B (484.20 ± 156.59 s). The mean adjusted horizontal (AdjHT: 35.24 ± 6.68 s) and vertical (VT: 33.58 ± 5.56 s) times were at the 45th and at the 40th percentile, respectively. In Test C, there was a high positive significant correlation between the saccadic speed (cc: 0.77; p < 0.001) and the saccadic length (cc: 0.74; p < 0.001) of both eyes. Conclusions: The eye-tracker is an objective method to evaluate the DEM test in subjects without binocular dysfunctions, measuring and quantifying ocular motility parameters that are impossible with the traditional subjective method. The eye movements of both eyes are conjugated in each subject, having saccades of the same length and speed. [ABSTRACT FROM AUTHOR]

We report a patient presenting with unique neuroophthalmological features of contraversive ocular tilt reaction and concomitant contralesional pseudo-abducens palsy. Magnetic resonance imaging confirmed the presence of an acute infarct in the right thalamomesencephalic region. We discuss the clinical topography of these unique neuroophthalmological findings. [ABSTRACT FROM AUTHOR]

Objective. Prematurity often results in important developmental sequelae of brain structures, particularly those involved in processing visual information, such as the optic nerve, primary visual cortex and visuomotor integration areas. The aim of this study is to analyse the functionality of the sensory and motor pathways of the visual system by means of an orthoptic-ophthalmological assessment. Materials and methods. In this retrospective study, 151 records were examined, covering a period from 2000 to 2020, of preterm patients with gestational age < 32 weeks and birth weight ≤ 1,500 g up to an average age of about 8 years, referred to the Centre for Paediatric Ophthalmology and Strabology of the Ophthalmology Clinic of the Policlinico Umberto I, La Sapienza University of Rome, who underwent a complete ophthalmological and orthoptic assessment including the following tests measurement of ocular deviations according to the Hirschberg method, Lang I-II test, Titmus Stereotest, objective convergence assessment and ocular motility examination. Results. From the charts reviewed, 24.5% (37/151) of patients had Retinopathy of the Premature (ROP); while 38% of the whole sample (57/151) had strabismic amblyopia, of the latter only 31.5% (18/57) had ROP. In 8% of patients (12/151) the stereoscopic sense was absent, in 45% (8/151) stereopsis was gross (> 60 seconds of arc). In addition, 20.52 % (31/151) had a manifest eye deviation. 7.28% (11/151) had hypermetropia in the right eye (RE); 7.95% (12/151) hypermetropia in the left eye (OS); 3.31% of the patients (5/151) had myopia in the RE; 2% (3/151), myopia in the left eye (LE). In addition, the study of ocular motility revealed varying degrees of alteration poorly correlated with prematurity status. Conclusion. It was found that amblyopia, stereopsis and objective convergence are more affected by ROP than strabismus, refractive defects and ocular motility, indicating that premature children are particularly susceptible to ophthalmological and orthoptical alterations. [ABSTRACT FROM AUTHOR]

Brown syndrome is an ocular misalignment disorder affecting the superior oblique tendon-trochlea complex. We report a case of a 45-year-old woman with protracted symptoms of presumed idiopathic Brown syndrome later diagnosed as ocular myasthenia gravis. Acquired Brown syndrome secondary to ocular myasthenia gravis has not previously been reported in the literature. Ocular myasthenia gravis should be considered a differential in any patient presenting with vertical strabismus presenting as Brown syndrome., Competing Interests: The authors have no conflicts of interest., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2025.)

Introduction: One-and-a-half syndrome is a condition characterized by horizontal gaze palsy and internuclear ophthalmoplegia. Its risk factors include conditions that predispose to pontine lesions and demyelinating conditions. The symptoms include blurred vision, diplopia, and oscillopsia. Management is addressing the underlying symptom and relieving the symptoms. The case of a 46-year-old hypertensive male who was diagnosed with one-and-a-half syndrome and who underwent inpatient management at an allopathic hospital is presented here. He initially approached Sreedhareeyam's OP division and was prescribed medicine and inpatient management. Main Clinical Findings: On examination, he had blurred vision, diplopia, and one-and-a-half syndrome. Intervention: He underwent an inpatient Ayurvedic protocol comprising of oral medicines, external therapies, and eye exercises. Outcome: Results at discharge and at three subsequent follow-ups demonstrated gradually improved ocular movements and relief of symptoms. Conclusion: This case illustrates that Ayurveda treatments may be explored for this condition.

AIM: To assess the role of orthoptics in referring patients with orbital floor blowout fracture (OFBF) for conservative or surgical treatment and based on the results, to propose a scoring system for such decision making. METHODS: A retrospective analysis of 69 patients with OFBF was performed (35 treated conservatively, 34 surgically). The role of orthoptics in referring to surgery or conservative treatment was retrospectively evaluated, the factors with the highest significance for decision making were identified, and a scoring system proposed using Logistic regression. RESULTS: According to defined criteria, the treatment was unsuccessful in 2 (6%) surgically treated and only in one (3%) conservatively treated patient. The proposed scoring system includes the defect size and several values resulting from the orthoptic examination, the elevation of the eyebulb measured on Lancaster screen being the most significant. CONCLUSION: The study demonstrates the benefits of orthoptic examination when making decisions on conservative or surgical treatment and for diagnosing ocular motility disorder (with or without binocular diplopia) in OFBF patients. The proposed scoring system could, following verification in a prospective study, become a valuable adjunctive tool.

This study aims to compare eye movements monitored with an eye tracker during two visuo-verbal tests for assessing ocular motility. The study explores the potential of digital assessment and eye tracking technology in enhancing the understanding of ocular motility during these tests. 47 healthy participants were included (20 males, 27 females), with a mean age of 21.34±1.77 years. The participants underwent optometric examinations to ensure visual health and exclude any dysfunctions or pathologies. The experimental protocol involved the digitized versions of the DEM and King-Devick tests, monitored with an eye tracker. The vertical subtests of DEM test showed fewer saccades, longer fixation durations, smaller saccade amplitudes, and slower saccade speeds compared to the horizontal subtest. The King-Devick test exhibited comparable fixation and saccade numbers, while fixation duration slightly increased with test difficulty. Statistically significant differences were found between the tests, but a positive correlation was observed. Statistically significant differences were observed between the DEM and King-Devick tests, indicating that they measure similar aspects but are not interchangeable. The DEM test offers more comprehensive information with vertical saccade assessment. Test duration correlates positively with saccade and fixation count, fixation duration, and saccade speed. [ABSTRACT FROM AUTHOR]

The management of blow-out orbital fractures (BOFs) continues to be controversial and regularly questioned. In recent years, treatment decision-making has shifted from a clinically dominated emphasis to a more objective data-based approach. This has come about through the refinement of imaging technologies that can more precisely define the fracture itself. Decision-making is now mainly driven by computed tomography (CT) parameters among which the fracture's size is by far the most often used. The variability in a patient's clinical presentation and outcomes for similar types of BOFs raises serious doubts about the pertinence of applying standardized guidelines based on quantitative data for the treatment of individual patients. An approach that fails to include patient variability and relies too heavily on average objective results with an emphasis on the application of quantitative rather than qualitative methods can lead to poor patient outcomes. A review of the knowledge accumulated over the many years of treatment of BOFs has demonstrated that despite the exceptional imaging-based technologies available, clinical acumen remains the most sophisticated decision-assistive tool. Thus, the treatment of BOFs must be regarded as a patient rather than merely a geometrical imaging issue. Imaging then becomes a valuable diagnostic rather than a final decision-making tool. This more conservative approach leads to a substantial decrease in indications for surgical repair. [ABSTRACT FROM AUTHOR]

Carotid-cavernous fistula (CCF) is an aberrant communication between the main trunk or branches of carotid artery and the cavernous sinus. Most of the cases of CCF occur following head trauma, but congenital and spontaneous cases have been reported. We report an interesting case of bilateral CCF with no history of trauma, thus most likely spontaneous form. Since it is rare, it was a diagnostic challenge. The suspicion of this diagnosis was made due to clinical features of headache, signs of increased Intracranial Pressure (ICP) (nausea, vomiting, and worsening headaches during Valsalva), exophthalmos, periorbital edema, periorbital erythema, chemosis, and conjunctival injection in both eyes. It was diagnosed with a 4-vessel angiography (digital subtraction angiography) which is the gold standard and was managed successfully with endovascular coil embolization. [ABSTRACT FROM AUTHOR]

Raffaele Migliorini,1 Anna Maria Comberiati,1 Fernanda Pacella,1 Anna Rosy Longo,1 Daniela Messineo,2 Edoardo Trovato Battagliola,1 Mariaelena Malvasi,1 Elena Pacella,1 Loredana Arrico1 1Department of Sense Organs, University Sapienza, Rome, Italy; 2Department of Radiology, Oncology, and Anatomopathological, University Sapienza, Rome, ItalyCorrespondence: Elena PacellaDepartment of Sense Organs, University Sapienza, Policlinico Umberto I, Viale del Policlinico 155, Rome, 00161, ItalyTel +39 336783409Email elena.pacella@uniroma1.itPurpose: Determine the usefulness of ocular motility testing to detect the presence of muscle entrapment.Materials and Methods: Cross-sectional study of patients with symptoms of diplopia secondary to facial trauma. Inclusion criteria: age between 20 and 80 years; symptoms of diplopia following facial trauma; presence of orbital floor fracture confirmed radiologically; presence of muscle entrapment confirmed at the time of surgery; best-corrected visual acuity of 0.6 or more. Exclusion criteria: muscle entrapment visible on computed tomography; candidate for immediate surgical correction; prior history of strabismus surgery. Outcome measures: Abnormal Head Position (AHP), Hirschberg Corneal Reflexes (CR), Cover/Uncover and Alternating Cover Test, Hertel exophthalmometry, Near Point of Convergence (NPC), Kestenbaum Limbus test, Red Filter test, and Hess screen test.Results: Forty-six subjects (38 males, 8 females, mean age 27 ± 3.3 SD years). Pre-operative assessment: forty-six (100%) reported diplopia on the Red Filter test and showed some degree of abnormality on the Hess Screen test. Forty-two (91%) showed AHP. Forty-one (89%) had exophthalmometry values that differed 2 mm or more between the two eyes and insufficient NPC. Thirty-two (69.6%) showed deficits of 3 mm or more on the Kestenbaum Limbus test. Sixteen (35%) had abnormal Hirschberg corneal reflexes. Eleven (24%) demonstrated constant or intermittent strabismus.Conclusion: Ocular motility testing can differentiate non-invasively, pre-operatively, and cost-effectively the presence of muscle entrapment even when this is not visible on computed tomography.Keywords: orbital blow-out fractures, orbital floor fracture, ocular motility, trauma, delayed surgical repair, muscle entrapment, traumatic diplopia

Purpose: Orbital floor fractures commonly occur during orbital trauma. Currently, the indications for orbital fracture repair and the appropriate duration between trauma and surgical intervention remain controversial. Methods: Eyes diagnosed with orbital floor fractures that underwent reconstruction surgery were retrospectively reviewed. Demographic data were analyzed. Patients were classified based on the timing of the surgical intervention after injury. Ocular limitation and diplopia were evaluated preoperatively and postoperatively at one week, one month, and three months. Results: Two hundred seventy eyes of 270 patients (174 males and 96 females, mean age: 40.9 ± 16.3 years) were identified. The mean duration from injury to surgical intervention was 18.0 ± 21.2 days (range: 0–117 days). In the subgroup analysis, compared to delayed treatment, the early repair of floor fractures, i.e., within 7 days, was associated with significant motility and diplopia resolution at one week (p = 0.001, p < 0.001), one month (p < 0.001, p < 0.001), and three months (p < 0.001, p < 0.001). Sex and the duration from injury to repair were significantly associated with postoperative ocular motility (p = 0.001; p = 0.024) and diplopia (p < 0.001; p = 0.008) at three months. Multivariate analysis revealed that preoperative limitation and diplopia were correlated with postoperative limitation (p = 0.007) and diplopia (p = 0.001), respectively. Conclusions: The duration between orbital floor fracture and surgical treatment was associated with postoperative limitation and diplopia. Our results suggest that earlier intervention in symptomatic patients with orbital trauma may improve postoperative visual function. [ABSTRACT FROM AUTHOR]

Purpose : To investigate the effects of orthoptic training for residual diplopia after blowout fracture (BOF) surgery. Methods : We retrospectively reviewed the medical records of 14 (average age, 22.9 ± 13.1 years) patients with residual diplopia, who had undergone orthoptic training after BOF surgery at the Department of Ophthalmology, Kindai University Hospital, between August 2013 and September 2019. The orthoptic training included exercises for eye movement, convergence, and fusional area expansion. We assessed the training effects by scoring patients' Hess screen (Hess) test results and fields of binocular single vision (BSV). The scores obtained before/after surgery and after training were compared. We also investigated the factors that influenced patients' BSV scores after training. p < 0.05 was considered statistically significant. Results: The respective pre- and postoperative and after-training average scores were 7.0 ± 5.3, 5.4 ± 4.3, and 2.5 ± 3.2 points for Hess and 50.0 ± 41.3, 48.2 ± 35.9, and 89.4 ± 14.0 points for BSV. Neither Hess nor BSV score showed a significant difference before and after surgery (p > 0.05, the Steel–Dwass test). Compared to the postoperative (i.e., before training) scores, both Hess and BSV scores significantly improved after training (p < 0.05 for Hess, p < 0.01 for BSV; the Steel–Dwass test). Conclusion: Orthoptic training appeared effective in resolving residual diplopia after BOF surgery by improving patients' ocular motility and expanding the BSV field. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate ocular motility (OM) abnormalities associated with Ehlers-Danlos Syndrome (EDS). Materials and methods: In this cross-sectional observational study, patients with EDS underwent a complete orthoptic examination. The following orthoptic tests were performed: corneal light reflex test, stereoscopic test, cover test, OM assessment, evaluation of eye pain in different gaze positions and red filter test for diplopia. Results: The corneal light reflex test at 33 cm showed an intermittent divergent deviation in 31.7% of patients and an intermittent horizontal deviation associated with a vertical deviation in 4.9% of patients. A manifest strabismus was observed in 2.4% of patients, whereas 2.4% of patients showed a microstrabismus. The corneal light reflex test at 5 m revealed microstrabismus in 9.8% and manifest strabismus in 2.4% of our patients. Moreover, intermittent exotropia was observed in 2.4% of cases. No significant alterations involving the inferior rectus and the superior oblique muscles were observed. Significant associations were observed between medial rectus muscle deficit of both eyes with pain (p = 0.020) and diplopia (p = 0.014). Furthermore, a significant association between lateral rectus muscle alteration of both eyes and pain was observed (p = 0.004). Conclusions: Our results show various OM alterations in patients with EDS, specifically superior and medial rectus muscle hypofunction. A full orthoptic evaluation in these patients is recommendable to detect OM involvement and possible ligamentous laxity changes over time through an accurate OM assessment.

Purpose: To describe the clinical symptoms, anatomical location of the injury and different etiologies of one-and-a-half syndrome and its variants. Observations: A small lesion to the brainstem can cause complex syndromes that involve the disfunction of different nuclei and pathways. A 52-year-old man presented with sudden onset of diplopia characterized by horizontal gaze palsy and internuclear ophthalmoplegia (INO). With these clinical characteristics, the patient was diagnosed with the one-and-a-half syndrome. Neuroimaging revealed an acute/subacute ischemic lacunar event in the pontine tegmentum. The one-and-a-half syndrome is described as a horizontal gaze palsy in one direction (damage to the paramedian pontine reticular formation [PPRF] or the VI nerve nucleus) and an internuclear ophthalmoplegia in the other direction (damage to the medial longitudinal fasciculus). Along with the traditional description, the closed anatomical proximity with other nuclei and pathways makes possible the appearance of other more complex syndromes that have been grouped as the one-and-a-half syndrome and its variants. Conclusions and importance: A detailed clinical neuro-ophthalmologic examination, along with a clear understanding of the neuroanatomical pathways, gives clinicians a good diagnostic opportunity to determine the precise location of injuries to the brainstem.

Abstract This case illustrates the need to correctly identify oscillopsia among cases of self‐reported dizziness, and ocular flutter itself as a presenting sign of potentially serious underlying disease. The neurologist should approach these patients in a systematic manner, in order to exclude concurrent or impending comorbidities such as neoplastic disease.

"AIM: To describe the etiology, clinical characteristics, surgical options and surgical outcomes of isolated inferior oblique palsy (IOP). METHODS: A retrospective review was performed on patients with isolated IOP who were seen between January 2010 and June 2017. The following clinical data were obtained from the patients’ charts: visual acuity, ocular alignment, ocular motility, cyclotorsion, stereoacuity, Parks three-step test, surgical methods, surgical outcomes and complications. Surgical success was defined as horizontal deviation ≤10 prism diopters (PD) and a vertical deviation ≤5 PD in primary gaze at both near and distant vision as assessed at last follow-up. RESULTS: The records from a total of 18 patients (8 males and 10 females) with an average age of 27.56y were included in this study. The right eye was affected in 11 patients, the left in 6 patients and both eyes in 1 patient. Twelve cases (66.7%) were congenital and 6 (33.3%) were acquired IOP. The 6 acquired cases involved 2 resulting from orbital trauma/surgery, 2 from midbrain microvascular ischemia, 1 from myasthenia gravis and 1 of unknown etiology. Strabismus surgery was performed in 13 cases. Surgical techniques included weakening of superior oblique and vertical rectus recession and resection. After a mean follow-up of 15.11mo, the corrected vertical deviation in primary position was 19.92±8.52 PD (P=0.000) and the corrected horizontal deviation was 14.31±12.68 PD (P=0.002). The surgical success rate was 61.5% and no surgical complications were present. CONCLUSION: Isolated IOP represents a rare condition, with most cases (66.7%) involving a congenital basis. The acquired cases included vascular, orbital trauma/surgery and myasthenia gravis. Weakening of the ipsilateral superior oblique muscle and/or contralateral superior rectus recession often resulted in favorable surgical outcomes with a surgical success rate of 61.5%."

Purpose: To report a case of neurovascular compression in a patient presenting with ophthalmic evidence of aberrant reinnervation. Observation: A 68-year-old woman diagnosed with right partial third nerve palsy with aberrant regeneration. Suspicion was based on isolated clinical features of the right eye, including ptosis, upper eyelid elevation on adduction, mydriasis, exotropia, and hypotropia. Magnetic resonance imaging revealed atrophy of the right oculomotor nerve secondary to neurovascular compression from a prominent right superior cerebellar artery. Conclusion and importance: This case highlights the importance of utilizing Fast Imaging Employing Steady-state Acquisition (FIESTA) for the diagnosis of oculomotor nerve palsy presenting with evidence of aberrant reinnervation.

Current literature reports synergistic divergence as a rare, congenital ocular motility pattern associated with adduction palsy. Its mechanism has been likened to Duane’s syndrome, and some suggest it be referred to as Duane’s Type 4 (Gupta et al. 2010; Schliesser et al. 2016; Wilcox et al. 1981; Khan et al. 2016). There are no published reports of synergistic divergence as an acquired condition, making this case report seemingly the first of its kind. This case report describes an 18-year-old female who presented to clinic in 2013 with symptoms of diplopia and left eye turning outwards. Orthoptic assessment and MRI confirmed a third nerve palsy secondary to cavernous sinus schwannoma. Further monitoring showed progression of the cranial nerve palsy but a stable schwannoma and no aberrant regeneration noted in five years of follow up. The patient was treated with multiple botulinum toxin injections and had squint correction surgery in 2017. Seven months later, synergistic divergence was first noted and remained stable in all following assessments. While the aetiology of acquired synergistic divergence in this case is unclear, we can be confident it is unlikely to be of congenital origin as it was not noted until adulthood and after five years of investigations. This report will discuss possible aetiologies of acquired synergistic divergence and, contrary to current literature, suggest clinicians should consider the possibility that synergistic divergence can be acquired, though is likely to be even rarer than its congenital form.

Purpose: Nystagmus is characterised by involuntary eye movement. A proportion of those with nystagmus experience the world constantly in motion as their eyes move: a symptom known as oscillopsia. Individuals with oscillopsia can be incapacitated and often feel neglected due to limited treatment options. Effective communication of the condition is challenging and no tools to aid communication exist. This paper describes a virtual reality (VR) application that recreates the effects of oscillopsia, enabling others to appreciate the condition. Methods: Eye tracking data was incorporated into a VR oscillopsia simulator and released as a smartphone app – “Nystagmus Oscillopsia Sim VR”. When a smartphone is used in conjunction with a Google Cardboard headset, it presents an erratic image consistent with oscillopsia. The oscillopsia simulation was appraised by six participants for its representativeness. These individuals have nystagmus and had previously experienced oscillopsia but were not currently symptomatic; they were therefore uniquely placed to judge the app. The participants filled in a questionnaire to record impressions and the usefulness of the app. Results: The published app has been downloaded ~3700 times (28/02/2018) and received positive feedback from the nystagmus community. The validation study questionnaire scored the accuracy of the simulation an average of 7.8/10 while its ability to aid communication received 9.2/10. Conclusion: The evidence indicates that the simulation can effectively recreate the sensation of oscillopsia and facilitate effective communication of the symptoms associated with the condition. This has implications for communication of other visual conditions.

Objectives: Acute diplopia is a diagnostic challenge for clinicians, in particular in the emergency department. The most common cause of acute diplopia are ocular motor nerve palsies (OMP). In this prospective study, we focused on identifying the most crucial signs and symptoms for differentiating between peripheral and central OMP. Methods: We prospectively evaluated 56 non-consecutive patients who presented at our emergency department with acute binocular diplopia (≤ 10 days). The patient history was taken using a standardized questionnaire and patients underwent a neurological, neuro-ophthalmological and neuro-otological examination, including measurement of the subjective visual vertical (SVV), Harms tangent screen test, and cranial MRI. Results: Forty-six out of 56 patients were diagnosed with an ocular motor cranial nerve palsy (OMP), 21 of peripheral and 23 of central origin; in two patients, the etiology remained unknown. The following features were different in peripheral and central OMP: (1) the presence of vertigo/dizziness was more frequent in central (43.5%) than in peripheral (9.5%) OMP. (2) Central ocular motor signs, such as saccadic smooth pursuit, additional internuclear ophthalmoplegia, skew deviation, and saccade palsies, were also found more frequently in the central than in the peripheral group (86.7% vs. 33.3%). (3) Further, a pathological SVV deviation by monocular testing of the non-affected eye was also more common in central (77.3%) than in peripheral OMP (38.9%). The presence of all three factors has a positive predictive value of 100% (CI 50–100%) for the presence of a central lesion. Conclusions: In acute diplopia due to central OMP, the most important accompanying symptom is vertigo/dizziness, and the most important clinical signs are central ocular motor disorders (which require examination of the non-paretic eye) and an SVV deviation in the non-paretic eye. [ABSTRACT FROM AUTHOR]

Though studies describe postconcussive changes in eye movements, there is a need for data describing baseline eye movements. The purpose of this study was to describe baseline eye movements and visual contrast acuity using the King-Devick (KD) Eye Tracking System and KD Visual Contrast Sensitivity Chart. Fewer total saccades were noted in soccer players than basketball players (soccer, 56.9 ± 14.3; basketball, 101.1 ± 41.3; p =.0005). No significant differences were noted for the number of saccades between sexes (males, 60.4 ± 20.3; females, 84.9 ± 41.8, p =.100) or in contrast acuity between all groups (p >.05). These results suggest the presence of sport-specific trends that may invalidate the comparison of postconcussion evaluation to generic baseline athlete eye movements. [ABSTRACT FROM AUTHOR]

With the wide spread of affordable virtual reality headsets, virtual environments are rapidly changing the way humans interact with reality. Understanding the effects of virtual environments on the mental and cognitive state is essential. In addition, defining methods for measuring and assessing visual fatigue in virtual environments is still needed. While eye movements are tightly coupled to the mental state, analysis of eye movement can add insights for safer virtual environments. Biomechanical analysis has been used extensively in the analysis of human movement. Simulation of different scenarios such as injuries and surgeries provided insights and solutions to problems that were otherwise impossible. This includes understanding the effects of changing insertion points of muscle on range of motion or how muscle activation can affect the motion produced. Extending the use of biomechanical simulation analysis into eye movement can be used to deepen our understanding of how virtual environments affect our visual and mental capabilities. This paper presents a thorough review on ocular biomechanics and ocular models in literature. We start with a brief introduction on the anatomy of the eye and eye kinematics. In addition, properties of the extraocular muscles (EOM) are described and the difference between EOMs and skeletal muscle is highlighted. The challenges facing biomechanical simulation and analysis of eye movement are presented along with the role of ocular models in assessing visual fatigue. Furthermore, the compatibility of available biomechanical tools to analyze ocular movements is discussed.

Niemann-Pick disease type C (NPC) is a rare autosomal recessive genetic disease caused by mutations in the NPC1 and NPC2 genes with an estimated incidence of 1:120 000 live births. The clinical presentations vary across the ages. Children present with visceral symptoms related to cholesterol accumulation in the liver and adults have predominantly neuropsychiatric features such as dementia. However, vertical supranuclear gaze palsy can be present from the first year of life and is a strong feature in the diagnosis of NPC, which can be confirmed by a skin biopsy. A 36-year-old female with long-standing depression was referred for an evaluation of dystonia. She had progressive cognitive decline, dysarthria, dysphonia, dystonia of the trunk and limbs, ataxia and supranuclear gaze palsy. A similar course of illness affected her brother. Her parents were first cousins. She had positive Filipin stain of fibroblasts cultured from her skin biopsy, confirming the diagnosis of NPC. Miglustat, the approved drug for treatment, was not accessible. She had been on simvastatin since diagnosis, with a poor response, and had ongoing severe cognitive and physical disability. There are few conditions that present with neuropsychiatric symptoms and supranuclear gaze palsy. This patient had been managed as chronic depression with psychosis since her teenage years and her diagnosis was reviewed only when she had developed dystonia. Supranuclear gaze palsy is an early diagnostic clinical clue that could be present from infancy and should be sought in patients with neurocognitive presentations.

Background: Convergence insufficiency (CI) in parkinsonian conditions causes disabling visual symptoms during near tasks and usually manifests as double vision. Since double vision is more common in patients who report cognitive symptoms, we sought to determine if symptomatic CI, as opposed to asymptomatic CI, could serve as a marker of cognitive impairment in parkinsonian disorders.Methods: Twenty-four participants with parkinsonian disorders (18 Parkinson's disease, 5 progressive supranuclear palsy, 1 multiple system atrophy) and objective findings of convergence insufficiency on neuro-ophthalmologic examination were included. Subjective visual symptoms and cognitive complaints were recorded, and the Self-Administered Gerocognitive Examination was used as a global cognitive screening measure.Results: 54.1% of parkinsonian participants had cognitive impairment, but there were no significant differences in the degree of convergence insufficiency, measured by near point of convergence (NPC), or cognitive outcomes between those with symptomatic CI, and asymptomatic CI. However, NPC was greater for those with cognitive impairment (x = 18.4 cm), compared to those who were cognitively intact (x = 12.5 cm, p = 0.003).Conclusions: Cognitive impairment commonly co-occurs in parkinsonian disorders with convergence insufficiency and is associated with significantly greater NPC distances. Clinicians should have a high index of suspicion for cognitive impairment in patients with objective findings of convergence insufficiency, whether symptomatic or not. Further investigation of convergence insufficiency in relationship to cognitive impairment in parkinsonian disorders is warranted, as there may be a shared mechanism of dysfunction.

Ocular motility has been linked to Sports Concussion Assessment Tool 5 scores. However, the link between ocular motility changes and assessment result changes remains unclear. Hence, we investigated that potential link in patients with sports-related concussions. We retrospectively included participants aged≥18 years who were diagnosed with a sports-related concussion. They underwent smooth pursuit eye movement assessment for allocation to the good improvement (rate of fundamental frequency≥15%) or minor improvement (<15%) groups. Sports Concussion Assessment Tool 5 scores were determined at baseline and two weeks later, and score changes were compared between the groups. Thirteen men (mean±standard deviation age: 20.6±5.0 years) were included: eight (19.0±4.5 years) in the good improvement group and five (20.6±5.7 years) in the minor improvement group. Symptom number (median=2.0 vs. 0.0), symptom severity (median=22.0 vs. 3.0), single-leg stance (median=4.0 vs. 0.5), tandem stance (median=1.0 vs. 0.0), and total errors (median=5.0 vs. 0.5) were worse (all p<0.05) in the minor improvement group. Smooth pursuit eye movement improvements measured using eye-tracking technology was linked to symptom recovery in patients with sports-related concussions. Therefore, ocular motility may be an objective indicator of sports-related concussions. Future studies with more patients are needed to confirm these findings., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Current literature reports synergistic divergence as a rare, congenital ocular motility pattern associated with adduction palsy. Its mechanism has been likened to Duane's syndrome, and some suggest it be referred to as Duane's Type 4 (Gupta et al. 2010; Schliesser et al. 2016; Wilcox et al. 1981; Khan et al. 2016). There are no published reports of synergistic divergence as an acquired condition, making this case report seemingly the first of its kind. This case report describes an 18-year-old female who presented to clinic in 2013 with symptoms of diplopia and left eye turning outwards. Orthoptic assessment and MRI confirmed a third nerve palsy secondary to cavernous sinus schwannoma. Further monitoring showed progression of the cranial nerve palsy but a stable schwannoma and no aberrant regeneration noted in five years of follow up. The patient was treated with multiple botulinum toxin injections and had squint correction surgery in 2017. Seven months later, synergistic divergence was first noted and remained stable in all following assessments. While the aetiology of acquired synergistic divergence in this case is unclear, we can be confident it is unlikely to be of congenital origin as it was not noted until adulthood and after five years of investigations. This report will discuss possible aetiologies of acquired synergistic divergence and, contrary to current literature, suggest clinicians should consider the possibility that synergistic divergence can be acquired, though is likely to be even rarer than its congenital form. [ABSTRACT FROM AUTHOR]

The human eye movement network is a complex system that requires the integration of sensory, motor, attentional, and executive processes. Here, we review the neuroanatomy of the eye movement network with an emphasis on functional neuroimaging applications. We consolidate the literature into a concise resource designed to be immediately accessible and applicable to diverse research interests, and present the novel Functional Oculomotor System (FOcuS) Atlas—a tool in stereotaxic space that will simplify and standardize the inclusion of the eye movement network in future functional neuroimaging studies. We anticipate this review and the FOcuS Atlas will facilitate increased examination of the eye movement network across disciplines leading to a thorough understanding of how eye movement network function contributes to higher-order cognition and how it is integrated with other brain networks. Furthermore, functional examination of the eye movement network in patient populations offers the potential for deeper insight into the role of eye movement circuitry in functional network activity, diagnostic assessments, and the indications for augmentative communication systems that rely on eye movement control. [ABSTRACT FROM AUTHOR]

Introduction: Approximately 20% of patients with Parkinson's disease (PD) experience diplopia; however, the cause of the diplopia is unclear. We aimed to explore the association of diplopia, and its subtypes, with oculomotor abnormalities, impaired vision, and visual hallucinations, in patients with PD. Methods: This exploratory study included 41 PD patients, recruited from two general hospitals, of whom 25 had diplopia and 16 did not have diplopia, as well as 23 healthy controls (HCs). We defined subtypes of diplopia as selective diplopia, i.e., diplopia of single objects, and complete diplopia, i.e., diplopia of the entire visual field. All participants underwent a full orthoptic and ophthalmologic examination. Results: PD patients with diplopia had a high prevalence of oculomotor abnormalities (84%), impaired vision (44%), and visual hallucinations (44%), compared to PD patients without diplopia (33%, 6%, and none, respectively, p < 0.01), and compared to HCs (23%, 9%, and none, respectively, p < 0.01). Oculomotor abnormalities were equally prevalent in both subtypes of diplopia (selective and complete), whereas impaired vision was predominantly found in patients with selective diplopia. Moreover, only patients with selective diplopia had visual hallucinations. Conclusions: In PD patients, diplopia may be indicative of oculomotor or visual impairments. Hence, it is worthwhile to refer PD patients with diplopia to an orthoptist and an ophthalmologist for evaluation and, possibly, treatment of diplopia. Furthermore, in the case of selective diplopia, the neurologist should consider the presence of visual hallucinations, which may require the adjustment of the patient's medication. [ABSTRACT FROM AUTHOR]

Background: Convergence insufficiency (CI) in parkinsonian conditions causes disabling visual symptoms during near tasks and usually manifests as double vision. Since double vision is more common in patients who report cognitive symptoms, we sought to determine if symptomatic CI, as opposed to asymptomatic CI, could serve as a marker of cognitive impairment in parkinsonian disorders. Methods: Twenty-four participants with parkinsonian disorders (18 Parkinson's disease, 5 progressive supranuclear palsy, 1 multiple system atrophy) and objective findings of convergence insufficiency on neuro-ophthalmologic examination were included. Subjective visual symptoms and cognitive complaints were recorded, and the Self-Administered Gerocognitive Examination was used as a global cognitive screening measure. Results: 54.1% of parkinsonian participants had cognitive impairment, but there were no significant differences in the degree of convergence insufficiency, measured by near point of convergence (NPC), or cognitive outcomes between those with symptomatic CI, and asymptomatic CI. However, NPC was greater for those with cognitive impairment (x = 18.4 cm), compared to those who were cognitively intact (x = 12.5 cm, p = 0.003). Conclusions: Cognitive impairment commonly co-occurs in parkinsonian disorders with convergence insufficiency and is associated with significantly greater NPC distances. Clinicians should have a high index of suspicion for cognitive impairment in patients with objective findings of convergence insufficiency, whether symptomatic or not. Further investigation of convergence insufficiency in relationship to cognitive impairment in parkinsonian disorders is warranted, as there may be a shared mechanism of dysfunction. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate ocular motility (OM) disorders and strabismus in a sample of patients with retinitis pigmentosa (RP) and a control sample., Methods: In this cross-sectional retrospective analysis, we studied a sample of RP patients with a mean age of 48.74 years and an average visual acuity of 7/10 based on Snellen optotype and a sample of control patients with similar mean age (49 years [men], 47 years [women]) and sex and an average visual acuity of 9.9/10, with the aim of assessing correlations between alteration of OM and strabismus in RP patients based on age, high refractive defect, or severely impaired binocular vision. The examination followed a protocol of testing for anamnesis and best-corrected visual acuity, as well as a complete eye examination, corneal reflex, cover test, OM, Hess screen, and Lang test., Results: At the first orthoptic evaluation, 45.16% of patients showed strabismus, 41.93% exotropia (25% of cases intermittent), 3.22% esotropia, and 6.45% vertical deviation. Later evaluation showed strabismus in 25.80% of patients, exotropia in 19.35% (9.67% intermittent), esotropia in 3.22%, and vertical deviation in 3.22%. Assessment of eye motility study showed 51.6% overaction of the inferior oblique and hypofunction of the superior rectus, and 18% overaction of the lateral rectus and hypofunction of the medial rectus. According to our results, alterations in OM and strabismus in RP patients are not correlated with age or high refractive defect. Therefore, motility disorders and strabismus are attributed to a genetic factor to which men are more susceptible., Conclusion: The incidence of OM disorder was 77.42%, and strabismus was present in 45.16% of patients., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Comberiati et al.)