Priest Hospital

This review provides an updated summary of the state of our knowledge of the genetic contributions to the pathogenesis of congenital heart disease. Since 2007, when the initial American Heart Association scientific statement on the genetic basis of congenital heart disease was published, new genomic techniques have become widely available that have dramatically changed our understanding of the causes of congenital heart disease and, clinically, have allowed more accurate definition of the pathogeneses of congenital heart disease in patients of all ages and even prenatally. Information is presented on new molecular testing techniques and their application to congenital heart disease, both isolated and associated with other congenital anomalies or syndromes. Recent advances in the understanding of copy number variants, syndromes, RASopathies, and heterotaxy/ciliopathies are provided. Insights into new research with congenital heart disease models, including genetically manipulated animals such as mice, chicks, and zebrafish, as well as human induced pluripotent stem cell-based approaches are provided to allow an understanding of how future research breakthroughs for congenital heart disease are likely to happen. It is anticipated that this review will provide a large range of health care-related personnel, including pediatric cardiologists, pediatricians, adult cardiologists, thoracic surgeons, obstetricians, geneticists, genetic counselors, and other related clinicians, timely information on the genetic aspects of congenital heart disease. The objective is to provide a comprehensive basis for interdisciplinary care for those with congenital heart disease.

BACKGROUND: Low birthweight has been associated with a higher risk of hypertension, type 2 diabetes mellitus (T2D), and cardiovascular disease. The Barker hypothesis posits that intrauterine growth restriction resulting in lower birthweight is causal for these diseases, but causality is difficult to infer from observational studies. METHODS: We performed regression analyses to assess associations of birthweight with cardiovascular disease and T2D in 237 631 individuals from the UK Biobank. Further, we assessed the causal relationship of such associations using Mendelian randomization. RESULTS: In the observational analyses, birthweight showed inverse associations with systolic and diastolic blood pressure (β, -0.83 and -0.26; per raw unit in outcomes and SD change in birthweight; 95% confidence interval [CI], -0.90 to -0.75 and -0.31 to -0.22, respectively), T2D (odds ratio, 0.83; 95% CI, 0.79-0.87), lipid-lowering treatment (odds ratio, 0.84; 95% CI, 0.81-0.86), and coronary artery disease (hazard ratio, 0.85; 95% CI, 0.78-0.94), whereas the associations with adult body mass index and body fat (β, 0.04 and 0.02; per SD change in outcomes and birthweight; 95% CI, 0.03-0.04 and 0.01-0.02, respectively) were positive. The Mendelian randomization analyses indicated inverse causal associations of birthweight with low-density lipoprotein cholesterol, 2-hour glucose, coronary artery disease, and T2D and positive causal association with body mass index but no associations with blood pressure. CONCLUSIONS: Our study indicates that lower birthweight, used as a proxy for intrauterine growth retardation, is causally related with increased susceptibility to coronary artery disease and T2D. This causal relationship is not mediated by adult obesity or hypertension.

BACKGROUND AND PURPOSE: EmboTrap is a novel stent retriever designed to achieve rapid and substantial flow restoration in acute ischemic stroke secondary to large-vessel occlusions. Here, we evaluated EmboTrap's safety and efficacy compared with established stent retrievers. METHODS: ARISE II (Analysis of Revascularization in Ischemic Stroke With EmboTrap) was a single-arm, prospective, multicenter study, comparing the EmboTrap device to a composite performance goal criterion derived using a Bayesian meta-analysis from the pivotal SWIFT (Solitaire device) and TREVO 2 (Trevo device) trials. Patients at 11 US and 8 European sites were eligible for inclusion if they had large-vessel occlusions and moderate-to-severe neurological deficits within 8 hours of symptom onset. The primary efficacy end point was achievement of modified Thrombolysis in Cerebral Ischemia (mTICI) reperfusion scores of ≥2b within 3 EmboTrap passes as adjudicated by the core laboratory. The primary safety end point was a composite of symptomatic intracerebral hemorrhage and serious adverse device effects. Secondary end points included functional independence (modified Rankin Scale, 0-2) and all-cause mortality at 90 days. RESULTS: value, <0.0001), and mTICI 2c/3 was 65%. After all interventions, mTICI 2c/3 was achieved in 76%, and mTICI ≥2b was 92.5%. The rate of first pass (mTICI ≥2b following a single pass) was 51.5%. The primary safety end point composite rate of symptomatic intracerebral hemorrhage or serious adverse device effects was 5.3%. Functional independence and all-cause mortality at 90 days were 67% and 9%, respectively. CONCLUSIONS: The EmboTrap stent-retriever mechanical thrombectomy device demonstrated high rates of substantial reperfusion and functional independence in patients with acute ischemic stroke secondary to large-vessel occlusions. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02488915.

PURPOSE: Cardiac rehabilitation (CR) is a program of structured exercise and interventions for coronary risk factor reduction that reduces morbidity and mortality rates following a major cardiac event. Although a dose-response relationship between the number of CR sessions completed and health outcomes has been demonstrated, adherence with CR is not high. In this study, we examined associations between the number of sessions completed within CR and patient demographics, clinical characteristics, smoking status, and socioeconomic status (SES). METHODS: Multiple logistic regression and classification and regression tree (CART) modeling were used to examine associations between participant characteristics measured at CR intake and the number of sessions completed in a prospectively collected CR clinical database (n = 1658). RESULTS: Current smoking, lower SES, nonsurgical diagnosis, exercise-limiting comorbidities, and lower age independently predicted fewer sessions completed. The CART analysis illustrates how combinations of these characteristics (ie, risk profiles) predict the number of sessions completed. Those with the highest-risk profile for nonadherence (<65 years old, current smoker, lower SES) completed on average 9 sessions while those with the lowest-risk profile (>72 years old, not current smoker, higher SES, surgical diagnosis) completed 27 sessions on average. CONCLUSIONS: Younger individuals, as well as those who report smoking or economic challenges or have a nonsurgical diagnosis, may require additional support to maintain CR session attendance.

PURPOSE: To compare the efficacy and safety profiles of XEN implant versus trabeculectomy as a surgical intervention for primary glaucoma. METHODS: A retrospective cohort study of mild to moderate stage glaucoma patients, who had undergone either XEN implantation or trabeculectomy with adjunctive mitomycin C, was performed in a tertiary eye center. RESULTS: Fifty-seven eyes for XEN implant and 57 eyes for trabeculectomy with medically uncontrolled glaucoma were included. Preoperative IOP was 16-33 mmHg. Visual field mean deviation was -9.11±6.93 dB in XEN group, and -9.67±5.06 dB in trabeculectomy group (p = 0.195). At the 24-month timepoint, mean IOP was reduced from 21.6±4.0 to 14.6±3.5 mmHg (32.4% reduction) in the XEN group (p<0.001), and from 22.5±5.8 to 12.5±4.1 mmHg (44.4% reduction) in the trabeculectomy group (p<0.001). Final IOP in XEN was significantly higher than trabeculectomy (p = 0.008) with lesser mean IOP percentage reduction at month 24 (p = 0.045). Mean number of medications was reduced from 2.2±1.4 to 0.5±0.7 in XEN group (p<0.001), and from 2.4±0.7 to 0.8±1.3 in trabeculectomy group (p<0.001). Final number of medications was not different between the groups (p = 0.225). Surgical success was comparable between XEN and trabeculectomy group. Overall success was 71.4% vs. 73.3% (p = 0.850), and complete success was 62.9% vs. 62.2% (p = 0.954), respectively. XEN had lower rate of numerical hypotony than trabeculectomy. No serious complication occurred in either procedure group. CONCLUSION: At 24 months, XEN showed a rate of success comparable to that of trabeculectomy. Although XEN had a higher final IOP than trabeculectomy, XEN achieved 32% IOP reduction, and achieved final IOP in mid-teen level. No serious complication occurred in either group. XEN can be applied for treatment of mild to moderate stages of glaucoma in Southeast Asian patients.

PURPOSE: Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR. METHODS: This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ 2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate. RESULTS: Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables. CONCLUSIONS: Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.

Three thousand and forty nine patients diagnosed with diabetes mellitus were examined in 13 community (district) hospitals in Lampang from January to December 2002. Complete eye examination with standard protocol was used to determine the prevalence and severity of diabetic retinopathy. The prevalence of the background or non-proliferative diabetic retinopathy (BDR or NPDR) was 18.9% and proliferative diabetic retinopathy (PDR) was 3% in all age groups. For the relationship of the duration of diabetes, it showed that the longer the duration of diabetes the higher the prevalence of diabetic retinopathy. In BDR or NPDR, the retinopathy varied from 13.11 to 22.91% in persons having diabetes for less than 10 years and up to 42.86% in those with diabetes for up to 20 years. In the PDR group, the prevalence was 2.15 to 2.42% in persons with diabetes for less than 10 years and up to 10.20% for those with diabetes for up to 20 years. The severity of retinopathy was found to be not only related to a longer duration of diabetes but also related to higher glycosylated hemoglobin levels, higher systolic blood pressure and the presence of proteinuria.

Taking tissue engineering applications into clinical trials requires the development of efficient and safe protocols incorporated with effective 3-dimensional cell culturing and differentiation systems in order to develop transplantable tissues that may offer a life-line for patients in the future. Cord blood, which is perhaps the most abundant world stem cell source, has shown previously practical and ethical advantages over other stem cells sources in many research and clinical applications including regenerative medicine. We previously developed a three-step protocol for isolation, expansion and sequential neuronal differentiation of cord blood pluripotent stem cells (characterized with our unique triple immunocytochemisty scheme for Oct-4, Sox-2 and Nanog) in defined serum-free culturing conditions. In this study we incorporated this protocol with 3-dimensional culturing systems which produced artificial neuronal tissues expressing Nestin, NF-200, TUJ1, PSD-95 and NeuN. We showed that cord blood pluripotent stem cells are a potential and promising candidate for future neural tissue engineering and regenerative medicine.

As the eye grows, the axial length increases while the cornea and lens flatten. High refractive errors which are common in the neonatal period, reduce rapidly during the first year of life through the process called emmetropization. The possibility that long-term full- time glasses wear may impede emmetropization must be considered. Hyperopia greater than 5.00 diopters (D) in young children is associated with an increased risk of amblyopia and strabismus, therefore optical correction should be prescribed. When hyperopia is associated with esotropia, full correction of the cycloplegic refractive error should be prescribed. Myopia greater than 8.00 D and astigmatism greater than 2.50 D are common causes of isometropic amblyopia. Patients with hyperopic anisometropia with as little as l D difference between the eyes may develop amblyopia while the difference should reach 3-4 D for myopic anisometropia to develop amblyopia. Full cycloplegic refractive difference between two eyes should be given to the anisometropic child in spite of age, strabismus and degree of anisometropia. Myopia control is the attempt to slow the rate of progression of myopia such as cycloplegic agents, plus lenses at near, and rigid contact lenses.

PURPOSE: To report the results of bupivacaine injection into the extraocular muscles to treat horizontal strabismus, both exotropia and esotropia. METHODS: Bupivacaine, 4.5 ml of a 0.50% solution, was injected into the medial rectus muscle in each of 14 exotropic patients and into the lateral rectus muscle in each of 6 esotropic patients with electromyographic control. The measures of alignment were made before the procedure and 1, 3, 6, and 12 months after injection. RESULTS: Of 20 patients, 15 had improved ocular alignment with the average change of 8.46, 8.2, 8.33 and 9 prism diopters (PD) at 1,3, 6 and 12 months, respectively. Two of 5 (40%) incomitant strabismus patients and 13 of 15 (86.66%) comitant strabismus patients had improvement in ocular alignment. Eleven of 14 exotropic patient and 4 of 6 esotropic patients had improvement in ocular alignment, averaging 9.73, 9.36, 9.54 and 6 PD in the exotropic group and 5, 5, 5, and 10.5 PD in the esotropic group. There was no serious complication from the injections. CONCLUSIONS: Bupivacaine injection improved ocular alignment in some patients. Denervated extraocular muscle did not respond well to bupivacaine. Bupivacaine improved ocular alignment equally in esotropic and exotropic patients.

BACKGROUND: Adenosine has been recommended as a first-line treatment for stable supraventricular tachycardia (SVT). Standard guidelines recommend 6-mg of adenosine administered intravenously (IV) with an immediate 20-ml IV bolus of normal saline solution (NSS; double syringe technique [DST]). However, a newly proposed single-syringe technique (SST), in which adenosine is diluted with an up to 20 ml IV bolus of NSS, was found to be beneficial. HYPOTHESIS: We hypothesized that the SST was noninferior to the DST for terminating stable SVT. METHODS: A pilot multicenter, single-blind, randomized controlled study was conducted at nine hospitals in north and northeast Thailand. Thirty patients who were diagnosed with stable SVT were randomized into two groups of 15, with one receiving adenosine via the DST and the other via the SST. We examined SVT termination, the average successful dose, and the complication rate of each group. Analyses were based on the intention-to-treat principle. RESULT: The termination rate was 93.3% in the DST and 100% in the SST group (p = 1.000), and the success rate of the first 6-mg dose of adenosine was 73.3% and 80%, respectively (p = 1.000). The total administered dose was 8.6 ± 5.1 mg in the DST group and 7.6 ± 4.5 mg in the SST group (p = .608). No complications were found in either group. CONCLUSIONS: The SST was non-inferior to the DST for termination of SVT. However, a further definitive study with a larger sample size is required.

In this paper, we consider the coordinated charging control of electrical vehicle (EV) in the charging stations. The goals are to minimize the total charging cost of all the vehicles at the charging station, respecting subscription type to electricity for charging station. The algorithm is based on a given future electricity prices and uses linear programming. This cost reduction of charging being achieved through bidirectional power flow between vehicles and grid. Thus functionalities of electrical vehicle can be divided into two aspects: on one hand, battery of the EV can be considered as a variable load. With optimal charging or smart charging for the battery, vehicle owners could maximize their profits by purchasing energy, G2V (Grid to Vehicle), at the lowest possible electricity price and in on the other hand, battery of the EV canal so be considered as energy storage capacity which has possibility to provide energy V2G (Vehicle to Grid). After the simulations performed by applying this strategy to coordinate EV charging, we achieved a cost reduction with 20% from the initial cost.

To evaluate the performance of a new swept source optical coherence tomography optical biometer, ANTERION, in ocular biometry and intraocular lens (IOL) calculation compared with the reference standard of Dual Scheimpflug Analyzer (GALILEI, G6). A prospective comparative study was conducted in a tertiary eye center. Cataract patients were scanned with both devices in a random fashion, and parameters from the devices were analyzed in terms of mean difference and intraclass correlation coefficient (ICC). Bland-Altman plots were performed to compare agreement between the devices. Ninety-six eyes from 96 patients were enrolled for evaluation. With the exception of ACD, all parameters were significantly different, but excellent agreement was revealed for all of them. The mean difference in axial length was 0.03 mm, and ICC was 0.999. Calculated IOL power with Barrett formula revealed that 93.75% were within 1 diopter and the prediction error was 0.03 diopter. Biometry of the devices were arithmetically different. However, the mean difference of the key factors in IOL calculation were small and appeared to be negligible for the purposes of clinical application. The performance of ANTERION was comparable to that of G6 in biometric measurement and IOL calculation; however, the devices cannot be used interchangeably.

PURPOSE: To investigate agreement between 2 swept source OCT biometers, IOL Master700 and Anterion, in various ocular biometry and intraocular lens (IOL) calculations of primary angle-closure disease (PACD). SETTING: Rajavithi Hospital, Bangkok, Thailand. DESIGN: Prospective comparative study. METHODS: This study conducted in a tertiary eye care center involving biometric measurements obtained with 2 devices in phakic eye with diagnosis of PACD. Mean difference and intraclass correlation coefficient (ICC) with confidence limits were assessed, and calculations of estimated residual refraction of the IOL were analysed using Barrett's formula. RESULTS: Sixty-nine eyes from 45 PACD patients were enrolled for the study. Excellent agreement of various parameters was revealed, with ICC (confidence limits) of K1 = 0.953 (0.861-0.979), K2 = 0.950 (0.778-0.98), ACD = 0.932 (0.529-0.978), WTW = 0.775 (0.477-0.888), and LT = 0.947 (0.905-0.97). Mean difference of axial length (AL) was -0.01 ± 0.02 mm with ICC of 1.000. IOL calculation was assessed with Barrett's formula, and Bland-Altman plot showed excellent agreement in the results of the 2 devices for the IOL power and estimated post-operative residual refraction (EPR). CONCLUSIONS: Mean differences of biometric parameters, obtained with IOL Master700 and Anterion, were small, and ICC showed excellent concordance. No clinical relevance in calculation of IOL power was found, and the two devices appeared to be comparably effective in clinical practice.

OBJECTIVE: To evaluate the effectiveness and safety of botulinum toxin A injection in treating overcorrected and undercorrected strabismus after unsatisfactory postoperative alignment. MATERIAL AND METHOD: The authors reviewed the outcomes of 20 patients aged 5 to 56 years (mean 29.1 years) who had botulinum toxin A injection following their unsatisfactory operation. The motor outcomes (percentage of successful motor outcome and percentage change in deviation) were recorded at 1 month, 3 months, 6 months, I year 2 years, 3 years, and 4 years after botulinum toxin injection. RESULTS: The mean pre-botulinum toxin injection angle of deviation was 20.6 prism dioptors (PD). Six of 20 (30%) patients maintained the successful position for the average of 2.66 years (range 1-4 years) with single injection. The mean percentage change of the deviation was 87.50%, 87.93 %, 73.05 % at 1, 2, and 3-year visit respectively. In 3 of 5 (60%) patients of consecutive esotropia, 4 of 8 (50%) residual esotropia, 1 of 4 (25%) of consecutive exotropia and 1 of 3 (33.33%) of residual exotropia had successful motor alignment at 6 month visit. There was no scleral perforation, visual loss, or retrobulbar hemorrhage from the injection treatment in the present study. CONCLUSION: Botulinum toxin A injection appears to be a safe and effective treatment for overcorrected and undercorrected strabismus after unsatisfactory surgery. It is very effective in rapid elimination postoperative diplopia. When the result is not adequate or the effect does not last long, repeat the injection or reoperation can be chose to perform later.

Decker, Kim A. PhD, RN, CNS; Hensel, Desiree PhD, RN, PCNS-BC, CNE; Kuhn, Thomas M. MSN, RN, APN-BC, COHN-S, CCM; Priest, Chad JD, MSN, RN Author Information

Boonsong Wanichwecharungruang,1,2 Aungnapa Kongthaworn,1,3 Doreen Wagner,4 Paisan Ruamviboonsuk,1 Kasem Seresirikachorn1 1Department of Ophthalmology, Rajavithi Hospital, Rangsit Medical College, Bangkok, Thailand; 2Department of Ophthalmology, Priest Hospital, Bangkok, Thailand; 3Department of Ophthalmology, Nakorn-Nayok Hospital, Nakorn-nayok, Thailand; 4Senior Clinical Project Manager, Wuppertal, GermanyCorrespondence: Boonsong WanichwecharungruangRajavithi Hospital, 2, Rajavithi Road, Bangkok, 10400, ThailandTel +66 813135040Email boonsongw@yahoo.comPurpose: To compare lamina cribrosa thickness (LCT) of primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG) using the enhanced depth-imaging mode of the Heidelberg Spectralis spectral-domain optical coherence tomography (EDI-OCT).Patients and Methods: A comparative cross-sectional study was conducted. We enrolled 34 patients with PACG, 38 with POAG, and 62 controls, testing only one eye of each participant. Lamina cribrosa thickness was determined at the center of the optic nerve head using EDI-OCT. Nine points of LCT were measured, and LCT averages were analyzed.Results: Mean age, number of glaucoma medications, current intraocular pressure (IOP), cup to disc ratio, and visual field indices, were not significantly different between PACG and POAG eyes. The maximum IOP (SD) was higher in PACG than in POAG, at 32.5 (10.46) vs 25.05 (6.42) mmHg (p = 0.001), and LCTs were significantly different among the PACG, POAG and control groups. Mean (SD) LCTs were 226.99 (31.08), 257.17 (19.46), and 290.75 (28.02) &mu;m, respectively (p &lt; 0.001). Lamina cribrosa thickness was correlated with mean deviation of the visual field (p = 0.001; correlation coefficient, rs = 0.347), while it was inversely correlated with maximum IOP (p &lt; 0.001; correlation coefficient, rs = &minus; 0.592). Linear regression analysis revealed that LCT was inversely related to age (p = 0.008), female (p = 0.018), and maximum IOP (p = 0.002). LCT was marginally related to visual field MD (p = 0.053).Conclusion: Glaucomatous eyes had thinner LCT than controls, and maximum IOP was inversely correlated to the LCT. PACG eyes had higher maximum IOP and thinner LCT than POAG ones. In living eye, EDI-OCT emphasizes the pressure-dependent mechanism of glaucoma on lamina cribrosa deformation and the higher IOP-loaded stress which leads to a greater lamina cribrosa strain.Keywords: lamina cribrosa thickness, primary angle-closure glaucoma, optical coherence tomography, Asian, intraocular pressure

ABSTRACT Nature-based solutions are increasingly used in domestic wastewater treatment, because of their potential to remove contaminants and pathogens from water (e.g., stormwater, river water, wastewater) as well as their provided co-benefits, such as mitigation of the heat island effect or enhanced biodiversity. The transition from traditional grey technologies towards nature-based solutions in domestic wastewater treatment might yield multiple benefits for local communities while enhancing biodiversity. Although some nature-based solutions such as treatment wetlands have been used for decades in domestic wastewater treatment, this is not the case for others such as green walls or roofs, which lack implementation guidelines and design criteria. Aiming to support implementation of nature-based solutions in domestic wastewater treatment, we have developed an online decision-support system for the pre-selection of the best nature-based solution to use in each socio-environmental context and adapted to the needs, as well as an estimate of the required area. Our decision-support system's recommendations are based on an expert knowledge-driven approach, building on two complementary expert knowledge elicitation workshops. We hope the developed online decision-support system will support the transition towards integrating nature-based solutions into urban water and wastewater treatment systems.

Purpose: To evaluate surgical outcomes of the four common procedures utilized for primary angle-closure glaucoma (PACG). Methods: A retrospective study of survival rate in surgical management of PACG was conducted in a referral eye center. One hundred and ninety-nine eyes from 173 PACG patients were collected for chart review. The procedures used were phacoemulsification (PE), combined PE with goniosynechialysis (PE-GSL), combined PE with trabeculectomy (PE-Trab), and trabeculectomy alone. Failure was defined as postoperative IOP > 21 mmHg in patients who needed second surgical intervention or those who had IOP < 5 mmHg with loss of light perception. Cumulative survival rates, risk of surgical failure, and complications were analyzed. Results: PE, PE-GSL, PE-Trab, and trabeculectomy were performed in 84 eyes (42.2%), 76 eyes (38.2%), 21 eyes (10.6%), and 18 eyes (9%), respectively. Cumulative survival rates at 60 months were 13%, 55%, 42% and 43%, respectively. Cox regression analysis indicated that each mmHg IOP increased, the risk of surgical failure decreased by 13% (adjusted hazard ratio (HR) 0.87; 95%CI: 0.84– 0.93, p < 0.001). Conclusion: Real-world surgical outcomes of PACG showed that PE alone had a low survival rate of 13% in 60-month follow-up whereas PE-GSL achieved the highest rate of 55%. PE-GSL should be initially considered for management of PACG, since it can restore and sustain the physiologic aqueous pathway and preserve the conjunctiva for future filtering surgery if needed. Keywords: primary angle-closure glaucoma, surgical outcome, combined procedure, phacoemulsification, trabeculectomy, goniosynechialysis, survival, Asian, complication

Diplopia following orbital decompression is a common complication in Graves' ophthalmopathy. Strabismus surgery is often required to treat the persistent diplopia. The author presents a successful treatment with botulinum toxin A injection in a case of diplopia following orbital decompression. Treatment with botulinum toxin A in the management of new-onset diplopia following orbital decompression has been suggested in a case that is not amenable to prism treatment and may eliminate strabismus surgery in some cases.