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BACKGROUND: Corrective squint surgery has a significant psychological impact, affecting both the quality of life and mental health of patients. This study highlights the quantitative and subjective assessment of both the psychological and functional outcomes of squint surgery in adults having horizontal strabismus with no preoperative diplopia using a Quality-Of-Life Adult Strabismus 20 (QOL AS-20) questionnaire. METHOD: The study is a retrospective cohort study on patients with uncomplicated, horizontal squint; with no vertical deviation and was conducted as part of a departmental clinical audit. It also aimed to challenge local clinical commissioning group (CCG) funding restrictions for what they regarded as a 'cosmetic procedure'. The QOL AS-20 questionnaires were completed before and 3 months after surgery and were analysed using the paired Wilcoxon signed rank t-test which showed significant improvement. A Freedom of Information Act request sought information on strabismus surgery funding restrictions from all CCGs to explore variations in perceptions throughout England. RESULTS: 28 patients were included in the study. The overall success of squint surgery was 67.5%. The median QOL AS-20 questionnaire overall score increased from 28.125 to 88.75 (p value<0.00001), functional subscale from 46.25 to 87.5 (p value<0.00001) and psychological subscale from 15 to 90 (p value<0.00001). CONCLUSION: Squint surgery in non-diplopic adults with horizontal squint surgery should be regarded as restorative of normal anatomy from a pathological state rather than a cosmetic procedure.Restrictions to accessing this surgery may increase, especially during post-COVID-19. This patient-focused service evaluation demonstrates the substantial psychosocial benefits of such surgery, as evidenced through quality-of-life assessments.

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INTRODUCTION: Amblyopia is a reduction in vision in one or both eyes due to impaired development of the visual pathway. This study explored the experience of amblyopia and treatment from the patient, caregiver, and clinician perspectives. METHODS: A targeted literature review, including a review of social media listening (SML) studies, was conducted. Next, qualitative interviews were conducted with amblyopia patients, caregivers of children with amblyopia, and ophthalmologists with experience treating patients with amblyopia. The findings informed the development of a disease model. Amblyopia clinical experts provided input at key stages. RESULTS: Twelve data sources were reviewed, including qualitative studies in the literature and SML studies. Overall, 133 patients/caregivers were interviewed (23 adults, 16 adolescents, 47 child-caregiver dyads), plus 10 ophthalmologists from the United States, France, and Germany. Reduced visual acuity, impaired depth perception, impaired peripheral vision, and double vision were the most frequently reported symptoms. Amblyopia impacted daily activities (reading, using digital devices), the ability to move around, school/work (productivity, seeing the board in class), emotional well-being (frustration, sadness), and social functioning (difficulty socializing). Treatments, including patching and corrective lens, also impacted daily activities (using digital devices, sports/leisure), mobility (bumping into things), and work/school (tasks taking longer) as well as emotional well-being (embarrassment), and social functioning (bullying/stigma). CONCLUSION: The findings contribute valuable insights into the adult and pediatric experience of amblyopia from a multi-stakeholder perspective. The findings were used to critically assess existing clinical outcome assessments and supported the development of patient- and observer-reported outcome measures for use in amblyopia clinical trials.

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INTRODUCTION: Amblyopia is a neurodevelopmental vision disorder, characterized by poor vision in one or both eyes. Given the lack of existing clinical outcome assessments (COA) considered fit-for-purpose for amblyopia clinical trials, this study developed new COAs to assess amblyopia symptoms and health-related quality of life (HRQoL) impacts in adult and pediatric amblyopia populations that conform with best practice standards and regulatory guidelines. METHODS: Findings from a targeted qualitative literature review informed the development of three versions of the new Amblyopia Quality of Life Questionnaire (AmbQoL): a patient-reported outcome measure (PRO) for individuals aged 13 years and older, a PRO for children aged 9-12 years, and an observer-reported outcome measure (ObsRO) for caregivers of children aged 4-8 years. Qualitative interviews were conducted with the target populations, and with ophthalmologists experienced in treating amblyopia patients to evaluate the content validity for further development of the AmbQoL. A translatability assessment was conducted to ensure cultural appropriateness and usability across multiple languages. Feedback from Food and Drug Administration (FDA) was also sought on the instruments, and clinical experts provided input at key stages. RESULTS: Interviews were conducted with 112 patients/caregivers and ten ophthalmologists from the USA, France, and Germany. The instructions, items, and response options were well understood across all AmbQoL versions. Feedback from the patients, caregivers, ophthalmologists, the translatability assessment, the FDA, and the expert clinicians informed minor wording modifications to enhance clarity and translatability. Some items were removed due to low relevance. The study resulted in a 23-item adult/adolescent PRO, 24-item child PRO, and 12-item ObsRO, each employing a 7-day recall period. CONCLUSION: Each AmbQoL version has documented support for its face and content validity for use in amblyopia populations aged ≥ 4 years. Further research is necessary to evaluate the psychometric measurement properties of the AmbQoL instruments to enable their use in amblyopia treatment trials.

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PURPOSE: To determine whether the long-term success of ptosis surgery is influenced by the use of absorbable or non-absorbable sutures to advance the levator aponeurosis onto the tarsal plate. METHODS: Multi-centre retrospective comparative study of re-operation rates in primary anterior approach ptosis surgery using absorbable polyglactin sutures (Vicryl) and non-absorbable polyester sutures (Ethibond). The Medisoft audit tool was used to identify all patients who underwent primary ptosis surgery for aponeurotic ptosis, performed by five oculoplastic consultants within a 7-year period, across two NHS Ophthalmology departments. The electronic patient records were reviewed for each patient. Basic demographics, suture material, and post-operative complications were recorded. All patients requiring repeat surgery between the study dates and the present day were recorded, allowing a minimum postoperative period of 3 years and 10 months. Re-operation rates in surgery using absorbable Vicryl sutures and non-absorbable Ethibond sutures were compared using Fisher's exact test. RESULTS: Four hundred and fifty-five operations in 330 patients were performed within the study period that met the inclusion and exclusion criteria. Fifty-seven percent of the patients were female, with an average age of 68.8 years. One hundred and sixty-nine operations in 128 patients were performed using absorbable Vicryl sutures. Of these, 22 (13.0%) required repeat operations. Two hundred and eighty-six operations in 202 patients were performed using non-absorbable Ethibond sutures. Of these, 17 (5.9%) required repeat operations. The two-tailed P-value was 0.0143. CONCLUSION: The use of non-absorbable Ethibond sutures to advance the levator aponeurosis onto the tarsal plate in primary ptosis surgery is associated with improved long-term success and reduced need for secondary surgery.

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AIMS: There is a paucity of literature concerning intractable diplopia. The aims of this study were to determine the incidence of intractable diplopia in the UK, identify the causes and any associated risk factors, establish how cases are managed and if the treatment is successful and tolerated. METHODS: A 1-year prospective observational study was undertaken via the British Ophthalmological Surveillance Unit (BOSU). This involved implementation of a reporting mechanism, which then triggered distribution of an incident questionnaire to explore clinical details concerning each case and a follow-up questionnaire 6 months later to explore how the case had been managed. RESULTS: The incidence of intractable diplopia was 53 cases per year. The most common preceding events were strabismus surgery (32%), no known preceding event, that is,spontaneous (25%), severe head trauma (8%), cataract surgery (6%) and vitrectomy (6%). In the at-risk age group of 7 years and above, the incidence of intractable diplopia following strabismus surgery is 1 in 494 (95% CI; 1 in 296 to 790) cases. A total of nine different treatments were used in the management, with many patients receiving between two and four different methods. The overall success rate was poor, but most effective were opaque intraocular lenses (IOLs) (86%) and opaque contact lenses (50%). CONCLUSION: Intractable diplopia is a relatively rare but important condition. The main risk factor is a pre-existing strabismus, and careful counselling is needed when planning surgical correction in patients with no demonstrable binocular function. Treatment success of intractable diplopia is high when using opaque IOLs, although with additional risk, but is often disappointing via other methods where it can be difficult to eradicate the diplopia successfully.

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Trigeminal trophic syndrome (TTS) is a condition whereby persistent facial ulceration presents consequent to central or peripheral insult to the trigeminal nerve. Lesions are created by repetitive self-inflicted manipulation and trauma of dysaesthetic skin within the trigeminal dermatome. We discuss four cases with aetiologies varied from presumed microvascular compromise to resection of cerebral meningioma, cerebrovascular accident, and herpes zoster ophthalmicus. We discuss the management of the under-recognised associated periocular skin ulcerations that result from physical manipulation of dysesthic skin and prove to be persistent and challenging to treat. Patient education and counselling are crucial in understanding and preventing the detrimental effect of physical manipulation of the skin. Occlusive dressings can reduce recurrent trauma. Topical lubricants, antibiotics, or autologous serum may be needed in cases with corneal involvement or exposure. Surgical interventions may be used, but frequently fail if the underlying neurological pathology and skin manipulation has not been adequately addressed. TTS should be suspected in persistent or recurrent facial ulceration with concomitant anaesthesia and paraesthesia in the trigeminal distribution, with alar nasi involvement being a key feature.

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This qualitative study sought to explore the experiences of patients who had undergone successful ptosis correction surgery. Participants were recruited from Bristol Eye Hospital. Nine participants were interviewed using a semi-structured interview schedule and open ended questions. Data were analysed using inductive thematic analysis. Four major themes were identified from patient accounts. Patients described the psychosocial and functional difficulties they experienced living with ptosis, and the subsequent benefits of surgery. Patients reported experiencing appearance related anxiety pre-operatively due to their condition and engaging in behaviours to avoid social encounters. Gender differences were noted in the internalization of perceived negative reactions from others, with men describing fewer adverse impacts. Patients described perceived barriers to seeking surgery including a lack of awareness of ptosis as a treatable condition, the perception that being concerned with their appearance could be seen as vain and the view that ptosis surgery is synonymous with cosmetic surgery. Following successful surgery patients outlined positive impacts on their vision, appearance and psychosocial well-being after successful surgery. This qualitative study highlights the complexities of the factors and processes contributing to the psychosocial impacts of ptosis and the potential benefits of surgery and/or psychosocial support. An increased awareness amongst people with ptosis of the potential positive impacts of surgery and an enhanced understanding of the reasons why patients may not seek treatment amongst health care professionals are likely to benefit this often overlooked patient group.

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The Smith Kettlewell Eye Research Institute (SKERI), celebrating its 50th anniversary in 2014, hosted a symposium to identify the most pressing clinical problems in strabismus and binocular vision. Forty-five experts from around the world shared their perspectives at the San Francisco meeting, held November 6-9, 2012. Prior to the meeting, the organizers (TR, APW, RH, JB, AJ) asked attendees to identify the most pressing clinical problems in strabismus and to discuss them in a workshop-based format. The clinical problems were organized into the following six areas: (1) esotropias; (2) binocular vision: amblyopia, suppression, and diplopia; (3) intermittent exotropia; (4) "oblique dysfunctions"; (5) dissociated vertical deviation (DVD); and (6) new approaches to strabismus management. Herein we highlight of some of the clinical problems discussed at the meeting.

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A child encountering difficulty in watching three-dimensional (3D) stereoscopic displays could have an underlying ocular disorder. It is therefore valuable to understand the differential diagnoses and so conduct an appropriate clinical assessment to address concerns about poor 3D vision.

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The aim of this qualitative study was to investigate the psychosocial impact of ptosis as a symptom of Myasthenia Gravis (MG). Participants were recruited from a MG patient group on Facebook. 166 participants answered a series of open ended questions examining the impact of ptosis, and responses were analysed using Inductive Thematic Analysis, which revealed four main themes. The first highlighted the extent to which ptosis impacted negatively on psychosocial functioning. The second related to ways in which ptosis can be framed in a positive way, eg, as a believable symptom. The final two themes revealed the complex inter-relationships between functional and appearance-related impacts, and a desire from many participants for health care professionals to provide more support directly related to their ptosis. This study suggests that ptosis impacts in ways not currently recognized in literature and practice.

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AIM: To assess the efficacy of 2-0 prolene brow suspension surgery in paediatric ptosis with poor levator function. MATERIALS AND METHODS: Retrospective review of cases that underwent 2-0 Prolene brow suspension surgery between 1997-2007. Primary surgical success was defined as post-operative lid height clear of the pupil and asymmetry of 2 mm or less. RESULTS: Twenty-seven patients (37 lids) were included in the study. The mean follow-up period was 71 months (range 2-173). There were 10 recurrences giving an overall success rate of 72.9%. The complication rate was 5.4%. CONCLUSIONS: Prolene brow suspension surgery in most patients has a long-lasting effect with a low complication rate. Success rates are comparable to other non-autogenous materials. This may obviate the need for a more definitive secondary procedure in the future.

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AIM: To assess a two-phase method of recording levator function in order to facilitate the identification of patients with ptosis who have a synkinesis between the levator and superior rectus muscles. METHODS: 40 consecutive patients who attended oculoplastic clinics with ptosis and 22 patients with normal lid function were recruited. In each subject, levator function was recorded by the conventional method, measuring total upper eyelid excursion between the extremes of down-gaze and up-gaze. Levator function was also assessed using our novel two-phase approach in which upper-eyelid excursion is measured separately between down-gaze and primary position (Phase 1), and between primary position and up-gaze (Phase 2). RESULTS: In normal patients and most of the patients with ptosis, the majority of lid movement and hence levator function occurs between down-gaze and the primary position (Phase1). In those patients with ptosis and levator-superior rectus synkinesis, a higher proportion of lid movement occurred on up-gaze (Phase2). CONCLUSION: The two-phase measurement of lid movement highlights levator function in differing gaze positions and facilitates the identification of those patients with levator-superior rectus synkinesis.

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PURPOSE: To determine the duration of postoperative conjunctival injection following strabismus surgery and to assess how this is affected by previous extraocular muscle surgery. This would improve preoperative counseling of strabismus patients. METHODS: Subjective evaluation of conjunctival redness based on patient questionnaire response. RESULTS: Fifty-three patients returned completed questionnaires. A total of 93 muscles were operated on. Of these, 46 had not undergone previous operations; 47 had. Previously unoperated eyes remained red for a median duration of 9.5 weeks; reoperated eyes remained red for a median of 11 weeks. Of the 93 muscles, 50 were sutured with adjustable sutures. These remained red for a median duration of 11 weeks. Muscles tied with nonadjustable sutures remained red for a median of 10 weeks. CONCLUSIONS: In both previously unoperated and reoperated eyes, conjunctival redness resolved in approximately 10 weeks; adjustable sutures did not alter the duration of redness significantly.

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PURPOSE: To study the pattern of facilitatory and suppressive binocular interactions in stereodeficient patients with strabismus and in healthy controls. METHODS: Visual evoked potentials were recorded in response to a Vernier onset/offset pattern presented to one eye, either monocularly or paired dichoptically with a straight vertical square-wave grating, which, when fused with the target in the other eye, gave rise to a percept of a series of bands appearing in depth from an otherwise uniform plane or with a grating that contained offsets that produced a standing disparity and the appearance of a constantly segmented image, portions of which moved in depth. RESULTS: Participants with normal stereopsis showed facilitative and suppressive binocular interactions that depended on which dichoptic target was presented. Patients with longstanding, constant strabismus lacked normal facilitative binocular interactions. The response to a normally facilitative stimulus was reduced below the monocular level when it was presented to the dominant eye of patients without anisometropia, consistent with classical strabismic suppression of the nondominant eye. The dominant eye of strabismic patients without anisometropia retained suppressive input from crossed but not uncrossed disparity stimuli presented to the nondominant eye. CONCLUSIONS: Abnormal disparity processing can be detected with the dichoptic VEP method we describe. Our results suggest that suppression in stereoblind, nonamblyopic observers is determined by a binocular mechanism responsive to disparity. In some cases, the sign of the disparity is important, and this suggests a mechanism that can explain diplopia in patients made exotropic after surgery for esotropia.

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BACKGROUND: Adjustable sutures are widely used in adult strabismus surgery, with a second procedure performed to close the conjunctiva irrespective of whether adjustment is required. We describe a technique where the conjunctiva is closed using a buried releasable suture, eliminating the second procedure if adjustment is deemed unnecessary. METHOD: The conjunctiva is closed using a 6/0 absorbable polyglactin 910 releasable suture. It is tied in a bow, like the muscle sutures, and tucked under the conjunctiva. If adjustment is not required, the eye does not need to be touched because the conjunctiva is secured by the suture. If adjustment is required, it is easy to untie the conjunctival suture, allowing good exposure to the underlying muscle sutures. RESULTS: In our prospective series of 30 patients, we found our technique effective and patient friendly. Patients had at least 3 months of follow-up with no significant complications. CONCLUSIONS: This technique is acceptable, accessible, and time saving for both surgeons and patients. It is especially useful for anxious patients and adolescents, for whom postoperative manipulation can be difficult, and for cases where the probability of adjustment is low.

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Research into the clinical management of amblyopia has, most recently, focussed on the effectiveness of amblyopia treatment. Given the mounting evidence that the condition is treatable, an important priority is the detection of individuals with the condition. Here, we review critically the means by which this can be achieved. We conclude that intensive early screening can produce improved outcomes but that the effectiveness of real-life screening programmes is very dependent on the coverage they obtain. An almost entirely neglected subfield of amblyopia treatment research is the identification of reasons why parents and children often fail to comply with occlusion therapy. Here, we examine a psychological approach to this problem and find it to be informative in predicting compliance. Lastly, we consider the disability arising from strabismus, again from a psychological perspective, and find that on a range of psychosocial well-being indicators, strabismus surgery results in significant gains.

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PURPOSE: Because of the lateral separation of the orbits, the retinal images differ in the two eyes. These differences are reconciled into a single image through sensory and motor fusional mechanisms. This study demonstrates electrophysiologically the effects that normal horizontal and vertical fusional processes have on the processing of monocular position signals. METHODS: VEPs were recorded in 16 healthy adults in response to a vernier onset-offset target presented to one eye. The vernier offsets appeared and disappeared at 2 Hz and were introduced into bar targets that were oriented either vertically (horizontal offsets) or horizontally (vertical offsets). The magnitude of the offsets was varied over the range of 0.5 to 10 arc min. VEP amplitude was measured as a function of the size of the dynamic offset under monocular viewing conditions and in the presence of two different static targets presented to the other eye. One of the static targets matched the dynamic test, except that it had no vernier offsets. The other static target, the static pedestal, matched the dynamic test, but contained a set of static vernier offsets in locations corresponding to the locations of the dynamic offsets presented to the other eye. RESULTS: VEP amplitude was a monotonically increasing function of vernier offset size under monocular viewing conditions. The addition of the static target without offsets in the other eye resulted in an increased amplitude VEP response. The addition of the static target with vernier offsets resulted in a decrease in VEP amplitude for both horizontal and vertical disparities. CONCLUSIONS: The normal process of fusion results in a single visual direction. To obtain a single visual direction, the visual system must synthesize a binocular visual direction that differs from the monocular components. One of the conditions (the static pedestal with offsets) produces binocular visual direction shifts that degrade the appearance of vernier onset-offset, and reduce VEP amplitude for both horizontal and vertical disparities. This characteristic evoked response marker is a promising tool for measuring binocular fusion objectively in patients with strabismus.

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