Utility of the MISDEF2 Algorithm and Extent of Fusion in Open Adult Spinal Deformity Surgery With Minimum 2-Year Follow-up

Objective: Long-segment fusion in adult spinal deformity (ASD) is often needed, but more focal surgeries may provide significant relief with less morbidity. The minimally invasive spinal deformity surgery (MISDEF2) algorithm guides minimally invasive ASD surgery, but it may be useful in open ASD surgery. We classified ASD patients undergoing focal decompression, limited decompression and fusion, and full correction according to MISDEF2 and correlated outcomes.Methods: A retrospective study of ASD patients treated by 2 surgeons at our hospital was performed. Inclusion criteria were: age > 50, minimum 2-year follow-up, and open ASD surgery. Tumor, trauma, and infections were excluded. Patients had open surgery including focal decompression, short segment fusion, or full scoliosis correction. All patients were categorized by MISDEF2 into 4 classes based upon spinopelvic parameters. Perioperative metrics were assessed. Radiographic correction, complications and reoperation were recorded.Results: A total of 136 patients met inclusion criteria. Mean follow-up was 46 ± 15.8 months (range, 24–118 months). Forty-seven underwent full deformity correction, 71 underwent short segment fusion, and 18 underwent decompression alone. There were 24 cases of class I, 66 cases of class II, 23 cases of class III, and 23 cases of class IV patients. Patients in class I and II had perioperative complication rates of 0% and 16.7% and revision rates of 8% and 21.2% when undergoing focal decompression or limited fusion. However, class II patients undergoing full correction had higher perioperative complications rate (p = 0.03) and revision surgery rates (p = 0.047). This difference was not seen in class III patients (p > 0.05). All class IV patients underwent full correction, but they had higher perioperative complication rates (p < 0.019), comparable revision surgery rates (p = 0.27), and better radiographic realignment (p < 0.001). In addition, full deformity correction was associated with longer length of stay, increased blood loss, and longer operative time (p < 0.001).Conclusion: The MISDEF2 algorithm may help guide ASD surgical decision making even in open surgery, with focal treatment used in class I and II patients as a viable alternative and full correction implemented in class IV patients because of severe malalignment. However, class II patients with ASD undergoing full deformity correction do have higher complication rates.

Brain Activation Induced by Myopic and Hyperopic Defocus From Spectacles

Purpose: To assess neural changes in perceptual effects induced by myopic defocus and hyperopic defocus stimuli in ametropic and emmetropic subjects using functional magnetic resonance imaging (fMRI).Methods: This study included 41 subjects with a mean age of 26.0 ± 2.9 years. The mean spherical equivalence refraction was −0.54 ± 0.51D in the emmetropic group and −3.57 ± 2.27D in the ametropic group. The subjects were instructed to view through full refractive correction, with values of +2.00D to induce myopic defocus state and −2.00D to induce hyperopic defocus state. This was carried over in three random sessions. Arterial spin labeling (ASL) perfusion was measured using fMRI to obtain quantified regional cerebral blood flow (rCBF). Behavioral tests including distant visual acuity (VA) and contrast sensitivity (CS), were measured every 5 min for 30 min.Results: Myopic defocus induced significantly greater rCBF increase in four cerebral regions compared with full correction: right precentral gyrus, right superior temporal gyrus, left inferior parietal lobule, and left middle temporal gyrus (P &lt; 0.001). The differences were less significant in low myopes than emmetropes. In the hyperopic defocus session, the increased responses of rCBF were only observed in the right and left precentral gyrus. Myopic defocused VA and CS improved significantly within 5 min and reached a plateau shortly after.Conclusion: This study revealed that myopic defocus stimuli can significantly increase blood perfusion in visual attention-related cerebral regions, which suggests a potential direction for future investigation on the relationship between retinal defocus and its neural consequences.

Management of resistant congenital clubfeet by the new operative procedure (Hussain's procedure): An experience of a fellowship program

Background and Objectives: Pakistan Society for Rehabilitation of the Disabled Orthopedic Hospital is renowned for the correction of orthopedic deformities including foot and ankle deformities. Consultant orthopedic surgeon Afzal Hussain, pioneers the treatment of orthopedic deformities and has developed a new operative technique for congenital clubfoot. This research was planned to report the success of Hussain's Procedure in detecting and managing the anomalous structures. Material and Methods: This research was mixed retrospective and prospective research carried out during fellowship of first author in which, operative procedure of the resistant congenital clubfoot associated with anomalous structures viz. anomalous muscles and tarsal coalitions, were performed with the new operative procedure by Dr. Hussain, were assisted by the first author and a minimum of 5 years of follow up of the cases was done by the senior author (Afzal Hussain). Cumming’s modification of Laavag and Ponseti score was applied for the calculation of the results at the follow-ups. Results: During the fellowship, 10 cases of clubfeet with muscle anomalies were managed. Similarly 7 clubfeet with tarsal coalitions were managed. There was full correction of the clubfoot deformity. The cases were followed up by the senior author (Afzal Hussain) for at least 5 years. During the minimum of 5 years followup post completion of treatment, Cumming’s modification of Laavag and Ponseti scores of the operated clubfeet were found to be excellent. Conclusion: The resistance to management of congenital clubfoot by casting may be because of anomalous structures. New operative procedure by Consultant Afzal Hussain names as Hussain's Procedure was helpful in detecting and managing the anomalous structures.

Neglected сlubfoot treated by Ilizarov and Ponseti methods

The Ponseti method has revolutionized clubfoot treatment. Though completely neglected clubfeet are now rare, partially or incompletely and improperly treated feet are not uncommon. Relapses after successful correction may occur due to non-compliance with bracing. In scarred soft tissues due to previous surgery, soft tissue distraction using external fixation helps achieve correction. The Ilizarov fixator permits us to follow the Ponseti protocol, using correction methods that may either be constrained or unconstrained by hinges. Applying force vectors perpendicular to the moment arm allows us to correct the еquinus without damaging the ankle joint. All of the above is possible when the talus is round. Full correction of the deformity is possible. However, longterm follow-up of these patients has revealed stiffness of the ankle setting and frequently with tibio-talar osteophytes anteriorly. They are probably a reaction to excessive pressure developed in the joint due to the tight soft tissues. Hence the author has now added a mild shortening of the tibia and fibula to reduce soft tissue tension, rather than resorting to further soft tissue releases through scarred tissues. This allows faster correction with the Ponseti-Ilizarov protocol and allows good ankle range of motion to persist.

Influence of Lenslet Configuration on Short-Term Visual Performance in Myopia Control Spectacle Lenses

Purpose: This study aimed to evaluate short-term visual performance and optical quality of three different lenslet configurations on myopia control spectacle lenses.Materials and Methods: This study utilized a cross-over design. Distance visual acuity (VA) was measured in 50 myopic children; contrast sensitivity (CS) was measured in 36 myopic children. For each test, four spectacle lenses were evaluated in a random order: single-vision lens (SVL), lens with concentric rings of highly aspherical lenslets (HAL), lens with concentric rings of slightly aspherical lenslets (SAL), and lens with honeycomb configuration of spherical lenslets (HC). The modulation transfer function (MTF) and MTF area (MTFa) were used to determine optical quality. All tests were performed monocularly on the right eye with full correction.Results: HAL and SAL had larger MTFa than HC. VA in lenses with lenslets was significantly reduced compared to SVL (all p &lt; 0.01). The reduction in VA was worse with HC than with SAL (p = 0.02) and HAL (p = 0.03); no effect of lenslet asphericity was found (p &gt; 0.05). VA changes induced by lenslets showed no correlation with spherical equivalent refraction (all p &gt; 0.05) and were weakly positively associated with age for SAL (r = 0.36, p = 0.01) and HC (r = 0.31, p = 0.03), but not for HAL (p = 0.30). The area under the log contrast sensitivity function (AULCSF) decreased with HAL and HC (all p &lt; 0.001) in all illumination levels, and AULCSF with HAL was higher than that with HC in a photopic condition (1.17 ± 0.10 vs. 1.10 ± 0.13, p = 0.0004). The presence of lenslets did not affect CS at 3 cycles per degree (cpd) (p = 0.80). At 6 to 18 cpd, CS was significantly reduced by HAL and HC (all p &lt; 0.05), but not SAL (p &gt; 0.05) compared to SVL. At high spatial frequencies (&gt;12 cpd) both SAL and HAL reduced CS significantly less than HC (all p &lt; 0.01).Conclusion: Short-term visual performance was minimally impaired by looking through the lenslet structure of myopia control spectacle lenses. Concentric rings with aspherical lenslets had a significantly lower impact on both VA and CS than honeycomb configuration with spherical lenslets.

The Evaluation of Deformity Correction in Idiopathic Clubfoot During Ponseti Casting Sessions: Two Scoring Methods Depicted Graphically

Background We graphically analyzed the correction of total Pirani and Dimeglio scores and their subcomponents at sequential casting sessions for children with idiopathic clubfeet. Methods Correction of scores at weekly sessions was represented graphically. The tenotomy effect was accounted for separately. We classified 1st to 3rd casts as early, 4th and 5th cast midlevel, and beyond 5 as final casts to describe casting treatment. Results A total of 88 clubfeet (34 bilateral) in 54 patients were studied. Both total Pirani and Dimeglio graphs were characterized by a steep fall in early casts; subsequent minimal improvement in midlevel and final casts; later marked correction with tenotomy. Equinus in both scores stood as the most resistant deformity, showed full correction only following tenotomy. Dimeglio graphs captured coupling of various foot motions better over early casts than Pirani graphs. Conclusions Both Pirani and Dimeglio scores can adequately guide caregivers to progressive deformity correction in clubfoot. Keywords: Clubfoot, CTEV, Pirani, Dimeglio, Scores, Graphs

Aniseikonia and visual functions with optical correction and after refractive surgery in axial anisometropia

PURPOSE To evaluate differences in the subjective aniseikonia and stereoacuity in patients with axial anisometropia after full correction of the refractive error with spectacles. contact lenses, and refractive surgery.METHODS A prospective study was performed in Cairo University Hospitals on 20 patients with axial anisometropia caused by unilateral myopia > 5 D with > 4 D inter-ocular difference in spherical equivalent who were suitable candidates for excimer laser ablation (LASIK) or implantable collamer lens implantation (ICL) were included. All patients had measurement of corrected distance visual acuity (CDVA), fusion, and stereoacuity testing, and measurement of aniseikonia with spectacles, contact lenses, and after surgery.RESULTS Mean age at time of surgery was 25.7 ± 3.1 years. There were no statistically significant differences in the CDVA or stereoacuity with spectacles, contact lenses, or after refractive surgery. Microkonia < 5%) was perceived with spectacles in 8 patients (40%) and remained unchanged in 7 of these 8 patients with contact lenses. Following LASIK (n = 11), there was macrokonia < 2% in 4 patients (36%), persistent microkonia of 3% in 1 patient (9%), and no change in image size in 6 (55%) patients. Following ICL implantation (n = 9), there was perceived macrokonia of 2% in 4 patients (44%), disappearance of microkonia in 1 patient (11%) and no change in 4 patients (44%).CONCLUSIONS Differences in CDVA, stereoacuity, and aniseikonia after correction of anisometropia by glasses, contact lens and surgery are both clinically and statistically significant. Retinal or neural adaptation might have a role in correction for differences in image size.

Accommodation Dynamics in Children Wearing Bifocal Soft Contact Lenses with High Addition Power

Purpose: to evaluate dynamics of subjective and objective accommodation in children wearing bifocal soft contact lenses (BSCLs) for myopia control with +4.00 D addition power. M e t h o d s: the study involved 22 patients (44 eyes).Mean age amounted to 10.1 ± 1.46 years and mean myopic refraction amounted to –3.21 ± 1.23 D. Patients were fitted Prima BIO Bi-focal BSCLs (OKVision Retail, Russia). All patients underwent cycloplegic refraction assessed with Auto Ref/Keratometer ARK 530A (Nidek, Japan), had axial length measured with IOL Master 500 optical biometry device (Carl Zeiss, Germany), had positive relative accommodation (PRA) assessed with and without lenses and had binocular (BAR) and monocular (MAR) accommodative response assessed at a distance of 33 cm with WAM-5500 Binocular Accommodation Auto Ref/Keratometer (Grand Seiko, Japan) prior to wearing BSCLs as well as 3, 6 and 12 months after wearing BSCLs.Results: neither MAR nor BAR measured without lenses changed after 3, 6 and 12 months of wearing BSCLs (p >0,05). A change in PRA evaluated without lenses was noted after 12 months (p < 0,05). PRA evaluated with lenses after 3, 6 and 12 months differed from baseline significantly (p < 0,001). Over 12 months of wearing BSCLs, changes in AL (0.09 ± 0.17 mm) and cycloplegic refraction (0.3 ±0.43 D) correlated with baseline BAR and MAR loosely. C o n c l u s i o n: objective accommodation (MAR and BAR) did not change in the course of wearing BSCLs with +4.00 D addition power. Increase in PRA evaluated without BSCLs may be associated with improvement of accommodation due to a full correction in the optic zone. The gradual increase in PRA evaluated with BSCLs probably indicates an adaptation of patients to addition zone in near vision conditions.

Outcome of surgery for near angle in patient with incomitant distance/near esotropia and without manifest deviation at distance

Introduction: To investigate how a subset of patients with partially accommodative esotropia, with a manifest deviation <10 Prism Diopters (PD) at distance and an angle of strabismus at near wider than 10 PD, could respond to a surgical approach based on the misalignment at near. Methods: Six patients examined from 2015 to 2019 met criteria for inclusion: partially accommodative esotropia, patients compliant to full correction for at least 6 months, angle of esotropia for near larger at least 10 PD, angle of misalignment obtained with the alternate prism cover test and simultaneous prism cover test at distance <10 PD. All patients underwent bilateral medial recti recession. They were examined at 3 weeks and at 6 months. Results: No significant difference in the angle of esotropia at distance was found at any follow-up (Baseline: 7.17 ± 1.33 PD vs 3 weeks: 7.0 ± 1.01 PD vs 6 months: 7.33 ± 1.03 PD, p = 0.65, and p = 0.36, respectively). No case of consecutive exotropia was described. Considering the angle at near, there was a significant reduction at 3 weeks (Baseline: 41.7 ± 6.83 PD vs 3 weeks: 9.33 ± 1.63 PD, p = 0.027), that remained stable at the final follow-up (9.0 ± 1.1 PD, p = 0.32). All patients were suppressors and had nil stereopsis pre-operatively, all of them developed fusion and a different degree of stereopsis [276 ± 284 arcseconds (Range 80–800)]. Conclusions: A surgical approach based on the angle of strabismus for near could obtain satisfactory ocular alignment without consecutive exotropia in children with partially accommodative esotropia wearing full refractive correction, with a manifest deviation for distance <10 PD and a higher misalignment for near, at least for 6 months after surgery.