Purpose: To investigate the usefulness of atropine (Isopto atropine 1% eye drops®; Alcon, Fort Worth, TX, USA) for cycloplegic refraction in patients with partially accommodative esotropia. Methods: We retrospectively analyzed the medical records of patients with partially accommodative esotropia who underwent cycloplegic refraction using both cyclopentolate and atropine at Pusan National University Hospital between November 2017 and December 2020. Patients who replaced their glasses after cycloplegic refraction with atropine were included in group 1 and all other patients were included in group 2. Clinical features and the angle of ocular deviation were compared between the two groups. Results: This study included 23 patients with a mean age of 58.2 ± 22.3 months and mean interval between the two examinations of 5.2 ± 4.1 months. Spherical equivalent was larger after cycloplegic refraction using atropine compared to cyclopentolate (+3.04 ± 1.70 and +2.31 ± 1.75 diopters, respectively; p = 0.001). Groups 1 and 2 included 19 (83%) and 4 (17%) patients, respectively. Clinical characteristics did not significantly differ between the two groups. In group 1, the angle of ocular deviation at near fixation significantly decreased from 28.7 ± 14.0 to 20.7 ± 11.6 prism diopters (p = 0.002) after correction of the refractive error. Conclusions Cycloplegic refraction with atropine may be useful for detecting latent hyperopia and managing strabismus in patients with partially accommodative esotropia.

PURPOSE: To report two cases of orbital apex syndrome caused by blunt orbital trauma without structural damage of the orbit. CASE SUMMARY: (Case 1) A 50-year-old male came to our clinic complaining of visual loss after blunt orbital trauma by a metal bar. The best-corrected visual acuity was no light perception and light reflex was not observed in the affected eye. He also presented with complete ptosis and ophthalmoplegia with relative sparing of adduction and depression. High signal intensity of the orbital soft tissue including the optic nerve sheath was revealed using a T2-weighted image in magnetic resonance imaging. After starting steroid pulse therapy, his visual acuity improved to counting fingers on the third day. Ocular movement and levator function recovered to the normal range while visual acuity remained counting fingers. (Case 2) A 64-year-old female presented with complete ptosis after trauma to her right eyeball. The best-corrected visual acuity was 20/25 in the right eye. Complete ptosis and ophthalmoplegia with relative sparing of abduction and depression in the right eye were observed at the initial presentation. Magnetic resonance images showed enhancement of the right periphery optic nerve and distal rectus muscle. Two months after undergoing steroid pulse therapy, levator function and ocular movement recovered completely, and visual acuity improved to 20/20. CONCLUSIONS: The orbital apex syndrome caused by blunt orbital trauma showed good response to steroid pulse therapy. Steroid treatments may therefore be considered for the treatment of traumatic orbital apex syndrome.
Depression ; Female ; Fingers ; Humans ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Ophthalmoplegia ; Optic Nerve ; Orbit ; Reference Values ; Reflex ; Visual Acuity

PURPOSE: To report a case of an orbital mass diagnosed as metastasis from small cell lung cancer and to provide a review of the literature. CASE SUMMARY: A 66-year-old male with a history of diabetes mellitus and hypertension presented with decreased visual acuity and exophthalmos in his left eye. He had been diagnosed with age-related macular degeneration 13 years prior and had a history of pneumonia that was treated for one month. The best corrected visual acuity was hand-motion in the right eye and 0.04 in the left eye. Optic disc swelling and splint hemorrhage of the left eye was observed on fundus examination. The left eye was protruded and eye movement was limited. On orbital magnetic resonance imaging, an irregular mass in the left intraconal space was found. Incisional biopsy was performed, and histopathologic examination revealed a small round tumor. According to the results of immunohistochemical staining, metastatic tumors were suspected. After systemic evaluation, the patient was diagnosed with primary small cell lung cancer with multiple metastases. After 2 months, the visual acuity was hand-motion and proptosis was not resolved. CONCLUSIONS: In patients with orbital masses, the possibility of metastatic tumors should be considered during differential diagnosis and early biopsy should be performed.
Aged ; Biopsy* ; Diabetes Mellitus ; Diagnosis, Differential ; Exophthalmos ; Eye Movements ; Hemorrhage ; Humans ; Hypertension ; Macular Degeneration ; Magnetic Resonance Imaging ; Male ; Neoplasm Metastasis ; Orbit* ; Pneumonia ; Small Cell Lung Carcinoma* ; Splints ; Visual Acuity

Purpose: To investigate the clinical features of strabismus in patients with congenital optic disc anomaly and compare and analyze the characteristics of patients who showed changes in the strabismus pattern with those who did not.
Methods: Medical records of the patients who were diagnosed with both strabismus and congenital optic disc anomaly and followed-up for ≥1 year were reviewed retrospectively. Clinical characteristics and ophthalmic features at the initial visit and final follow-up were assessed. Patients with a change in the direction of strabismus or a difference of >10 prism diopters in the deviation angle during the follow-up period were allocated to the changed group. The remaining patients were assigned to the unchanged group. The clinical characteristics of the two groups were compared.
Results: Twenty-eight patients (15 boys) were included (mean age, 39.0 months; range, 5–150 months). Three (10.7%) patients were born preterm and four (14.3%) had other underlying systemic disease. Sixteen (57.1%) patients had exotropia, and 12 (42.9%) had esotropia. Concurrent vertical strabismus was present in three (10.7%) patients. Strabismus features changed in 14 (50.0%, changed group) patients and remained unchanged in 14 (50.0%, unchanged group) patients. Age, sex, and laterality did not differ between groups. Preterm birth history (n = 3) and combined systemic disease (n = 4) were only observed in the changed group (p = 0.111 and p = 0.049, respectively).
Conclusions Considering the possibility of changes in strabismic features, close monitoring of patients with strabismus combined with congenital disc anomaly is essential, particularly in those with preterm birth history or underlying systemic conditions.

Purpose: We compared bilateral lateral rectus recession with down transposition and slanted bilateral lateral rectus recession as surgical methods for convergence insufficiency-type exotropia. Methods: We included patients who underwent bilateral lateral rectus recession with down transposition or slanted bilateral lateral rectus recession for convergence insufficiency-type exotropia from January 2012 to January 2021 and observed them for more than 1 year. We retrospectively analyzed sex, age, preoperative best-corrected visual acuity, spherical equivalent, axial length, amount of surgery, and deviation angle before surgery and after surgery (immediately, 1 week, 6 months, and 1 year). We also examined surgical success and stereopsis before surgery and after 6 months and 1 year. Results: The down transposition group included 45 patients and the slanted group included 40. The deviation angle of distance, deviation angle of near and the near-distance disparity (NDD) all decreased in the down transposition group and slanted group 1 year after surgery (1.96 ± 8.77 prism diopter [PD] and 4.60 ± 4.99 PD, respectively; 5.53 ± 9.09 PD and 9.03 ± 9.09 PD, respectively; and 3.58 ± 5.26 PD and 4.43 ± 5.32 PD, respectively). Surgical success after 1 year was 55.6% in the down transposition group and 52.5% in the slanted group, and there was no significant difference between the two groups. Conclusions In convergence insufficiency-type exotropia, both bilateral lateral rectus recession with down transposition and slanted bilateral lateral rectus recession were effective to correct the deviation angle of near, distance, and NDD. Both are suitable primary surgical methods for convergence insufficiency-type exotropia.

Purpose: To report a case of traumatic optic neuropathy aggravated by orbital emphysema after an orbital fracture.Case summary: A 19-year-old man with no specific medical history was referred for a right orbital fracture caused by blunt trauma to the supraorbital rim of the right eye. Computed tomography (CT) showed a right orbital fracture involving the inferomedial wall and inferomedial strut. The corrected visual acuity was 0.4 in the right eye (RE) and 1.0 in the left and the intraocular pressure was 15 and 18 mmHg, respectively. Restriction on downgaze, abduction, and an indefinite relative afferent pupillary defect (RAPD) were observed in the RE. Fundus exam was non-specific other than commotio retinae on the temporal side of the macula in the RE. After 12 hours post trauma, the visual acuity of the RE had decreased to light perception. Definite RAPD was observed with optic disc swelling on the fundus photo and optical coherence tomography. Orbital CT showed air shadows, which were not seen on the initial evaluation, adjacent to the optic disc. We diagnosed traumatic optic neuropathy aggravated by orbital emphysema. High-dose intravenous steroid was given for 3 days. Despite a lateral canthotomy and cantholysis to decompress the right orbit, visual acuity did not improve above counting fingers. Conclusions Increased intraorbital pressure and congestion caused by orbital emphysema may exacerbate traumatic optic neuropathy. Therefore, close observation is required.

PURPOSE: To evaluate the efficacy of modified Anderson procedure in infantile nystagmus with face turn less than 30 degrees. METHODS: This study was a retrospective review of the medical records of 13 consecutive patients who underwent a modified Anderson procedure for abnormal head position in infantile nystagmus at Pusan National University hospital from February 2002 to March 2017. We compared best-corrected visual acuity (logarithm of minimal angle of resolution, logMAR), refraction, degree of face turn, ocular motility, and angle of deviation preoperatively and at 1 week postoperatively, 6 months postoperatively, and the final visit. Recession of the yoke rectus muscles responsible for the slow phase of nystagmus was performed, depending on the direction of face turn; the medial rectus muscle of the eye to which the head was turned was recessed 10 mm, whereas the lateral rectus muscle of the contralateral eye was recessed 12 mm. RESULTS: The mean age of the patients was 8.9 (2–25) years, and the mean follow-up period after surgery was 51.3 (6–183) months. Twelve patients (92.3%) had no residual head posture or <10° at 6 months postoperatively, and three patients (23.1%) achieved this outcome with an additional operation. The mean degrees of face turn were 22.30° before surgery and 3.85° post-operatively (p = 0.001). Best-corrected visual acuity (logMAR) was 0.41 in the better eye and 0.50 in the worse eye before surgery; this improved to 0.34 and 0.45 at 6 months postoperatively (p = 0.068 and p = 0.228, respectively). Despite the large recessions involved, only one patient showed mild limitation of abduction after surgery. CONCLUSIONS: The modified Anderson procedure may be effective for correcting abnormal head position in infantile nystagmus with face turn less than 30 degrees; patients were not overcorrected.
Busan ; Follow-Up Studies ; Head ; Humans ; Medical Records ; Muscles ; Posture ; Retrospective Studies ; Visual Acuity

Purpose: To investigate the clinical features of strabismus in patients with congenital optic disc anomaly and compare and analyze the characteristics of patients who showed changes in the strabismus pattern with those who did not.
Methods: Medical records of the patients who were diagnosed with both strabismus and congenital optic disc anomaly and followed-up for ≥1 year were reviewed retrospectively. Clinical characteristics and ophthalmic features at the initial visit and final follow-up were assessed. Patients with a change in the direction of strabismus or a difference of >10 prism diopters in the deviation angle during the follow-up period were allocated to the changed group. The remaining patients were assigned to the unchanged group. The clinical characteristics of the two groups were compared.
Results: Twenty-eight patients (15 boys) were included (mean age, 39.0 months; range, 5–150 months). Three (10.7%) patients were born preterm and four (14.3%) had other underlying systemic disease. Sixteen (57.1%) patients had exotropia, and 12 (42.9%) had esotropia. Concurrent vertical strabismus was present in three (10.7%) patients. Strabismus features changed in 14 (50.0%, changed group) patients and remained unchanged in 14 (50.0%, unchanged group) patients. Age, sex, and laterality did not differ between groups. Preterm birth history (n = 3) and combined systemic disease (n = 4) were only observed in the changed group (p = 0.111 and p = 0.049, respectively).
Conclusions Considering the possibility of changes in strabismic features, close monitoring of patients with strabismus combined with congenital disc anomaly is essential, particularly in those with preterm birth history or underlying systemic conditions.

Purpose: To report a case of unilateral progressive atypical acute zonal outer retinitis in a healthy young female.Case summary: A 32-year-old healthy woman presented with visual disturbance in the left eye for 1 week. Best corrected visual acuity was 0.4 in the left eye. No abnormal findings were detected on brain magnetic resonance imaging and a laboratory work-up. Zonal retinal opacity around the optic nerve disc was noticed in a fundus photo which was consistent with the outer retinal signal defect on optical coherence tomography and a defect in the central visual field from perimetry. Multiple evanescent white dot syndrome was suspected based on fluorescein angiography and indocyanine green angiography. Prednisolone was prescribed. Visual acuity was reduced to hand-motion after 10 days with extended zonal retinal opacity. No virus was detected by multiplex polymerase chain reaction of the aqueous humor. The lesion did not improve despite high-dose intravenous steroid and antiviral treatment. Conclusions Visual function was lost with the progression of outer retinitis. This case differed from previous cases as the outer retinitis progressed rapidly from the posterior pole to the peripheral retina. It was named fulminant progressive atypical acute zonal outer retinitis.

Purpose: To report a case of spontaneously improved visual acuity in a patient with suprasellar meningioma.Case summary: A 55-year-old female presented with decreased visual acuity for 1 week. She had chronic headache and ocular pain. Her visual acuity of the right eye was 0.1 and temporal and inferior visual field defects were found. Relative afferent pupillary defect was observed in the right eye. On orbital magnetic resonance image, a homogenous enhancing mass with a broad dural base at the jugum sphenoidale was found. This was likely to represent a meningioma and was referred to neurosurgery. The patient refused the surgery and did not receive any treatment. After 1 month, the visual acuity of the right eye improved to 0.5. The improved vision remained until 6 months later. Conclusions Visual loss associated with meningioma can spontaneously improve and this should be considered when making diagnostic and treatment decisions for meningioma.