Journal of Current Ophthalmology
Volume:33 Issue: 3, Jul-Sep 2021

To assess the diagnostic accuracy measures such as sensitivity and specificity of smartphone‑based artificial intelligence (AI) approaches in the detection of diabetic retinopathy (DR).

A literature search of the EMBASE and MEDLINE databases (up to March 2020) was conducted. Only studies using both smartphone‑based cameras and AI software for image analysis were included. The main outcome measures were pooled sensitivity and specificity, diagnostic odds ratios and relative risk of smartphone-based AI approaches in detecting DR (of all types), and referable DR (RDR) (moderate nonproliferative retinopathy or worse and/or the presence of diabetic macular edema).

Smartphone‑based AI has a pooled sensitivity of 89.5% (95% confidence interval [CI]: 82.3%–94.0%) and pooled specificity of 92.4% (95% CI: 86.4%–95.9%) in detecting DR. For referable disease, sensitivity is 97.9% (95% CI: 92.6%‑99.4%), and the pooled specificity is 85.9% (95% CI: 76.5%–91.9%). The technology is better at correctly identifying referable retinopathy.

The smartphone-based AI programs demonstrate high diagnostic accuracy for the detection of DR and RDR and are potentially viable substitutes for conventional diabetic screening approaches. Further, high‑quality randomized controlled trials are required to establish the effectiveness of this approach in different populations.

To review the clinical features, diagnosis, treatment modalities, and prognosis of arthropod-borne infectious diseases.

This is a narrative review on arthropod-borne infectious diseases including general and ophthalmological aspects of these infectious diseases. A comprehensive literature review between January 1983 and September 2020 was conducted in PubMed database. Epidemiology, clinical features, diagnosis, treatment, and prognosis of arthropod-borne infectious diseases were reviewed.

Emergent and resurgent arthropod-borne infectious diseases are major causes of systemic morbidity and death that are expanding worldwide. Among them, bacterial and viral agents including rickettsial disease, West Nile virus, Dengue fever, Chikungunya, Rift valley fever, and Zika virus have been associated with an array of ocular manifestations. These include anterior uveitis, retinitis, chorioretinitis, retinal vasculitis, and optic nerve involvement. Proper clinical diagnosis of any of these infectious diseases is primarily based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. The diagnosis is confirmed by laboratory tests. Ocular involvement usually has a self-limited course, but it can result in persistent visual impairment. Doxycycline is the treatment of choice for rickettsial disease. There is currently no proven specific treatment for arboviral diseases. Prevention remains the mainstay for arthropod vector and zoonotic disease control.

Emerging arthropod vector-borne diseases should be considered in the differential diagnosis of uveitis, especially in patient living or with recent travel to endemic countries. Early clinical diagnosis, while laboratory testing is pending, is essential for proper management to prevent systemic and ocular morbidity.

To review various types of extraocular muscle transposition procedures for management of strabismus in sixth cranial nerve palsy with little lateral rectus (LR) muscle function, along with their pros and cons.

We performed a comprehensive review of transposition procedures in sixth cranial nerve palsy, based on literature published anytime up to March 2021. A thorough search through PubMed and Cochrane databases was performed. All types of clinical studies on different transposition procedures in LR palsy, were included.

Eighty-six original articles in English, with full text or abstracts available, were included in the review, among which 16 are prospective studies, 48 retrospective, 3 review articles, 1 randomized clinical trial, 17 case reports, and 1 letter. Vertical rectus transposition has demonstrated promising results, especially in abduction improvement and expansion of binocular diplopia‑free visual field, albeit the possible adverse effects such as anterior segment ischemia, especially in the presence of medial rectus contracture, and induced vertical deviation may become troublesome. Partial muscle transposition, single muscle transposition, and also transposition without tenotomy have all been introduced to reduce the risk of multiple muscle manipulation and ischemia. On the other hand, different adjustable transpositions are being utilized to manage concomitant or induced vertical deviations.

Transposition procedures are highly effective in the treatment of esotropia caused by complete LR palsy. Various techniques for vertical muscle transposition have been proposed, with each of them having certain advantages and disadvantages.

To compare the results of the new strategy Swedish Interactive Thresholding Algorithm (SITA) Faster to the results of SITA Standard in patients with glaucoma.

This was a cross-sectional study of 49 patients with glaucoma and previous experience with standard automated perimetry. Two consecutive tests were performed in random order, one with SITA Standard and another one with SITA Faster, in the studied eye of each patient. Comparisons were made for test time, mean deviation (MD), visual field index (VFI), and number of depressed points in pattern deviation map and total deviation map for every level of significance.

The average test time was 56% shorter with SITA Faster (P < 0.001). The intraclass correlation coefficient (ICC) for MD and VFI showed excellent agreement between both strategies, ICC = 0.98 (95% confidence interval [CI]: 0.96, 0.99) and ICC = 0.97 (95% CI: 0.95, 0.99), respectively. For the number of depressed points in total deviation map and pattern deviation map, ICC demonstrated good agreement with values between 0.8 and 0.95.

Our study shows that SITA Faster is a shorter test with strong agreement with SITA Standard parameters. These results suggest that SITA Faster could replace SITA Standard for glaucoma diagnosis.

To compare the outcomes of combined phacoemulsification–trabeculectomy surgery with intraoperative sponge‑applied versus subconjunctival injection of mitomycin-C (MMC) in Asian eyes.

This was a retrospective review of 95 eyes that consecutively underwent combined phacoemulsification–trabeculectomy surgery in a tertiary eye center in Singapore from January 2013 to June 2014. Data collected included intraocular pressure (IOP), best corrected visual acuity, and number of glaucoma medications. Outcome measures included postoperative IOP and complications at various timepoints up to 12 months after surgery.

Twenty eyes (21.1%) received 0.2 mg/ml subconjunctival MMC injection (“Group 1”) and 75 (78.9%) received 0.4 mg/ml sponge-applied MMC (“Group 2”). There was no difference between groups in demographics, IOP, and number of glaucoma medications preoperatively. There was a reduction in IOP at postoperative month (POM) 1, 6, and 12 in both the groups (POM12: Group 1, −2.8 ± 5.36 mmHg, P < 0.001; Group 2, −5.8 ± 6.29 mmHg, P = 0.054). At POM1, Group 2 showed a trend toward greater IOP reduction (−5.89 ± 7.67 mmHg vs. −1.55 ± 5.68 mmHg, P = 0.061). However, at both POM6 and POM12, there was no statistically significant difference in IOP reduction between the two groups. At POM12, complete success, defined as achieving an IOP of between 6 and 15 mmHg without the use of antiglaucoma medications, was achieved in 11 (55%) eyes in Group 1 and 48 (64%) in Group 2 (P = 0.9). There was a lower rate of postoperative hypotony in the Group 1 (0%) compared to Group 2 (8%) (P = 0.34).

Combined phacoemulsification–trabeculectomy with subconjunctival MMC injection has comparable outcomes to that with sponge-applied MMC, with a similar reduction in IOP at 1, 6, and 12 months postoperatively and a lower postoperative complication rate.

To investigate the effects of topical and perilesional interferon alpha-2b as primary treatment for ocular surface squamous neoplasia (OSSN).

In this prospective interventional case series, topical interferon alpha-2b (3 MIU/mL) was used as the initial treatment of OSSN, with perilesional interferon alpha-2b (3 MIU/mL) added based on clinical response. The primary outcome was complete tumor resolution. Spearman’s rank correlation test was used to investigate the association of complete tumor resolution and time to resolution with baseline tumor characteristics and the American Joint Committee on Cancer (AJCC) classification for OSSN.

Ninety-two patients (92 OSSN tumors) were included in the study. The total follow-up duration was 13.57 ± 2.14 months (median: 12, range: 3–23). The median basal tumor diameter was 4 mm (mean: 4.13 ± 1.37). Complete tumor resolution was achieved in 89 cases (96.73%), with a median time to complete tumor resolution of 5 months (mean: 4.64 ± 1.92). Complete tumor resolution was 57 of 57 in T1 (100%), 8 of 9 in T2 (88.88%), and 21 of 23 in T3 (91.30%). There were statistically significant correlations between AJCC classification and complete tumor resolution (Spearman’s r = −0.22, P = 0.03) and maximal basal tumor diameter and the time to complete resolution (Spearman’s r = 0.35, P = 0.001). There were no recurrences during the study follow-up period.

Topical interferon alpha-2b is effective and well tolerated as a primary treatment for OSSN, with a high rate of tumors responding completely to therapy.

To compare the effectiveness of anterior subconjunctival anesthesia (ASCA) with sub-tenon’s anesthesia (STA) for manual small incision cataract surgery (MSICS), regarding pain, akinesia, surgeon comfort, and complications.

This trial randomized 164 patients into two groups. Group 1 received ASCA, and Group 2 received STA. MSICS was performed on all patients. Any complications of anesthesia were noted before starting surgery. Patient ocular motility during surgery was scored between 0 and 4 based on the number of directions of gaze in which movement persisted. Following surgery, patients scored pain felt during surgery on a visual pain-score analog, and the surgeon graded for “discomfort” felt during surgery from 0 (Nil) to 4 (additional anesthesia needed).

Chemosis due to anesthesia and persistence of ocular motility in all four gaze directions were seen in all 82 patients of Group 1, but these did not prevent the surgeon from performing MSICS. Seventy-seven patients (94%) in Group 1 and 79 (96.4%) in Group 2 had no or mild pain during surgery. The surgeon had moderate-to-severe discomfort in 14 (17.2%) Group 1 patients and 3 (3.6%) Group 2 patients, most of whom had deep-set eyes or exhibited excessive eye movements. Two patients in Group 1 and one patient in Group 2 were converted to peribulbar block.

ASCA is a safe and effective alternative for performing MSICS. It does not induce akinesia but provides adequate anesthesia for the surgery in most patients, except those with deep-set eyes, especially if displaying increased anxiety.

To assess the therapeutic efficacy of a combinational therapy, including conventional treatment and intense pulsed light (IPL) technique on sleep quality of patients with meibomian gland dysfunction (MGD).

Fifty participants with a clinical diagnosis of MGD were enrolled in this study. Participants underwent three sessions of IPL therapy. There was a 2-week interval between IPL sessions 1 and 2 and 1 month between sessions 2 and 3. Treatment was supplemented with conventional home-based therapy (including lid hygiene, warm compress, eyelid massage, and lid margin scrub) for MGD. Dry eye symptomatology, tear film, and ocular surface parameters were evaluated at baseline (day 0) and days 15, 45, and 75. Sleep quality was assessed before and after the study using Pittsburgh Sleep Quality Index (PSQI).

PSQI components improved significantly at day 75 in comparison with the baseline (all P < 0.05). Ocular Surface Disease Index (OSDI) score, noninvasive Keratograph tear break‑up time (NIKBUT), fluorescein tear break‑up time (FTBUT), meibomian gland expressibility, meibum quality score, and tear osmolarity improved at follow-up visits (P < 0.05). Younger patients showed more improvement in NIKBUT, sleep quality, and duration (P = 0.024, P = 0.047, and P = 0.008). Sleep latency decreased with increased NIKBUT and FTBUT and decreased OSDI score (P = 0.001, P = 0.005, and P = 0.041).

The treatment of MGD is effective for improving sleep quality. Younger patients may preferentially benefit from the treatment.

To compare the outcomes of Descemet’s membrane endothelial keratoplasty (DMEK) combined with phacoemulsification versus DMEK following phacoemulsification.

In this interventional retrospective comparative nonrandomized case series study, patients with Fuchs endothelial corneal dystrophy (FECD) with either cataract or previous cataract surgery with intraocular lens (IOL) implantation were assigned to one of the two groups according to lens status. Group 1 included patients who had cataract and FECD and would undergo triple procedure (phacoemulsification with IOL implantation and DMEK), whereas Group 2 included patients who had FECD and had phacoemulsification with IOL implantation earlier and would undergo DMEK only as a sequential procedure.

Postoperative best corrected visual acuity (BCVA) in both groups at 1 week, 1 month, 3 months, and 6 months revealed a statistically nonsignificant difference between the two groups with mean logMAR BCVA at 6 months of 0.07 ± 0.18 and 0.07 ± 0.19 in Group 1 and Group 2, respectively (P > 0.05). The drop in endothelial cell density by the end of the 6th postoperative month was by 39.44% ±7.92 and 38.73% ±8.10 in the triple-procedure group and DMEK only group, respectively (P = 0.005). Total postoperative complications rate and the rebubbling rate were statistically similar between both groups with 13.5% and 12.5% rebubbling rate in Group 1 and Group 2, respectively (P > 0.05).

Visual outcomes, endothelial cell loss, and rebubbling rate are comparable when DMEK is combined with phacoemulsification or when it is performed as staged procedure, without statistically significant difference in the outcomes.

To evaluate the visual, refractive, and topographic outcomes of accelerated corneal collagen cross-linking (CXL) in the pediatric age group.

In this retrospective case series study, 89 eyes of 56 patients with progressive keratoconus (KCN) who were under or equal to 18 years old at the time of surgery were included. All patients underwent accelerated corneal CXL. A thorough baseline and follow-up ophthalmic examination including uncorrected distance visual acuity, best corrected visual acuity (BCVA), slit-lamp and fundus examination, and corneal tomography by Scheimpflg camera Pentacam (Oculus, Wetzlar, Germany) were performed.

The mean age of patients was 16.2 ± 1.8 years. Mean follow‑up was 16.46 ± 11.6 months (range, 6–40 months). The mean BCVA improved significantly from 0.26 ± 0.26 to 0.16 ± 0.19 (logMAR) after accelerated CXL (P < 0.001). The mean corneal astigmatism based on refraction decreased from 3.69 ± 2.12 to 3.15 ± 1.86 after the intervention (P = 0.016). The mean maximum keratometry (Kmax) reduced significantly from 53.23 ± 6.07 diopter (D) to 52.23 ± 6.33 D (P = 0.047). The mean flat keratometry (K1) reduced from 46.37 ± 3.69 to 45.95 ± 3.65 after the intervention (P = 0.119).

Our study shows that accelerated CXL increases visual acuity and stabilizes or improves keratometric indices in pediatric patients with progressive KCN without any serious complication for a mean follow-up time of 16 months.

To evaluate the microstructural corneal changes during acute endothelial graft rejection and following treatment using in vivo confocal microscopy (IVCM).

Patients with a clinical diagnosis of severe acute endothelial graft rejection following penetrating keratoplasty were included in this study. IVCM was performed on the 1st day the patient presented with rejection signs and at the time of clinical resolution.

Twenty‑three patients were included in this study. Inflammatory cells appeared as dendritic cells (DCs) and less frequently, as non‑DCs in basal epithelial and subbasal areas. Activated keratocytes (AKs) (type 1: large cells with visible cytoplasmic processes; type 2: elongated and spindle‑shaped keratocytes) were visible in acute phase. Following resolution, type 1 AKs considerably reduced, but type 2 cells were more often persisted. Multiple types of keratic precipitates (KPs) were also visible in acute phase which resolved following resolution of rejection.

Acute graft rejection was associated with an increase in the number of DCs, activation of keratocytes, and aggregation of various types of KPs. Inflammatory process subsided in almost all cases, but the IVCM changes did not return to normal early after clinical resolution of rejection.

To determine the rate and factors affecting pterygium recurrence in the Hispanic population of the Northeastern United States, based on patient demographic information.

In this retrospective cross-sectional study, data were collected on ethnically Hispanic patients from 2013 to 2018 who had primary single-headed pterygia excision and conjunctival autograft, with the minimum of 4-month follow-up time. This study was conducted in an academic institution in the Northeastern United States, with all patients being from the surrounding community.

In 168 Hispanic patients with confirmed primary single‑headed pterygium, most pterygia occurred nasally (161/168). The average age of presentation was 46.3 ± 12.0 years (range, 23–77 years). There were 22 recurrences (13.1%), occurring at an average of 3.0 ± 1.6 months (1–8 months). This cohort demonstrated a unimodal recurrence distribution. Age is significantly inversely correlated with the incidence of recurrence (r = −0.219, P = 0.004), but not with the size of the recurrent pterygia (r = −0.112, P = 0.621). There was no significant difference between recurrence based on gender (P = 0.265), location (P = 0.824), or laterality (right or left eye) (P = 0.213). Mean corrected visual acuity improved from 20/40 to 20/32 after pterygium excision (P < 0.001). Cox regression analysis for age groups shows the risk of recurrence for patients aged 20–29 is 11.4‑time that of patients aged 50 and above (P < 0.001).

Recurrence occurred unimodally at around 3 months postoperatively. Younger patients are significantly more susceptible to recurrence. Future studies may seek to determine the incidence of pterygia and their recurrence patterns in relation to occupations and sun exposure time in a geographic area.

To investigate retinal layers’ thickness and vascular density after successful scleral buckle surgery using the optical coherence tomography angiography (OCTA) method.

In this prospective interventional case-control study, 24 patients with macular-off rhegmatogenous retinal detachment (RRD) were included after performing successful reattachment by scleral buckling. Retinal layers’ thickness and vascular density were assessed in the patients using the OCTA method compared to normal fellow eyes as controls 10 months postoperation.

Inner retinal layers showed no significant difference, but there was a significant reduction in outer central 1‑mm retinal layers’ thickness. Outer plexiform-Bruch’s membrane (153.1 ± 24.3 μm vs. 166.2 ± 15.1 μm, P = 0.003) and ellipsoid zone to Bruch’s membrane (51.25 ± 9.3 μm vs. 57.35 ± 3.8 μm, P = 0.009) were thinner in the operated eyes compared to fellow eyes. Vascular density within a 300 μm wide region around the foveal avascular zone (FAZ) (foveal density‑300) was significantly lower in the detached eyes (46.28% ± 7.12% vs. 51.01% ± 4.73%, P = 0.016), however, there was no difference in superficial and deep vascular density at 1‑mm central circle. Superficial parafoveal vascular density was lower in the operated eyes (46.24% ± 5.30% vs. 49.52% ± 5.93%, P = 0.026) with no significant difference in deep parafoveal vascular density (49.93 ± 4.29% vs. 51.88% ± 4.79%, P = 0.137). There was no difference in FAZ area and perimeter between the two groups.

Complete recovery of retinal thickness and vascular density did not achieve in the patients with RRD even after 10 months of reattachment by scleral buckling surgery. Superficial capillary vascular density was more affected than deep vascular density almost in the parafoveal area.

To define the characteristics of vitreoretinal surgeries amid coronavirus disease 2019 (COVID‑19) pandemic restrictions in Turkey.

This descriptive, cross-sectional study was conducted for vitreoretinal surgeries during the 10-week period (during this period, all elective surgeries were postponed across the country by the order of the Republic of Turkey Ministry of Health) in a single tertiary referral hospital in Ankara, Turkey. The number of surgeries, surgical indications, risk factors, etiological factors, and associated conditions were investigated and compared with the clinical features of the patients who underwent vitreoretinal surgery in the same period of the recent year.

During this period, vitreoretinal surgery was performed more commonly for the male population (P < 0.001). The number of vitreoretinal surgeries was statistically significantly correlated with the number of COVID‑19 cases (P = 0.006 and r = −0.791 for weekly numbers of new surgeries and cases, and P < 0.001 and r = 0.929 for cumulative numbers of surgeries and cases). Diabetes mellitus in 26 patients (32.9%) was the most common systemic comorbidity. The most common indication for vitreoretinal surgery was rhegmatogenous retinal detachment in 44 patients (55.7%) followed by diabetic retinopathy complications in 21 patients (26.6%). No one was operated on for vitreoretinal interface disorders during this period, and the rate of rhegmatogenous retinal detachment was higher than the same period of the recent year (P = 0.003).

Amid COVID-19 pandemic restrictions in Turkey, the number of vitreoretinal surgeries was inversely associated with the number of confirmed COVID‑19 cases. The male population needed more vitreoretinal surgery, and rhegmatogenous retinal detachment was the most common indication for all patients.

To determine the benefits of performing preoperative spectral domain optical coherence tomography (SD‑OCT) and to identify occult macular pathologies in patients scheduled for routine cataract surgery.

In this cross-sectional study, macular SD-OCT scans were performed on all patients with clinically undetected macular abnormalities who were scheduled for cataract surgery. Patients with clinically evident macular abnormalities were excluded from the study. A retinal specialist reviewed all the scans. The severity of the cataract was determined using the Oxford Clinical Cataract Classification and Grading System.

Of the 598 evaluated cases, 33 patients (5.52%) had an occult macular abnormality. The most common pathology found in these patients was idiopathic epiretinal membrane, which was detected in 17 eyes (51.52%), followed by vitreomacular traction in nine eyes (27.27%), and dry age‑related macular degeneration in four eyes (12.12%). Full‑thickness macular holes and a lamellar macular hole were found in two patients (6.06%) and one patient (3.03%), respectively. The frequency of cortical cataracts was significantly lower in patients without macular lesions (P = 0.012) than in those with macular lesions. Multivariate logistic regression analysis revealed that age >70 years (P = 0.025 and odds ratio [OR] =11.12), smoking history (P = 0.043 and OR = 3.43), and hypertension were independently associated with occult macular lesions. The surgical plan was changed for five patients (0.83%).

Macular SD-OCT can be used to detect occult macular lesions and provide useful information about a macula before cataract surgery. Although preoperative OCT found macular abnormalities in about 5% of patients with presumed normal fundus examination, it can result in changing the surgical plan in 0.83% of all patients.

To identify the factors associated with the pain level in patients receiving intravitreal injection.

A total of 120 patients were prospectively evaluated, and 104 were included in the study. Patients were asked to rate their pain intensity from 0 to 10 on the visual analog scale. Factors that were possibly associated with pain level were evaluated using a sociodemographic data form, state anxiety inventory, and the hospital anxiety and depression scale.

Of the participants, 54 (51.9%) were female, and 50 (48.1%) were male, with a mean age of 65 ± 9.01 years. There was a positive correlation between pain level and state anxiety scores (r = 0.30; P < 0.001) and a negative correlation between hospital anxiety score (r = −0.23; P = 0.02) and hospital depression score (r = −0.27; P = 0.01). The correlation between pain score and education level was significantly higher in primary and secondary school graduates (P < 0.01). Smokers were observed to have higher pain scores (6.50 ± 2.21 in smokers and 4.87 ± 2.50 in nonsmokers; P = 0.01). Among diagnostic groups, pain scores were found to be significantly lower in the diabetic retinopathy (DR) group (6.82 ± 1.99 in age-related macular degeneration, 5.94 ± 2.27 in retinal vein occlusion, and 3.58 ± 1.97 in DR; P < 0.001). When pain scores were evaluated according to the drug injected, the group receiving bevacizumab injection was observed to have higher pain scores (7.32 ± 1.81 in bevacizumab, 4.00 ± 2.08 in aflibercept, and 3.92 ± 1.96 in ranibizumab; P < 0.001). Based on the multiple regression analysis, the state anxiety score, hospital anxiety score, hospital depression score, and smoking status were observed not to be significant predictors. The level of education, diagnosis, and active substance were found to have a statistically significant effect on pain perception.

In this study, pain levels have been found to be high in smokers, those with a low educational level, individuals receiving bevacizumab for intravitreal injection, and those having a higher level of state anxiety, whereas patients with DR have lower pain scores.

To report the results of plication augmentation of the augmented Anderson procedure in patients with infantile nystagmus syndrome and face turn.

In this retrospective study, all patients who underwent plication augmentation of the augmented Anderson procedure between August 2015 and November 2018 were included. Our study included patients older than 6 years with a face turn >25°. We also included patients with residual face turns ≥15° after Anderson‑type procedures. The face turn was measured by a goniometer and also quantified with prisms placed with apex in the direction of the face turn. We plicated the medial rectus of one eye by 5.0 mm and lateral rectus of the fellow eye by 7.0 mm based on the direction of the face turn in addition to the augmented Anderson procedure. Patients were reviewed on the 1st postoperative day, 1st month, and every 6 months thereafter.

Eight patients with a mean face turn of 27.5° ± 6.5° underwent plication augmentation of the augmented Anderson procedure. Two patients had residual face turns after a previous Anderson-type procedure. We obtained a mean correction of 25° ± 6.5° with a median prismatic correction of 45 prism diopters (PD) for each eye. The median face turn at the last review was 2.5°, and all patients were corrected to within 10°. Excluding patients operated for residual face turns, we had a mean dose response of 2.7 PD/mm and 1.7°/mm of surgery on each eye. Five patients had an improvement in null zone visual acuity. Two patients had a restriction in ocular motility of −2 in the direction of the recessed extraocular muscle at the last review, and the remaining had a −1 restriction.

Plication augmentation of the augmentation Anderson procedure appears to be a safe and effective procedure for patients with infantile nystagmus syndrome and a face turn more than 25°. It may also be used for residual face turns more than 15°.

To evaluate the correlation between the angle of deviation in different gazes and the amount of head tilt in patients with congenital unilateral superior oblique muscle palsy (SOP).

This case series study was performed on 20 consecutive SOP patients with head tilt. Based on the Bielschowsky three-step test, the angle of deviation was measured in different gazes. Furthermore, the hypertropia difference between the two lateral gazes (gaze difference) and the two head tilt sides (bilateral head tilt difference) was calculated. For measuring head tilt, close‑up pictures from 40 cm with a habitual abnormal head position were captured and analyzed by the Corel Draw X7 software.

The mean age of patients was 13 ± 9 years (range, 2.5–31 years). The mean angle of hypertropia in ipsilateral and contralateral head tilt was 24.5 Δ ± 7.1 Δ and 6.5 Δ ± 4.2 Δ, respectively (P < 0.001), and in ipsilateral and contralateral lateral gaze positions, it was 8.2 Δ ± 5.5 Δ and 22.5 Δ ± 6.1 Δ, respectively (P < 0.001). The mean of bilateral head tilt hypertropia difference was 18 Δ ± 5.3 Δ and gaze hypertropia difference was 14.3 Δ ± 6.16 Δ. There was a positive correlation between bilateral head tilt hypertropia difference and the amount of head tilt (R = 0.609, R2 = 0.371, P = 0.004, the amount of head tilt = 0.39 × [Bilateral head tilt hypertropia difference] +1.77). The amount of head tilt also had a positive correlation with the gaze hypertropia difference (R = 0.492, R2 = 0.242, P = 0.028, the amount of head tilt = 0.27 × [gaze hypertropia difference] +4.81).

In SOP patients, the amount of head tilt had a positive correlation with bilateral head tilt hypertropia difference and also gaze hypertropia difference.

To report a novel management technique using pericardial patch graft for severe corneal wound burn following phacoemulsification of dense cataract with shallow anterior chamber (AC) and overfilled AC with viscoelastic.

Case report.

A 46‑year‑old patient with a shallow AC and dense cataract, who underwent phacoemulsification using “soft shell” technique had severe wound burn which was refractory to conventional management with corneal suturing and placing bandage contact lens. He underwent Tutoplast® (Innovative Ophthalmic Products, Inc., Costa Mesa, CA, USA) pericardium patch graft, which fully resorbed and resolved the wound leak over 6 weeks, leaving a well-healed corneal wound.

Pericardium patch graft is a safe and effective technique to manage extensive phaco wound burn which is refractory to conventional management options.

To report a rare retinal manifestation of toxic posterior segment syndrome following vitreoretinal surgery.

In this case series, we report three cases of rhegmatogenous retinal detachment for which pars plana vitrectomy with silicone oil injection was done. All three patients developed an intense anterior chamber reaction along with occlusive vasculitis-like fundus picture.

The three patients were started on topical and systemic steroids, and there was a dramatic improvement in vision and clinical signs at postoperative week 1.

Toxic posterior segment syndrome is a sight-threatening complication after vitreoretinal surgery, but responds well to topical and systemic steroids

To report a case of Toxoplasma retinochoroiditis that was complicated by macular infarction following intravitreal clindamycin injection.

A 32-year-old otherwise healthy woman with the diagnosis of reactivation of Toxoplasma retinochoroiditis in her right eye, underwent intravitreal clindamycin injection. Shortly after injection, the visual acuity deteriorated, and the fundus examination revealed an extensive area of macular necrosis accompanied by vascular occlusion.

The patient was observed. Unfortunately, the condition did not improve over time and resulted in a large area of retinal atrophy.

Macular infarction should be considered a rare but disastrous complication that can result in severe, irreversible visual loss.

To report a challenging case of medial rectus (MR) damage secondary to endoscopic sinus surgery (ESS).

A 37‑year‑old woman presented with diplopia, exotropia, and adduction deficit of the right eye due to the right MR injury secondary to the ESS.

As a stepwise approach, she respectively underwent repairing of the damaged MR plus ipsilateral lateral rectus recession, half-tendon vertical rectus transposition to the MR insertion, and eventually nasal globe fixation with temporalis fascia that ultimately provided a single vision in the primary position with orthophoria.

Re‑establishment of an acceptable field of a single binocular vision in the context of iatrogenic MR injury is challenging and often requires multiple step‑wise operations. Temporalis fascia is a safe and strong autogenous material, which can be used for globe fixation in this setting.

To report a case of pseudotumor cerebri (PTC) in a child associated with multisystem inflammatory syndrome in children (MIS‑C), associated with presumed coronavirus disease 2019.

A previously healthy 11-year-old female child presented with a 4-day history of fever, headache, vomiting, and loose stools. Laboratory investigations revealed neutrophilic leukocytosis, and markers of inflammation (C‑reactive protein, ferritin, and interleukin‑6) were significantly elevated. Pharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction was negative while anti-SARS-CoV-2 antibody was highly reactive. Ophthalmic evaluation for transient visual obscurations during hospital course revealed swelling of the optic disc in both eyes. Spectral‑domain optical coherence tomography and ultrasonography confirmed the ophthalmoscopic findings. There was no neurologic deficit. Magnetic resonance imaging of the brain and magnetic resonance venogram revealed no structural lesion. The opening pressure of cerebrospinal fluid (CSF) was 336 mm of water, and CSF composition was normal.

A diagnosis of PTC associated with MIS‑C was made, and the child was treated with oral acetazolamide. Edema of the optic disc regressed following therapy, and the child is under follow-up.

PTC can occur in association with MIS-C. Clinicians need to be aware of this potential neuro-ophthalmic complication in MIS-C. Prompt diagnosis and treatment can prevent visual loss.