Won Jae Kim

The Stabilization of Postoperative Exo-drift in Intermittent Exotropia after Surgical Treatment.

Purpose To investigate the long-term clinical course of intermittent exotropia after surgical treatment to determine whether and when postoperative exo-drift stabilizes, and the required postsurgery follow-up duration in cases of intermittent exotropia. Methods We retrospectively reviewed the medical records of patients diagnosed with intermittent exotropia who underwent surgical treatment between January 1992 and January 2006 at Yeungnam University Hospital and postoperatively performed regular follow-up examinations for up to 7 years. We also analyzed the difference in exo-drift stabilization, according to surgical procedure. Results A total of 101 patients were enrolled in the study. Thirty-one patients underwent lateral rectus recession and medial rectus resection (R&R) and 70 patients underwent bilateral lateral rectus recession (BLR). The postoperative angles of deviation increased significantly during the initial 36 months, but no subsequent significant changes were observed for up to 84 months. Follow-ups for 7 years revealed that more than 50% of the total amount of exo-drift was observed within the first postoperative year. In addition, the angles of deviation at 1 year correlated with those at 7 years postoperatively (Pearson correlation coefficient r = 0.517, p < 0.001). No significant exo-drift was observed after 36 months in patients who underwent BLR, whereas after 18 months in patients who underwent R&R. Conclusions The minimum postoperative follow-up required after surgical treatment to ensure stable results is 36 months. In particular, careful follow-up is necessary during the first postoperative year to detect rapid exo-drift. Patients who underwent BLR required a longer follow-up than those who underwent R&R to ensure stable postoperative alignment.

Permanent tonic pupil following inferior oblique myectomy

The postoperative dilation of the pupil following an inferior oblique weakening procedure is a disconcerting event. Previous studies have reported nearly full recovery of the pupil within a few months. We report the case of a patient with who experienced permanent tonic pupil following inferior oblique myectomy.

Accommodative Esotropia Who Needs Spectacles for Good Ocular Alignment after Refractive Shift below +2.00 Diopters

Purpose The aim of this study is to investigate the clinical characteristics of patients diagnosed with refractive accommodative esotropia (RAE) whose refractive errors were gradually reduced to below +2.00 diopters (D) during follow-up but use of spectacles was still required for maintenance of good ocular alignment. Methods We conducted a retrospective review of the medical records of patients diagnosed with RAE from 1995 to 2011. Patients were divided into 2 groups according to their ocular alignment at the last visit. Inclusion criteria were hyperopia ≥+2.00 D detected with cycloplegic refraction at the initial visit, which then became mild hyperopia (<+2.00 D) or myopia during follow-up, with more than 5 years of follow-up. Results A total of 92 patients met the inclusion criteria. Twenty-six patients showed persistent esotropia (≥10 prism diopters [PD]) without spectacles (group A) and 66 patients showed good ocular alignment (<10 PD) without spectacles (group B) at the last visit. No statistically significant differences in the spherical equivalent of the refractive errors at the initial and last visit were observed between the two groups. A significantly lower number of positive responses on the Lang I stereotest was observed in group A (n = 1, 3.8%) compared to group B (n = 22, 33.3%) (p = 0.003). There were increasing trends toward group A with worsening stereoacuity measured by the Stereo Fly Stereotest between the two groups (p = 0.016, linear by linear association). The results of the Lang I test, Stereo Fly Stereotest, and duration between the onset of esotropia and prescribing spectacles showed a significant association with the discontinuation of spectacles in the univariate logistic analysis. Conclusions Stereoacuity showed more significant associations than refractive errors in RAE with refractive error <+2.00 D but still required spectacles for maintenance of good ocular alignment. The prompt treatment of accommodative esotropia at the onset of esotropia is important for the discontinuation of spectacles.

Effects of remifentanil maintenance during recovery on emergence delirium in children with sevoflurane anesthesia

Emergence delirium is a common complication of sevoflurane anesthesia in children.

Slit Ventricle Syndrome in Pediatric Patient Presenting with Only Visual Symptoms

Dear Editor, A ventriculoperitoneal (VP) shunt is effective for hydrocephalus. However, the shunt may malfunction due to obstruction, breakage, migration, or infection [1]. Slit ventricle syndrome (SVS) is a rare symptomatic condition presenting with neuroimaging findings of small ventricles in a patient with a VP shunt. Accurate diagnosis can be difficult and adequate treatment may be delayed because neuroimaging of small ventricles can be misinterpreted as a properly working shunt [1-3]. In Korea, there have been no reports of SVS presenting with only visual symptoms. We report the case of a pediatric patient with SVS who presented with visual, but not systemic symptoms. A 10-year-boy visited our ophthalmic department. He was born at 33 weeks of gestation, with a birth weight of 2,030 g. He underwent VP shunt placement at the age of 6 months for hydrocephalus due to intraventricular hemorrhage. During the present visit, he described gradual onset of bilateral visual disturbances and horizontal intermittent diplopia for 1 week. He did not report other systemic symptoms suggesting increased intracranial pressure, such as headache, nausea, vomiting, or altered consciousness level. Visual acuity was 20 / 50 in the right eye and 20 / 20 in the left, but color vision test using an Ishihara plate was decreased in the both eyes. Pupils showed normal response to light and near stimulation. He demonstrated 20 prism diopters esotropia in the right eye, with mild abduction limitation (Fig. 1A). Fundus examination showed optic disc swelling, increased vessel tortuosity, and bilateral macular exudates (Fig. 1B and 1C). Computerized tomography of the brain did not show ventricuolmegaly or other signs of increased intracranial pressure (Fig. 1D-1F). A serologic work-up was conducted to rule out other inflammatory or infectious causes; the results were within normal limits except for a white blood cell count of 12,090/μL (normal, 4,000 to 10,000). Two weeks later, follow-up computerized tomography was performed instead of intracranial pressure measurement; there was no clear difference compared to previous studies. However, fundus examination revealed more severe optic disc swelling compared to that observed at the previous visit. Shunt revision was performed and visual symptoms gradually improved. Six months later, visual acuity had improved to 20 / 20 in both eyes, and fundus showed no optic disc swelling (Fig. 1G and 1H). He was orthotropic and had no diplopia. SVS refers to the occurrence of headache, vomiting, and possibly some degree of impaired consciousness and visual deterioration in children with hydrocephalus and VP shunts [3]. The pathogenesis remains unclear. Overdrainage, periodic shunt malfunction, intracranial hypertension, and decreased brain parenchyma compliance to variations in cerebrospinal fluid volume have been proposed as SVS Korean J Ophthalmol 2017;31(1):92-93 ht tps://doi.org/10.3341/k jo.2017.31.1.92

Exotropia and hypotropia as the initial presentation sign of thyroid eye disease in an 18-year-old man

Exotropia is rarely reported in thyroid eye disease (TED). We report the case of an 18-year-old patient with TED who developed exotropia and hypotropia as an initial presentation of TED.

Exotropia in a pediatric patient with rhabdomyolysis caused by an insect sting

Various ocular and systemic reactions have been associated with insect sting. However, insect stings have been rarely reported to cause exotropia and diplopia. We encountered exotropia in a 6-year-old child with rhabdomyolysis of the left lower extremities caused by an insect sting. Exotropia and diplopia developed within 1 day after the sting and improved completely 1 week after the onset of symptoms. Clinicians should be aware of the potential for the development of exotropia in patients with insect stings, which requires careful follow-up.

Inferior Rectus Muscle Restriction after Sub-Tenon's Anesthesia

Dear Editor, Sub-Tenons anesthesia (STA) is widely used for regional orbital anesthesia. Complications of STA are rare but include inferior rectus muscle restriction [1,2,3]. There have been no reports of inferior rectus restriction after STA in Korea. We encountered a patient with inferior rectus muscle restriction after STA who eventually required surgical treatment and report the case herein. A 64-year-female visited our clinic in May 2013 for diplopia in the whole field of vision. She had undergone cataract surgery under local anesthesia using STA with 2% lidocaine without hyaluronidase at another clinic in March 2013 and complained of diplopia beginning in the immediate postoperative period. She had no systemic disease or preoperative history of diplopia or strabismus. She demonstrated 20 prism diopters hypotropia in the left eye in the primary position with limited elevation. Visual acuity was 20 / 20 in both eyes. Blood tests, including thyroid function tests and anti-acetylcholine receptor antibody, were within the normal ranges. No abnormal extraocular muscle findings were seen on orbital computed tomography. The diplopia increased to 30 prism diopters hypotropia in the left eye over five months postoperatively. Surgical treatment was recommended, but the patient initially refused. As the clinical findings did not change during follow-up, surgery was performed in August 2014. Restriction of the inferior rectus muscle of the left eye was confirmed through the forced duction test. During surgery, conjunctival scarring over the inferior rectus muscle was noted, in addition to a linear scar along the medial border of the muscle. The inferior rectus muscle of the left eye was recessed by 5 mm and the superior rectus muscle of the right eye was recessed by 5 mm. The postoperative ocular alignment showed orthotropia, and the patient achieved binocular single vision (Fig. 1). Fig. 1 (A) Preoperative images of the subject in nine diagnostic positions of gaze, demonstrating hypotropia of the left eye in the primary position with limited elevation. (B) Three months postoperatively, hypotropia of the left eye had improved and the patient ... STA is becoming increasingly popular because it provides good analgesia without the passage of sharp needles in the orbit. The reported complications of STA include subconjunctival hemorrhage, chemosis, extraocular muscle paresis, and optic neuropathy [2,3]. Postoperative diplopia following cataract surgery under STA is particularly disconcerting for the surgeon. Jaycock et al reported three cases of persistent rectus muscle restriction after STA [4]. They postulated that direct trauma to the muscle with hematoma formation occurred at the time of the STA with subsequent contracture of the affected muscle. We agree with their hypothesis based on our surgical findings. Although inferior rectus muscle restriction after STA is uncommon, the surgeon needs to be aware of this possibility; care must always be taken to avoid direct trauma to the muscle during the procedure.