ABSTRACT Purpose: To determine whether the type of refractive error influences visual acuity recovery in children with anisometropic amblyopia and to assess differences in treatment responsiveness across hyperopic, myopic, and astigmatic anisometropia. Methods: A prospective longitudinal interventional study was conducted on 54 children aged 3–9 years diagnosed with unilateral anisometropic amblyopia. Participants were classified into three groups based on refractive error: hyperopic anisometropic amblyopia (HAA, n = 17), myopic anisometropic amblyopia (MAA, n = 18), and astigmatic anisometropic amblyopia (AAA, n = 19). All children underwent refractive adaptation followed by a standardized occlusion schedule according to amblyopia severity. Visual acuity was assessed using logMAR charts at baseline and at Weeks 4, 8, 12, and 16. One-way ANOVA was used to compare visual outcomes between groups overall and within severity subgroups (mild, moderate, severe). Results: All groups showed significant improvement in amblyopic-eye visual acuity over the 16-week period; however, the magnitude of recovery differed according to refractive error type. As early as Week 4, children with myopic anisometropic amblyopia showed significantly greater visual improvement compared with the hyperopic and astigmatic groups, with differences becoming highly significant by Week 8. Highly significant differences were observed across all severity levels (all p < .001). At Week 16, final mean visual acuity reached 0.30 ± 0.05 (HAA), 0.06 ± 0.04 (MAA), and 0.13 ± 0.09 logMAR (AAA), with strong statistical significance between groups (p < .0001). The MAA group showed the greatest overall improvement, followed by AAA and HAA. Conclusion: Refractive error type significantly influences visual outcomes in children with anisometropic amblyopia after 16 weeks of occlusion therapy. Myopic anisometropia is associated with better final visual acuity at the 16-week follow-up, whereas hyperopic anisometropia demonstrates comparatively poorer visual outcomes. These results suggest that refractive error type should be considered a key prognostic factor when individualizing amblyopia management strategie

ABSTRACT Purpose: Monocular Elevation Deficiency (MED) is characterized by limited ability to elevate the affected eye in any gaze position, while maintaining normal duction in all other gazes. The type of surgeries described in MED include Knapp’s surgery, vertical muscle recession and resection, contralateral superior rectus recession. Recently, the Nishida’s procedure has also been explored as a treatment for isolated cases of MED. Hence, we conducted this study to evaluate the surgical outcome of Modified Nishida’s procedure in cases of MED in a series of 15 patients. Methods: This prospective interventional study was performed on 15 patients with MED attending the Strabismus Clinic and outpatient department of our tertiary care centre over a period of 1 year from October 2023 to October 2024. In this study, 15 patients of age more than 13 years with Type 2 Congenital MED with negative forced duction test for inferior rectus, hypotropia more than 10 prism diopters and no horizontal deviation were included. Patients with previous history of strabismus surgery or with bleeding diathesis were excluded. Preoperatively, ocular deviation was measured using vertical prisms in terms of prism diopters (PD). Elevation deficit was noted in all the patients on a scale of 0 to -4 with 0 indicating full rotation and -4 indicating severe limitation (not crossing midline). All patients underwent Modified Nishida’s procedure following forced duction test for inferior rectus. Postoperatively, all the measurements were recorded at the end of first week, first month and the final follow up was done at the end of third month. Primary outcome included correction of vertical deviation at 3 months post Modified Nishida’s procedure. Secondary outcome included assessment of elevation deficit. Results: The mean age of the patients was 23.33 ± 15.73 years. There was statistically significant improvement in mean hypotropia from preoperative measurement of vertical deviation of 28.67 ± 9.904 PD to 7.60 ± 10.176 PD (p < 0.001) at the final follow up. There was statistically significant improvement in elevation deficit ranging from mean value of -3.47 ± 0.74 at baseline to -2.73 ± 0.70 postoperatively at final follow up (p < 0.01). Conclusion: The study demonstrated that the Modified Nishida’s procedure is effective in managing MED in terms of improvement of vertical deviation and elevation deficit.

ABSTRACT Purpose This study evaluates the effectiveness of prism therapy in patients with ocular motor palsies affecting the oculomotor (nerve III), abducens (nerve VI), and trochlear (nerve IV) nerves, focusing on four key criteria: deviation, diplopia, head posture, and ptosis. Methods A comparative analysis was conducted on patients diagnosed with nerve III, nerve VI, or nerve IV palsy. Deviation measurements, diplopia occurrence, head posture abnormalities, and ptosis presence were assessed before and after prism therapy. Statistical analysis was performed to determine significant changes within each group and to compare outcomes across the three palsy types. Results Therapeutic prism use resulted in significant improvements in ocular deviation and diplopia across all groups (p < .05). Mean deviation decreased from 22Δ to 12Δ in third nerve palsy, from 38Δ to 14Δ in sixth nerve palsy, and from 18Δ to 8Δ in fourth nerve palsy. Diplopia in primary gaze was reduced from over 80% to below 21% across all groups. Although cyclodeviation was observed only in 29% of fourth nerve palsy cases, 71% of those patients reported subjective improvement. No statistically significant differences were found between the groups regarding treatment success (p > .9). Conclusion Prism therapy appears effective in improving ocular alignment and visual symptoms across all three types of ocular motor palsy. Its benefits extend to reducing diplopia and abnormal head posture, and selectively improving ptosis and torsional symptoms in certain cases. These findings support the broader application of prism therapy as a valuable non-surgical management strategy.

ABSTRACT Purpose Acute acquired comitant esotropia (AACE) is a subtype of non-accommodative esotropia for which the exact underlying mechanism remains unclear. With most AACE adults being myopic, it is crucial to detect and rectify myopic over-correction in AACE considering its possible role in inducing and/or worsening eso-deviations. This report aims to emphasize the importance of appropriate refraction and suitable myopic prescriptions in managing AACE. Results This report presents two middle-aged patients with moderate myopia who were diagnosed with AACE. At initial presentation, both were found to have varying AACE control and angles ranging from 4∆ to 14∆ on prism cover test. Manifest refraction with fogging revealed that they have been over-corrected for myopia. Immediate improvements in AACE symptoms, control and measurements were noted with new myopic prescriptions – one fully corrected and the other intentionally under-corrected – of a difference in at least −0.38 diopter sphere (spherical equivalent) in both eyes alone. Conclusion Appropriate and early refraction alongside well-fitted prescriptions is essential in managing AACE. Further research is required to establish the potential of intentional myopic under-correction as a new, alternative conservative management for AACE.

ABSTRACT Introduction Straatsma syndrome (SS) is a rare congenital entity defined by myelinated retinal nerve fibers (MRNF), amblyopia, and axial myopia, frequently with marked anisometropia and strabismus. Visual prognosis is often guarded, yet early multimodal management may modify outcomes. Methods We report a pediatric right-eye SS with extensive, type-2 MRNF. At baseline the patient had alternating esotropia and high anisomyopia (cycloplegic refraction: RE −19.25/−2.50 × 005 D; LE −4.00/−3.00 × 165 D). Axial length measured 32.0 mm (RE) and 25.5 mm (LE). Optical coherence tomography (OCT) showed parafoveal retinal nerve fiber layer hyperreflectivity with foveal sparing. Management comprised full cycloplegic optical correction and structured occlusion/orthoptic therapy initiated at age 2, introduction of a scleral lens at age 7 to improve image quality and reduce aniseikonia, and strabismus surgery at age 10. Follow-up continued to age 13. Results Despite severe amblyopia and anisometropia, best-corrected visual acuity (BCVA) in the affected eye improved from 0.7 to 0.1 logMAR by age 10 and was 0.0 logMAR at age 13, with stable primary-gaze alignment. The scleral lens was worn ≥8h/day and was well tolerated; it optimized retinal image quality and minimized spectacle-induced minification/aniseikonia associated with the high myopic correction. Discussion This case illustrates that, even in the presence of type-2 MRNF, extreme axial length, and high anisometropia – features traditionally linked to poor prognosis – early aggressive amblyopia therapy, contact-lens – based aniseikonia control, and timely alignment surgery can achieve excellent long-term visual outcomes. The timeline underscores the importance of starting therapy in early childhood and maintaining adherence through optical optimization and orthoptics. While a single case cannot define generalizability, it supports the view that structural macular integrity on OCT, coupled with coordinated multimodal care, can overcome several adverse prognostic factors in SS.

ABSTRACT Introduction Extraocular muscle trauma can occur blunt or penetrating injury. This report highlights medial rectus muscle rupture after trauma. Methods A 41-year-old male presented with double vision after hitting a wall while riding a bike. Results Initial examination revealed right exotropia with −3 adduction limitation. Systemic corticosteroids were given to relieve orbital edema. The right medial rectus muscle could be partially retrieved upon strabismus surgery. Postoperatively, the patient complained of blurred vision, and optical coherence tomography revealed serous retinal detachment near upper vascular arcade, which did not affect the macula. Serous elevation decreased upon tapering the corticosteroids. Discussion Rupture of the medial rectus muscle can occur after blunt trauma and can occasionally be treated by retrieving the muscle in the early posttraumatic period. However, it should be borne in mind that factors related to the treatment of or trauma itself may threaten vision, therefore meticulous follow-up is mandatory.

ABSTRACT Introduction: Acute acquired comitant esotropia (AACE) is a rare type of esotropia for which until now the main treatment modalities prescribed are prism glasses, botulinum toxin injection and surgery. The purpose of our study is to compare the surgical outcomes in patients with AACE managed with and without pre-operative prism adaptation test (PAT). Methods: We have done a prospective, interventional study for the duration of one year. Forty patients with AACE were randomly divided into two groups by computerized randomization – those undergoing surgery after pre- operative PAT and those undergoing surgery without it. In control group (Group C), patients underwent surgery based on the angle of deviation at distance measured by prism bar cover test (PBCT) and wearing full cycloplegic correction, while in test group (Group T), patients underwent surgery based on the preoperative prism-adapted angle at distance wearing prism power determined by PBCT and wearing full cycloplegic correction. The primary outcome was post-operative deviation and secondary outcome was stereopsis. Post-operatively, patients were followed up at week 1, week 4 and final follow-up was done at week 12. Results: The mean age of the 40 patients was 13.95 ± 5.36 years. The age of the youngest and the oldest patients enrolled were 8 years and 35 years, respectively. The mean SD (standard deviation) of the PBCT for distance (measured in prism diopters – PD), PBCT for near (measured in prism diopters – PD) and stereopsis for near (measured in seconds of arc using Titmus Fly Test) at last follow-up visit (week 12) in the test versus control group were as follows: 1.70 ± 1.42 PD versus 4.75 ± 3.39 PD, 2.55 ± 1.82 PD versus 6.95 ± 3.35 PD and 74.90 ± 53.47 sec of arc versus 48.60 ± 31.97 sec of arc, respectively, which were statistically significant (p = <0.01, p = <0.01 and p = .03, respectively). The change in visual acuity and spherical equivalent in each group was insignificant. Discussion: Surgical outcomes in patients of AACE are better when surgical planning is done after performing pre-operative PAT as opposed to when surgery is planned without PAT. Better motor alignment (less under correction and over correction) and better sensory results in terms of improvement in stereopsis were observed. We recommend the use of pre-operative PAT in surgical planning in patients of AACE.

ABSTRACT Introduction: Canine tooth syndrome is a rare condition defined by the simultaneous presence of superior oblique palsy and Brown syndrome, resulting from pathological changes in the trochlear region. This syndrome can develop through various mechanisms, including dog bites, head trauma, infections, inflammation, and scarring. This report highlights its occurrence following sinus surgery for the first time. Methods: Medical and surgical records of an 18-year-old girl who presented with reading position diplopia after sinus surgery for right-side frontoethmoidal osteoma were retrospectively reviewed. Results: Strabismus examination revealed 8 Prism Diopter (PD) primary position hypertropia in the right eye that increased to 20 PD in downgaze. In the upward gaze to the left, the right eye showed 12 PD hypotropia with a positive forced duction test. The patient exhibited simultaneous signs of paresis and restriction of the right superior oblique muscle, consistent with type 7 of the Knapp classification. The patient declined strabismus surgery, and vertical diplopia was managed with prism spectacles. Long-term follow-up showed spontaneous resolution of superior oblique paresis leaving the patient with isolated Brown syndrome in the right eye. Discussion: Canine tooth syndrome can arise as a complication of frontoethmoidal sinus surgery due to excessive intraoperative manipulation of the superior and medial orbital wall, particularly in the trochlear region.

ABSTRACT Purpose: The study sought to compare the number of cycles (NOS) for the first and second thirty-seconds (FASTS) within 1 min of accommodative facility (AF) and vergence facility (VF) testing to explore possibilities of reducing testing time to 30 s. Methods: In this cross-sectional study, a multistage sample of school children (aged 8–17 years) was taken through ocular-visual screening. Eligible participants (586) underwent refraction, stereo-acuity measurement, AF testing using ± 2D lens flippers, and VF testing using 3Δ BI/12Δ BO flipper prisms. The NOS within the FASTS of AF and VF tests were compared, respectively. Results: A statistically insignificant mean difference of 0.01 cycles was found between the NOS for the FASTS of monocular AF in the right eye (Wilcoxon Signed Rank test, p = .715). Statistically significant differences of 0.06, 0.14, and 0.09 cycles (Wilcoxon Signed Rank test, p < .05) which are not clinically meaningful were found for monocular AF in the left eye, binocular AF, and VF with no level of agreement on Bland Altman analysis, respectively. There were no clinically meaningful differences between the first 30-s cycles multiplied by two (FTSMT) and the full 1-min test period cycles for monocular AF, binocular AF, and VF. Conclusion: The FTSMT approach may be applied during gross screening to shorten testing time as further study is recommended for its diagnostic validity.