Squint Free Papers - aioseducation

Squint
Free Papers

Contents
SQUINT
Contents
Atropine Cycloplegia: A Novel Method to Predict Accommodative Component
in Esotropia with Hypermetropia --------------------------------------------------------945
Dr. Mihir Trilok Kothari, Dr. Shalaka Paralkar, Dr. Najeeha Shukri, Dr. Florence Manurung
Psychological Impact to Mother of Strabismus ------------------------------------950
Dr. Meet Ramani, Dr. Shreta Shah, Dr. Mehul Ashvin Kumar Shah, Dr. Ricky Barot
Results of Esotropia Management: One Eye vs Bimedial Recession ------954
Dr. Rakesh Kumar Bansal, Dr. Nitee Gupta, Dr. Nishat Bansal, Dr. Neeti Gupta
Attainment of Binocularity Following Late Alignment for Early Onset
Strabismus ---------------------------------------------------------------------------------------956
Dr. Sathya T Ravilla, Dr. Muralidhar Rajamani, Dr. P Vijayalakshmi, Dr. Shashikanth
Shetty
To Study The Role of Television Exercises as A form of Near Visual Activities
in Amblyopia Therapy ------------------------------------------------------------------------958
Dr. Subhash Dadeya, Dr. Sonal Dangda, Dr. Pramod Pandey
Dose Response of Botulinum Toxin without Electro-myographic Assistance
for Sixth Nerve Palsy -------------------------------------------------------------------------966
Dr. Manish Sharma, Dr. Varshini Shanker, Dr. Vikas Tyagi, Dr. Suma Ganesh,
Dr. Priyanka Arora
Management of Myopic Strabismus Fixus: A New Approach ----------------- 971
Dr. Kuldeep Kumar Srivastava
To Study Surgical Outcome in Pediatric Patients with Monocular Elevation
Deficiency (MED) ------------------------------------------------------------------------------- 973
Dr. Kalpana Narendran, Dr. Neelu Agrawal, Dr. Rajesh Prabu, Dr. Ramakrisnan,
Dr. Saurabh Mundhada
Role of Simultaneous Superior Rectus Recession and Anterior Transposition
of Inferior Oblique Muscle in The Surgical Treatment of Lost inferior Rectus
Muscle --------------------------------------------------------------------------------------------- 977
Dr. Pramod Kumar Pandey, Dr. Subhash Dadeya, Dr. Sonal Dangda, Dr. Vijay Shinde,
Dr. Shagun Sood
Clinical Features and Surgical Management of Bilateral Medial Rectus
Agenesis: A Rare Presentation ----------------------------------------------------------- 981
Dr. Neha Rathi, Dr. Pramod Kumar Pandey, Dr. Abhishek Sharma, Dr. Anupam Singh,
Dr. Shagun Sood
Role of Repeated Peribulbar Triamcinolone Acetonide Injections on
Strabismus Due To Thyroid related Ophthalmopathy (TRO) -------------------984
Dr. Deepali Garg, Dr. Pramod Kumar Pandey, Dr. Neha Rathi, Dr. Abhishek Sharma,
Dr. Shagun Sood
943

Squint correction with spectacles
Atropa Belladonna
Orthophoric child

Squint Free Papers
SQUINT
Chairman: Dr. (Mrs.) Vinita Singh; Co-Chairman: Dr. Elizabeth Joseph
Convenor: Dr. Jyoti Matalia; Moderator: Dr. Kamini Audich
Dr. MIHIR TRILOK KOTHARI: MBBS (1998), MGIMS, Nagpur; MS (2001),
CMC, Vellore; DNB (2001), New Delhi; Fellowship in Pediatric Ophthalmology
and Strabismus (2003), Aravind Eye Hospital, Madurai and same in 2006 from
Wilmer Ophthalmological Institute, USA and 2011 from Smith Kettlewell Eye
Research Institute, San Francisco, USA; Presently, Director, Jyotirmay Eye
Clinic and Pediatric Low Vision Center. E-mail: drmihirkothari@jyotirmay.com
Atropine Cycloplegia: A Novel Method to
Predict Accommodative Component in
Esotropia with Hypermetropia
Dr. Mihir Trilok Kothari, Dr. Shalaka Paralkar, Dr. Najeeha Shukri,
Dr. Florence Manurung
Childhood esot ropia is com mon ly associated with sig n ificant hypermet ropia.
Depending upon the effect of correction of hyperopia on the ocular
alignment (i.e. the accommodative component), childhood esotropia can be
further classified into following categories. 1 Fully refractive accommodative
esotropia (RAE), where in refractive correction produces orthotropia in all
the directions of gaze, Partial accommodative esotropia (PAE), where in
esodeviation significantly reduces with refractive correction, but substantial
deviation still persists, Non accommodative esotropia (NAE), where in
refractive correction of hyperopia has no significant effect on esodeviations.
An esotropia that measures significantly more [8-10 prism diopters (Δ) 2 for near
than the distance is called convergence excess type of esotropia (CE). Based
upon this character of the esotropia, each of the above mentioned categories
can be further sub-classified into Fully refractive accommodative esotropia
(RAE) with Convergence excess (CE), Partial accommodative esotropia (PAE)
with Convergence excess (CE), Nonaccommodative/hypoaccommodative
esotropia (NAE) with Convergence excess (CE).
In the patients where significant esotropia persists despite of refractive
correction with/without a bifocal lens, a prompt squint surgery offers better
chance to restore binocularity and stereoacuity than a delayed surgery. 4 In this
study we tested our hypothesis that cycloplegia abolishes the accommodative
component of deviation in esotropia, thereby helps a clinician anticipate the
amount of residual deviation that would persist despite of full refractive
correction. A literature search did not reveal any peer reviewed study
pertinent to this subject.
945

946
69th AIOC Proceedings, Ahmedabad 2011
MATERIALS AND METHODS
This prospective interventional cohort study included 44 consecutive cases.
The inclusion criteria were 1) age 1 to 16 years, 2) comitant esotropia ≥12 prism
diopters (Δ), 3) hyperopia ≥+2.00D (spherical equivalent), 4) patients cooperative
for reliable measurement of ocular deviation, 5) minimum three months
follow up and 6)100% compliance to the spectacle wear. Exclusion criteria were
1) associated ocular co-morbidity viz. coloboma, nystagmus, albinism etc., 2)
poor fixation and 3) systemic abnormalities viz. birth asphyxia, cerebral palsy,
Down’s syndrome etc.
The ocular deviation was measured using a prism cover test with age
appropriate accommodative targets that could be resolved easily for the near
(40 cm) and for the distance (6 meter). The measurements were taken under
following conditions. At presentation, without any optical correction and
without cycloplegia; after three days, under complete cycloplegia and without
optical correction; after three months of spectacle wear; with full refractive
correction (prescribed as per the cycloplegic retinoscopy) and without
cycloplegia; near deviation was measured with +3.0D addition if the near
deviation measured more than the distance deviation by ≥8Δ (Convergence
excess). In children

Squint Free Papers
Table 1: Distribution and the angle of deviation of esotropic patients in
various groups
n=44 Normal Convergence Convergence Excess Total
%, (n) Angle of %, (n) Angle of Angle of %, (n)
deviation (∆) deviation (∆) deviation (∆)
mean±sd (distance) (near)
(range) mean±sd mean±sd
(range) (range)
RAE 40.9% 37.2 ± 10.3 18.2% 40 ±25.2 51.4 ±28.4 59.1%
(18) (14-50) (8) (20-100) (30-120) (26)
PAE 22.7% 54.5 ± 20.3 6.8% 23.3 ±14.5 43.3 ±7.6 29.5%
(10) (35-100) (3) (14-40) (35-50) (13)
NAE 11.4% 42 ± 16.9 0, (0) NA NA 11.4%
(5) (20-65) (5)
Table 2: Age, refractive error and ocular deviation in different groups
of esotropia
n=44 RAE (n=18) RAE+CE PAE (n=10) PAE+CE NAE (n=5)
mean ± sd range (n=8) (n=3)
Age (Yrs) 4 ± 2.1 (1-9) 6.5 ±2.4(3-9) 6 ±2.6(1.5-9) 7 ±1.0(6-8) 4.4 ±1.8(2-6)
Spherical 6.7 ±1.7 4.6 ±1.5 5.1 ±2.5 3.3 ±1.4 3.8 ±1.4
Eqivalent (3.4-10) (2.3-7.6) (0-10) (1-4.8) (1.8-5.8)
(Diopters)
Anisometro- 0.7±0.6 0.7±0.6 0.7±0.9 1±2(0-3) 0.6±0.6
pia (Diopters) (0-1.9) (0-1.6) (0-2.8) (0.1-1.5)
Cover test (∆) 37.2±10.3 46.9±24.0 54.5±20.3 61.7±20.2 42±16.8
on presentation (14-50) (25-100) (35-100) (50-85) (20-65)
NEAR
Cover test (∆) 36±10.9 41.7±29.4 55.6±21 55±31.2 37.5±12.6
on presentation (14-50) (20-100) (35-100) (30-90) (20-50)
DISTANT
Cover test (∆) 0±0(0) 0±0(0) 29.9±9.8 24±14.0 39.6±17.6
under cycloplegia (18-40) (14-40) (20-68)
NEAR
Cover test (∆) 0 0 27.9±9.8 22.7±15 33.8±9.5
under cycloplegia (18-40) (14-40) (20-40)
DISTANT
Cover test (∆) 0 13.1±3.8 26.9±9.8 43.3±7.6 38±16.8
with full correction (8-18) (18-40) (35-50) (20-65)
NEAR
Cover test (∆) 0 0 27.9±9.8 23.3±14.5 32.5±8.7
with full correction (18-40) (14-40) (20-40)
DISTANT
Cover test (∆) with Not 0 Not 22.7±15.5 Not
addition lens Applicable Applicable Applicable
947

948
69th AIOC Proceedings, Ahmedabad 2011
patients with PAE, the deviation measured under cycloplegia was equal to
that measured with full refractive correction. In the patients with PAE with
CE, the deviation measured under cycloplegia was equal to that measured
with full refractive correction with +3.0D addition indicating that cycloplegia
abolished the accommodative component of the esotropia. In the patients
with NAE, the deviation measured under cycloplegia was same as that with
spectacle correction.
There was no patient in the sub category of NAE with CE. However, during
the study period, there was one child of NAE with CE (nonaccommodative
convergence excess) who did not have a refractive error hence he was not
included in the study. However, it was interesting to see him orthotropic with
the bifocal spectacles but esotropic under cycloplegia.
The correlation coefficient for the ocular deviation under cycloplegia and full
refractive correction (with +3D addition in the patients with CE) was 1.0.
Three patients developed slight fever that required oral medication. None of
the patients had severe rash / high grade fever necessitating discontinuation
of the atropine.
DISCUSSION
From the results we believe that the measurement of ocular deviation under
cycloplegia in esotropes with hyperopia can predict the effect of spectacle
correction on ocular deviation. Under the condition of complete cycloplegia,
the accommodative component of the esodeviation is abolished. Whatever
deviation persists under cycloplegia, is the non-accommodative component
which persists even after the spectacle correction and it is controlled by the
fusional divergence or require prisms/squint surgery.
Clinicians are well aware that an accommodative esotrope (RAE) often have
straight eyes when he/she is not accommodating. As soon as the child tries to
resolve, the accommodative convergence manifests into a large esodeviation.
The same principle underlies the measurement of ocular deviation
under cycloplegia i.e. to abolish the accommodative effort completely. If
accommodative efforts persist, esotropia will persist. It is possible that under
incomplete cycloplegia, when the child is pressed to read smaller size of the
target, an accommodative effort may still be deployed that may manifest
into an esodeviation. For the reliable measurement of the ocular deviation,
presence of complete cycloplegia is an absolute necessity.
We used 7 cumulative doses of atropine sulphate 1% eye ointment to achieve
complete cycloplegia. Whether the same effect can be achieved with less potent
cycloplegic agents (viz. cyclopentolate, homatropine or tropicamide) or lesser
application of atropine is unknown. Based on the previous literature and well

Squint Free Papers
dilated pupils, we assumed that 7 applications of atropine were enough to
produce complete cycloplegia. Ideally, a clinician should routinely perform
dynamic retinoscopy to confirm complete cycloplegia for every patient
especially if less potent cycloplegic agent is used. In this study, atropine was
not associated with any severe systemic side effects.
In one patient who had esotropia with nonaccommodative convergence
excess, the esotropia persisted under cycloplegia. The esotropia persisted for
smaller as well as larger size of the accommodative targets and on the torch
light evaluation. It was evident that atropinic cycloplegia was unable to abolish
excessive convergence in that patient. It was less likely to be due to incomplete
cycloplegia because, in this patient, we had confirmed complete cycloplegia
using dynamic retinoscopy and dynamic autorefractometry. 6
In conclusion, measurement of ocular deviation under cycloplegia can
be helpful to differentiate the accommodative component from the nonaccommodative
component in patients with esotropia and hyperopia. In this
study we could reliably differentiate the patients with esotropia and hyperopia
who would achieve orthotropia by full refractive correction alone (59.1%). An
ophthalmologist can inform the parents accordingly. Of the remaining 40.9%,
how many would be controlled by the fusional divergence or will need prisms
or will need a squint surgery can be known from the follow up. The effect of
other cycloplegic agents and the utility of measurement of ocular deviation
under cycloplegia in accommodative esotropes pursuing a refractive surgery
need further studies.
REFERENCES
1. Von Noorden G K, Campos E C. Esodeviations. In: von Noorden G K, Campos
E C, Editors, Binocular Vision and Ocular Motility. Theory and management of
strabismus. 6th ed. St. Louis: Mosby. 1990;pp 311-55.
2. Vivian A J, Lyns C J, Burke J. Controversy in the management of convergence
excess esotropia. Br J Ophthalmol 2002;86:923-9.
3. American Academy of Ophthalmology. Preferred Practice Pattern. Amblyopia.
Guidelines for prescribing eye glasses for young children. 2002;6.
4. Birch E E. Binocular Sensory Outcomes in Accommodative E T. J AAPOS
2003;7:369-73.
5. Mcgregor MLK. Autonomic drugs. In: Mauger T F, Craig EL, editors. Havener’s
ocular pharmacology. 6th ed. St. Louis: Mosby: 1994. pp 53-171.
6. Manny RE, Chandler DL, Scheiman MM, Gwiazda JE, Cotter SA, Everett DF, et;
al. Accommodative lag by autorefraction and two dynamic retinoscopy methods.
Optom Vis Sci. 2009;86:233-43.
7. Nemet P. Ocular deviation under atropine cycloplegia as a predictor of
accommodative component of esotropia. In: Lenerstrand G, editor: Update on
949

950
69th AIOC Proceedings, Ahmedabad 2011
strabismus and pediatric ophthalmology: Proceedings of Joint ISA and AAPO and
S meeting. Vancouver, Canada. Jun 19 to 23, 1994. 1st ed. Vancouver: CRC press;
1995. pp 214-6.
8. Polat S, Can C, Ilhan B, Mutluay AH, Zilelioglu O, Laser in situ keratomileusis for
treatment of fully or partially refractive accommodative esotropia. Eur J Ophthalmol
2009;19:733-7.
9. Jianhua Y, Shaomei Y, Yimin W. The deterioration of refractive accommodative
esotropia. Yan Ke Xue Bao. 1997;13:144-7.
Psychological Impact to Mother of Strabismus
Dr. Meet Ramani, Dr. Shreta Shah, Dr. Mehul Ashvin Kumar Shah,
Dr. Ricky Barot
The psychosocial implications of the effect of strabismus on an individual’s
life have not gained adequate attention in the medical or behavioral science
literature. The presence of strabismus has been considered a social disability
because it may lead to loss of normal eye contact and thereby interfere
with normal socialization. In literature, subjective feelings produced by the
presence of strabismus on the affected individual have been studied.
Till now, very little is known about the emotional and psychosocial effects
on the parents and the families. The aim of this study was to investigate how
strabismus affected the psychological profile (depression and anxiety) of
mothers of the children with strabismus, their attitudes to their children, and
their family relationships. This study also investigated the impact of factors,
such as the magnitude of deviation and surgery, on the psychosocial state of
the mothers.
MATERIALS AND METHODS
This study was conducted, between Jan 2008 to Jun 2009 and involved
two group strabismus and a control group both included 31 children and
their mothers. They were selected randomly from, Pediatric out patients
department. The study was approved by the institutional ethical committee
and informed consent was obtained from each participating mothers. Patients
and controls were excluded if they had facial deformities, neurological
disorders, any other ophthalmologic disorder, any chronic medical problem,
or any psychiatric disorder. Children with known intellectual disability
were excluded. Patients and controls were recruited from areas with similar
demographic characteristics (mother’s age, mother’s education etc.). Mothers
of children with strabismus and controls were excluded if they had any known
chronic disease or any known psychiatric disorder.
After enrolment anterior and posterior segment examination was done

Squint Free Papers
according to standard methodology by slit lamp, cycloplegic refraction and
indirect ophthalmoscope.
Strabismus was evaluated for motor functions by prism and alternate cover
test for near and distance. Stereo acuity was examined by the Titmus fly test
and Worth Four Dot test.
In those patients who had surgical correction of strabismus, success was
defined as alignment within 10 prism diopters of orthophoria in primary
position. Amblyopia was defined as at least a 2-line difference between 2 eyes
(tumbling E) or fixation preference for preverbal children.
Socio demographic data, medical history, and familial history of children and
mothers were recorded on a pre-tested data form.
The data related to strabismus included: the duration of strabismus, direction
of deviation, magnitude of deviation, strabismus surgery, wearing glasses,
and occlusion treatment with patching for amblyopia.
All mothers of children were asked to complete Beck Depression Inventory
(BDI), State-Trait Anxiety Inventory (STAI), Parental Attitude Research
Instrument (PARI) and Family Assessment Device (FAD). for depression
symptoms, we used BDI, which was developed by Beck and commonly used
to assess depressive symptoms in clinical settings. For anxiety symptoms,
we used the STAI. STAI has been used in studies assessing the impact of
chronic medical conditions on psychological well-being of patients and their
families. Mothers’ attitudes were evaluated with PARI. PARI has been used
as a parental adjustment measure in families of disabled children. Family
functioning was assessed with FAD. FAD has been used in several studies
assessing functioning among mothers and fathers of children with chronic
conditions such as juvenile rheumatic disease and juvenile diabetes. The
reliability and validity of all these instruments have been established in the
Turkish population. The scales and their adaptations are summarized in Table.
All questionnaires were self-reporting inventories that are commonly used in
psychiatric studies and are applicable to chronic conditions.
RESULTS
Results are displayed in tables.
Table 1: Details of strabismic children having Exotropia
Exotropia in prism diopters No. of Patients
15^ - 30^ 3
31^ - 45^ 1
46^ - 60^ 0
>/= 60^ 1
951

952
69th AIOC Proceedings, Ahmedabad 2011
Table 2: Details of strabismic children having esotropia
Esotropia in Prism Diopters No. of Patients
15^ - 30^ 7
31^ - 45^ 11
46^ - 60^ 3
>/= 60^ 5
Table 3: Comparative study of psychological indices for both groups
PTI Indicators Mean +/- SD in patients Mean +/- SD in control P value
BDI 13.36+/-4.98 1.533+/-0.62

Squint Free Papers
with strabismus had increased attitudes of hostility and rejection, as compared
with mothers from the control group. This may indicate that mothers of the
children with strabismus are unhappier and more unsatisfied with respect
to maternal role than the mothers of the control group. They were nervous,
distressed, and angry in the relationship with their children. Strabismus
creates a significant negative social prejudice, having a child whose cosmetic
appearance is distorted or having a child with chronic disorder may cause
trouble undertaking motherhood role.
Mothers of the children with strabismus experienced more problems in family
functions, such as roles, affective responsiveness, and general functioning,
than the mothers of the control group in this study. Poor general functioning
may suggest that there is a general problem in all functions in the family
such as problem solving, communication, roles, affective responsiveness,
affective involvement, and behavior control. Chronic conditions can upset
existing structures within the family system and may provoke changes
to restore equilibrium and reestablish or recreate roles, rituals, and daily
routines. Families must deal with illness-related stressors such as the need for
frequent medical visits, demands of the multi-component treatment regimen,
and unpredictable illness course. Roles include satisfying the food, clothing,
and support needs of family members, safeguarding the boundaries of the
family system, and maintaining the standards and management of the family
system such as housekeeping, bills, health issues, and decision making. In
families of the children with strabismus, it may be related to the fact that the
mothers of the children with strabismus could not to perform their roles such
as providing for the needs of family members, safeguarding the boundaries
of family system and maintaining the standards because of their depressive
symptoms. Affective responsiveness means the ability of family members to
respond with appropriate emotion to an event or to other family members.
It encompasses feelings of welfare (joy, love, concern, tenderness) and
emergency (sadness, depression, anger, fear). Parents of the children with
strabismus may display a controlled behavior in expressing their feelings
especially emergency feelings such as sadness, depression, anger and fear
toward the children with strabismus. They may also display more nervous
and angry feelings toward their children with the intention of protecting
the child or with the fear of hurting the child. As the severity of strabismus
increases, family functions such as problem solving and roles are affected.
Problem solving reflects the families’ ability to resolve problems. Mothers
whose strabismic children have undergone an operation scored significantly
lower levels in democratic attitude (which shows a supportive and a sharing
relationship), as compared with those whose strabismic children had not been
operated. The lower scores of democratic attitude are accepted as negative
953

954
69th AIOC Proceedings, Ahmedabad 2011
attitude. Children with noticeable strabismus are viewed negatively. Hence,
correction of strabismus may provide psychosocial benefits even when there
is no hope of improving visual function Mruthyunjaya et al also found that
surgical correction of strabismus in childhood is clearly perceived by parents
to be both successful and important to them and their children. We also
confirmed the same.
In conclusion, this study shows one more indication for the correction of
strabismus in a child: maintenance of normal psychosocial relationships
between mothers and their children. Strabismus seems to affect the well-being
of the entire family and proper approaches should have an important place in
the treatment of this disorder.
Dr. RAKESH KUMAR BANSAL: MBBS (1981), Guru Gobind Singh Medical
College, Faridkot; MS (1984), PGIMER, Chandigarh; FRCS Ed. (2000).
Former (i) Deputy Medical Superintendent, GMCH-32, Chandigarh; (ii)
Muthusamy Gold Medal for Best Candidate in FRCS Ed examination in 2000.
Presently, Consultant Ophthalmology and GMCH-32, Chandigarh.
E-mail: bansalrk@hotmail.com
Results of Esotropia Management: One Eye vs.
Bimedial Recession
Dr. Rakesh Kumar Bansal, Dr. Nitee Gupta, Dr. Nishat Bansal, Dr. Neeti
Gupta
Congenital esotropia represents deviations observed within the first 6
months of life and not associated with any other neurological abnormality.
Generally, deviations are large angle and stable. Esodeviation occurs as a
result of primary motor fusion defect accompanied by secondary sensorial
fusion insufficiency. Primary management is surgery.
The choice of surgery for a child with esotropia can be either “selective“ where
one eye is operated (medial rectus recession and lateral rectus resection) or
it can be “uniform” where both eyes are operated in a symmetrical fashion
(bimedial recession or bilateral resection). The ideal age for patients to undergo
surgery for congenital esotropia is unknown but it is always advantageous to
perform surgery on patients younger than 2 years of age. The goal of early
surgery is to establish binocular functions. The aim of our study was to
compare the anatomical and functional results of bimedial recession with one
eye recession–resection procedure.
MATERIALS AND METHODS
It was a retrospective, non randomized study on 42 patients with congenital
esotropia. The records were scrutinized for, age of onset, amount of deviation,

Squint Free Papers
associated ocular anomalies, surgical procedure, post operative deviation,
any additional surgical procedure and binocular status. Those patients who
completed 6 months of follow-up were included in analysis. The patients
underwent either bimedial recession or monocular recession-resection
procedure. The recession of medial rectus was done using the hang-back
technique and resection of lateral rectus by conventional technique. The
success was quantified as anatomical success (deviation

956
69th AIOC Proceedings, Ahmedabad 2011
successful ocular alignment in 12(75%) patients though 4 (25%) patients were
undercorrected. Consecutive exotropia was not seen in any patient. Kadircan
et al 3 in a study of 214 patients reported that success rate of bilateral medial
rectus recession for ocular realignment with one operation is approximately
50%. We saw success in 65% of the patients with bimedial recession.
We conclude that bimedial recession is more successful compared to unilateral
recession-resection procedure in patients of congenital esotropia, however to
maintain long term alignment additional surgical procedures may be required.
This method is quick, simple, and less traumatic compared to unilateral
recession-resection procedure.
REFERENCES
1. George B. Bartley, John A, Dyer: Characteristics of Recession-Resection and
Bimedial Recession for Childhood Esotropia. Arch Ophthalmol 1985;103:190-5.
2. Alexandros G Damanakis: 8mm Bimedial rectus recession in infantile esotropia of
80-90 prism dioptres. Br J Ophthalmol 1994;78:842-4.
3. Kadircan H. Keskinbora, Nuray Karakuscu Pulur: Long-Term Results of Bilateral
Medial Rectus Recession for Congenital Esotropia. J Pediatr Ophthalmol Strabismus
2004;41:351-5.
Attainment of Binocularity Following Late
Alignment for Early Onset Strabismus
Dr. Sathya T Ravilla, Dr. Muralidhar Rajamani, Dr. P Vijayalakshmi,
Dr. Shashikanth Shetty
Early surgical alignment has been proven to provide the best chance
of functional binocular improvement. A number of studies including
animal trials have shown that the recovery of stereopsis in infantile esotropia
progressively declines with advancing age of alignment. 1
Is it then that adults undergoing surgery for early onset strabismus only achieve
cosmetic rather than functional gain? An improvement in interpersonal
interactions and psychosocial functioning has often been demonstrated. 2
Wortham and Greenwald 3 have reported that some adults with long-standing
constant esotropia may experience an expansion of their binocular field after
strabismus surgery. Previous studies have investigated the improvement in
binocularity following surgical correction of strabismus in adults. Kushner and
Morton 4 reported an increase in binocularity as determined by the Bagolini
lenses, which was correlated with long-term, favorable postoperative ocular
alignment. In a study of 24 patients with long standing strabismus, Morris et
al 5 achieved an improved postoperative alignment as well as peripheral fusion
at near, demonstrated by the Worth 4-Dot test.

Squint Free Papers
In this prospective study, we studied the attainment of binocularity with the
Worth 4-Dot test and Bagolini lenses following late alignment for strabismus
with onset within 2 years of age.
MATERIALS AND METHODS
Prospective study of 39 patients, aged between 5 and 32 years with an onset of
squint before 2 years of age were included. They underwent surgical correction
of strabismus between June 2007 and September 2009 with a post-operative
alignment within 14 prism diopters.
The complete examination of patients was done preoperatively. Data collected
included: age at time of surgery, visual assessment by Snellen’s chart,
refraction, complete orthoptic examination, anterior segment evaluation
and fundus examination. Orthoptic examination included prism bar cover
test for near and distance, extraocular muscle movement, pattern deviation,
dissociated vertical deviation, evaluation of binocularity by Worth four dot
and Bagolini for both distance and near. All patients included in the study did
not show binocularity pre-operatively. Anterior segment evaluation was done
at the slit-lamp. Fundus evaluation was done using a 90 dioptre lens with slitlamp
biomicroscopy or indirect ophthalmoscopy.
Following surgical alignment within 14 prism dioptre, patients were asked
to review four weeks later. On review, a complete orthoptic assessment was
repeated. In those patients in whom binocularity was present, stereopsis was
tested using the TNO book.
RESULTS
The study included 26 males and 13 females. Of the 39 patients, 20 had
esotropia and 19 had exotropia. Mean age at time of surgery was 12.94 ± 7.8
years. 16(53.3%) of the 30 patients who gave a history of onset of squint before
6 months of age demonstrated binocularity by Bagolini’s striated glasses at 4
weeks post-operatively; comparable to 5(55.6%) of the 9 patients with onset of
squint between 1 and 2 years of age.
21 subjects (53.8%) and 30.8% attained binocularity for near and distance
respectively by Bagolini as compared to 14 subjects (35.9%) and 20.5%
respectively by Worth Four dot test. All patients who showed binocularity
with Worth four-dot test also showed binocularity by Bagolini. Of the 21
patients that attained binocularity, showed stereopsis with the TNO book, two
of whom attained 60 seconds of arc.
DISCUSSION
These results show that the attainment of binocularity following squint
surgery at an older age is not as rare as previously believed. Squint surgery
957

958
69th AIOC Proceedings, Ahmedabad 2011
at an older age thus has more than just a cosmetic value. Aiming for optimum
alignment in adulthood may also act as a barrier to prevent further drift.
REFERENCES
1. Lawrence Tyschen, MD: Can Ophthalmologists Repair the brain in Infantile
Esotropia? Early surgery, Stereopsis, Monofixation Syndrome, and the legacy of
Marshall Parks, J AAPOS 2005; 9:510-521.
2. Denise Satterfield, MD; John L Keltner, MD; Thomas L Morrison, PhD: Psychosocial
aspects of strabismus study, JPOS 1997; 34:159-164.
3. Edwin Wortham V, MD; Mark J. Greenwald, MD: Expanded Binocular Peripheral
Visual Fields following surgery for esotropia, JPOS 1989; 26:109-112.
4. Burton J. Kushner, MD, Gail V. Morton, CO: Postoperative Binocularity in Adults
with Longstanding Strabismus; Ophthalmology 1992;99:316-319.
5. Morris RJ, Scott WE, Dickie CF. Fusion after surgical alignment of longstanding
strabismus in adults. Ophthalmology 1993;100:135-8.
To Study The Role of Television Exercises as A
form of Near Visual Activities in Amblyopia
Therapy
Dr. Subhash Dadeya, Dr. Sonal Dangda, Dr. Pramod Pandey
Amblyopia is an important public health problem as visual impairment is
lifelong. 1
Various treatment modalities like refractive correction alone2 , patching3,4, penalization. 5-7 pharmacological therapy8 have been tried, but none of them is
foolproof. Occlusion of the sound eye with an adhesive skin patch is perhaps
the most effective means of treatment.
Near visual activities are often prescribed during patching for amblyopia
based on the assumption that those activities stimulate the visual system. 9
A number of uncontrolled case series during the middle and later half of
twentieth century have suggested a benefit to prescribing near activities. 10-13 but
the question has not been rigorously studied. The Amblyopia treatment study
(ATS), however, has resumed interest in the active home vision exercises. 3,4,9,14-17
Among the various activities forming the spectrum of near activities, we feel
that video games using television will be an interesting modality in view of
better compliance. Television being popular among all age groups, especially
children and its easy access in majority of households has made it an important
means of entertainment.
In spite of its huge popularity, there have not been any long term prospective

Squint Free Papers
studies using television games as a form of near visual activities in amblyopia
therapy. Hence this study was conducted to assess whether near exercises
using television games can be prescribed as supplementary therapy to the
gold standard treatment of patching.
MATERIALS AND METHODS
This comparative randomized intervention study was conducted at Guru
Nanak Eye Centre, New Delhi, between Oct 2008 and January 2010. Forty
patients in the age group of 4 to 7 years with unilateral amblyopia associated
with strabismus, anisometropia, or both and having visual acuity in the
amblyopic eye between 6/60 – 6/12 were taken. Refractive error was corrected
with spectacles for at least 6weeks prior to occlusion therapy. The study was
duly approved by the institutional ethical committee.
They were randomly divided into two groups of twenty patients each.
Group A – patching alone (thumb age rule).
Group B – near activities at 1mtr (television games, exposures of half an hour
each, at weekly intervals for twelve wks) along with patching (thumb age rule).
Exclusion criteria included patients who were bilateral amblyopes, given any
form of amblyopia treatment or previous surgery, those with ocular cause of
reduced visual acuity, myopia more than 6D in the amblyopic eye, and those
with known skin reaction to patch.
Informed consent was obtained from parents of patients prior to initiation of
therapy.
A detailed history with onset, course, and treatment of amblyopia was taken.
Ophthalmological evaluation included visual acuity (distance and near)
refraction under atropine, stereoacuity (stereo fly test) and fundus examination
done by the same examiner.
Following the session, visual acuity was recorded in group B patients after
3rd, 6th, 9th and 12th exposure (i.e. weeks). Correspondingly the visual acuity
assessment of group A patients was done at 3rd, 6th, 9th, and 12th weeks of
start of patching.
RESULTS
The mean age of patients in group A was 5.82 years and in group B it was 6.25
years.
The mean visual acuity (in decimal units) in group A at baseline was 0.12 which
improved by spectacle correction alone to 0.15 and after occlusion therapy to
0.31 at 12 weeks follow up (Table 1). The mean visual acuity (in decimal units)
in group B at baseline was 0.125 which improved by spectacle correction alone
959

960
69th AIOC Proceedings, Ahmedabad 2011
to 0.14 and after occlusion therapy with television games to 0.38 at 12 weeks
follow up (Table 2). This improvement was found to be statistically significant
at all follow ups in group A (p value 0.010, 0.001, 0.001, 0.000) and highly
significant in group B (p 0.000) by wilcoxon signed rank test.
An improvement of 2.5 lines in study group (B) was noted as compared to 1.6
lines in control group (A) on final follow up at 12 weeks. At 3, 6 and 9 weeks
of follow up the mean improvement was 1.0, 1.5, 1.9 lines in study group (B)
as compared to 0.45, 0.80 and 1.05 lines in control group (A) respectively. The
difference between the two groups was found statistically significant at all
follow up weeks (p values were 0.021, 0.005, 0.003, and 0.005 at 3, 6, 9 and 12
weeks respectively, wilcoxon ranksome test).
We also studied the effect on near visual acuity. The mean baseline near visual
acuity in group A was 17.9 which improved after 6 weeks of spectacle use to
14.9 and the mean BCVA at 12 weeks follow up was 8.9 (Table 3). In group B
the mean baseline near visual acuity was 19.8 which improved after 6 weeks
of spectacle use to 14.8 and the mean BCVA at 12 weeks follow up was 6.3
(Table 4). The mean lines of improvement in near BCVA at 3, 6, 9 and 12 weeks
was 1.2, 1.85, 2.65 and 2.85 lines in study group (B) as compared to 0.30, 0.55,
0.95 and 1.6 lines respectively in control group (A). The difference between
the two groups was found highly statistically significant (p 0.000 by wilcoxon
ranksome test).
A note was also made of the improvement in stereoacuity in both the groups
and the difference between the two was statistically significant from 6th week
onwards (p 0.007).
Table 1: Changes in Visual Acuity (DISTANCE) in Group A
Sl. Age Sex Visual Acuity
No. Baseline Aided 3 Weeks 6 Weeks 9 Weeks 12 Weeks
1 7 M 0.10 0.25 0.33 0.33 0.33 0.33
2 7 F 0.17 0.25 0.33 0.33 0.50 0.50
3 6 F 0.10 0.10 0.10 0.10 0.10 0.17
4 7 M 0.10 0.10 0.10 0.10 0.10 0.17
5 4 F 0.10 0.10 0.10 0.10 0.17 0.25
6 7 F 0.25 0.33 0.33 0.33 0.33 0.50
7 7 M 0.10 0.17 0.25 0.25 0.25 0.33
8 4 M 0.10 0.10 0.17 0.17 0.17 0.17
9 7 F 0.10 0.10 0.10 0.17 0.17 0.25
10 7 M 0.17 0.17 0.33 0.50 0.50 0.67
11 5 1/2 M 0.10 0.10 0.10 0.10 0.17 0.25
12 5 M 0.10 0.10 0.17 0.17 0.25 0.25

Squint Free Papers
13 4 1/2 M 0.25 0.25 0.33 0.33 0.50 0.50
14 4 M 0.10 0.10 0.17 0.25 0.25 0.33
15 6 F 0.10 0.10 0.10 0.17 0.17 0.25
16 4 F 0.10 0.17 0.17 0.25 0.25 0.25
17 6 F 0.10 0.25 0.25 0.33 0.33 0.50
18 7 M 0.10 0.10 0.10 0.10 0.10 0.17
19 7 F 0.10 0.10 0.10 0.10 0.10 0.10
20 5 F 0.10 0.25 0.25 0.33 0.33 0.33
Table 2: Changes in Visual Acuity (DISTANCE) in Group B
Sl. Age Sex Visual Acuity
No. Baseline Aided 3 Weeks 6 Weeks 9 Weeks 12 Weeks
1 7 M 0.10 0.10 0.17 0.17 0.17 0.25
2 4 M 0.10 0.10 0.17 0.25 0.33 0.33
3 5 M 0.10 0.10 0.10 0.17 0.25 0.33
4 6 M 0.10 0.10 0.17 0.25 0.33 0.33
5 5 M 0.10 0.10 0.17 0.17 0.17 0.17
6 6 F 0.25 0.25 0.33 0.50 0.50 0.67
7 6 M 0.10 0.10 0.17 0.25 0.25 0.25
8 6 F 0.17 0.17 0.25 0.25 0.33 0.50
9 7 M 0.25 0.25 0.33 0.50 0.50 0.67
10 7 F 0.10 0.17 0.17 0.25 0.33 0.33
11 7 F 0.10 0.17 0.25 0.33 0.33 0.50
12 7 F 0.10 0.10 0.10 0.17 0.25 0.33
13 7 M 0.17 0.17 0.33 0.33 0.33 0.50
14 7 F 0.17 0.25 0.33 0.33 0.50 0.50
15 7 M 0.10 0.17 0.50 0.50 0.67 0.67
16 7 M 0.10 0.10 0.17 0.17 0.17 0.17
17 4 F 0.10 0.10 0.25 0.25 0.33 0.50
18 6 F 0.10 0.10 0.17 0.17 0.17 0.25
19 7 M 0.10 0.10 0.10 0.10 0.10 0.10
20 7 F 0.10 0.10 0.17 0.25 0.25 0.33
Table 3: Changes in Visual Acuity (NEAR) in Group A
Sl. Age Sex Visual Acuity
No. Baseline Aided 3 Weeks 6 Weeks 9 Weeks 12 Weeks
1 7 M 18 12 12 10 10 10
2 7 F 12 10 10 8 6 6
3 6 F 36 18 18 18 18 12
4 7 M 36 36 18 18 18 12
961

962
69th AIOC Proceedings, Ahmedabad 2011
5 4 F 10 10 10 10 10 8
6 7 F 8 8 6 6 6 6
7 7 M 18 18 12 12 10 8
8 4 M 36 36 18 18 18 18
9 7 F 18 18 18 18 12 12
10 7 M 18 12 12 12 10 8
11 5 1/2 M 12 10 10 10 10 8
12 5 M 10 10 10 10 8 6
13 4 1/2 M 8 8 6 6 6 6
14 4 M 12 12 10 10 10 8
15 6 F 18 18 18 18 12 12
16 4 F 18 12 12 10 10 8
17 6 F 12 10 10 8 8 6
18 7 M 10 10 10 10 8 8
19 7 F 36 18 18 18 12 8
20 5 F 12 12 12 10 10 8
Table 4: Changes in Visual Acuity (NEAR) in Group B
Sl. Age Sex Visual Acuity
No. Baseline Aided 3 Weeks 6 Weeks 9 Weeks 12 Weeks
1 7 M 18 12 10 10 8 6
2 4 M 36 18 18 10 6 6
3 5 M 36 18 12 10 10 8
4 6 M 36 36 18 12 8 8
5 5 M 18 18 12 10 8 8
6 6 F 10 8 6 6 5 5
7 6 M 18 18 10 8 6 6
8 6 F 10 10 8 6 6 6
9 7 M 18 18 8 8 6 6
10 7 F 10 8 8 6 6 6
11 7 F 36 18 12 8 6 6
12 7 F 12 12 10 10 8 6
13 7 M 12 8 6 6 5 5
14 7 F 10 10 8 6 6 6
15 7 M 12 10 5 5 5 5
16 7 M 10 10 8 8 8 6
17 4 F 10 8 5 5 5 5
18 6 F 12 12 8 8 8 6
19 7 M 36 18 18 12 10 10
20 7 F 36 18 12 10 8 6

DISCUSSION
Squint Free Papers
Near visual activities are often prescribed during patching for amblyopia
based on the assumption that those activities stimulate the visual system. 9
A number of uncontrolled case series during the middle and later half of
twentieth century have suggested a benefit of prescribing near activities 10-13 but
the question has not been rigorously studied. The major proponents of these at
that time were Francois and James, 10 Callahan and Berry, 11 and Von Noorden
and colleagues. 12 They incorporated tracing pictures, completing puzzles,
coloring small symbols on exercise sheets for one hour a day during occlusion.
Watson and colleagues also described playing a visually demanding game
while patched. 13 Due to lack of rigorous studies using randomized control trial
methods, with masking and standardization of visual acuity assessment, their
significance remained controversial. 9
Park et al in a retrospective study published in 2008 highlighted the importance
of near visual activities with part time patching (6 hours) in treating children
(mean age 4.86 yrs) with anisometropic, strabismic or combined amblyopia
(both moderate and severe). They noted 86% success rate with visual acuity
improving from baseline by an average of 3.2±2.5 lines in a follow-up period
of 1.62±1.20 years. 18
In the recent times the role of near activities again has come to forefront
with the Pediatric Eye Disease Investigator Group incorporating near visual
activities into the prescribed treatment regimes. 3,4,14-16 Although different
doses of patching, combined with near visual activities, were successful in
improving visual acuity in 27%-80% children, it is unclear whether concurrent
near visual activities enhanced the effect of patching.
A randomized pilot study to determine whether children randomized to near
or non-near activities would perform prescribed activities was conducted by
the PEDIG. 17 In this, the children were randomly assigned to receive either
two hours of daily patching with near activities or two hours of daily patching
without near activities. They noted a mean 2.6 lines versus 1.6 lines, respectively
(p=0.07) and suggested that performing near activities while patched may
be beneficial in treating amblyopia and to conduct a formal randomized
amblyopia treatment trial of patching with and without near activities.
The main RCT was conducted between February 2005 and June 2007 with
425 patients. 9 Near activities included arts and craft, counting up close, board
games, card games, computer games, video games, homework, stacking coins,
string of beads, writing, reading, activity books. Distance activities included
active physical games, counting at distance, general outdoor games, watching
television at a distance of 6 mts.
963

964
69th AIOC Proceedings, Ahmedabad 2011
At 8 weeks, improvement in amblyopic eye visual acuity averaged 2.6 lines
in the distance activities group and 2.5 lines in the near activities group. The
two groups also appeared statistically similar at the 2-week, 5-week, and 17week
visits. The investigators did not notice any difference in visual acuity
improvement between children who performed common near activities and
those who performed distance activities while patched. This finding was in
contrast to the results of the previous randomized pilot study 17 and also to
several case series reporting the effect of near activities or activities involving
eye-hand coordination. 10-13
The present study is not comparable to the above as both the groups were
prescribed full time patching while in the above study each patient was
prescribed two hours of patching per day along with the prescribed activity.
The patients in the present study were divided into two groups of twenty each
and television games at one metre distance as near activities additional to
patching was given only in one group while the other group was of patching
alone, hence serving as the control group.
The results of this study indicate a greater improvement in distance as well as
near visual acuity and stereoacuity in group B as compared to group A which
is in agreement with the results of the pilot study, but in contrast to the similar
improvement noted between near and non near activities group as reported
by the main RCT.
We feel that ethnic variations in treatment may play a role in this and also
compliance was not objectively monitored in ATS. In the present study
compliance was objectively monitored and noted to be 100% with the
investigator personally helping the child perform the task at each weekly visit,
upto the whole of study period. A lack of a strict methodology also makes
it harder to interpret their results. In this study the television games given
were in a balanced manner along with full time patching, in all subjects of
the group B. In the ATS 6 measurement of visual acuity in each eye was by the
ATS single-surround HOTV testing protocol on the Electronic Visual Acuity
Tester. In present study the acuity was measured using Snellen’s chart, hence
allowing for the crowding phenomenon. Also the difference in the sample size
among the two studies may be a reason for this difference in the outcome.
The choice of television as a modality of providing near activities finds its
basis in the colossal influence, it enjoys in our daily lives. The television games
have been tried as treatment of amblyopia in the past with limited success.
Flicker et al used the TV games in a modification of stripe (CAM) therapy. 19
A current study at UC Berkley, California, has linked playing video games
with improvement in vision of amblyopes 20 by 45 to 50%. Low vision software
developed by Tenglnet companies and the amblyopia Institute of Cruz

Squint Free Papers
University, Amblyopia ABC, is a treatment of 3-12 year-old children through
their favourite computer games, given 2-3 times per day for 10-15 minute. 21
To conclude, in the present study we have noted improvement in the distance
visual acuity, near visual acuity, stereoacuity in both the groups, but these
were found to be better in group B i.e. the television games group as compared
to group A i.e. the control group. Although this was a small pilot study, based
on our results, we recommend use of near visual activities in the form of
television games along with full time occlusion in the treatment of amblyopia.
REFERENCES
1. Hills A, Flynn JT, Hawkins BS. The evolving concept of amblyopia: a challenge to
epidemiologists. Am J Epidemiol. 1983;118:192-205.
2. Cotter SA, Edwards AR, Wallace DK, Beck RW, Arnold RW, Astle WF, et al.
Pediatric eye disease investigator group. Treatment of anisometropic amblyopia in
children with refractive correction. Ophthalmology. 2006;113:895-903.
3. Repka MX, Beck RW, Holmes JM, Birch EE, Chandler DL, Cotter SA, et al. Pediatric
Eye Disease Investigator Group. A randomized trial of patching regimens for
treatment of moderate amblyopia in children. Arch Ophthalmol. 2003;121:603-11.
4. Holmes JM, Kraker RT, Beck RW, Birch EE, Cotter SA, Everett DF, et al. Pediatric Eye
Disease Investigator Group. A randomized trial of prescribed patching regimens
for treatment of severe amblyopia in children. Ophthalmology. 2003;110:2075-87.
5. Simons K, Stein L, Sener EC, Vitale S, Guyton DL. Full-time atropine, intermittent
atropine, and optical penalization and binocular outcome in treatment of
strabismic amblyopia. Ophthalmology. 1997;104:2143–55.
6. Cotter SA, Astle WF, Beck RW, Birch EE, Chandler DL, Davitt BV, et al. Pediatric
Eye Disease Investigator Group. The course of moderate amblyopia treated with
atropine in children: Experience of the amblyopia treatment study. Am J Ophthalmol.
2003;136:630-9.
7. Repka MX, Cotter SA, Beck RW, Kraker RT, Birch EE, Everett DF, et al.Pediatric Eye
Disease Investigator Group. A randomized trial of atropine regimens for treatment
of moderate amblyopia in children. Ophthalmology 2004;111:2076-85.
8. Leguire LE, Rogers GL, Walson PD, Bremer DL, McGregor ML.Occlusion and
levodopa-carbidopa treatment for childhood amblyopia. J AAPOS. 1998;2:257-64.
9. Holmes JM, Lyon DW, Strauber SF,Birch EE, Beck BW, Bradfield YS. A Randomized
Trial of Near versus Distance Activities while Patching for Amblyopia in Children
3 to < 7 years old. Ophthalmology. 2008;115:2071–8.
10. Francois J, James M. Comparative study of amblyopic treatment. Am Orthopt J.
1955;5:61-4.
11. Callahan WP, Berry D. The value of visual stimulation during contact and direct
occlusion. Am Orthopt J. 1968;18:73-4.
12. Von Noorden GK, Springer F, Romano P, Parks M. Home therapy for amblyopia.
Am Orthopt J. 1970;20:46–50.
965

966
69th AIOC Proceedings, Ahmedabad 2011
13. Watson PG, Sanac AS, Pickering MS. A comparison of various methods of
treatment of amblyopia: a block study. Trans Ophthalmol Soc UK. 1985;104:319–28.
14. Scheiman MM, Hertle RW, Beck RW, Edwards AR, Birch E, Cotter SA, et al. Pediatric
eye disease investigator group. Randomised trial of treatment of amblyopia in
children aged 7 to 17 years. Arch Ophhalmol. 2005;123:437-47.
15. Scheiman MM, Kraker RT, Beck RW, Tamkins SM, Hertle RW, Holmes JM, et al.
Pediatric Eye Disease Investigator Group. A prospective, pilot study of treatment
of amblyopia in children 10 to < 18 years old. Am J Ophthalmol 2004;137:581-3.
16. Wallace DK, Edwards AR, Cotter SA, Beck RW, Arnold RW, Astle WF, et al. Pediatric
Eye Disease Investigator Group. A randomized trial to evaluate 2 hours of daily
patching for strabismic and anisometropic amblyopia in children. Ophthalmology
2006;113:904-12.
17. Holmes JM, Edward AR, Beck RW, Arnold RW, Johnson DA, Klimek Dl, et al.
Pediatric Eye Disease Investigator Group. A randomized pilot study of near
activities versus non-near activities during patching therapy for amblyopia. J
AAPOS 2005;9:129-36.
18. Park KS, Chang YH, Na KD, Hong S, Han SH. Outcomes of 6 Hour Part-time
Occlusion Treatment Combined with Near Activities for Unilateral Amblyopia.
Korean J Ophthalmol. 2008;22:26-31.
19. Fricker SJ, Kuperwaser MC, Stromberg AE, Goldman SG. Stripe therapy for
amblyopia with a modified television game. Arch Ophthalmol 1981;99:1596-99.
20. Turner A. video games may improve vision. The daily Californian. [cited 2010 april
22]. Available from: http://www.dailycal.org.
21. Windows winset. Tenglnet share software net science and technology co;
amblyopia ABC. Available from http://www.tlwinset.com.
Dr. MANISH SHARMA: MBBS (1998), V S S Medical College, Burla; MS
(2003), Pt. B D Sharma PGIMS; Fellowship, Paediatric Ophthalmology
and Strabismus (2004), Sankara Nethralaya, Chennai and in 2009 from
University of Wisconsin, Madison, US. Presently, Sr. Consaltant, Pediatric
Ophthalmology and Strabismus at Dr. Shroff’s Charitable Eye Hospital,
Daryaganj, New Delhi. E-mail: drmanishsharma@gmail.com,
Dose Response of Botulinum Toxin without Electromyographic
Assistance for Sixth Nerve Palsy?
Dr. Manish Sharma, Dr. Varshini Shanker, Dr. Vikas Tyagi, Dr. Suma
Ganesh, Dr. Priyanka Arora
Sixth nerve palsy is the most common nerve palsy seen in ophthalmic
practice. Patel et al have given the annual incidence of sixth nerve palsy
as 11.3 per 100,000 population. 1 The first aim of management is to identify
and treat the cause of the condition, where this is possible, and to relieve the
patient’s symptom of diplopia, where present, with prisms or occlusion of

Squint Free Papers
one eye. In recent years botulinum toxin has been most commonly used for
symptomatic relief.
Botulinum toxin works by causing a flaccid paralysis of the injected muscle
and the eye position changes allowing the visual axes to align. It is known that
contracture of medial rectus occurs even in patients who have recovered fully
and having small angle esodeviation. 2 Botulinum toxin acts as therapeutic
agent by preventing the contracture of the medial rectus muscle. Scott and
Kraft in 1985 used botulinum toxin for strabismus concluded that it helped
in achieving single binocular vision in many patients. 3 Contracture release
was explained as relaxation of sarcomere overlap occurring in the ipsilateral
antagonist (medial rectus muscle).
Botulinum toxin can be given directly in the muscle or subtenon’s space with
or without electromyographic (EMG) guidance in the office setting. 4,5
Ophthalmologists have used 2.5 units to as high as 15units in a single muscle
but the effect of toxin in terms of response as measured in prism dioptre of
deviation is not known whether used with or without electromyographic
(EMG) assistance. 6
To evaluate the effect, complications and dose response of botulinum toxin
A injection in the treatment of sixth nerve palsy without electromyographic
(EMG) assistance.
MATERIALS AND METHODS
• Design: Retrospective interventional case series.
• Inclusion criteria: Initial examination within three months of history of
sixth nerve involvement, Inability to abduct one eye, Diplopia in primary
position, Distance esotropia ≥ 10 prism dioptres, No previous botulinum
toxin or surgical treatment
• Exclusion criteria: History of strabismus prior to sixth nerve palsy, Any
other cranial nerve palsies, Pregnancy
• Data including age, sex, date of onset of palsy, etiology of palsy, systemic
condition, degree of abduction deficit and angle of deviation. The amount
of esotropia in primary position at 6m and 33cm was recorded by prism
and alternate cover test pre and post botulinum injection visits.
• Abduction deficit was graded by using the scale 0 (normal), -1 (can rotate
eye from midline to 75% of full rotation), -2 ( to 50% of full rotation), -3 ( to
25% of full rotation),-4 (to midline) and -5 (inability to rotate to midline).
• Injection technique: Botulinum toxin [Botox ® ] (Allergan) was be used in
all patients transconjunctivally under topical anaesthesia (Proparacaine)
967

968
69th AIOC Proceedings, Ahmedabad 2011
without EMG assistance. Eyelid speculum used and the patient asked to
look temporally and medial rectus belly was held with dastur’s superior
rectus holding forceps ( commonly used in cataract surgeries) and a 1 ml
syringe with a 30 gauge needle with the bevel of needle facing the globe
introduced transconjunctivally at 6mm from the limbus into the belly of
medial rectus muscle/ subtenon’s space and advanced by 5 mm and Botox
injected.
• Recovery was defined as absence of diplopia in primary position and/ or
a distance esotropia of less than 10 prism dioptres (PD) at follow up and
improvement in abduction.
• Complications and side effects were recorded at each visit in first week and
at one month.
RESULTS
Total number of patients in which medial rectus muscle injections given for
sixth nerve palsy -13. (Table 1). 7 males (53.8%) and 6 females (46.2%). 10 Left
eye (76.9%) and 3 Right eye (23.1%). Etiology in our case series were: Idiopathic
5(38.5%), Diabetic 5(38.5%), Traumatic 1(7.69%), Sinusitis 1(7.69%), Hypertension
1(7.69%).
5 unit Botox in 10 patients (76.92%) and 2.5 unit Botox in 3 patients (23.07%).
Complete resolution was seen in 8 patients. 6 patients improved within a week
of the injection and all 8 recovered at one month follow up.
Mean abduction deficit in successful cases was -2 and unsuccessful cases was
-3.4.
Mean deviation in primary position in successful cases was 27 prism diopter
and unsuccessful cases was 33 prism diopter.
Traumatic case underwent vertical muscle transposition one month after
Botox. Injection was repeated in one case after 1 month.
Complication: There were no complications except for one case of
subconjunctival hemorrhage which presented next day.
Three cases were given 2.5u of the toxin out of which only one was successful.
5u of toxin effectively reduced up to 30prism diopter of primary deviation.
DISCUSSION
Botulinum toxin can be safely given without electromyographic assistance
and when given in this manner 5 units of the toxin effectively reduces up to 30
prism diopter of primary deviation.
Majority of the studies have used either direct visualization of muscle for

Squint Free Papers
injection of botulinum toxin into belly of muscle or EMG assistance. We
injected botulinum toxin without EMG assistance. Our technique was similar
to what has been described by Sanjari in 2008 and Talebnejad et al. 4,7
Acheson found the effect of medial rectus chemodenervation was an
immediate reduction in distance esotropia, and the mean change was 34.5 PD.
His patient received 3.75 units of botulinum toxin A (Dysport) under EMG
guidance which is roughly equal to 1.25 units of Botox. 8 Fitzsimons et al found
an average change of 28 PD in a group of unilateral sixth nerve patients using a
high dose regimen of 0.1 ml (6.25 ×10-4 μg Dysport or 3.12 ×10-4 Allergan). 9 But
Repka reported a mean change of only 16 PD after a single injection of between
2.5 and 7.5 units. 10 Others have also reported varying levels of response. 11
Elston in a large group of strabismic adults, with a range of diagnoses, found
a mean of 34 PD change and had used two different doses. 12 He discussed that
intensity and duration of flaccid paralysis is dose dependent but independent
of the size and direction of the strabismus. In our study, when 2.5 unit was
used only one patient responded and results were better with 5 units, but in
our cases size of pre injection deviation did make a difference. Cases which
had abduction deficit of 4 and 30-35 prism dioptre and more of deviation did
not respond to the treatment. Most likely, the diffusion of the toxin into the
muscle is less and thus less muscle fibres are denervated as compared to EMG
guided procedure. In cases of large strabismus, fibrosis and contracture of the
muscle combined with large abduction deficit may contribute to poor response
and hence large dose or multiple injections will be required to get effect when
injecting botulinum toxin without EMG assistance.
Sanjari et al did not found any statistically significant difference between the
two groups (injection with and without EMG assistance) regarding the mean
change of angle of deviation and success rate at each follow up visit. In their
study the avg. deviation was 35 prism diopter which was nearly same as ours
but they have used Dysport. 4
Acheson noted that the peak effect of reduced esotropia post Botulinum toxin
injection came at 1-2 weeks. In our study 6 patients improved within a week of
the injection and all 8 recovered at one month follow up. 8
Loba have reported the use of botulinum toxin in diabetic sixth nerve
palsy and have noted its usefulness in reducing the diplopia and assuring
the quality of life and professional activity. 6 In our series we also found 50%
patients recovering within a week of injection thus making them symptom
free and improving their quality of life.
No major complications were noted in our series of patients. Only one patient
969

970
69th AIOC Proceedings, Ahmedabad 2011
had subconjunctival hemorrhage. No ptosis was observed in our review.
There are certain limitations as ours is a small series and retrospective
review. Not much comparison can be made between different doses of toxin.
A large randomized therapeutic trial with longer follow up will further help
in establishing the dose required in moderate to large angle deviation due to
sixth nerve palsy. In conclusion Botulinum toxin in the dose of 5 units can be
safely and effectively used for treatment of acute sixth nerve palsy without
electromyographic assistance in small to moderate deviations up to 30 prism
dioptres.
REFERENCES
1. Patel SV, Mutyala S, Leske DA, Hodge DO, Holmes JM. Incidence, associations and
evaluation of sixth nerve palsy using a population - based method. Ophthalmology.
2004;111 (2): 369-375.
2. Magoon EH. Botulinum toxin in the management of strabismus. In: Daniel M.
Albert, Frederick A. Jakobiec. editors. Principles and Practice of Ophthalmology,
1994;3:4393. W.B. Saunders Co.
3. Scott AB, Kraft SP. Botulinum toxin injection in the management of lateral rectus
paresis. Ophthalmology. 1985;92:676-83.
4. Sanjari MS, Faavarjani KG, Kashkouli MD, Aghai GH, Nojomi M, Rostami H.
Botulinum toxin injection with and without electromyographic assistance for
treatment of abducens nerve palsy. Journal of AAPOS. 2008;12:259-62.
5. Kao LY, Chao AN. Subtenon injection of botulinum toxin for treatment of traumatic
sixth nerve palsy. J Pediatr Ophthalmol Strabismus. 2003;40:27-30.
6. Loba AB, Czupryniak L, Nowakowska O, Loba J. Botulinum toxin A in the early
treatment of sixth nerve palsy-induced diplopia in type 2 diabetes. Diabetes care.
2004;27:846.
7. Talebnejad MR, Sharifi M, Nowroozzadeh MH.The role of botulinum toxin in
management of acute traumatic third nerve palsy. Journal of AAPOS 2008;12:510-3.
8. Acheson JF, Bentley CR, Hoffmann JS, Gresty MA. Dissociated effects of botulinum
toxin chemodenervation on ocular deviation and saccade dynamics in chronic
lateral rectus palsy. Br J Ophthalmol. 1998;82:67-71.
9. Fitzsimons R, Lee J, Elston J. The role of botulinum toxin in the management of
sixth nerve palsy. Eye 1989;3:391-400.
10. Repka MX, Lam GC, Morrison NA. The efficacy of botulinum neurotoxin A for the
treatment of complete and partially recovered chronic sixth nerve palsy. J Pediatr
Ophthalmol Strabismus. 1994;31:79-83; discussion 84.
11. Hung HL, Kao LY, Sun MH. Botulinum toxin treatment for acute traumatic
complete sixth nerve palsy. Eye 2005;19:337-41.
12. Elston JS, Lee JP, Powell CM, Hogg C, Clark P. Treatment of strabismus in adults
with botulinum toxin A. Br J Ophthalmol. 1985;69:718-24.

Squint Free Papers
Management of Myopic Strabismus Fixus: A
New Approach
Dr. Kuldeep Kumar Srivastava
Patients with high myopia may develop a myopathy which frequently
results in myopic strabismus, a sort of convergent strabismus fixus. Myopic
strabismus fixus is a rare restrictive ocular motility disorder characterized
by acquired progressive esotropia and hypotropia associated with restricted
elevation and abduction. 1 One possible etiology is an enlarged globe herniating
superotemporally through muscle cone. High resolution magnetic resonance
imaging has demonstrated the inferolateral displacement of lateral rectus
muscle in this restrictive motility disorder.
Surgical treatment of myopic strabismus fixus is challenging. Various surgical
procedures including combined recess-resect procedure, muscle belly union,
Yamada’s surgical procedure, partial Jensen’s procedure, loop myopexy and
lateral fixation of sclera to periosteum has been described. We report four
cases of myopic strabismus fixus which were managed by lateral fixation of
globe combined with large recession of medial rectus muscle.
MATERIALS AND METHODS
Four patients of severe myopic strabismus of more than 90 prism diopter
esotropia and hypotropia were managed by lateral fixation of globe to lateral
orbital wall. All patients underwent complete ophthalmic examination
including best-corrected visual acuity, slit lamp biomicroscopy, refraction,
axial length, fundus examination and ocular motility evaluation. The ocular
deviation was measured with Hirschberg corneal reflection test because angle
of deviation was more than 45 degrees in all the four patients. Forced duction
tests, in order to verify the restrictions were performed in all four patients.
All the patients had measurement of deviations at one day, one week, one
month and six months after surgery, as well as during their last follow up
visit. Postoperatively, ocular deviations were measured by prism cover test
and Krimsky corneal reflex tests placing prisms in front of the operated eye.
Surgical Technique
Large medial rectus muscle recession with hang back technique was performed
in all four patients until globe was able to move beyond the midline. A limbal
conjuntival incision was made on temporal side. Conjunctiva was retracted
laterally. A 5-0 polyester (Ethibond) suture was passed through sclera at the
insertion of lateral rectus muscle and through the periosteum at Whitnall’s
tubercle on inner lateral wall of orbit. Suture was tightened and globe was
971

972
69th AIOC Proceedings, Ahmedabad 2011
left little exotropic. Conjunctiva was sutured with 8-0 vicryl suture. Postoperatively,
commercially available topical corticosteroid-antibiotic drops
were prescribed for six weeks.
RESULTS
Results were defined in the terms of ocular deviation in the primary position of
gaze. A satisfactory result was defined as an ocular deviation within 20 prism
diopters of orthophoria. Procedure was performed on four patients, two males
and two females. All four patients had acquired myopic strabismus fixus.
Three patients had unilateral disease and one patient had bilateral disease. All
patients had significant ocular movement restriction on passive force duction
testing on abduction. Preoperative best corrected visual acuity ranged from
6/12P to 2/60 and did not change in any patient after surgery. Preoperative
ocular deviation in primary position was more than 90 prism diopters in all
the patients. Postoperatively, ocular alignment was substantially improved in
all patients. There was no significant change in ocular alignment during the
follow-up period of 7.2 months (range 1 month to 9 months). Preoperatively,
all patients had obvious hypotropia in addition to esotropia which improved
significantly after surgery.
DISCUSSION
Many surgical methods to stabilize the globe in high myopia have been
described, including disinsertion or large recession of the MR muscle and
recession–resection procedures with limited success. Hayashi et al found
that medial rectus muscle recession and lateral rectus muscle resection
was effective in the early stages, but a modified Jensen procedure with
transposition of the SR and inferior rectus (IR) muscles combined with MR
muscle recession was required in patients with severe limitation of abduction. 2
Krzizok et al demonstrated a deviant LR path on MRI and used a scleral stay
suture to anchor the LR muscle to the physiological (3 or 9 o’clock) meridian. 3
Wong et al used other transposition procedures, such as loop myopexy of the
LR and SR muscles, or a partial Jensen procedure of the SR and LR muscles,
with or without MR muscle recession. 1 Periosteal fixation of sclera has been
performed for third Nerve palsy with satisfactory results. More recently,
Murthy managed a case of myopic strabismus fixus by lateral fixation of sclera
to periosteum and disinsertion of medial rectus muscle. 4
In our cases, we performed fixation of globe to Whitnall’s tubercle on lateral
orbital wall combined with large recession of medial rectus muscle. We believe
that this technique is effective than the traditional procedures like horizontal
recess–resect procedures.

Squint Free Papers
REFERENCES
1. Wong I, Leo SW, Khoo BK. Loop Myopexy for treatment of myopic strabismus. J
AAPOS 2005;9:589-91.
2. Hayashi T, Iwashige H, Maruo T. Clinical features and surgery for acquired
progressive esotropia associated with severe myopia. Acta Ophthalmol Scand
1999;77:66-71.
3. Krzizok T, Kaufmann H, Traupe H. New approach in strabismus surgery in high
myopia. Br J Ophthalmol 1997;81:625-30.
4. Murthy R. Lateral fixation of sclera to the periosteum with medial rectus
disinsertion for severe myopic strabismus fixus. Indian J Ophthalmol 2008;56:419-21.
To Study Surgical Outcome in Pediatric Patients
with Monocular Elevation Deficiency (MED)
Dr. Kalpana Narendran, Dr. Neelu Agrawal, Dr. Rajesh Prabu,
Dr. Ramakrisnan, Dr. Saurabh Mundhada
To study the outcome of monocular elevation deficit and the effect of inferior
rectus recession and Knapp’s procedure in pediatric patients.
Study design: Retrospective study.
Monocular Elevation Deficiency, also known by the older term Double Elevator
Palsy, is an inability to elevate one eye above midline. This is same in both
adducted and abducted positions. It can be due to varied reasons: superior
rectus palsy, inferior rectus restriction and/or supranuclear aetiologies. Overall
after certain duration no definitive demarcable cause can be pointed out, as a
case of primary palsy. This is due to development of secondary restriction of
the ipsilateral antagonist muscle. Success or failure in strabismus depends on
a proper preoperative study of the patient. In MED it depends upon amount
of preoperative squint, results of FDT, associated presence of other ocular
findings viz ptosis, amblyopia and associated ocular abnormality.
This paper deals with the surgical results obtained in patients of MED of
paediatric age group. Preoperative amount of strabismus is one of the guides
for the surgical procedure to undertake.
MATERIALS AND METHODS
A computer based database retrieval system at the medical records section
was used to search retrospectively patients that underwent surgery for MED
from January 2006 to December 2008, after obtaining institutional review
board approval. Twenty three patients from age group of 0 to 16 years were
included in this study.
973

974
69th AIOC Proceedings, Ahmedabad 2011
Patients with restrictive strabismus due to orbital fractures, orbital inflammation,
orbital tumours, myasthenia gravis, ocular fibrosis and those with prior ocular
and extra ocular muscle surgery were excluded from this study.
All patients underwent a detailed workup, including full ophthalmic and
orthoptic evaluation prior to surgery. This included assessment of visual
acuity as appropriate for the age of the patient, full cycloplegic refraction and
dynamic refraction, anterior segment slit-lamp bio microscopy and fundus
examination. Deviation was measured by alternate prism cover test for both
near (33 cm) and distance (6 m) using fixation targets and with full optical
correction. Neutralizing prisms were placed on the eye with MED to measure
the primary deviation, which formed the target angle for surgery. Fusion was
assessed for near and distance, using Worth four dot test, with room lights
on, to make the test, as much less dissociative as possible and stereopsis was
measured using TNO test, in both primary and chin up position. Ocular
movements were tested, including ductions, versions and vertical saccades.
True ptosis, when present, was thoroughly evaluated. Pre-existing amblyopia
was treated with occlusion therapy. A forced duction test (FDT) was
performed preoperatively for both elevation and depression intraoperatively
for all patients.
Postoperative ocular deviation was measured at the end of one month. The
follow-up period ranged from three months to three years. FDT was positive
in all the cases. Patients were divided into two groups depending upon the
preoperative amount of hypotropia and surgical procedure done.
Group-A: Includes those with hypotropia of < 30 prism dioptre. In these
patients Inferior rectus recession was done alone. Includes 14 patients.
Group-B: Includes those with hypotropia > 30 prism dioptre. In these patients
Inferior rectus recession followed by Knapp procedure in two sittings with a
gap of four months. Includes 9 patients.
Knapp procedure combined with horizontal muscle (MR and LR) recession
and resection for the associated horizontal strabismus was done in 7 cases.
Monocular elevation deficiency can present as hypotropia alone or hypotropia
associated with esotropia or exotropia. Associated horizontal strabismus was
corrected by recession and resections of MR and LR in 11 patients, out of these
7 cases were combined with Knapp’s procedure.
RESULTS
Include 23 patients, 14 in group A and 9 in group in group B. The study had
30 % of females and 70% of males. The mean age at surgery in this study was
7.6 years with a range three to 15 years. Right eye (OD) was involved in cases
(%) and left eye (OS) in (%) cases. The best-corrected visual acuity ranged from

Squint Free Papers
6/6 to 3/60 in the affected eye. True ptosis was present in 65.22%, pseudoptosis
in 34.78% and Marcus Gunn jaw winking phenomenon was present in 60.87%.
The preoperative ocular deviation varied from 15 to 60 prism diopters of
hypotropia in primary position, with a mean deviation of 34.6 prism diopters.
The FDT was positive in 23 cases (100%) 11 cases (47.83%) had horizontal
deviation. 7 cases underwent recession-resection of horizontal muscles along
with Knapp’s procedure. All these were aligned to within 10 prism diopters.
In patients with hypotropia < 30prism diopter mean correction seen with
Inferior rectus recession (IRR) alone was 16.5 prism diopter. In patients with >
30pd hypotropia mean correction with IRR alone was 24.11pd and following
combined surgery (IRR+Knapp’s) was 43.56pd. Overall a total mean correction
of 27.08 prism diopter from mean preoperative deviation 34.6 prism diopter
was seen in this study. It was found that the patient with 30% prism
diopters of hypotropia with inferior rectus recession alone had a mean amount
of squint corrected to 24.11pd. An additional surgery Knapp’s procedure was
needed, that gave correction within 10 prism diopters of correction in 66.67%
of patients (group B). Additionally we found out that 1mm of inferior rectus
recession gives 2.85 prism diopters of correction. Statistical analysis done by
Wilcoxon signed ranked test shows a significant P value of 0.001 in Group
A patients where Inferior Rectus Recession was done alone. In group B who
underwent combined surgery (IRR + Knapp’s) p value of 0.0076 was observed
that was statistically significant.
Table 1: Patients in group A
pre op squint amount of recession post op squint amount of correction
(pd) (mm) (pd) (pd)
16 6 4 12
25 6 10 15
15 6 0 15
25 5 9 14
25 5.5 0 25
18 6 7 11
30 6 12 18
25 5.5 14 11
25 5.5 0 25
30 6 14 16
25 6 10 15
20 5.5 7 13
30 6 16 14
25 6 0 25
975

976
69th AIOC Proceedings, Ahmedabad 2011
Table 2: Patients in group B
pre op squint amount of recession post op squint amount of correction
(pd) (mm) (pd) (pd)
>50 6 28 0
>50 6 20 8
>50 6 25 10
40 6 27 8
45 6 25 0
45 6 23 0
52 6 32 11
45 5.5 25 15
55 6 40 18
DISCUSSION
The treatment of MED is surgical. It is difficult to treat MED with a single
surgical formula. Successful alignment of MED has been described following
different surgical modalities. The procedure of choice is determined by the
FDT, which ascertains whether the cause is paretic due to SR palsy and/or IO
palsy or restrictive due to IR restriction.
In presence of SR palsy, the procedure employed is a Knapp transposition.
Since in our study FDT was positive in 100% of patients Knapp procedure was
not done alone as a primary procedure and all patients underwent inferior
rectus recession as a primary surgery. Incidence of inferior restriction is high,
although all our patients had restriction of inferior rectus. This high percentage
has been reported by other authors. Wright has stated that the incidence of
inferior restriction in MED is 70%. Scott and Jackson reported IR restriction
in 11 out of 15 patients (73.3%). Metz reported 12 out of 15 patients of MED
having restriction in elevation on FDT (80%). Some authors have advised, in
such cases, IR recession ranging from 5 to 8 mm, while others have reported
increased complications with recessions exceeding 5 mm. We have restricted
IR recession to a maximum of 6 mm, to lower the complications of hypertropia
in down gaze and lower lid retraction. The average correction was 20.3 PD
from an average preoperative deviation of 34.6 prism diopters.
Inferior rectus recession needs to be followed by Knapp procedure in the
presence of residual SR palsy, due to persistent hypotropia. In our series, 14
such patients underwent both surgeries, with an average correction of 43.56
pd of deviation, at the end of two surgeries .Kocak-Altimtas et al., reported
a series of six MED patients with positive FDT, who underwent IR recession,
followed by Knapp, achieving a mean correction of 25.8 ± 5.6 pd. Scott reports a
higher average correction of 38 pd following two surgeries. The two surgeries

Squint Free Papers
were spaced by a gap of four months. Anterior segment ischemia (ASI) has
been reported to occur after such procedures, due to disruption of ciliary
circulation. None of our patients had ASI. This can be attributed to younger
age of the patients and a two staged procedure.
In conclusion, MED management depends on FDT and when positive,
monocular elevation deficit of fewer amounts can be corrected with single
surgery and of larger amount needs an additional surgery without major
complications in pediatric patients.
REFERENCES
1. Cooper EL, Greenspan J. Operation for double elevator palsy. J Paediatr Ophthalmol
Strabismus 1971;8:8-14.
2. Metz HS. Double elevator palsy. Arch Ophthalmol 1979;97:901-3.
3. Taylor D, Hoyt CS. Elsevier Sauders: Paediatric ophthalmology and strabismus.
2005;3:969-70.
4. Kocak-Altinas AG, Kocakkkk-Midilleo I, Babil H, Duman S. Selective managemnt
of DEP by either inferior rectus recession and/or Knapps type transposition
surgery. Binocul Vis Strabismus Q 2000;15:39-46.
5. Rosenbaum AL, Santiago AP. Clinical strabismus management. W.B. Saunders
Company: Principles and Surgical Techniques. 1999. p. 272-9.
6. Wright K, Spigel PH. Springer: Paediatric ophthalmology and strabismus. 20 0 3;2:2 57- 8.
7. Surgical Management of Strabismus. Mosby: An Atlas of Strabismus Surgery.
1993;4:513-4.
8. Scott W, Jackson OB. Double elevator palsy: The significance of inferior rectus
restriction. Am Orthopt J 1977;27:5-10.
9. Prieto Diaz J, Souza Dias C. Stabismus. Butter Worth Heinemann: 2000;4:337.
10. Bagheri A, Sahebgulam R, Abrishami M. Double elevator palsy: A 10 year review
of operated patients. Bina J Ophthalmol 2006;12:81-8.
Role of Simultaneous Superior Rectus Recession
and Anterior Transposition of Inferior Oblique
Muscle in The Surgical Treatment of Lost inferior
Rectus Muscle
Dr. Pramod Kumar Pandey, Dr. Subhash Dadeya, Dr. Sonal Dangda,
Dr. Vijay Shinde, Dr. Shagun Sood
Slipped and lost extraocular muscles (EOM) present one of the most
challenging surgical problems in the field of strabismus as one has to
countenance an extremely large deviation, contracture of the antagonist and
977

978
69th AIOC Proceedings, Ahmedabad 2011
exasperating induced incomitance. EOM can become traumatically detached
from the globe as a result of injury or lost as a complication of strabismus
surgery, retinal detachment, orbital, or paranasal sinus surgery. 1 EOM may
also slip subsequently as a consequence of poorly executed strabismus surgery.
Any EOM can be lost but most commonly lost one is medial rectus followed by
inferior rectus (IR). 2 IR seems to be most commonly lost muscle due to trauma
as globe is pushed up due to Bell’s phenomena whenever eye is threatened and
forced closure follows. 3
Clinical signs of lost IR include a large primary position hypertropia (HT)
and marked limitation of depression, most prominent in abduction. Some
depression may be allowed by the synergistic superior oblique in the field of
action of IR but resultant intorsion and abduction spoil the broth. Attendant
succeeding superior rectus contracture may render depression worse with
passage of time with out much spread of comitance. Forced duction test will
reveal the contracture of superior rectus.
High resolution magnetic resonance imaging (MRI) can at times confirm
the discontinuation of muscle from the globe but such studies can often be
inconclusive or misleading. 3 So much so that some believe that diagnostic
imaging need not be done routinely. The retrievable rate of lost muscles being
low, 3 conventional surgical options invariably include a large recession of
antagonist SR and inverse Knapps with variable results.
We report clinical presentation and alternative surgical option of superior
rectus (SR) recession with resection and anterior transposition of inferior
oblique (ATIO) in cases of lost or disinserted IRs.
MATERIALS AND METHODS
Five patients with a provisional diagnosis of lost IR on the basis of large
primary position HT, marked limitation of depression in abduction, confirmed
by diagnostic imaging or surgical exploration were included in the study.
Patients were seen over a period of past 5 years at a tertiary care institution.
Nature of trauma and patient complaints and their evolution/ regression were
recorded. Ocular examination included assessment of visual acuity, abnormal
head posture, ocular deviation in PP and ocular motility.
Forced duction test and force generation test were done in all the cases. Fundus
torsion was evaluated subjectively by double Maddox rods and objectively
by fundus photography and graded by Guyton’s method. Park’s 3 step test
was done pre- operatively. MRI imaging was done in all. ATIO with or with
out resection of inferior oblique of 3 to 5 mm with simultaneous recession
of ipsilateral SR was done under local anesthesia. Outcomes analyzed at 3
months postoperatively.

Squint Free Papers
RESULTS
All were males aged 13, 18, 23, 28 and 35 years. Time from injury to presentation
ranged from 6 months to 8 years. Visual acuity was 6/12 or better OU in all of
them.
All complained of cosmetic blemish and 3 complained of vertical diplopa
and 2 had additional horizontal diplopia. Primary position (PP) deviation
ranged from 40 to 70 prism diopters (PD), it was > 70 PD in abduction and
depression in all of them with gross limitation of depression in abduction.
Two had an additional exodeviation of 12 and 18 PD. FDT was mildly to
moderately positive in all of them for depression. Objective intorsion between
8 to 14 degrees was noted in all whereas on double Maddox rods it was 4, 6
and 8 degrees in 3 of them, only in the affected eye. Neuro imaging confirmed
the diagnosis of lost muscle in 3 and on surgical exploration other 2 had
pseudotendon attached at the insertion site but muscle could not be retrieved
as fat started prolapsing. Three patients underwent resection of inferior
oblique 3, 4 and 5 mm along with ATIO and 2 underwent ATIO with out
resection. SR recession of 5mm, 7 mm in 2 each and of 8 mm in one patient was
done simultaneously. Immediately post operatively vertical alignment with in
6 PD of HT was obtained with improvement of depression, intorsion was not
worsened significantly to give rise to any torsional symptoms. However it was
not maintained over subsequent 3 months and HT slowly worsened upto 18
PD in one case. Elevation was limited but patients were asymptomatic.
DISCUSSION
Traumatic dis-insertions and lost IRs apart, even isolated IR palsies are very
rare. In a report of 1000 cases of 3rd, 4rth and 6th cranial nerve palsies IR palsy
was not reported at all. 5
A substantial number of acquired IR palsies are either ischemic or traumatic in
origin and recover spontaneously. 6 Von Noorden reported a series of 21 patients
of isolated IR palsies, 7 of them were traumatic with 5 having a radiologically
confirmed fracture of orbital floor. 4 Forced duction test was negative in most,
abnormal head posture was noted in 13 but was variable and lacked fidelity,
head tilt test was positive in 3 patients only. Ipsilateral recession of SR and
resection of IR was the most commonly performed surgical procedure with
correction of upto 20 PD of HT in PP.
Early intervention is most efficacious while dealing with a lost or slipped IR
as delay may complicate clinical picture due to contracture of SR along with
scarring and fibrosis at the site of injury as happened in our cases. A careful
search for thin avascular muscle capsule/fibrosed tissue should be made and
if found it is likely that muscle has just slipped. In such cases scar tissue should
979

980
69th AIOC Proceedings, Ahmedabad 2011
be excised and muscle advanced. We were able to find attenuated fibrous tissue
in 2 but could not find the muscle in any one. Scarring had taken place and fat
was raring to prolapse in the wound, rendering extensive dissections fraught
with possibilities of certain fat adherence syndrome. As deviations are large
a recession/ resection of vertical recti is not the procedure of choice in such
cases as under-corrections will rule the roost. A recession of the superior rectus
along with vertical transposition of horizontal recti done in separate sittings
seems to be the next option, however as all 4 recti are detached, possibility of
anterior segment ischemia, multiple surgical procedures and propensity for
under-corrections plague this option.
Anterior transposition of inferior oblique has been used to treat patients
with inferior oblique overaction and dissociated vertical deviations with
encouraging results 7 Resection of inferior oblique upto 6 mm along with ATIO
has been used in 2 cases with lost inferior rectus muscles in cases of recent
origin, however residual hypertropia was still the concern. 8 Simultaneous
recession of superior rectus with resection of inferior oblique and ATIO seems
to be the most logical option in such cases but has not been reported till now.
Resection of inferior oblique along with ATIO seems to help ameliorate vertical
alignment in primary position. As the condition is rare and esoteric with great
variability in clinical presentation further studies using this approach will
lend more insight into management paradigms of such abstruse strabismus
entities.
REFERENCES
1. Helveston E M, Grossman D; Extra- ocular muscle lacerations; Am J. Ophtjalmol.
1976;91:754-60.
2. Bilson F; Fitzgerald A; Diagnosis and management of lost muscle followinmg
strabismus surgery; Austral. N. Z J.Ophthalmol. 1985;13:67-9.
3. Lenart T D, Lambert S. R; Slipped and lost extra- ocular muscles; Ophthalmology
Clinics of North America; 2001;14:433-42.
4. Von Noorden G K, Hansell R; Clinical characteristics and treatment of isolated
inferior rectus paralysis; Ophthalmology 1991;98:253-7.
5. Rush J A, Younge B R; Paralysisof cranial nerves III, IV and VI ; Causes and
prognosis in 1000 cases; Arch Ophthalmol. 1981;99:76-9.
6. MacEwen C J, Lee J P, Fells P, Aetiology and management of the “detached’’ rectus
muscle; Br. J. Ophthalmol 1992;76:131-6 .
7. Burke J P, Scott W E, Kutschke P J; Anterior transposition of the inferior Oblique
muscle for dissociated vertical deviation; Ophthalmology 1993;100;245-50.
8. Parvataneni M, Olitsky S E; Unilateral anterior transposition with resection of
inferior oblique muscle for the treatment of hypertropia; J. Pediatr. Ophthalmol.
Strabismus 2005;42;163-5.

Squint Free Papers
Clinical Features and Surgical Management
of Bilateral Medial Rectus Agenesis: A Rare
Presentation
Dr. Neha Rathi, Dr. Pramod Kumar Pandey, Dr. Abhishek Sharma,
Dr. Anupam Singh, Dr. Shagun Sood
Absence of one or more extra-ocular muscles is a rare event and is usually
seen in association with syndromic craniofacial disorders. 1 In such
situations superior rectus and superior oblique are affected most frequently.
Bilateral hypoplasias and aplasias have been described, with inferior recti2 and superior oblique tendons being affected most frequently. Isolated bilateral
absence of medial recti has been described recently in a 10 month old boy and
a diagnosis of congenital cranial dysinnervation disorder invoked with out
any tangible evidence of dys- innervation. 3
We describe the clinical presentation, systemic nonsyndromic craniofacial
associations along with successful surgical management of bilateral absence
of medial recti in a 14 year old girl and educe the underpinnings of infantile
exotropia in the esoteric presentation.
RESULTS
A 14 year old girl from non-consanguineous marriage presented with inability
to move either eye medially and a large angle divergent squint since early
childhood. Birth history was unremarkable. Family history of a divergent
strabismus was positive with her younger sister also sporting one. Her
unaided visual acuity was 20/20 with a retinoscopy of + 2.5 diopter sphere
OU. She adopted a slight face turn to opposite side of fixating eye.
There was no syndromic craniofacial disorder but mandibular hypoplasia,
high arched (Byzantine) palate, microdontia, polydontia and arachnodactyly
were noted. No telecanthus was suggested. Palpebral fissures measured
15 mm vertically and 32 mm horizontally and bare sclera was visible both
superiorly and inferiorly suggesting lid retractions. She sported a large angle
exotropia of >70 prism diopter with gross limitation of adduction bilaterally
with reduced saccadic velocity and alternate fixation. Convergence was
absent, accommodation was unaffected. Smooth pursuit asymmetry was
noted in both eyes along with other markers of infantile deviation in the form
of primary inferior oblique overaction and dissociated vertical deviations
OS>OD.
Latent nystagmus was conspicuous by its absence. No globe retraction was
noted on attempted adduction. Fundi were normal, abnormal extorsion
OS>OD was present with V pattern. Forced ductions were mildly positive for
981

982
69th AIOC Proceedings, Ahmedabad 2011
adduction with poor active muscle force generation. Iris was hypoplastic with
rudimentary crypts and collarrette displaced peripherally. Pupils were miotic
with normal reactions and no light/ near dissociation. Anterior chamber
angles wee normal with no evidence of dysgenesis Bilateral hypoplasia of
medial recti was suspected along with other subtle non-syndromic craniofacial
associations.
Magnetic Resonance Imaging of brain and orbits revealed absent medial recti
bilaterally with hypoplastic lateral recti. A two staged surgical procedure
was carried out with a gap of 3 months bilaterally. Bilateral lateral recti were
recessed 12 mm in the first stage followed by full muscle width horizontal
transposition of vertical recti with 3 mm resection of inferior rectus and
lateral augmentation with a Foster suture. Horizontal alignment within 6
prism diopter was obtained post-operatively. Smooth pursuit asymmetry
persisted and sensory fusion and stereopsis were not elicited. Inferior oblique
overaction and DVD were unchanged, OS>OD alongwith V pattern in upgaze.
Her younger sister underwent strabismus surgery, only mildly hypoplastic
medial recti were encountered with successful surgical outcomes
DISCUSSION
Sevel from a study of 54 embryos and fetuses inferred that origin, belly and
insertions of extra ocular muscles developed contemporaneously. 4 The extra
ocular muscles arose from 2 distinct mesodermal complexes; the superior
complex formed the superior rectus, superior oblique and levator palpebrae
superioris while the inferior complex formed the inferior rectus, inferior
oblique muscles. The horizontal recti arose from both the complexes.
The origin of medial rectus was found to be contiguous with that of inferior
rectus (inferior complex) and superior rectus (superior complex). 4 Previously
investigators had suggested that EOM arose from muscle plates and these
primordia migrated forward into the orbit. 5 As both medial recti failed to
develop and lateral recti appeared hypoplastic, improper differentiation or
failure of migration of mesodermal primordia responsible for embryogenesis
of horizontal recti is indicted. The systemic associations in the form of
abnormalities of dentition, mandibular hypoplasia and iris hypoplasia point
toward cognated abnormalities arising from potentially abnormal migration
of neural crest primordia. 6
The arcane presentation has to be distinguished from more common clinical
entities like infantile exotropia, tight lateral recti with X pattern in alternate
divergent strabismus, bilateral congenital internuclear ophthalmoplegia? and
non- fusing exo Duane’s retraction syndrome. The last entity is most likely to
create a diagnostic dilemma as globe retraction may take time to appear and
both may share features of infantile deviations.

Squint Free Papers
However the characteristic presentation with widened palpebral fissures and
gross bilateral adduction deficits left little doubt about hypoplasia of medial
recti. Smooth pursuit asymmetry points towards infantile deviation and in
the absence of any opportunity for binocular interaction, it was retained.
However absence of latent nystagmus, the visuo- vestibular component in the
yaw plane espouses a different mechanism for it’s evolution. 7
The presence of primary inferior oblique overaction and dissociated vertical
deviations, the other 2 fellow travelers of infantile deviations in pitch and roll
plane underscore the pre-requisite of normal development of horizontal gaze
pathways for the bubbling up of these visuo- vestibular abnormalities. 7
MRI is helpful but may not reveal the aplasia as some tenuous attenuated
tissue is invariably found. Surgical exploration is confirmatory, however no
anterior ciliary arteries were visualized here, as is often the case with inferior
rectus aplasias, the reasons for the same are difficult to fathom and underscore
the primacy of anterior ciliary circulation for vertical recti.
Surgical management in the form of large lateral rectus recessions followed
by horizontal transposition of vertical recti with lateral augmentation with
Foster suture produced entirely satisfactory results. Three mm resection
of inferior rectus was carried out to ameliorate DVD but it did not seem to
work well as DVD still persisted Hypoplasia/ aplasia of medial recti can be
associated with subtle craniofacial features and should be suspected in the
presence of large angle exotropia with grossly limited adduction, widened
palpebral fissures, slowing of adduction saccades and presence of smooth
pursuit asymmetry. Primary inferior oblique overaction, DVD, a V rather A
pattern may be cognated as fellow travelers for infantile deviations along-with
bilateral extorsion. Abnormalities linked to migration of neural crest cells may
also be associated. An MRI is helpful in the diagnosis.
Surgical outcomes are fair as far as horizontal alignment is concerned
but functional outcomes are more difficult to achieve as there has been no
opportunity for binocular interaction, especially if surgical intervention is
delayed. Surgical planning should also take cognizance of coexisting DVD,
inferior oblique overaction, V pattern and abnormal extorsion. An early
diagnosis with high index of suspicion and prompt surgical intervention are
suggested as they may help normalization of smooth pursuit asymmetry
and negate emergence of other visuo vestibular movements inimical to
development of good binocularity, in the form of latent nystagmus, inferior
oblique overaction and dissociated deviations, as normal development of
binocularity is almost completely pre-empted. 7 The cognated link between
medial rectus aplasia and inferior oblique overaction, DVD, V pattern and
extorsion is stressed and is being reported for the first time.
983

984
69th AIOC Proceedings, Ahmedabad 2011
REFERENCES
1. Fries P D, Ketowitz J A; Congenital craniofacial anomalies of ophthalmic
importance; Surv. Ophthalmol. 1990;35:87-119.
2. Lin P, yen M; Congenital absence of bilateral inferior rectus muscles: A case report;
J. Pediatr. Ophthalmol. Strabismus 1997;34;382-4.
3. Hootman A C, Hocking G, Lloyd C, Biswas S; large angle congenital exotropia due
to absent medial recti.; Eye 2009;23;1489-90.
4. Sevel D; a reappraisal of the origin of human extra ocular muscles; Ophthalmology
1981;88:1330-8.
5. Fink W H; The development of the orbital fascia; Am J. Ophthalmol. 1956;42;269-7.
6. Idrees F, Vaideanu D; Fraser SG; Sowden J C; Khaw P; A review of anterior segment
agenesis; Surv. Ophthalmol 2006;51;213-31.
7. Brodsky M C; Visuo-vestibular eye movements; Arch. Ophthalmol. 2005;123;837-42.
Role of Repeated Peribulbar Triamcinolone
Acetonide Injections on Strabismus Due To
Thyroid related Ophthalmopathy (TRO)
Dr. Deepali Garg, Dr. Pramod Kumar Pandey, Dr. Neha Rathi,
Dr. Abhishek Sharma, Dr. Shagun Sood
Graves’ disease is a systemic illness characterized by the triad of
hyperthyroidism, diffuse nodular goiter and ophthalmopathy. Thyroid
related ophthalmopathy (TRO) is the ocular inflammatory disease that
accompanies thyrotoxicosis in about 40-50% Graves’ disease. 1 It presents with
typical congestive inflammatory signs of the eye and orbit with lid edema and
proptosis occurring secondary to congestion of the orbit. The inflammatory
process in the orbit affects muscles, connective and adipose tissues in different
degrees contributing to the variable presentation of the disease. Over time,
the inflammatory signs abate and the picture is one of restricted, fibrotic
extraocular muscles. Limited upgaze is the most common ocular motility
defect followed by restricted depression and a reduced range of adduction.
Although the process is bilateral, the abnormalities may be limited to one eye
or markedly asymmetric.
Management of TRO aims at improving ocular motility, primary position
deviation and anomalous head posture. Treatment modalities in the acute
inflammatory phase include non surgical options like long term systemic
corticosteroids (with antecedent complications), immunosuppressives
like cyclosporine, radiation therapy and botulinum toxin injections. The

Squint Free Papers
progression of the disease with resulting variable ocular motility and instability
of disease status makes surgical management tricky and warranting frequent
resurgeries.
Triamcinolone has been variously used intravitreally, sub- tenon or sub
conjunctivally by ophthalmologists to treat different inflammatory conditions.
Previous studies have reported the improvement of TRO with orbital injections
of methylprednisolone and triamcinolone. 1 This study aims to identify the role
of triamcinolone acetonide injections on strabismus due to TRO as an option to
the above mentioned modalities without associated adverse effects.
MATERIALS AND METHODS
Ten patients with stable restrictive strabismus following TRO presenting to the
squint clinic, Guru Nanak Eye Centre, Maulana Azad Medical College were
included in the study. After informed consent, the patients were evaluated
for ocular motility ( ductions and versions), primary position deviation( PPD)
and anomalous head position (AHP). Diplopia charting was done in 9 gazes
alongwith applanation tonometry, measurement of proptosis with Hertel
exophthalmometer and recording of BCVA for distance and near. Forced
duction testing (FDT) was done in all the cases for rectus muscles.
Peribulbar injections of 20 mg triamcinolone acetonide were given every 2
weeks in 4 doses, 2 injections each in supero-medial and infero-lateral orbits.
Patients were followed after upto 12 weeks and complete examination was
done pre and post treatment. and ocular motility, primary position deviation,
AHP, diplopia evaluation, amount of proptosis was re- evaluated .FDT was
done to assesss the improvement in restriction.
RESULTS
Ten patients with stable restrictive strabismus due to Thyroid related
ophthalmopathy (TRO) were included in the study in the age group of 30 to 62
years. There were 7 women and 3 men. All the patients had a primary position
deviation ranging from 10 to 28 PD. FDT showed restriction in all for elevation,
two had it for adduction and rest had it for all gaze positions. In all cases,
Peribulbar injections of 20 mg triamcinolone acetonide were given every 2
weeks in 4 doses, 2 injections each in supero-medial and infero-lateral orbits.
Post treatment assessment was done at 12 weeks. Restriction was ameliorated
in all with all or no primary position deviation in 4 of 10 patients. AHP was
eliminated in 60% cases. Adverse effects life IOP elevation was not seen in any
patient. Repeated peribulbar injections of Triamcinolone acetonide seems to
be a viable option to strabismus surgery in improving ocular motility, primary
position deviation and anomalous head posture in patients with TRO.
985

986
69th AIOC Proceedings, Ahmedabad 2011
DISCUSSION
The restrictive type of strabismus seen in thyroid related orbitopathy
represents the end stage of the process occuring in the orbit, There are
some unique features to this type of restrictive strabismus. The process is
invariably bilateral linvolving multiple muscles, the misalignment can occur
in horizontal, vertical and torsional directions in various permutations and
combinations the patient often adopts an abnormal head posture to obviate
diplopia and or to separate the images further. There may be little deviation
with grossly limited ocular motility. Elevation deficits as well as adduction
failures simulating upgaze palsy or bilateral internuclear ophthalmoplegia
are commonly encountered. Triamcinolone injections have shown excellent
results in the treatment of symptoms related to tissue inflammation. In
previous studies repeated triamcinolone injections have been shown to be
a safe and effective treatment option for the inflammatory features of TRO
including exophthalmos, optic neuritis and upper lid retraction. 1,2
The most frequent side effect of triamcinolone injections is rise in IOP,
but this tends to be transient and controlled in all patients with topical
medications. 3 Peribulbar triamcinolone injections should be regarded as a
treatment option before putting these patients under the knife. As surgical
difficulties are immense in these cases and surgical results unpredictable,
a trial of triamcinolone injections seems to be justified. The dosage and
frequency of administration need to be standardized. Exophthalmos,
compressive optic neuropathy and lid retraction may also show improvement
as fibroblast proliferation with resultant excessive secretion and accumulation
of glycosaminoglycans is the seminal immunopathogenetic process in TRO. 4
Further studies are required to study safety efficacy and refine indications and
contraindications of peribulbar application of triamcinolone acetonide in TRO.
REFERENCES
1. Bordaberry M, Marques D L, Periera Lima J C, Marcon I M, Schmid H; Repeated
peribulbar injections of triamcinolone acetonide: a successful and safe treatment
for moderate to severe Graves’ ophthalmopathy. Acta Ophthalmol 2009;87:58-64.
2. Chee E, Chee S P: Subconjunctival injections of triamcinolone in the treatment of
lid retraction of patients with thyroid eye disease: a case series. Eye 2008;22:311-5.
3. Jermak C M, Dellacroce J T, Heffer J, Peyman G A: Triamcinolone acetonide in
ocular therapeutics; Surv Ophthalmol. 2007;52:503-22.
4. Campbell J C: Immunology of Graves’ ophthalmopathy: Retrobulbar histology
and histochemistry; Acta Endocrinol 1989:1219-6.