Shailja Tibrewal

Comparison of augmented superior rectus transposition with medial rectus recession for surgical management of esotropic Duane retraction syndrome.

BACKGROUND Medial rectus recession (MRc) and vertical rectus transpositions are procedures used to treat esotropic Duane retraction syndrome. Recently superior rectus transposition (SRT) combined with MRc has also been shown to improve primary alignment and abduction. The purpose of this study is to compare the results of augmented (ie, with scleral fixation) SRT with or without MRc with either unilateral or bilateral MRc for treatment of esotropic Duane syndrome. METHODS The medical records of patients who underwent surgery for esotropic Duane syndrome between May 2007 and February 2013 were retrospectively reviewed. Success was defined as alignment within 8(Δ) of orthotropia and abnormal head posture of <5°. RESULTS There were 8 patients in the SRT group (6 of whom had additional ipsilateral MRc) and 13 in the MRc group (6 unilateral and 7 bilateral). In the SRT group, the mean preoperative deviation was 20(Δ) of esotropia; the mean postoperative deviation, 3(Δ). In the MRc group, the mean preoperative deviation was 24(Δ) of esotropia; the mean postoperative deviation, 4(Δ). The success rate was 87% in the SRT group; 77%, in MRc group (P = 0.98). Mean abduction limitation improved from -3.6 to -2.4 units in the SRT group and from -3.6 to -3.3 units in the MRc group (P = 0.003). Induced vertical deviation or subjective torsion was not seen. Three patients in each group developed adduction limitation postoperatively. CONCLUSIONS Although both the procedures successfully correct esotropia in Duane syndrome, SRT with or without MRc has the additional advantage of improving abduction.

Hyperopic corneal refractive surgery in patients with accommodative esotropia and amblyopia: comment.

To the Editor: We commend the authors of “Hyperopic corneal refractive surgery in patients with accommodative esotropia and amblyopia” for addressing very important issue of concurrent amblyopia in patients with accommodative esotropia and exploring the possibility of hyperopic refractive surgery in such patients. We would like to comment on the study’s methodology and results. Esodeviation was apparently measured with respect to near fixation alone; we failed to find any information regarding deviation for distance, presence of any near distance disparity, and high ratio of accommodative convergence to accommodation. All of these findings are extremely important in the ultimate response to any type of optical or surgical correction in patients with accommodative esotropia; therefore, the motor alignment results would have been more appropriate and complete had these factors also been studied. The authors found that most of their amblyopic patients (70% in synoptophore tests and 50% in Titmus fly test) showed improvement in gross stereopsis following surgery. This result is much better than previous studies, which noted only a modest improvement or no improvement, in spite of the fact that most of these studies involved nonamblyopic subjects. We would like to ask the authors whether a masked evaluation of the postoperative visual acuity, alignment, and stereopsis was performed to neutralize observer bias. The data on patient no. 3 in Table 2 shows that the spectacle-corrected esotropia of 40 improved to unaided 10 after refractive surgery. Such large improvements in

Clomiphene citrate-induced visual hallucinations: a case report

BackgroundPolycystic ovary syndrome is a common cause of chronic anovulation and infertility in otherwise healthy fertile couples. Clomiphene citrate is used as a first-line ovulation induction therapy in patients with polycystic ovary syndrome. Clomiphene citrate can cause both systemic and ocular side effects. We report a rare side effect of illusory palinopsias in a patient with polycystic ovary syndrome treated with ovulation induction therapy with clomiphene citrate, and emphasize the need for gynecologists and their patients to be aware of this rare ocular side effect.Case presentationA 30-year-old Asian woman complained of persistent visual afterimages following treatment with 100 mg clomiphene citrate for anovulation. Her symptoms started on the fourth day after commencing the treatment and would last for 5 to 10 minutes. Similar visual symptoms were noted during her second cycle of treatment with clomiphene citrate. The severity of her symptoms reduced following the stoppage of the medication; however, the symptoms have persisted for more than 1 year since she stopped taking the drug.ConclusionsClomiphene citrate can cause disturbing illusory palinopsias. These afterimages persist even after stopping the infertility medication. It is a side effect not frequently seen by gynecologists or ophthalmologists. Gynecologists should make their patients aware of this rare ocular side effect when their patients start treatment with clomiphene citrate for infertility.

Risk of Anterior Segment Ischemia Following Simultaneous Three Rectus Muscle Surgery: Results from a Single Tertiary Care Centre

ABSTRACT Purpose: The aim of the study was to determine the risk of anterior segment ischemia (ASI) after simultaneous three rectus muscle surgery. Methods: A retrospective cohort study was conducted. All patients who underwent simultaneous three rectus muscle surgery from January 2003 to December 2014 were included. Medical records were reviewed for signs of acute ASI in the postoperative period or presence of any late sequelae. Those patients who had pre-existing corneal pathology obscuring visualisation of anterior chamber and iris were excluded. Results: A total of 87 patients (54 males and 33 females) were included in the analysis. The mean age at the time of surgery was 22.5 ± 12.9 years (range 3.5 to 69.5 years). The common indications for surgery were monocular elevation deficit, sensory strabismus and third and sixth cranial nerve palsies. Mild form of ASI was seen in two patients, with no systemic or local illness, aged 30 and 9 years respectively. Both the patients underwent surgery on two vertical rectus muscle and one horizontal rectus muscle via the fornix approach. ASI resolved with topical steroids within two weeks in both the patients. Conclusions: The risk of anterior segment ischemia after uncomplicated simultaneous three rectus muscle surgery was found to be 2.3% (95% CI = 0.3 to 8.1). It may occur in otherwise healthy young patients and even after fornix approach surgery.

Accuracy of noncycloplegic refraction performed at school screening camps

Purpose: The aim of this study was to compare noncycloplegic refraction performed in school camp with that performed in eye clinic in children aged 6–16 years. Methods: A prospective study of children with unaided vision <0.2 LogMAR who underwent noncycloplegic retinoscopy (NCR) and subjective refraction (SR) in camp and subsequently in eye clinic between February and March 2017 was performed. A masked optometrist performed refractions in both settings. The agreement between refraction values obtained at both settings was compared using the Bland–Altman analysis. Results: A total of 217 eyes were included in this study. Between the school camp and eye clinic, the mean absolute error ± standard deviation in spherical equivalent (SE) of NCR was 0.33 ± 0.4D and that of SR was 0.26 ± 0.5D. The limits of agreement for NCR were +0.91D to − 1.09D and for SR was +1.15D to -1.06D. The mean absolute error in SE was ≤0.5D in 92.62% eyes (95% confidence interval 88%–95%). Conclusion: A certain degree of variability exists between noncycloplegic refraction done in school camps and eye clinic. It was found to be accurate within 0.5D of SE in 92.62% eyes for refractive errors up to 4.5D of myopia, 3D of cylinder, and 1.5D of hyperopia.

Anomalous Lateral Rectus Muscle Band in a Case of Duane Retraction Syndrome

ABSTRACT Anomalous orbital structures are suspected in restrictive strabismus with features of severe globe retractions, overshoots, or synergistic movements. We report a case of suspected Duane syndrome that was found to have an anomalous band beneath the lateral rectus muscle. Such abnormal structures are rare, but it is important to identify and manage them to optimize outcomes.

A double-masked randomized trial of postoperative local anaesthetic for pain control in pediatric strabismus surgery

To the Editor: We congratulate Enyedi and colleagues on their well-conducted randomized double masked controlled trial on this very relevant and pertinent issue of postoperative pain in children undergoing strabismus surgery. We would like to comment on their methodology and results. Although it is a randomized, controlled trial, the authors do not mention the details of sample size calculation, including the power of the study. Because the average pain scores in patients in all three groups were low, a difference in pain score by even a small fraction could be clinically significant. Yet the authors do not mention the effect size (ie, difference in pain scores between any two groups that was considered significant) used to calculate the sample size. The authors found that sub-Tenon’s bupivacaine injection had better pain scores compared to the control group; however, they acknowledge in the

Appraising the spectrum of firework trauma and the related laws during Diwali in North India

Purpose: To evaluate the epidemiological characteristics and outcomes of ocular injuries resulting from the use of firecrackers during the Diwali festival in all age groups. Materials and Methods: A single-center, retrospective, hospital-based case series presenting with ocular trauma consequent to fireworks usage in a tertiary eye care center in North India during the 5 days of Diwali festival from 2011 to 2015 was conducted. Results: A total of 53 eyes of 45 patients were included in the study, out of which the vast majority (39/87%) were males. The mean age was 20.55 years. Almost an equal number of bystanders (25/55.5%) were affected as compared to people handling the fireworks (20/44.44%). Five (9.43%) eyes had open-globe injury, whereas 48 (90.56%) eyes had closed-globe injury. Eighteen (33.96%) eyes underwent surgical intervention. Thirty-three (62.26%) eyes had final vision >20/200 with eight (15.09%) eyes being vision <3/60 in the affected eye. Conclusion: Firework-related ocular trauma can lead to serious visual impairment. Mandatory legislative laws pertaining to the manufacture, sale, and use of fireworks and creating public awareness can reduce the incidence of this preventable cause of blindness in the society. Initiating new policies for retailers involved in sale of these firecrackers can also bring in decrease of such morbidities.

Contralateral eye surgery with adjustable suture for management of third nerve palsy with aberrant regeneration

Aberrant regeneration of the third nerve following its palsy is commonly seen after trauma and compressive lesions. This phenomenon is thought to result due to misdirection of the regenerating axons. Surgical management is a great challenge in the third nerve palsy owing to multiple muscle involvement and is often accompanied by ptosis and poor Bells phenomenon. We present a case of a 27-year-old male who developed isolated complete third nerve palsy of the left eye following head trauma. Features of aberrant regeneration were seen after 6 months, namely, inverse Duanes sign and Pseudo-Von Graefes sign. He underwent recess-resect procedure in the unaffected eye with adjustable suture technique which not only corrected the deviation but also the ptosis by utilizing the oculomotor synkinesis. Thus, contralateral eye surgery combined with adjustable suture technique resulted in an accurate alignment of the eye and obviated the need for ptosis correction.

A simple and novel grading method for retraction and overshoot in Duane retraction syndrome

Strabismus in Duane retraction syndrome is frequently associated with significant globe retraction and overshoots. However, there is no method to objectively grade retraction and overshoot. Our purpose is to describe a novel objective grading method. This novel and simple grading method has excellent agreement. It will help standardise measurements and guide the clinician in taking the decision for surgery and predicting its outcome.