Journal of Pediatric Ophthalmology and Strabismus

Original Article Supplemental Data

Congenital Zika Syndrome: Surgical and Visual Outcomes After Surgery for Infantile Strabismus

Liana O. Ventura, MD, PhD; Simone Travassos, MD; Marcelo C. Ventura Filho, MD; Polyana Marinho, MD; Linda Lawrence, MD; M. Edward Wilson, MD; Noelle Carreiro, MD; Valeska Xavier, MD; Adriana L. Gois, MD; Camila V. Ventura, MD, PhD

Abstract

Purpose:

To evaluate the surgical and functional outcomes in children with congenital Zika syndrome who underwent strabismus surgery.

Methods:

This prospective case series included children with congenital Zika syndrome who presented with horizontal infantile strabismus and underwent strabismus surgery. Ocular motility and visual fields were assessed preoperatively and postoperatively. Visual fields were considered normal if they exceeded 70 degrees in the temporal meridian. Postoperatively, parents and caregivers answered a questionnaire that assessed their child's behavioral improvements. A final ocular alignment within ±10 prism diopters (PD) and expansion of the visual fields were considered satisfactory motor surgical results at 6 months postoperatively.

Results:

Five children (3 girls [60%]) with congenital Zika syndrome (age: 36.4 ± 0.9 months) were included in this study. All children (100%) presented with moderate to severe visual impairment and 4 (80%) presented with funduscopic abnormalities. Preoperatively, 4 children (80%) had infantile esotropia (mean preoperative angle of deviation: 41.3 ± 6.3 PD) and 1 (20%) had infantile exotropia measuring 65 PD. The postoperative outcomes demonstrated ocular alignment in 4 children (80%) at the 6-month follow-up visit. Expansion of the temporal visual field was observed in 7 eyes (70%) of 4 children (80%). Four caregivers (80%) reported behavioral improvement in daily activities, and all caregivers (100%) reported improved peripheral target detection and socialization skills.

Conclusions:

Strabismus surgery can be an effective procedure for treating horizontal strabismus in children with congenital Zika syndrome because it can improve ocular alignment, expand the visual field, and improve the child's social, functional, and behavioral skills.

[J Pediatr Ophthalmol Strabismus. 2020;57(3):169–175.]

Abstract

Purpose:

To evaluate the surgical and functional outcomes in children with congenital Zika syndrome who underwent strabismus surgery.

Methods:

This prospective case series included children with congenital Zika syndrome who presented with horizontal infantile strabismus and underwent strabismus surgery. Ocular motility and visual fields were assessed preoperatively and postoperatively. Visual fields were considered normal if they exceeded 70 degrees in the temporal meridian. Postoperatively, parents and caregivers answered a questionnaire that assessed their child's behavioral improvements. A final ocular alignment within ±10 prism diopters (PD) and expansion of the visual fields were considered satisfactory motor surgical results at 6 months postoperatively.

Results:

Five children (3 girls [60%]) with congenital Zika syndrome (age: 36.4 ± 0.9 months) were included in this study. All children (100%) presented with moderate to severe visual impairment and 4 (80%) presented with funduscopic abnormalities. Preoperatively, 4 children (80%) had infantile esotropia (mean preoperative angle of deviation: 41.3 ± 6.3 PD) and 1 (20%) had infantile exotropia measuring 65 PD. The postoperative outcomes demonstrated ocular alignment in 4 children (80%) at the 6-month follow-up visit. Expansion of the temporal visual field was observed in 7 eyes (70%) of 4 children (80%). Four caregivers (80%) reported behavioral improvement in daily activities, and all caregivers (100%) reported improved peripheral target detection and socialization skills.

Conclusions:

Strabismus surgery can be an effective procedure for treating horizontal strabismus in children with congenital Zika syndrome because it can improve ocular alignment, expand the visual field, and improve the child's social, functional, and behavioral skills.

[J Pediatr Ophthalmol Strabismus. 2020;57(3):169–175.]

Introduction

The developing brains of fetuses can harbor the Zika virus, which is known to cause congenital malformations including severe brain damage that negatively affects brain function.1 The neurological findings observed in children with congenital Zika syndrome may lead to a wide range of dysfunctions, including severe visual impairment.2,3

Despite knowing that Zika virus may directly damage the eye, Ventura et al.3 reported that 85% of indiviuals with normal ocular examinations had visual impairment. The discordance between the ocular findings and visual impairment suggests the presence of abnormalities more posteriorly along the visual pathways, characterizing cerebral/cortical visual impairment.4

As a result of the visual pathway injury and ocular findings caused by Zika virus during prenatal development, these children have a high prevalence of strabismus.2,3 Ocular misalignment with poor visual-motor performance in children with developmental delay can affect their ability to perform the basic functional tasks of daily living, including hand–eye coordination and gross motor skills.5 Self-image and social interactions also are negatively affected.6 Nevertheless, there is no consensus concerning management of ocular misalignment in children with neurologic impairment because the angles of misalignment are more unstable, and poor patient cooperation challenges full ophthalmic assessments and may lead to a worse prognosis.6–8

To date, no study has investigated the potential benefits of strabismus surgery in children with congenital Zika syndrome. The current study describes the surgical interventions we performed in 5 children with congenital Zika syndrome and horizontal strabismus. The authors report the surgical, visual, and behavioral outcomes obtained 6 months after strabismus surgery.

Patients and Methods

The Ethics Committee of Altino Ventura Foundation, Recife, Brazil (No. 3.159.805) approved this study. The children were enrolled after parents/caregivers provided written informed consent in accordance with the guidelines of the Declaration of Helsinki.

The inclusion criteria were children with congenital Zika syndrome (positive immunoglobulin M antibody capture enzyme-linked immunosorbent assay from cerebrospinal fluid), the presence of infantile strabismus with constant horizontal heterotropia measured at least three times during different preoperative visits, no history of previous strabismus surgery, and a minimum follow-up of 6 months after strabismus surgery. Patients with dyskinetic strabismus and gaze palsy were not surgical candidates.

Infantile onset strabismus in children younger than 6 months was estimated from a combination of caregiver reports, facial photographs, and review of the patients' medical records.

Consecutive children underwent surgery for infantile strabismus (esotropia or exotropia) between October and November 2019 at the Altino Ventura Foundation, Recife, Brazil.

Data collection included patient demographics, medical history, preoperative and postoperative ophthalmologic assessments, strabismus surgery outcome, and caregiver's perception of the child's social, functional, and behavioral response to surgery.

Preoperative Evaluation

Experienced pediatric ophthalmologists conducted at least three complete ophthalmologic examinations of the children preoperatively. Assessments included measurement of the best corrected visual acuity (BCVA), ocular motility, visual fields, and posterior segment evaluation.

The BCVA was evaluated using Teller Acuity Cards in cycles/centimeter9 and was categorized into range of visual loss using the visual acuity ranges adopted by the International Council of Ophthalmology.10

The ocular motility examination evaluated the dissociated vertical deviation, A- or V-pattern, inferior oblique overaction, and vertical deviation. The angle of deviation was measured in prism diopters (PD) at near fixation (0.33 m) by the Krimsky prism reflex test due to the patients' poor visual acuity and visual function. Unstable esotropia or exotropia was defined as a variation of 10 PD or greater between measurements.

For deviation measurements, abnormal refractive errors and/or hypoaccommodation were fully corrected preoperatively and postoperatively. The refractive error was considered visually significant if the hyperopia was 2.00 diopters (D) or greater or the myopia or astigmatism was 1.00 D or greater. The refractive errors were reported as the spherical equivalent (SE) and graded as high myopia that exceeded −4.00 D, low to moderate myopia between −1.00 and −4.00 D, emmetropia between −0.50 and +1.75 D, low to moderate hyperopia between +2.00 and +4.00 D, high hyperopia greater than +4.00 D, and anisometropia when the difference between the eyes exceeded 1.50 D with a SE of 6.00 D or less or a 25% difference when the SE exceeded 6.00 D.11

Bilateral confrontation visual fields were measured using the LEA Flicker Wand test (Good-Lite Co., Elgin, IL), with a flashing diode wand (small light).12 The horizontal extent of the visual fields was assessed in all children at every follow-up visit. The stimulus light was introduced across the child's visual fields silently at the midway point between the examiner and the child at a testing distance of 30 cm. The stimulus was moved from behind the child in the horizontal meridians. For testing, the patient's head was centered with both eyes open, and the child was stimulated to fixate in front at the examiner's face. Each point on the visual fields was repeated a minimum of three times to ensure a consistent response. In all cases, testing was performed with and without the use of optimal spectacle correction. The children's behavioral reactions, such as movements of the head (turns/tilts), eyes, or limbs toward the peripheral light target, were used to estimate the outline of the horizontal visual fields in degrees. The visual field assessments were judged reliable if the children's responses and behaviors were coherent and consistent during the test session and a positive judgment of cooperative capacity was noticed. Abnormal visual fields were reexamined to exclude false-positive findings. The visual fields were considered normal if they exceeded 70º in the temporal meridian.12,13

Cycloplegic retinoscopy was performed at least 30 minutes after instillation of one drop of 0.5% cyclopentolate hydrochloride and 0.5% tropicamide in each eye. A fundus examination was performed through indirect binocular ophthalmoscopy and fundus imaging using a wide-angle digital fundus camera (RetCam Shuttle; Natus Medical Inc., Pleasanton, CA).

Strabismus Surgery

The surgeries were performed under general anesthesia. Surgical planning was based on the near measurements and considered the smallest angle of deviation measured. Bilateral medial rectus recession was performed in all cases with infantile esotropia. In one patient (patient 2), a one-tendon width superior transposition of the horizontal medial rectus with recession for an A-pattern (exceeding 10 PD in up gaze) associated with an esotropia was performed. One patient (patient 5) with large angle infantile exotropia and superior oblique overaction underwent bilateral lateral rectus recession, unilateral medial rectus resection of the left eye, and bilateral superior oblique tenectomy, performed on the temporal portion of the superior oblique muscle.

Postoperative Outcomes

Postoperative outcomes were assessed 4 and 6 months postoperatively and followed the same preoperative protocol. An ocular deviation within 10 PD of orthophoria in horizontal alignment was considered a successful surgical outcome. Any visual field expansion was considered a functional improvement.

Social, Functional, and Behavioral Improvements in the Daily Activities Questionnaire (SFBIDA-Q)

The caregivers answered a questionnaire (SFBIDA-Q) that addressed the child's social, functional, and behavior improvement in daily activities 6 months postoperatively. The SFBIDA-Q investigated whether caregivers noticed any improvement in visual contact, visual attention, and behavioral reaction to peripheral field target in daily activities, and the surgical impact on the child's social skills.

Data Analysis

Statistical analysis was performed using SPSS for Windows software, version 25.0 (SPSS Inc., Chicago, IL). Continuous variables were expressed as the mean ± standard deviation and categorical variables by their absolute and relative frequencies.

Results

Five children (3 girls, 2 boys) with congenital Zika syndrome underwent surgery for infantile horizontal strabismus and were included in this study. The mean age at surgery was 36.4 ± 0.9 months (range: 35 to 37 months). All children had a history of seizures and were treated with medication. Two children (40%) were previously diagnosed as having hydrocephalus and underwent ventriculoperitoneal shunt surgery.

All 5 children (100%) had moderate to severe visual impairment and wore glasses for significant refractive errors. Low to moderate hyperopia was detected in 2 eyes (20%), high hyperopia in 2 eyes (20%), low to moderate myopia in 3 eyes (30%), and high myopia in 2 eyes (20%). With-the-rule astigmatism that ranged from −1.50 to −3.00 D was observed in 6 eyes (60%). Anisometropia was seen in 1 child (20%). Ocular fundus abnormalities were found in 7 eyes (70%) of 4 children (80%) (Table 1).

Preoperative Ophthalmologic Characteristics

Table 1:

Preoperative Ophthalmologic Characteristics

Table 2 shows the preoperative ocular motility characteristics and surgical plans. Three children (60%) had stable strabismus. Infantile esotropia was detected in 4 children (80%) (41.3 ± 6.3 PD; range: 35 to 50 PD). One child (20%) had infantile exotropia of 65 PD associated with compromised visual attention and bilateral up gaze limitation.

Preoperative Ocular Motility and Surgical Procedures Performed

Table 2:

Preoperative Ocular Motility and Surgical Procedures Performed

Figure 1 shows the postoperative outcomes of the 5 children with infantile strabismus at 4 and 6 months postoperatively. Ocular alignment was obtained in all children (100%) at 4 months and in 4 children (80%) at 6 months (Figure 2). Patient 3 had a 10 PD consecutive exotropia at 4 months and developed bilateral overaction of the superior oblique muscle (+2) and an A-pattern exotropia of 16 PD in primary gaze at 6 months. Intermittent right hypertropia occurred in patient 1 (20%) and compensated dissociated vertical deviation in the right eye of patient 2; both had undergone surgery for esotropia.

Preoperative and postoperative ocular alignment at 4 and 6 months after strabismus surgery.

Figure 1.

Preoperative and postoperative ocular alignment at 4 and 6 months after strabismus surgery.

Image showing two children with congenital Zika syndrome presenting esotropia (A) and exotropia (C) prior to surgery and ocular alignment after strabismus surgery (B, D).

Figure 2.

Image showing two children with congenital Zika syndrome presenting esotropia (A) and exotropia (C) prior to surgery and ocular alignment after strabismus surgery (B, D).

Four children (80%) had abnormal visual fields (constricted field of view) preoperatively: 3 (75%) of whom had infantile esotropia and 1 (25%) who had infantile exotropia. Four months postoperatively, improvement in the horizontal visual fields was observed in 7 (70%) eyes of 4 children (80%). The visual fields expanded in 5 (50%) eyes of 3 children (60%) 6 months postoperatively (Table A, available in the online version of this article).

Preoperative and Postoperative Horizontal Visual Fields in Children With Congenital Zika Syndrome

Table A:

Preoperative and Postoperative Horizontal Visual Fields in Children With Congenital Zika Syndrome

Six months postoperatively, the caregivers reported social and behavioral improvements; 4 (80%) reported visual contact, visual attention, and postural improvements, and all (100%) noticed peripheral vision and social skills improvements (Table B, available in the online version of this article).

Children's Social, Functional, and Behavioral Improvements in the Daily Activities Questionnaire (SFBIDA-Q): Caregivers' Perceptions After Strabismus Surgery

Table B:

Children's Social, Functional, and Behavioral Improvements in the Daily Activities Questionnaire (SFBIDA-Q): Caregivers' Perceptions After Strabismus Surgery

Discussion

The current study, which was performed to investigate the surgical and functional outcomes of strabismus surgery in children with congenital Zika syndrome, considered ocular alignment, visual field expansion, and the parents' and caregivers' perceptions of their child's social, functional, and behavioral interactions in daily life activities.

Surgical outcomes of strabismus surgery in children with neurological disorders often focus only on alignment, and do not address developmental improvements, social/communication, or other functional improvements for the child. One of the strengths of this study is addressing this important aspect of rehabilitation.

The surgical visual outcomes at the 4- and 6-month follow-up visit were investigated in 5 children with infantile strabismus (4 with esotropia, and 1 with exotropia). All of the children had developmental delay and poor visual acuity, and most had binocular peripheral visual field constriction. Within the 6-month follow-up, motor-surgical success was achieved in 4 children (80%). Two children (40%) presented with mild vertical misalignment, 1 with intermittent hypertropia, and 1 with compensated dissociated vertical deviation. Overcorrection was found in 1 patient (patient 3) with esotropia who presented preoperatively with latent nystagmus and unstable angles of strabismus. Postoperatively, the patient developed overaction of the superior oblique muscle, consecutive exotropia (16 PD), and an A-pattern esotropia.

Children with neurodevelopmental delays have strabismus at rates that exceed those detected in neurologically typical children.6–8 Consequently, anomalous eye movements impair mobility, communication, reading, writing, learning, daily living skills, and assisted communication skills.11 In prenatal Zika virus infection, the developing fetal brain is highly vulnerable to pathogenic outcomes due to the neurotropic nature of the virus.14 Thus, children with congenital Zika syndrome often present with microcephaly and other neurologic disorders, such as hydrocephalus, seizures, or cognitive and developmental delays related to the location of the brain damage.1 There was a history of hydrocephalus in 40% of our patients, and all of our patients used seizure medication, both of which can affect the ocular motility.15

A spectrum of visual disorders, including reduced visual acuity and visual function, visual function defects, oculomotor system dysfunction, and cerebral/cortical visual impairment resulting from retrogeniculate visual pathway involvement, are considered the core findings of congenital Zika syndrome.3 In addition, refractive errors and poor accommodation are commonly found in children with congenital Zika syndrome, which may contribute to their visual impairment.2,3 Thus, many of these children may need refractive correction and bifocals for hypoaccommodation before strabismus surgery is planned.16

Few patients with cerebral/cortical visual impairment and strabismus (16%) experience spontaneous resolution of the strabismus.17 In their 10-year follow-up cohort, Binder et al.17 achieved long-term orthotropia in 56% of the patients with cerebral/cortical visual impairment. Therefore, surgery may be considered for misalignment correction in these patients. Nevertheless, the results of strabismus surgery are considered less predictable in children with neurological disorders. It has been said that standard strabismus surgery corrections in patients with neurological disorders could result in an overcorrection of the deviation, suggesting that less correction should be performed in these patients.18 In contrast, other studies have achieved good success rates following standard surgical tables for procedural planning in patients with Down syndrome.19,20 Considering the visual impairment in our sample, the deviation was measured at near and the angle of strabismus in primary position was used for surgical planning. Moreover, the surgical team opted to perform a lower degree of horizontal surgery for the patients with infantile esotropia than suggested in the standard surgical tables to avoid overcorrection.

Restoration of binocular fusion, expansion of the binocular peripheral visual fields, and improvement in psychosocial and daily functioning are major reasons to correct strabismus.6,7,21,22 Defective visual field performance may reflect on the patient's visual function and adaptive sensorimotor coordination.23–25 In pediatric patients with brain damage (cerebral palsy and cortical visual impairment), accurate visual fields assessment represents a challenge because they have visual attention and fixation deficits and postural difficulties.12,23 Despite having to consider this when interpreting the results, measuring the visual fields is important to assess the visual function and plan the surgery.12,13,17

In our sample, bilateral visual fields were assessed preoperatively and postoperatively. Normal bilateral visual fields in the temporal meridian were only observed in 3 (30%) of 10 temporal fields preoperatively compared to 7 (70%) of 10 temporal fields within 6 months postoperatively. Postoperatively, an expansion of the binocular temporal visual function occurred in two children with infantile esotropia and one child with infantile exotropia (patients 2, 4, and 5). Although binocular field expansion was commonly found in patients with esotropia after successful surgery for misalignment, one of our patients with exotropia (patient 5) also had postoperative visual function expansion.25 This same child with infantile exotropia presented with preoperative bilateral limitation in up gaze and bilateral adduction and responded with motor success, including elevation and adduction in the postoperative assessments. It is important to emphasize that this happened regardless of the presence of structural ocular findings and/or cortical visual impairment.

Patient 3 presented with reduced visual fields in both temporal meridians on two different testing days postoperatively, possibly explained in part by the seizures that the child had at the time despite treatment.

In the current study, the social, functional, and behavioral gains in daily activities reported by the children's caregivers after surgery for infantile strabismus (esotropia or exotropia), regardless of the presence of visual impairment, may be due to the postoperative expansion of their bilateral visual fields. If this is true, it further reinforces the importance of the strabismus correction in children with congenital Zika syndrome. Their caregivers mentioned that they would recommend strabismus correction for other children with congenital Zika syndrome.

The strengths of the current study include our sample selection, in that only patients were included who have been examined routinely since the neonatal period, every 3 months during the first 3 years of life, and every 6 months thereafter by the same group of pediatric ophthalmologists from the Altino Ventura Foundation. In addition, for strabismus surgery planning, a minimum of three preoperative assessments, during which the patients wore correction for refractive error and/or hypoaccommodation, were performed and the surgeries were done using the same protocol.

The limitations of the current study included the small sample size and short follow-up, which we plan to address as we expand our cohort. Other limitations included the patients' severe visual impairment, attention deficit, presence of other comorbid conditions including seizures, and use of medications that may have affected the ocular alignment measurements and could explain the visual field variations detected in patients 3 and 4 at the 4- and 6-month follow-up visits. Another potential limitation was that this was a single-center study; therefore, the results cannot be generalized. Future large, multicenter, prospective studies are recommended.

Nevertheless, our results suggested that selected children with congenital Zika syndrome may achieve motor surgical success and visual field expansion, which are great benefits for their global development. This successful surgical outcome also has positively impacted the children's social, functional, and behavioral skills, as subjectively reported by parents and/or caregivers. Strabismus surgery can improve ocular alignment, expand visual fields, and improve social, functional, and behavioral skills in children with congenital Zika syndrome.

References

  1. Moore CA, Staples JE, Dobyns WB, et al. Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric clinicians. JAMA Pediatr. 2017;171(3):288–295. doi:10.1001/jamapediatrics.2016.3982 [CrossRef]
  2. Ventura LO, Ventura CV, Lawrence L, et al. Visual impairment in children with congenital Zika syndrome. J AAPOS. 2017;21(4):295–299.e2. doi:10.1016/j.jaapos.2017.04.003 [CrossRef]
  3. Ventura LO, Ventura CV, Dias NC, et al. Visual impairment evaluation in 119 children with congenital Zika syndrome. J AAPOS. 2018;22(3):218–222.e1. doi:10.1016/j.jaapos.2018.01.009 [CrossRef]
  4. Good WV. The spectrum of vision impairment caused by pediatric neurological injury. J AAPOS. 2007;11(5):424–425. doi:10.1016/j.jaapos.2007.08.002 [CrossRef]
  5. Jackson J, Castleberry C, Galli M, Arnoldi KA. Cerebral palsy for the pediatric eye care team—part II: diagnosis and treatment of ocular motor deficits. Am Orthopt J. 2006;56(1):86–96. doi:10.3368/aoj.56.1.86 [CrossRef]
  6. Ghasia F, Brunstrom-Hernandez J, Tychsen L. Repair of strabismus and binocular fusion in children with cerebral palsy: gross motor function classification scale. Invest Ophthalmol Vis Sci. 2011;52(10):7664–7671. doi:10.1167/iovs.10-6906 [CrossRef]
  7. Can CÜ, Polat S, Yasar M, Ilhan B, Altintas AG. Ocular alignment and results of strabismus surgery in neurologically impaired children. Int J Ophthalmol. 2012;5(1):113–115.
  8. Habot-Wilner Z, Spierer A, Barequet IS, Wygnanski-Jaffe T. Long-term results of esotropia surgery in children with developmental delay. J AAPOS. 2012;16(1):32–35. doi:10.1016/j.jaapos.2011.10.013 [CrossRef]
  9. Teller DY, McDonald MA, Preston K, Sebris SL, Dobson V. Assessment of visual acuity in infants and children: the acuity card procedure. Dev Med Child Neurol. 1986;28(6):779–789. doi:10.1111/j.1469-8749.1986.tb03932.x [CrossRef]
  10. Colenbrander A. Aspects of vision loss–visual functions and functional vision. Vis Impair Res. 2003;5(3):115–136. doi:10.1080/1388235039048919 [CrossRef]
  11. Ghasia F, Brunstom J, Tychsen L. Visual acuity and visually evoked responses in children with cerebral palsy: Gross Motor Function Classification Scale. Br J Ophthalmol. 2009;93(8):1068–1072. doi:10.1136/bjo.2008.156372 [CrossRef]
  12. Myers VS, Gidlewski N, Quinn GE, Miller D, Dobson V. Distance and near visual acuity, contrast sensitivity, and visual fields of 10-year-old children. Arch Ophthalmol. 1999;117(1):94–99. doi:10.1001/archopht.117.1.94 [CrossRef]
  13. Quinn GE, Fea AM, Minguini N. Visual fields in 4- to 10-year-old children using Goldmann and double-arc perimeters. J Pediatr Ophthalmol Strabismus. 1991;28(6):314–319.
  14. Tang H, Hammack C, Ogden SC, et al. Zika virus infects human cortical neural progenitors and attenuates their growth. Cell Stem Cell. 2016;18(5):587–590. doi:10.1016/j.stem.2016.02.016 [CrossRef]
  15. Richa S, Yazbek JC. Ocular adverse effects of common psychotropic agents: a review. CNS Drugs. 2010;24(6):501–526. doi:10.2165/11533180 [CrossRef]
  16. Ventura LO, Lawrence L, Ventura CV, et al. Response to correction of refractive errors and hypoaccommodation in children with congenital Zika syndrome. J AAPOS. 2017;21(6):480–484.e1. doi:10.1016/j.jaapos.2017.07.206 [CrossRef]
  17. Binder NR, Kruglyakova J, Borchert MS. Strabismus in patients with cortical visual impairment: outcomes of surgery and observations of spontaneous resolution. J AAPOS. 2016;20(2):121–125. doi:10.1016/j.jaapos.2015.12.010 [CrossRef]
  18. Pickering JD, Simon JW, Ratliff CD, Melsopp KB, Lininger LL. Alignment success following medical rectus recessions in normal and delayed children. J Pediatr Ophthalmol Strabismus. 1995;32(4):225–227. doi:10.3928/0191-3913-19950701-05 [CrossRef]
  19. Yahalom C, Mechoulam H, Cohen E, Anteby I. Strabismus surgery outcome among children and young adults with Down syndrome. J AAPOS. 2010;14(2):117–119. doi:10.1016/j.jaapos.2010.01.009 [CrossRef]
  20. Hiles DA, Hoyme SH, McFarlane F. Down's syndrome and strabismus. Am Orthopt J. 1974;24(1):63–68. doi:10.1080/006595 5X.1974.11982348 [CrossRef]
  21. Habot-Wilner Z, Spierer A, Glovinsky J, Wygnanski-Jaffe T. Bilateral medial rectus muscle recession: results in children with developmental delay compared with normally developed children. J AAPOS. 2006;10(2):150–154. doi:10.1016/j.jaapos.2005.11.013 [CrossRef]
  22. Jacobson L, Ygge J, Flodmark O, Ek U. Visual and perceptual characteristics, ocular motility and strabismus in children with periventricular leukomalacia. Strabismus. 2002;10(2):179–183. doi:10.1076/stra.10.2.179.8132 [CrossRef]
  23. Philip SS, Dutton GN. Identifying and characterising cerebral visual impairment in children: a review. Clin Exp Optom. 2014;97(3):196–208. doi:10.1111/cxo.12155 [CrossRef]
  24. Han SY, Han J, Han SH, Lee JB, Rhiu S. Ocular alignment after bilateral lateral rectus recession in exotropic children with cerebral palsy. Br J Ophthalmol. 2015;99(6):757–761. doi:10.1136/bjophthalmol-2014-305758 [CrossRef]
  25. Kushner BJ. Binocular field expansion in adults after surgery for esotropia. Arch Ophthalmol. 1994;112(5):639–643. doi:10.1001/archopht.1994.01090170083027 [CrossRef]

Preoperative Ophthalmologic Characteristics

Ophthalmologic ExaminationPatienta

12345





ODOSODOSODOSODOSODOS
Visual acuity (cy/cm)3.20b2.40b4.80c0.86c2.40b4.80b0.64b3.20b1.60c0.00c
Visual impairmentdSVLPVLSVLPVLSVLMVLPVLSVLPVLNTVL
Spherical equivalent (D)+2.00+2.00+3.50+4.00−2.50−2.75−9.00−9.00−3.00−0.25
Fundus fiindings
  Optic nerve
    HypoplasiaNNNNNNYYNN
    PallorNNNNNNYYNN
    Increased disc cuppingNNNNNNYYYY
  Retina
    Pigment mottlingNNNNYNYYNN
    Chorioretinal scarNNNNNNYYNN
    Hypochromic lesionsNNNNNNNNNY
  Retinal vasculature
    Vasculature attenuationNNYYNNYYNN
    Increased tortuosityNNNNNNNNYY

Preoperative Ocular Motility and Surgical Procedures Performed

PatientNystagmusPreoperative AlignmentaSurgical Procedure (mm)
1NET = 35 PDBMR = 4.0
2YbET = 40 PDcOD MR = 6.5, SRT; OS MR = 5.0, SRT
3YdET = 50 PDBMR = 5.5
4YbET = 40 PDBMR = 5.0
5NXT = 65 PD; OASO OUBLR = 11.0; OS MRc = 4.0; BSOT

Preoperative and Postoperative Horizontal Visual Fields in Children With Congenital Zika Syndrome

PatientEyeVisual FieldVisual Field Improvement (%)


Preoperativea4 Monthsa6 Monthsa4 Months6 Months
1bOD45609033%100%
OS45609033%100%
2bOD9090900%0%
OS60909050%50%
3bOD907590−17%0%
OS906090−33%0%
4bOD459050100%11%
OS60909050%50%
5cOD45605033%11%
OS53060500%1100%

Children's Social, Functional, and Behavioral Improvements in the Daily Activities Questionnaire (SFBIDA-Q): Caregivers' Perceptions After Strabismus Surgery

PatientEye ContactVisual AttentionPeripheral Field Target DetectionPostureSocialization
1YesYesYesNoYes
2YesYesYesYesYes
3NoNoYesYesYes
4YesYesYesYesYes
5YesYesYesYesYes
Total improvement (%)808010080100
Authors

From the Department of Ophthalmology, Altino Ventura Foundation, Recife, Brazil (LOV, ST, MCVF, PM, NC, VX, ALG, CVV); the Department of Ophthalmology, HOPE Eye Hospital, Recife, Brazil (LOV, ST, PM, NC, ALG, CVV); Private Ophthalmology Practice, Salina, Kansas (LL); and the Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina (MEW).

The authors have no financial or proprietary interest in the materials presented herein.

The authors thank the Department of Research of the Altino Ventura Foundation for their efforts with the preparation of this manuscript and the children and their families for participation in this study.

Correspondence: Camila V. Ventura, MD, PhD, Altino Ventura Foundation, Rua da Soledade, 170 Boa Vista, Recife, 50070-040 PE, Brazil. E-mail: camilaventuramd@gmail.com

Received: December 26, 2019
Accepted: February 17, 2020

10.3928/01913913-20200331-01

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