Search Results (56)

Botulinum toxin, once known only as the cause of botulism, has become a versatile therapeutic agent whose use in children now extends across many medical and surgical specialties. This narrative review synthesises the clinical use of botulinum toxin in patients up to eighteen years of age. We describe its pharmacology, the non-interchangeable commercial preparations, and the weight-based dosing and safety principles specific to childhood, then examine its applications by organ system. Gastrointestinal uses include functional constipation and internal anal sphincter achalasia, persistent obstruction after surgery for Hirschsprung disease, anal fissure, and achalasia. Urological uses centre on neurogenic and idiopathic detrusor overactivity and on sphincter-directed injection for dysfunctional voiding. Neurological uses are dominated by cerebral palsy spasticity and, on considerably weaker evidence, dystonia, while head and neck uses include sialorrhoea, congenital muscular torticollis, and strabismus. We also address neonatal brachial plexus palsy together with hyperhidrosis and aesthetic use in adolescents. The evidence supporting these uses is markedly uneven. Randomised controlled trials exist for only a small number of paediatric indications, chiefly spasticity in cerebral palsy, neurogenic detrusor overactivity, and chronic sialorrhoea, whereas most remaining applications rest on observational cohorts, small case series, or extrapolation from adult practice, and we grade the certainty of evidence separately for every indication. Only a few indications are formally approved, and most remain off-label, though increasingly supported. Botulinum toxin is a reversible and generally safe adjunct, but rigorous paediatric trials are still needed. Full article

Background/Objectives: The primary aim of this study was to evaluate the rate of strabismus and surgical outcomes in pediatric hydrocephalus (HC) patients, and compare the results in patients with and without ventriculoperitoneal (VP) shunt surgery. Methods: This study includes pediatric HC patients who were followed at the pediatric ophthalmology and strabismus unit of a tertiary hospital. Detailed ophthalmological examinations including deviation angle were performed. Preoperative measurements and surgeries were carried out by one strabismus expert. Postoperative deviation of ≤10 prism diopters (PD) was considered successful. Results: In total, 64 subjects were included in this study (29 female, 35 male), and 42 had a VP shunt (shunt+), while 22 were shunt−. The mean age of participants was 8.5 ± 4.6 years, and 50% (n = 32) of them had strabismus (22 esotropia, 10 exotropia). Both groups had similar refractive error and visual acuities (p > 0.05). Amblyopia rates were 21% (9/42) vs. 23% (5/22) in the shunt+ and shunt− groups. In 40% of shunt+ patients (17/42) there was strabismus, compared to 68% of shunt− patients (15/22). Among 22 patients with esotropia, 12 underwent strabismus surgery. Surgical success was achieved in nine patients (75%). In exotropic patients only one had surgery and it was successful. The operation rate in the strabismus group was 41% (13/32). Others mostly did not have surgery due to systemic comorbidities. Patients with strabismus had approximately 3.7 times higher odds of having epilepsy or spina bifida compared to those without strabismus (p = 0.049; OR = 3.69; 95% CI: 1.13–12.11). Conclusions: These findings suggest that children with hydrocephalus may benefit from regular pediatric ophthalmologic follow-up to detect strabismus, amblyopia, and refractive errors at an early stage. Although acceptable alignment outcomes were observed in selected operated patients, the small surgical cohort limits definitive conclusions regarding surgical success or the influence of VP shunting; therefore, treatment decisions should be individualized within a multidisciplinary framework. Full article

Introduction: This study aimed to investigate the impact of strabismus on self-concept in school-aged children and to evaluate changes in self-concept six months after strabismus surgery. Subjects and Methods: This prospective multicenter study included children aged 7–15 years who underwent strabismus surgery at the Strabismus Units of Beyoğlu Eye Research and Training Hospital and Marmara University Hospital between December 2023 and June 2024. Self-concept was assessed using the validated Turkish version of the Piers–Harris Self-Concept Scale (PHSCS) before surgery and six months postoperatively. Only patients with complete preoperative and postoperative assessments were included in the final paired analysis. Results: A total of 116 children were enrolled, of whom 84 (42 boys and 42 girls; mean age, 10.9 ± 2.2 years) had complete data and were included in the final analysis. Overall, 73.6% of participants reported that strabismus affected their daily lives, with 77.4% describing this impact as negative. Furthermore, 65.5% stated that strabismus affected their relationships with friends. Following surgery, 80.9% of participants were satisfied with the surgical outcome, and 85.7% would recommend the procedure to others. The mean total PHSCS score increased from 58.2 ± 10.4 preoperatively to 59.0 ± 10.1 postoperatively, although this difference did not reach statistical significance (p = 0.05). In contrast, the Physical Appearance and Attributes subscale showed a significant improvement after surgery (8.3 ± 1.6 vs. 8.9 ± 1.9, p < 0.005), whereas no significant changes were observed in the remaining subscales. Conclusions: School-aged children with strabismus may experience psychosocial challenges related to their condition, particularly in their interactions with peers. Although overall self-concept remained largely unchanged, self-perception of physical appearance improved following strabismus surgery. These findings suggest that surgical correction may contribute to improvements in selected aspects of self-concept; however, larger prospective controlled studies are needed to confirm these observations. Full article

Background: Emergence delirium (ED) is a common complication in pediatric patients following general anesthesia. Reduced cholinergic neurotransmission is closely associated with cognitive impairment and an increased risk of delirium. This study aimed to compare the effects of a cholinesterase inhibitor versus sugammadex–used as neuromuscular blockade reversal agents–on the incidence of ED following pediatric strabismus surgery. Methods: Seventy-six patients, aged 4–7 years, were enrolled and randomly allocated to either the pyridostigmine group (Group P) or the sugammadex group (Group S). The dose of each agent was determined according to the train-of-four count or ratio. The Pediatric Anesthesia Emergence Delirium (PAED) scale was assessed at 15-min intervals in the post-anesthesia care unit until the score fell below 10. ED was defined as a PAED score ≥ 10. Results: Of the 73 patients who completed the study, 36 were in Group P, and 37 were in Group S. The incidence of ED was 50.0% in Group P and 40.5% in Group S (odds ratio = 0.682; 95% confidence interval = 0.270–1.721; p = 0.417). The peak PAED scores were 10.0 (7.0, 15.5) in Group P and 9.0 (7.5, 11.5) in Group S (median [interquartile range]; p = 0.277). Conclusions: The choice of neuromuscular reversal agent did not significantly affect the incidence of ED in pediatric patients undergoing strabismus surgery. Full article

Background/Objectives: To evaluate the long-term outcomes of strabismus treatment in children with cerebral palsy (CP) and to investigate factors associated with postoperative alignment success and the development of consecutive strabismus. Methods: The retrospective, single-center study included 73 children with CP and strabismus who were followed from January 2015 to December 2024. Demographic characteristics, ophthalmological findings, treatment methods, and postoperative outcomes were assessed. Ocular deviation was measured through prism and alternate cover testing or a modified Krimsky test, and surgical success was defined as a final deviation of ≤10 prism diopters (PD). Patients were assessed at the patient level. Comparisons between exotropic and esotropic patients and between patients who had consecutive exotropia and those who had successful alignment were made using appropriate statistical tests. Results: Study participants included 55 patients with esotropia (75.3%) and 18 patients with exotropia (24.7%). The mean follow-up period was 32.6 ± 7.18 months. A successful ocular alignment was achieved in 32 of 46 patients (69.6%) with esotropia and in 10 of 17 patients (58.8%) with exotropia following surgical treatment and/or BTA. Consecutive exotropia developed exclusively in patients initially treated for esotropia (39.1% vs. 0%, p = 0.001). Patients with consecutive exotropia underwent surgery at a younger age and had larger preoperative deviation angles than those who had successful alignment, but these differences were not statistically significant. Conclusions: Strabismus treatment provides satisfactory long-term motor alignment in many children with cerebral palsy. However, consecutive exotropia following esotropia surgery remains a common postoperative condition and is the principal source of alignment instability in this population. Younger surgical age and larger preoperative deviations were more common among patients with consecutive exotropia, but no statistically significant associations between the evaluated clinical variables and consecutive exotropia were identified in the exploratory univariate analyses. Full article

Primary open-angle glaucoma (POAG) is rarely recognized in large felids, yet it may cause severe vision loss and chronic pain. This case report presents the ophthalmological evaluation of a four-year-old Siberian tiger (Panthera tigris altaica) maintained under human care that exhibited signs of visual impairment and altered sensorium. Under neuroleptic analgesia, clinical findings included bilateral convergent strabismus, persistent mydriasis, pathologically elevated intraocular pressure (48–52 mmHg), extensive map-like retinopathy, and focal retinal degeneration, supporting a diagnosis of advanced-stage bilateral POAG with irreversible vision loss. Pupillary light reflexes were absent, while fluctuations in pupil size were attributed to ketamine. Although medical and surgical options used in domestic cats may be applicable to non-domestic felids, frequent topical treatment was impracticable and unsafe, vision-preserving surgery was no longer indicated, and advanced diagnostics and specialist ophthalmic surgery were unavailable on site. The therapeutic goal was therefore shifted from vision preservation to long-term pain surveillance and welfare maintenance, including housing adaption and a defined threshold for humane euthanasia. Two types of neurological episodes were also documented as secondary findings; however, their causal relationship with the ocular disease could not be established without advanced neuroimaging. This case highlights the need for accessible on-site or referral-based ophthalmic diagnostics and surgical capacity in zoo settings. Full article

Background/Objectives: To evaluate the numerical agreement and variability between large language model (LLM)-generated surgical dosage recommendations and expert surgical planning in strabismus surgery under controlled conditions. Methods: This retrospective, single-center study included patients who underwent horizontal strabismus surgery between January 2023 and May 2025 and achieved successful postoperative alignment (≤±10 prism diopters at 3 months). Standardized preoperative clinical data were provided to three LLMs (ChatGPT-5.2, Gemini 3.0 Pro, and DeepSeek v3.2), each prompted to generate surgical dosage recommendations in millimeters. Model outputs were compared with the surgeon’s preoperative plans. Agreement and variability were assessed using intraclass correlation coefficients (ICC) and Bland–Altman analyses. Results: A total of 68 patients were included (44.1% female; mean age 11.7 ± 10.5 years). Agreement between LLM-generated and surgeon-determined surgical dosages was heterogeneous across models and surgical subtypes. Moderate ICC values were observed in selected subgroups; however, confidence intervals were frequently wide and, in several instances, crossed zero, indicating limited statistical reliability. Bland–Altman analyses demonstrated wide limits of agreement, often approaching or exceeding ±1 mm. Agreement tended to be higher in smaller deviation angles (≤35 prism diopters) and lower in larger deviations and more complex surgical scenarios. Conclusions: LLM-generated surgical dosage recommendations demonstrated variable and context-dependent agreement with expert planning, with substantial variability and limited reliability across subgroups. These findings indicate that current LLM-based systems do not achieve the level of precision required for quantitative surgical decision-making and should be considered investigational and not suitable for independent clinical use. This study represents a variability and calibration analysis rather than an evaluation of clinical accuracy or decision-making performance. Full article

The reconstruction of complex orbitomaxillary defects requires biomaterials that can simultaneously provide structural stability, biocompatibility, and accurate restoration of facial volume and contour. While rigid polymers such as polyetheretherketone (PEEK) offer reliable mechanical support, they do not adequately replicate the viscoelastic behavior of soft tissues. This report presents a translational revision case employing a personalized hybrid biomaterial approach that combines a 3D-printed PEEK implant for structural orbital floor support with a patient-specific polydimethylsiloxane (PDMS) implant for malar volumetric augmentation. Reconstruction was planned using CT segmentation and contralateral mirroring. Patient-specific implants were subsequently designed using CAD/CAM techniques, combining a rigid PEEK implant for structural orbital support with a flexible PDMS implant for malar volumetric augmentation with complementary mechanical properties. Revision surgery included the removal of inadequately positioned titanium hardware, the release of incarcerated extraocular muscles, and the restoration of orbital anatomy and facial symmetry. Postoperative imaging demonstrated stable implant positioning and sustained orbitomaxillary stability. Despite successful anatomical reconstruction, residual functional sequelae, including strabismus related to the severity of the initial orbital trauma, persisted and were addressed separately in a staged manner, resulting in satisfactory ocular alignment and resolution of diplopia in primary gaze. This case underscores the complementary functional roles of rigid and elastic polymers and highlights the translational potential of PDMS as a permanent, patient-specific implant material for volumetric and contour restoration in craniofacial reconstruction. Full article

Background and Objectives: Intermittent exotropia (IXT) is a common childhood strabismus with variable natural history and no universally accepted first-line management. We aimed to characterize long-term real-world outcomes and identify factors associated with alignment stability across surgical and non-surgical strategies. Materials and Methods: This retrospective single-center cohort study reviewed consecutive patients with IXT managed between January 2008 and March 2024. Clinical data included IXT subtype, prism and alternate cover test measurements, binocular control (ECS), stereopsis, refractive error, and treatments (observation, over-minus lenses, and surgery). Postoperative success was defined as ≤10 prism diopters (PD) of eso/exophoria without diplopia. Longitudinal refractive change was analyzed using linear mixed-effects modeling, and time to alignment failure (≤±10 PD at near and distance) was evaluated using Kaplan–Meier and Cox regression analyses. Results: A total of 415 patients were included (mean follow-up 53.2 ± 47.8 months). Over-minus therapy was used in 252 (60.7%) patients for a median of 24 months, and 61 (14.7%) achieved spontaneous alignment. At the final visit, combined near-and-distance alignment success was 41.0% (170/415). Among surgically treated patients (n = 167), motor success was 65.3% (109/167), with reoperation required in 12.6% (21/167). Kaplan–Meier analysis showed cumulative alignment survival of 0.899 at 1 year, 0.563 at 5 years, and 0.302 at 10 years (median 70 ± 4.7 months). In Cox modeling, surgery was strongly protective (HR 0.174), while older age (HR 1.040 per year) and poor baseline distance control (HR 1.421) increased the risk of failure; over-minus therapy was not independently associated with survival. Both treatment groups showed a similar myopic shift over time (β = −0.25 D/year), with no between-group difference. Conclusions: In this longitudinal cohort, intermittent exotropia showed a variable course, with many patients ultimately requiring surgery despite initial non-surgical management. Long-term success was more closely tied to preoperative control quality than age. These findings support an individualized, control-based approach to treatment planning and timing of intervention. Full article

Background/Objectives: Conjunctival closure may influence early postoperative comfort and wound healing after pediatric strabismus surgery. We compared fibrin glue with absorbable sutures using anterior segment optical coherence tomography (AS-OCT)-based conjunctival thickness, serial clinical scores, ocular-surface screening, and operative time. Methods: We retrospectively reviewed 82 children (5–15 years) who underwent bilateral medial rectus recession. The conjunctiva was closed with 8-0 polyglactin 910 (Vicryl) (suture group, n = 40) or fibrin glue (fibrin group, n = 42) according to routine practice; right eyes were analyzed. Conjunctival thickness was measured by AS-OCT preoperatively and at week 6. The comfort questionnaire (CQ) score and inflammation score (IS) were recorded on postoperative day 1 and weeks 1, 2, and 6. Total operative time and closure time were obtained from surgical video recordings. Ocular Surface Disease Index-6 (OSDI-6) and non-invasive keratographic break-up time (NIKBUT) were assessed preoperatively and at week 6 in cooperative children (n = 62). Results: Conjunctival thickness increased in both groups and was slightly higher at week 6 with sutures (p < 0.001), with a slightly greater percentage increase (p = 0.001). CQ and IS were worse with sutures through week 2 (all p < 0.05) and converged by week 6 (both p > 0.05). Fibrin glue shortened total operative time (32.75 vs. 35.46 min; p < 0.05) and closure time (3.90 vs. 5.35 min; p < 0.001). In the ocular-surface subset, OSDI-6 and NIKBUT did not differ between groups at week 6. No infections or granulomas occurred; two early conjunctival wound gaps occurred in the fibrin group and one resolved with topical management, while the other met the dehiscence definition (≥2 mm) and required re-suturing, and both healed without sequelae. Conclusions: In pediatric strabismus surgery, fibrin glue demonstrated better early comfort with a modest difference in conjunctival thickness at week 6 along with slightly shorter operative time while clinical scores converged by week 6, and ocular-surface screening outcomes were similar. Full article

Background: The direction of deviation in strabismus may influence the predictability of the surgical procedure, but this factor remains insufficiently investigated. The aim of this study was to compare postoperative changes in ocular deviation, measured by video oculography, following surgical treatment in patients with concomitant exotropia and esotropia. Methods: A prospective longitudinal study included 49 patients with horizontal strabismus. All patients underwent an eye examination before and after surgery, with ocular deviation measured in nine gaze positions using video oculography. Preoperative and postoperative results were analyzed separately for esotropias and exotropias to assess surgical efficacy in both conditions. Results: Ocular deviation significantly improved after strabismus surgery in both esotropia and exotropia across all nine gaze positions (p < 0.05). The greatest improvement was observed in the primary position, with an efficacy rate of 75% in exotropia (mean reduction of 14.93 prism diopters) and 78% in esotropia (mean reduction of 17.50 prism diopters). Residual postoperative deviation was similar between the two types of strabismus (p > 0.05). In non-primary gaze positions, surgical efficacy was lower—particularly during complex eye movements—in both groups. Conclusions: Strabismus surgery resulted in a significant reduction in ocular deviation across all gaze positions in patients with concomitant horizontal strabismus, as objectively assessed by video oculography. Postoperative improvements were comparable between exotropia and esotropia, with the highest surgical efficacy observed in the primary gaze position. These findings support the use of objective multigaze evaluation to more comprehensively characterize postoperative alignment and to inform future assessments of surgical outcomes. Full article

Objective: Assess visual acuity (VA) and strabismus changes in children after Baerveldt 350 (BV350) device placement. Methods and Analysis: Retrospective cohort study of children (<21 years of age) who had superotemporal BV350 placement (2011–2023) and >6-month follow-up. Ocular diagnoses, surgical details, and preoperative and final follow-up exam findings were collected. In bilateral cases, first eye implanted was included in analysis. Results: Ninety-seven patients underwent BV350 surgery with median age of 6.7 (interquartile (IQR) 3.1, 11.2) years and with a median of 4.2 (IQR 1.8, 6.8) years of follow-up. Most common glaucomas were secondary to non-acquired ocular anomaly (n = 31) or primary congenital glaucoma (n = 21). There was no difference in preoperative and final VA (p = 0.6583). Twenty-seven (28%) and twenty-five (26%) patients were orthophoric preoperatively and at final follow-up, respectively. Orthophoria at final follow-up was associated with preoperative (odds ratio (OR)1.8 [1.2, 2.9]) and final VA (OR1.5 [1.1, 2.3]). At final follow-up, 13 patients (13%) and 19 patients (20%) showed worsened or improved horizontal deviation (>10 prism diopter (PD) change), respectively. No patients reported postoperative diplopia. Only four patients, all with esotropia, underwent subsequent strabismus surgery. Conclusions: Children who underwent BV350 placement did not have significant change in VA, and a high percentage of patients had strabismus prior to (72%) and following (74%) glaucoma surgery. Orthophoria was associated with better VA. The majority of patients did not show worsening of strabismus postoperatively, and none reported diplopia. Full article

Purpose: To evaluate short-term motor and sensory–motor outcomes following postoperative OT in children with IXT after strabismus surgery. Methods: This prospective before–after observational study included children with IXT who underwent bilateral lateral rectus recession and were referred for postoperative OT based on predefined clinical criteria. A structured 12-week OTplan was initiated approximately six months after surgery. Outcome measures included angle of deviation (prism diopters, PD), near point of convergence (cm), positive fusional vergence amplitudes (PD), and convergence amplitudes at distance and near (PD). Pre- and post-therapy changes were analysed using paired-samples t-tests with effect sizes calculated using Cohen’s d. Final postoperative alignment was additionally compared cross-sectionally between children who underwent OT and those managed without OT. Results: Eighty-eight children had complete paired motor and sensory–motor data and were included in the analyses. Changes in static ocular alignment were small, with mean residual deviation improving from −7.02 ± 6.91 PD to −5.22 ± 6.60 PD after OT (mean change +1.80 PD; p < 0.01; d ≈ 0.30). No significant difference in final postoperative alignment was observed between the OT and non-OT groups (p = 0.827). In contrast, marked improvements were observed in sensory–motor outcomes. Positive fusional vergence amplitude increased from 7.30 ± 8.33 PD to 22.19 ± 9.26 PD (p < 0.001; d ≈ 1.5). Distance convergence amplitude improved from 7.30 ± 8.33 PD to 22.19 ± 9.26 PD, and near convergence amplitude from 10.95 ± 12.50 PD to 33.29 ± 13.89 PD (both p < 0.001; d ≈ 1.5). Near point of convergence showed a modest but significant improvement. Conclusions: Postoperative OT was associated with substantial short-term improvements in sensory–motor function, particularly fusional and convergence capacities, while changes in static ocular alignment were small and of limited clinical relevance. These findings support the role of OT as a functional adjunct to surgery, aimed at enhancing binocular control and postoperative sensory–motor stability in children with IXT. Full article

Strabismus, or squint or deviating eyes, is defined as misalignment of the eyes when fixating on an object and is a common problem in ophthalmology. Palsy of the third, fourth or sixth cranial nerve is one of the leading underlying causes for paralytic strabismus, often requiring surgery. However, uncertainty regarding factors influencing surgical success remains. Background/Objectives: The purpose of this study is to review the outcome and influencing factors of strabismus surgery in patients with cranial nerve palsy. Methods: A retrospective study of 57 patients with third cranial nerve (CN3) palsy, fourth cranial nerve (CN4) palsy, sixth cranial nerve (CN6) palsy or combined nerve palsy who underwent strabismus surgery between October 2009 and December 2023 was conducted. Analyzed data included demographic details, type of surgical intervention, etiology of nerve palsy, pre- and postoperative angle of deviation (AOD), vertical deviation (VD), best-corrected visual acuity (BCVA), and refractive error. Results: Mean age was 41.29 ± 23.14 years with a mean follow-up of 10.8 ± 15.38 months. 30 patients (52.63%) had CN6 palsy, 12 patients (21.05%) had CN3 palsy, eight patients (14.04%) had CN4 palsy and seven patients (12.28%) had combined nerve palsy. Brain neoplasm was the most common cause of nerve palsy (33.33%). Mean preoperative AOD improved from 17.54° ± 10.68 to 7.13° ± 8.93 and from 17.21° ± 9.58 to 7.49° ± 9.75 for near and distance, respectively (p < 0.001). Changes in VD, refractive error, and BCVA were not statistically significant. Conclusions: Age, gender, preoperative AOD, subtype and etiology of nerve palsy had no significant influence on surgical outcomes, which are satisfactory in patients with cranial nerve palsy (80.7%). Full article

Background and Objectives: Postoperative nausea and vomiting (PONV) is a common and potentially crucial side effect in pediatric patients. Neuromuscular blockade reversal drugs (NMBRDs) used during surgery have been associated with PONV. This study investigated whether sugammadex, a recently approved NMBRD for children in Korea, induces PONV and possible changes after NMBRD administration in children undergoing strabismus surgery. Materials and Methods: In total, 60 pediatric patients (3–16 years old) undergoing strabismus surgery with general anesthesia were included. They were divided into two groups: sugammadex (group S, n = 30) or pyridostigmine (group P, n = 30). The primary endpoint was the incidence of PONV using the Baxter Animated Retching Faces (BARF) scale at 0.5, 1, 3, and 6 h after NMBRD administration. The secondary endpoints included the recovery time (train-of-four > 0.9) and changes in heart rate following NMBRD administration. Results: There was no significant difference in PONV incidence between the groups according to the BARF scale (13.3% vs. 13.3% at 0.5 h, 6.7% vs. 3.3% at 1 h). Sugammadex demonstrated a significantly faster recovery time than pyridostigmine (p < 0.001). The changes in heart rate were more significant in the sugammadex group than those in the pyridostigmine group after NMBRD administration (p < 0.001); however, the heart rate returned to preoperative levels without any need for rescue medications or anticholinergics during the emergence period. Conclusions: There was no significant difference in PONV incidence between the administration of sugammadex and pyridostigmine in pediatric patients after strabismus surgery. Nevertheless, sugammadex appeared to facilitate faster recovery from the neuromuscular blockade without requiring intervention for the heart rate. Full article