Cyclic strabismus is a rare form of strabismus whereby individuals experience the disease in a pattern of alternating days with or without strabismus in a circadian rhythm-dependent manner. However, the molecular mechanism that underlies this rhythm is unknown. OPHN1 encodes a Rho GAP protein, and mutations specifically in the BAR or GAP domains of OPHN1 cause OPHN1 syndrome characterized by intellectual disability and often also strabismus. In this study, we identified a novel hemizygous variant of OPHN1 in a male patient with cyclic strabismus but without intellectual disability. This novel K306N variant affected the PH domain of OPHN1, and enhanced its ability to bind to the phosphatidylinositol phosphates (PIPs), PI4P and PI5P. We propose that this enhanced binding may affect the subcellular localization of the OPHN1 Rho GAP protein in a cyclic manner, leading to cyclic strabismus. Our work indicates that some cases of cyclic strabismus may be due to a gain-of-function variant of OPHN1. The online version contains supplementary material available at 10.1038/s41598-026-48129-7.
To compare visual motor integration (VMI) in non-amblyopic children with and without horizontal strabismus. VMI, visual perception, and motor coordination were evaluated in non-amblyopic children aged 6 to 17 years old using the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery-VMI), together with its supplementary Developmental Tests of Visual Perception and Motor Coordination. Forty-five non-amblyopic children with horizontal strabismus (23 males, 22 females; mean age: 126.0±33mo) and 45 children without strabismus (22 males, 23 females; mean age: 126.2±34mo) were enrolled. Children with horizontal strabismus exhibited significantly lower mean Beery-VMI scores (P<0.001), visual perception scores (P<0.001), and motor coordination scores (P<0.001) compared with controls, even after adjustment for confounding variables including sex, age, regular sports participation, number of siblings, and stereopsis. Non-amblyopic children with horizontal strabismus demonstrate significantly poorer performance in Beery-VMI, visual perception, and motor coordination compared with children without strabismus.
Childhood strabismus and amblyopia may affect reading ability. Previous studies have demonstrated slower reading speed among amblyopic children compared with controls, but the relationships between strabismus without amblyopia or prior treated amblyopia and reading speed have not been established. The purpose of this study was to investigate whether strabismus or history of successfully treated amblyopia independently affect binocular reading speed in adolescents and to characterize the clinical parameters associated with reading performance. A total of 124 adolescents (10-17 years) were enrolled and divided into four groups: strabismic with prior successfully treated amblyopia, strabismic without prior amblyopia, nonstrabismic with prior successfully treated amblyopia, and control. Binocular reading speed was assessed using standardized passages from the IReST-Hebrew. Statistical analysis involved Wilcoxon tests to compare reading speeds between groups and Spearman correlations to explore associations with clinical variables. No statistically significant differences in binocular reading speed were found between the four groups (all P > 0.05). Subgroup analysis revealed no significant differences based on strabismus type (esotropia vs exotropia). Within-group associations were observed: in the strabismic with prior amblyopia group, a significant negative correlation existed between reading speed and arcseconds of stereopsis (r = -0.51, P = 0.01), whereas in the nonstrabismic with prior amblyopia group, reading speed correlated negatively with near point of convergence (r = -0.47, P = 0.02). In our study cohort, nonamblyopic adolescents with a history of strabismus, amblyopia, or both did not exhibit slower binocular reading speed than controls. These findings suggest that in adolescents without current amblyopia or after successful amblyopia treatment, reading performance is preserved.
To estimate the cumulative incidence of strabismus among children diagnosed with retinopathy of prematurity (ROP). Retrospective cohort study. Children aged ≤18 years with a diagnosis of ROP, with or without treatment exposure. We defined treated ROP as receipt of laser photocoagulation and/or intravitreal anti-vascular endothelial growth factor (VEGF) injection, while untreated ROP had no record of either intervention. We estimated the cumulative incidence of strabismus at 1, 3, and 5 years after ROP diagnosis using Kaplan-Meier analysis. We used Cox proportional hazards models to calculate adjusted hazard ratios (aHR) and 95% confidence intervals (CIs), adjusting for demographic variables and ocular comorbidities. Development of strabismus following ROP diagnosis. The cohort included 27,720 ROP patients: 973 were treated and 26,747 were untreated. Cumulative incidence of strabismus was consistently higher among treated patients. At 5 years, cumulative incidence was 34.78% in treated patients compared with 22.14% in untreated patients, with esodeviations as the most common subtype, occurring in 22.35% of treated patients and 11.87% of untreated patients. Treatment exposure was independently associated with an increased hazard of strabismus (aHR, 1.58; 95% CI, 1.29 to 1.95; P < 0.001). Amblyopia (aHR, 2.58; 95% CI, 2.25-2.96; P < 0.001) and nystagmus (aHR, 1.76; 95% CI, 1.48-2.1; P < 0.001) were also independently associated with increased hazard. ROP confers an increased hazard of developing subsequent strabismus, with higher cumulative incidence among children who undergo treatment for ROP.
The prevalence of the 2 types of horizontal strabismus, esotropia and exotropia, varies considerably between studies. This variability has been attributed to factors such as geography/environment, research methodology, age of study subjects, and/or ethnicity. Comprehensive estimates of regional and global prevalences of esotropia and exotropia are lacking, making it difficult to recognize true patterns, trends, and etiologies. We compile prevalences and ratios of esotropia to exotropia from 315 population-based studies and 374 clinic-based studies. We analyze data to assess effects of ethnicity, geography, age, and we identify generational changes of horizontal strabismus. Major ethnicities differ in patterns and ratios of esotropia and exotropia prevalence, not only in Caucasians and East Asians, but also Latinos/Hispanics, South Asians, Africans, and Native Americans. Compared to population-based studies, clinic-based studies underestimate exotropia frequency. By weighing prevalences according to the population size of ethnicities, we estimate the worldwide prevalence of horizontal strabismus in the current generation at 1.81% (138.5 million people), comprising 60.0 million people with esotropia (0.67%) and 87.5 million with exotropia (1.14%). In the previous generation, the worldwide prevalence of horizontal strabismus was 1.64% (86.5 million people), comprising 50.5 million with esotropia (0.96%) and 36.0 million with exotropia (0.68%). Esotropia and exotropia prevalences differ between generations within the same ethnicity, indicating that extrinsic factors can modify the underlying intrinsic (genetic) disposition.
Purpose: Strabismus management in developmental-delayed children presents challenges, as outcomes are unpredictable due to factors such as limited neuroplasticity, poor central control, and subnormal binocular potential. This meta-analysis evaluates the outcomes of strabismus surgery in these children. Methods: Eligible studies published before 28 May 2023 were extracted from MEDLINE, EMBASE, CINAHL, Cochrane, PsychINFO, and gray literature. A meta-analysis was performed using STATA 14.0. The comparator group were children without developmental delays who underwent strabismus surgery. Fixed-effect and random-effect models were computed based on heterogeneity. Results: Our meta-analysis included 31 articles, with a total of 3687 subjects. There was no significant difference in the surgical dose for children with developmental delays compared to children without developmental delays (SMD -0.06, 95% CI: [-0.36, 0.23]). Post-operatively, developmentally delayed children had a significant improvement in their angle of deviation (SMD 2.79, 95% CI: [2.50, 3.08]) and could achieve a post-operative angle of deviation similar to children without developmental delays (SMD -0.20, 95% CI: [-0.51, 0.11]). The median rate of undercorrection was similar between developmentally delayed and children without developmental delays, at 20.4% and 20.2%, respectively. For the median rate of overcorrection, developmentally delayed children had a higher rate of 12%, compared to 4.35% in children without developmental delays. For developmentally delayed children, the median incidence is 71.45% for needing one surgery, 23.9% for two surgeries, and 7.15% for three surgeries. Conclusions: Strabismus surgery in developmentally delayed children may have higher rates of overcorrection and may need more repeat operations but could achieve significant improvements in their ocular alignment.
Extraocular muscle (EOM) tension during strabismus surgery produces trigemino-vagal bradycardia as a form of the oculocardiac reflex (OCR). Surface pain in the eye can cause bradycardia in premature infant eye examinations, so we evaluated the effect on the heart rate of different aspects of strabismus surgery. Electrocardiograph heart rate (H.R.) was monitored during outpatient strabismus surgery without anticholinergic or local anesthetic. The impact of limbus-based conjunctival incision was compared to 200 gram, 10-second tension on rectus muscles. The 239 patients aged 0.6 to 83 years (16±20) during the limbal conjunctival incision had median change in H.R. from 100 bpm to 103 bpm, while initial rectus tension changed from 102 bpm to 75 bpm. Compared to median (and interquartile range) %HR with incision of 100% (100%, 101%) the corresponding first rectus tension 82% (65%, 98%) and subsequent rectus tension 80% (65%, 92%) were significantly greater (Kruskal-Wallis X2(2) = 251, p < 0.001) independent of gender, race, iris color, neurologic deficit, use of fentanyl or dexmedetomidine. Younger patients had greater percent heart rate drop with muscle tension but not conjunctival incision. Despite uninhibited pain receptors and general anesthesia in children and adults, conjunctival incision produced essentially no OCR compared to EOM rectus tension. Clinical trial registration NCT04353960. https://www.abcd-vision.org/references/OCR%20Incision%202025.pdf. During strabismus surgery without anticholinergic or local anesthetic, rectus muscle tension of 10-seconds and 200 grams produced a median heart rate drop of 18% however the preceding conjunctival incision elicited no change.
Purpose: To evaluate the outcomes of strabismus surgery in patients with cerebral palsy (CP) and identify factors influencing surgical success. Methods: A retrospective chart review was conducted at the Ophthalmology Outpatient Clinic of Associação de Assistência à Criança Deficiente in São Paulo, Brazil, including patients with CP who underwent strabismus surgery between January 2016 and December 2022. Patients were divided into two groups based on their preoperative diagnosis of esotropia or exotropia. Surgical success was defined as a deviation ≤ 10 prism diopters (PD) at the final follow-up visit. Patients with <6 months of follow-up were excluded. Results: A total of 83 patients were included: 47 (56.6%) with exotropia and 36 (43.4%) with esotropia. The mean preoperative deviation was 50.5 ± 15.9 PD and 36.3 ± 14.0 PD in the exotropia and esotropia group, respectively (p < .001). Surgical success was achieved in 63.8% of the exotropia group and 47.2% of the esotropia group (p = .078). Exotropia cases exhibited more undercorrection (36.2% vs. 22.2%), whereas overcorrection was seen only in the esotropia group (30.6%). A longer postoperative follow-up (p = .006), younger age at surgery (p = .003), and larger preoperative deviation (p < .001) were associated with poorer surgical outcomes. Conclusions: Strabismus surgery in patients with CP demonstrates moderate success rates, with notable tendency toward postoperative drift, particularly toward divergence. Poorer outcomes were associated with younger age at surgery, larger preoperative deviations, and longer follow-up periods.
To evaluate the outcomes of hang-back recession applied to mechanically restricted rectus muscles in patients with thyroid eye disease (TED)-related strabismus, focusing on alignment stability and surgical success. This retrospective observational study included patients with TED who underwent hang-back recession of mechanically restricted rectus muscles for diplopia and/or restrictive ocular motility. Surgical dose was determined based on preoperative deviation magnitude and intraoperative findings rather than a fixed nomogram, and postoperative alignment outcomes were assessed at standardized follow-up visits. Fourteen patients (17 eyes) were included. Mean age was 48.8 ± 10.2 years, and all patients presented with diplopia. Horizontal deviation (10 eyes) showed a significant reduction at all postoperative time points at both near and distance fixation (p = 0.005), while vertical deviation (8 eyes) also demonstrated significant improvement throughout follow-up (p ≤ 0.012). Improvement was evident from the first postoperative week, with stable alignment achieved by the third postoperative month. No overcorrection occurred after horizontal surgery, and a mild vertical overcorrection (4 prism diopters) was observed in one patient. Based on a success criterion of postoperative deviation within ± 5 prism diopters, surgical success was achieved in 100% of cases, and no reoperation was required. Hang-back recession may provide effective and stable correction of TED-related strabismus. This tension-free approach was associated with favorable postoperative alignment and a low incidence of clinically significant overcorrection in the present series. These findings should be interpreted considering the relatively small cohort and the absence of a control group.
This study aimed to evaluate the effectiveness of Comfort Theory-guided nursing care in reducing perioperative anxiety and improving recovery outcomes among children undergoing strabismus surgery. The hypothesis was that a structured comfort-based nursing approach addressing physical, psychospiritual, sociocultural, and environmental needs would yield superior emotional and functional outcomes compared with conventional care. A prospective study was conducted involving 184 pediatric patients scheduled for elective strabismus correction. Participants were randomly assigned to receive either routine nursing (n = 92) or Comfort Theory-guided nursing interventions (n = 92). The comfort-based model included individualized psychological preparation, environmental optimization, parental involvement, and continuous emotional support. Anxiety was measured using the Modified Yale Preoperative Anxiety Scale (m-YPAS), pain using the Face-Legs-Activity-Cry-Consolability (FLACC) scale, and behavioral recovery using the Post-Hospitalization Behavior Questionnaire (PHBQ). Compared with routine care, the Comfort Theory group showed markedly lower anxiety both before induction (44.1 ± 8.9 vs. 61.5 ± 9.7, p < 0.001) and on postoperative day 1 (40.6 ± 7.5 vs. 53.4 ± 8.2, p < 0.001). Physiological stress responses were also blunted, with lower heart rate (100.2 ± 8.8 vs. 108.5 ± 9.2 bpm, p < 0.001) and mean arterial pressure (83.1 ± 6.7 vs. 88.4 ± 7.1 mmHg, p < 0.001) before induction. Postoperative pain scores were significantly reduced across all time points (p < 0.001), and behavioral recovery improved, with lower PHBQ scores (7.4 ± 3.1 vs. 10.2 ± 3.7, p < 0.001). Children in the intervention group regained consciousness earlier (19.6 ± 3.8 vs. 22.4 ± 4.1 min, p < 0.001), resumed oral intake faster (4.9 ± 1.0 vs. 5.8 ± 1.2 h, p < 0.001), and had shorter hospital stays (3.4 ± 0.7 vs. 3.9 ± 0.8 days, p < 0.001). Comfort Theory-guided nursing care may help alleviate perioperative anxiety, stabilize physiological stress responses, reduce postoperative pain, and support behavioral and functional recovery in pediatric strabismus surgery. As a holistic nursing approach, it may offer a practical framework for improving perioperative care; however, the findings should be interpreted in light of the single-center design, lack of full blinding, and multimodal nature of the intervention.
AimTo evaluate and compare the performance of five artificial intelligence (AI) chatbots-ChatGPT (OpenAI 4), Google Gemini, Grok (xAI), DeepSeek, and Meta Llama -in delivering accurate, clear, educational, and safe responses to caregiver-facing queries related to strabismus.MethodsSixteen standardized caregiver questions on strabismus were presented to each chatbot in independent sessions. Five fellowship-trained pediatric ophthalmologists rated each response across four domains-Accuracy, Clarity, Educational Value, and Safety-using a 5-point Likert scale (1 = Poor, 5 = Excellent). Between-chatbot differences were analyzed using cumulative link mixed models (CLMMs) with odds ratios (OR) and 95% confidence intervals (CI). Holm-adjusted pairwise contrasts corrected for multiple comparisons. Inter-rater reliability was assessed using quadratic-weighted Fleiss' κ and Gwet's AC1 to address prevalence and bias effects.ResultsChatGPT achieved the highest proportion of top ratings (≥4) for Accuracy (65%) and Clarity (59%), followed by Llama (41% and 47.5%, respectively). For Educational Value, Llama (43.8%) and Gemini (42.5%) performed slightly better, while Safety ratings were highest for Gemini (40%) and Llama (37.5%). CLMM analysis showed significant between-chatbot differences for Accuracy, Clarity, and Educational Value (p < 0.05) but not for Safety. Compared with ChatGPT, lower odds of higher ratings were seen for Grok (OR 0.48) and DeepSeek (OR 0.61). Inter-rater reliability indicated moderate agreement (Fleiss' κ = 0.59) and strong consensus (Gwet's AC1 = 0.87).ConclusionChatGPT showed superior accuracy and clarity, while Gemini and Llama excelled in educational value and safety. High expert agreement supports AI chatbots as adjuncts in pediatric ophthalmology education requiring continued validation.
Background: Strabismus, a common ocular disorder marked by misalignment of the visual axes, can impair depth perception and visual function, while also affecting facial appearance and psychosocial wellbeing. In recent years, the field has seen a growing body of research focusing on its pathogenesis, risk factors, and therapeutic approaches. However, the literature is still fragmented, making it difficult to assess overarching trends. Therefore, a comprehensive bibliometric analysis is needed to understand research developments and identify emerging hotspots in this domain. Materials and Methods: A bibliometric analysis was conducted using VOSviewer and CiteSpace on 6,540 English-language articles and reviews related to strabismus, published between 1995 and 2025, and retrieved from the Web of Science Core Collection (WOSCC). Results: The updated analysis revealed consistent growth in publication output, with particularly rapid expansion in recent years. While the United States remained a key contributor, China has overtaken the U.S. in annual output since 2023. Keyword co-occurrence and burst analysis identified both long-standing research interests (e.g., intermittent exotropia [IXT], AACE, surgical outcomes) and newer focus areas such as digital screen exposure, artificial intelligence in diagnostics, and individualized surgical planning. Conclusion: This study provides an updated and comprehensive bibliometric evaluation of global strabismus research through 2025. The results highlight evolving academic contributions, changing geographical trends, and shifting research priorities, offering guidance for future investigations and clinical advancements.
Sevoflurane is a widely used agent for the rapid induction and maintenance of anesthesia. Diffuse alveolar hemorrhage (DAH) is characterized by acute onset of alveolar infiltrates and hypoxemia, resulting in progressive alveolar bleeding that requires urgent treatment. This report highlights the potential role of inhaled tranexamic acid (TXA) as an adjunctive therapy in DAH. A 29-year-old male, ASA-I patient underwent outpatient strabismus surgery. The patient presented to the emergency department (ED) with hypoxia and hemoptysis. These symptoms manifested within the first hour after surgery in the anesthesia unit. Based on the clinical findings, a diagnosis of DAH was established. The patient's hypoxemic respiratory distress was managed with high-flow nasal cannula (HFNC). For DAH, the patient was treated with intravenous glucocorticoids (1 mg/kg for 3 days) and a single 1 g dose of inhaled TXA. At discharge, the patient had no residual symptoms and abnormal clinical findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The popularity of outpatient surgery units is increasing; therefore, emergency and critical care clinicians should be particularly vigilant with post-anesthesia patients. The association between sevoflurane and DAH has not yet been fully elucidated. Further research is required to clarify the underlying pathophysiological mechanisms. DAH is a potentially fatal clinical condition. Clinicians must remain vigilant and be prepared to implement rapid resuscitation strategies. Inhaled TXA may form part of such strategies; however, further randomized controlled trials are required.
Up to 4% of adults will develop strabismus in their lifetime. The most common surgical intervention involves adjusting the length of one or more extraocular muscles to correct the angular deviation. This correction depends on surgical expertise and statistical reference tables, which often fail to yield optimal results for patients with atypical eye morphology. Our work proposes a physics-based modeling approach to personalized surgical planning, accounting for patient-specific eye anatomy. We built a physics-based simulator of the eye and its muscles, incorporating patient-specific geometry and Hill-type muscle biomechanics. We solve an optimization problem to find the surgical dosage that minimizes angular deviation. The model is implemented as a fully differentiable simulation, enabling efficient optimization. We validated the framework by comparing its predictions with standard surgical tables for emmetropic eyes before applying it to anatomically atypical virtual patients. Our model's predictions for emmetropic eyes were first validated, demonstrating a strong fit with standard surgical tables. More importantly, for high-myopia models, the framework computed a clinically significant increase in the required surgical dosage compared to standard eyes. This computed recession difference is highly relevant as surgical plans are adjusted in 0.5 mm increments. Our results show that our model provides a calibrated surgical plan that, unlike standard tables, also accounts for pathologies involving atypical eye shapes. This patient-specific model represents a step toward personalized surgical planning, with the potential to improve dosage accuracy and surgical outcomes for atypical cases.
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Two prior studies suggested a relationship between spatial neglect and reduced diplopia reporting. In spatial neglect with visual extinction phenomenon, the double image on the neglected side may be extinguished from perception, representing a pathological binocular suppression. We retrospectively reviewed the binocular vision testing battery routinely performed at one inpatient rehabilitation hospital vision clinic to better understand reduced diplopia reporting and look for evidence of pathological suppression. One hundred fifty-five consecutive patient charts were retrospectively reviewed. Significant predictors of denial of double vision in patients with recent stroke and strabismus (N = 55) or prism induced strabismus (N = 98) were identified with logistic regression. Additionally, three clinicians rated the likelihood (1 to 10) of suppression in each case and predictors of the rating were identified with a cumulative logit model. Cases with likelihood rating >7/10 were flagged and examined individually. Only 15 of 155 patients passed all suppression tests administered (9.7%). Fifty-three percent of patients with strabismus actively denied diplopia. When controlling for significant effects of age, patients with spatial neglect had 3.9 greater odds of denying diplopia (OR (95% CI) 3.91 (1.70, 8.96)). Inter-ocular acuity difference and hemianopia were not significant predictors. A high likelihood of suppression was associated with parietal lobe injury, (3.40 (1.22-9.30)). The side of the brain was not significant (α = 0.05). Five patients had a likelihood rating greater than 7 out of 10 and so were likely exhibiting pathological suppression. Denial of diplopia is associated with spatial neglect and age. In some cases, this likely represents a pathological suppression of binocular vision.
Retinopathy of prematurity (ROP) remains a leading cause of childhood vision loss, often resulting in long-term complications such as strabismus, amblyopia, and glaucoma. Despite advances in screening, limited data exist on which infants are at highest risk and when these complications typically emerge-an important gap given the nationwide shortage of pediatric ophthalmologists. This study aimed to identify predictors of post-ROP ocular complications and determine the optimal timing and frequency of pediatric ophthalmology follow-up visits. We retrospectively reviewed 223 infants who underwent ROP screening between 2018 and 2021 and subsequently followed up with pediatric ophthalmology. The primary outcome was the development of ocular complications following ROP resolution, including their type and timing of detection. Univariate and multivariate logistic regression were used to identify independent risk factors, and Kaplan-Meier analysis assessed time to complication onset. Of 223 infants, 54 (24.2%) developed at least one ocular complication. The most common were refractive error (17.0%), strabismus (13.9%), and amblyopia (4.5%). Most complications occurred within two years after ROP clearance. Strabismus was diagnosed earliest, followed by refractive error and amblyopia. Longer NICU stay was an independent predictor of ocular complications (OR 1.30, 95% CI 1.04-1.63; p = 0.022). Nearly one in four infants developed ocular complications after ROP screening, typically within the first two years. NICU length of stay independently predicted risk, supporting the need for risk-stratified surveillance to ensure timely detection, optimize resource allocation, and reduce preventable vision loss in infants screened for ROP.
Acute acquired comitant esotropia (AACE) has recently garnered attention, as numerous case-series studies have reported its occurrence following excessive smartphone use. However, no large-scale epidemiological evidence of an increase in esotropia has been provided. This study aimed to investigate the change in the annual incidence of esotropia in Japan between 2014 and 2019-a period marked by a rapid increase in smartphone users. This nationwide population-based cohort study used the National Database of Health Insurance Claims and Specific Health Checkups of Japan, which covers almost the entire Japanese population. We counted the number of newly diagnosed esotropia cases and esotropia-related strabismus surgeries for each year from 2014 to 2019. Annual incidence rates were calculated by dividing these numbers by the corresponding year's population. We also investigated the correlation between the annual incidence rate and smartphone household penetration, based on data from the Japanese Ministry of Internal Affairs and Communications. The annual incidence of esotropia gradually increased from 32.26 (95% confidence interval [CI], 31.95-32.57) to 36.61 (95% CI, 36.28-36.95) per 100,000 person-years between 2014 and 2019. The mean annual increase rate was 2.49 ± 1.62%. The number of esotropia-related strabismus surgeries also increased from 3,061 to 3,743 during the same period. The annual incidence of esotropia correlated significantly with smartphone household penetration (P = 0.005, r = 0.943). In conclusion, this ecological study provides the first population-based evidence of a significant uptrend in the annual incidence of esotropia and related strabismus surgeries in Japan between 2014 and 2019. The rapid increase in digital device use warrants caution and may be associated with this increase, suggesting a need for clinical guidelines on screen time.