Forced Duction Test Research Articles

Coexistence of congenital superior rectus muscle fibrosis and Marcus Gunn jaw-winking phenomenon

A 6-year-old male involving a coexistence of congenital fibrosis of the superior rectus muscle (SR) with Marcus Gunn Jaw-Winking phenomenon presented with an elevation of the upper eyelid along with a chronically open mouth that had been present since early infancy. There was extropia and hypertropia, a limitation of elevation and depression in the right eye, and an abnormal head posture (AHP) with a left head tilt, right face turn, and a chin-up head position. He also displayed an upper eyelid retraction and a 2-mm lagophthalos in the right eye. Results of the forced duction test indicated a constricted SR of the right eye. A dissection of the SR from the levator palpebrae superioris and a 5-mm SR recession was performed within the right eye. At 2 months post surgery, there was a 3 prism diopters (PD) hypertropia in the right eye when the left eye was fixated on the target and a 10 PD hypotropia in the left eye when the right eye was fixated on the target, along with an improvement in his AHP. In this rare case with a coexistence of congenital fibrosis of the SR and Marcus Gunn jaw-winking phenomenon, we found that the performance of an individualized surgical protocol proved effective in reducing the vertical deviation and improving AHP.

Medial Rectus Disinsertion for the Management of Large-Angle Sensory Esotropia.

Background and Objectives: The aim of the report is to report the outcomes of the medial rectus (MR) disinsertion procedure for the management of large-angle esotropia (ET) patients. Materials and Methods: This is a retrospective case series of patients with large-angle ET who underwent an MR disinsertion procedure between March 2012 to April 2022. The procedure happened accidentally during muscle surgery. The demographic and clinical data, including sex, age, visual acuity, pre- and postoperative angle of strabismus, duction limitations, results of intraoperative forced duction tests, and follow-up duration were collected from medical records. Results: Five patients were enrolled in this study. The mean age was 62.2 ± 9.8 years, and the mean follow-up was 24.8 ± 8.7 months. The ET at the primary position of gaze was 92.0 ± 17.9 prism diopters (PD) before MR disinsertion and 38.0 ± 29.5 PD after MR disinsertion only. Abduction deficiency was -4 before after MR disinsertion, which improved to -1 at the last follow-up. Conclusions: The results of MR disinsertion were not as frustrating as anticipated. MR disinsertion may be considered in patients with large-angle sensory ET who refuse surgery on the opposite eye.

Surgical management of unilateral restrictive strabismus in an 8-month-old dog

ABSTRACT Case history An 8-month-old male, entire, mixed-breed dog was presented with a 1-month history of left exophthalmos and green mucopurulent ocular discharge. Subsequently, exophthalmos resolved but esotropia (medial strabismus) developed in the left eye, prompting referral to an ophthalmologist. Clinical findings At the initial referral consultation, enophthalmos and esotropia of the left eye were identified. The patient showed mild improvement after a 3-week tapering course of oral prednisolone and doxycycline. MRI was performed and showed left medial rectus muscle atrophy with increased contrast enhancement which was consistent with chronic extraocular muscle myositis (EOM). A forced duction test was performed to confirm the diagnosis of fibrosing esotropia, which is likely a sequela of chronic EOM. Diagnosis Fibrosing esotropia presumably caused by untreated EOM. Treatment and outcome One month later, esotropia progressed to a marked ventro-medial strabismus resulting in visual deprivation. Surgical release of the ventral oblique, medial and ventral recti muscles was performed, resulting in immediate resolution of the enophthalmos. Despite a tapering post-operative course of oral prednisolone, mild esotropia was present 4 weeks later. In an effort to stabilise the globe position, the low dose of prednisolone was increased to a higher anti-inflammatory dose before slowly tapering over 2 months. The vision in the left eye was improved after surgery and has been maintained since without further treatment. Clinical relevance This is the first documented case of fibrosing esotropia in a young dog with prior signs of acute exophthalmos. Fibrosing esotropia has been documented in certain breeds or as a sequela to chronic EOM. In this patient, it was presumably caused by EOM, which was strongly supported by the case history, progression and MRI findings. Most historical reports of EOM described it as a bilateral condition that resolves with systemic corticosteroids at an anti-inflammatory dose. EOM has been shown to also present unilaterally and it can progress to strabismus if not promptly recognised and treated with systemic steroids. Surgical management can restore vision when severe strabismus results in visual deprivation.

Unrevealing abducens palsy vs. divergence insufficiency: A comprehensive review

Background: The article "Unraveling Abducens Palsy vs. Divergence Insufficiency" provides a comprehensive review of two common ophthalmological conditions, namely Abducens Palsy and Divergence Insufficiency. Aim: In this review article, we aim to unravel the key differences between these conditions, providing healthcare professionals with valuable insights for accurate diagnosis. It provides a comprehensive analysis of the clinical features, diagnostic criteria, etiology, and management strategies for each condition. Methods: A systematic literature search was conducted in electronic databases, including PubMed, MEDLINE, and Google Scholar. Case reports, clinical trials, observational studies, and review articles were considered. The extracted data included information on the clinical presentation, diagnostic tests, etiology, and treatment options for these conditions. Results: The authors emphasize the importance of a thorough ophthalmological examination, including the Hirschberg test and forced duction test, in diagnosing Abducens Palsy accurately. The article also explores the potential causes of Divergence Insufficiency, such as age-related changes and neurologic disorders. The management strategies for both conditions are thoroughly discussed, encompassing both conservative and surgical approaches. Conclusion: The authors present a comprehensive analysis of the clinical features, diagnostic criteria, and management strategies for these two conditions.It serves as a valuable resource for healthcare professionals, providing them with the necessary knowledge to accurately diagnose and manage Abducens Palsy and Divergence Insufficiency. Further research in this field is warranted to enhance our understanding of the underlying mechanisms and optimize treatment outcomes.

INFERIOR RECTUS FIBROSIS AND RESIDUAL DIPLOPIA FOLLOWING SCLEROTHERAPY FOR ORBITAL VENOUS MALFORMATION

Orbital vascular lesions are challenging to treat and observation is often preferred if symptoms are mild. Historically, surgical excision of the lesions used to be the preferred treatment, but intraoperative bleeding and incomplete removal were common. Therefore, sclerotherapy has become the treatment of choice by virtue of being minimally invasive and extremely effective. Sclerotherapy involves multiple intralesional injections of sclerosing agents like bleomycin and sodium tetradecyl sulfate. In this communication, we describe an unusual complication associated with sclerotherapy to treat an orbital venous malformation in a young woman diagnosed with a type-2 low flow venous malformation (orbital varices) in her left orbit. There was complete resolution of the lesion. However, following the procedure, she complained of diplopia accompanied by left hypotropia. The condition persisted six months after the procedure. Forced duction test confirmed a tight inferior rectus and she refused any further intervention. This case report discusses the possible mechanisms of this rare and unusual complication associated with sclerotherapy while treating orbital vascular lesions.

Monocular elevation deficit management

Aim The aim of the study is to study cases of monocular elevation deficit (MED), and find an appropriate procedure to follow in management. Patients and methods This prospective study included 21 patients presenting with MED, complete ocular examination including ocular motility examination in all directions, forced duction test (FDT) were performed, then cases having hypotropia in the affected eye in primary position were operated, and the choice of operation was depending on the result of FDT. Results The total number of cases was 21 patients, 18 patients had hypotropia in primary position accompanied by pseudoptosis, and three cases had no hypotropia. Sixteen cases of hypotropia had positive FDT, inferior rectus muscle recession by hang back procedure was performed in them, while in two cases of hypotropia with negative test, Knapp’s muscle transposition was performed. All operated cases had postoperative good ocular alignment and spontaneous regaining of normal lid position except two cases. Cases with no hypotropia were not operated and only followed up. Conclusion MED or double elevator palsy, can present with hypotropia and pseudoptosis, so requiring management, or presenting with normal eyes in primary position, requiring follow up. The choice of surgical procedure depended on results of FDT.

Clinical effect of superior oblique re-tucking for recurrent or residual compensatory head position

Objective: To evaluate the effects of re-tucking the superior oblique muscle on recurrent or residual compensatory head position. Methods: A retrospective case series study was conducted. 12 recurrent or residual compensatory head position patients (12 eyes) with congenital superior oblique palsy who underwent superior oblique re-tucking in Tianjin Eye Hospital from March 2015 to February 2021 were included. All patients had a history of superior oblique tucking procedure and showed signs of superior oblique muscle palsy without inferior oblique muscle overaction. During surgery, the Guyton forced duction test is used to evaluate the relaxation of the superior oblique muscle tendon, which affects the re-tucking length of the muscle.Their head position, vertical deviation, eye movement, fovea-disa angle, and Bielschowsky head tilt test were assessed pre-and post-surgery. Statistical analysis was performed using ttest and paired samples Wilcoxon signed rank test. Results: Out of the 12 patients, 8 were male and 4 were female, aged between 2 and 9 years. The initial surgery was done at age 6, with a superior oblique recession length of (7.17±1.03) mm. Recurrent head tilt occurred in 11 patients after (3.82±0.98) months postoperatively, and 1 patient had residual head tilt, with a followup period of six months or more. Ocular motility examination revealed underaction of the superior oblique muscle, positive Bielschowsky's head tilt test, and Guyton forced duction tese indicating relaxation of the paralyzed superior oblique muscle tendon. Scar adhesion was observed at the stop of the superior oblique muscle, as well as the previous sutures. The scar and the sutures around the stop of the superior oblique muscle were released, the mean re-tucking amount was(7.83±1.59)mm. Follow-up at 12 to 18 months postoperatively showed disappearance of compensatory head position, significant improvement in superior oblique muscle lag, normal ocular motility, and no occurrence of Brown syndrome. The results of Bielschowsky head tilt were negative in 9 cases and still positive in 3 cases after superior oblique re-tucking. The primary vertical deviation was 2.5 (2.0, 5.3) prism diopter pre-operatively and 1 (0, 1) prism diopter post-operatively, respectively. The difference was statistically significant (U=6.00, P<0.001). The total amount of FDA in both eyes was (-22.04±5.47)° and (-15.27±6.08)° pre-and post-operatively, respectively. The difference was statistically significant (t=2.87, P=0.009). All 12 patients have normal eye movement after superior oblique re-tucking procedure. All patients had no compensatory head position at last follow-up. Conclusions: Superior oblique re-tucking is suitable for patients with relaxation of the superior oblique muscle tendon and extrocular rotation as the main sign. It can effectively and safely correct the recurrent or residual compensatory head position after re-tucking the superior oblique muscle.

Combined recession and resection of the same lateral Rectus in the treatment of exotropia.

Besides rest position abnormalities, exotropia could also be due to hypertonia of the Lateral Recti (LR) given divergence frequently decreases under general anesthesia (GA). Combined Recession-Resection of the Same Muscle (RRSM) is a promising alternative to the Faden procedure in the surgical treatment of overacting MR in esotropia. We thus examined here the effectiveness of combined RRSM of the LR for the treatment of exotropia that decrease under GA. We performed a retrospective, single-center evaluation over a 16-month period of 100 patients operated on for exotropia that decreased under deep GA (91% of 110 consecutive operated cases). We excluded re-operations and pure convergence insufficiencies. We performed a combined RRSM of one or two LR. It included a 10mm-recession and a "fine-tuned" resection of LR based on Quantitative Forced Duction Test scores. MR resection was combined when exotropia exceeded 35PD or for unilateral surgery. We report on patient outcomes 6 months after surgery. Successful results were obtained (-8-+8 PD measured on Alternate Cover Test) among 83% of cases at distance fixation and 91% at near fixation after 6 months. The Newcastle Control Score also improved from 5.8 to 1.7 after 6 months. No surgery-related complications or repeat surgeries were reported. In our experience a majority of exotropias decrease under GA and our strategy of combined RRSM of the LR is effective for the treatment of such exotropias. Long-term follow-up of the cohort is required to investigate the stability of these outcomes, and confirmation of our results by other works.

How to Reduce Inferomedial Orbital Wall Fracture Using a Navigation System: Tips and Pearls.

The orbit is a confined space with a defined bony structure. Bony protrusion into the ethmoid or maxillary sinuses by the blowout fracture can displace orbital tissues, including rectus muscles and adjacent fascial septae. Especially, reconstructing the orbit's floor and medial wall can be challenging when the inferomedial strut or posterior bony ledge is affected, leading to a loss of critical anatomic landmarks and support. Correctly positioning an implant in the precise anatomic location can be challenging. Recent updates to the navigation system have addressed this issue. Despite its early application, using a navigation system in these orbital fractures advances plastic surgeons in a way that has more confidence and accuracy in surgical planning. The video demonstrates how these 2 can be combined in an operating room. Intraoperatively, the authors check the superior, anterior, and posterior ends of the medial wall fracture and the posterior end of the floor fracture. A single orbital implant was trimmed and reshaped to match defect measurements. The implant placement was meticulously executed to repair the fracture while ensuring the inferior oblique muscle was not injured. After confirming the correct placement of the implant, it was secured to the inferior orbital rim using a single screw. Depending on the medial orbital wall fracture depth or degree of soft tissue herniation, the authors used an artificial dermal matrix or trimmed absorbable mesh plate to cover the uppermost part of the medial wall fracture to prevent postoperative enophthalmos. Finally, a forced duction test was performed. Our study shows that navigation-assisted inferomedial orbital wall reconstruction using materials readily available in the market is safe and effective.

Management of Recurrent Entropion in Traumatic Proptosis

Introduction : Shortening of posterior lamella due to fibrotic tissue is the pathomechanism of cicactricial entropion. It may be complicated by proptosis in a post traumatic patient which may require repeated repair procedure.&#x0D; Case Illustration : A 29-year-old woman came with complaints of protruding left eye since being hit by an iron tip 2 months prior. She also complained off double vision. Left eye presenting visual acuity was 0.08 with hipotropic position, proptosis, lid retraction, and entropion of the inferior lid. CT scan examination showed unremarkable results. The patient then underwent forced duction test, exploration, and muscle restriction release on the left eye, followed by inferior rectus recess and superior rectus resect procedures 3 months later. A month later the patient underwent entropion repair in the left eye using the tarsal fracture method. However, a week later the patient complained of a recurrent entropion, thus a grey line splitting procedure combined with retractor repositioning and tightening of the tarsus was performed. At the 7 days follow-up time, the eyelid margin was succesfully everted with an acceptable result.&#x0D; Discussion : Skin graft procedure is one of the option for cicatricial entropion. However, its risk of recurrences and more difficult secondary repair can be harrowing. Thus, a grey line splitting procedure is an alternative that can be considered.&#x0D; Conclusion : Combined procedure of grey line splitting, retractor repositioning, and posterior lamellar tightening showed a good cosmetic result in an uncommon case of entropion.

Management of Recurrent Entropion in Traumatic Proptosis

Introduction : Shortening of posterior lamella due to fibrotic tissue is the pathomechanism of cicactricial entropion. It may be complicated by proptosis in a post traumatic patient which may require repeated repair procedure.&#x0D; Case Illustration : A 29-year-old woman came with complaints of protruding left eye since being hit by an iron tip 2 months prior. She also complained off double vision. Left eye presenting visual acuity was 0.08 with hipotropic position, proptosis, lid retraction, and entropion of the inferior lid. CT scan examination showed unremarkable results. The patient then underwent forced duction test, exploration, and muscle restriction release on the left eye, followed by inferior rectus recess and superior rectus resect procedures 3 months later. A month later the patient underwent entropion repair in the left eye using the tarsal fracture method. However, a week later the patient complained of a recurrent entropion, thus a grey line splitting procedure combined with retractor repositioning and tightening of the tarsus was performed. At the 7 days follow-up time, the eyelid margin was succesfully everted with an acceptable result.&#x0D; Discussion : Skin graft procedure is one of the option for cicatricial entropion. However, its risk of recurrences and more difficult secondary repair can be harrowing. Thus, a grey line splitting procedure is an alternative that can be considered.&#x0D; Conclusion : Combined procedure of grey line splitting, retractor repositioning, and posterior lamellar tightening showed a good cosmetic result in an uncommon case of entropion.

Jednooczny deficyt unoszenia gałki ocznej – obraz kliniczny i metody leczenia chirurgicznego

The aim of this paper is to present Monocular Elevation Deficiency, previously known as a double elevator palsy. Monocular Elevation Deficiency is the limitation of elevation of the affected eye in both adduction and abduction. This condition can lead to hypotropia and can be associated with ptosis or pseudoptosis. Monocular Elevation Deficiency can be congenital or acquired, what can cause serious consequences like amblyopia. For paediatric patients early treatment is essential to avoid amblyopia and obtain binocular vision. Most of Monocular Elevation Deficiency cases require surgical treatment, however there are types of this motility disorder which require only observation. The choice of surgical procedure varies according to nderlying cause and the strabological examination results. Generally, the result of forced duction test is the most important component in choosing an adequate procedure in the management of Monocular Elevation Deficiency. There is a broad range of surgeries in this form of strabismus: Knapp’s procedure and it’s modifications, recession of inferior rectus muscle or other types of operations on contralateral eye. The main rule in treatment Monocular Elevation Deficiency is that the vertical deviation has to be corrected first to ensure the pseudoptosis element is eliminated, and as a second step ptosis can be surgically cured.

A Novel Technique Using Paretic Superior Rectus as a Globe Suspender for Monocular Elevation Deficiency.

Surgical innovations in strabismus provide opportunities to improve visual function, eye alignment, and cosmesis in rare pediatric ophthalmological conditions. Monocular elevation deficiency is a rare and multifactorial disease in which the affected eye is equally limited in terms of elevation during adduction and abduction. We aimed to present a novel procedure for the treatment of acquired monocular elevation deficiency using the paretic superior rectus muscle as a globe suspender to resolve hypotropia. We report the case of an eight-year-old girl with left eyelid ptosis and hypotropia two months after draining a left orbital abscess. Left inferior rectus muscle recession was performed at five years, with residual left hypotropia. Ophthalmological examination revealed a best-corrected visual acuity of 20/20 OD and 20/100 OS. Severe left eyelid ptosis and poor levator function were also observed. Extraocular motility showed left hypotropia of 40 prism diopters with the left superior rectus muscle under action (-4) in the adduction and abduction positions. A force duction test negative for restrictions on the inferior rectus muscle was performed intraoperatively. To reduce the risks of the Knapp procedure, the left superior rectus muscle was split into medial and temporal halves. Double-armed sutures were secured in half, and the halves were detached from the sclera. The medial and temporal halves were reattached anteriorly to the medial and lateral rectus insertions, respectively. Eight weeks after surgery, the patient had nine prism diopters of hypotropia in the primary gaze. Ten weeks after surgery, there was no change in visual acuity. In the cover test, the patient exhibited residual left hypotropia of nine prism diopters with a restriction (-4) of elevation in adduction and abduction. The parents were pleased with the satisfactory cosmetic outcomes, and postoperative clinical photographs of the patient showed improved hypotropia and persistent minimal elevation of the left eye during adduction and abduction. Superior rectus muscle splitting and vertical transposition to the medial and lateral rectus could be safer and simpler alternatives to the Knapp procedure and may offer a lower risk of anterior segment ischemia. Further studies are required to confirm these findings.

A Case of Third Cranial Nerve Palsy Accompanying Thyroid Eye Disease

Purpose: To report a patient who developed thyroid eye disease and third cranial nerve palsy at the same time and showed good response to high dose steroid therapy.Case summary: A 50-year-old woman who was diagnosed with Graves' disease presented with binocular vertical diplopia for 1 month. Diplopia was persistent and did not show any fluctuation daily. Up gaze was limited in the right eye. Orbital computed tomography showed hypertrophy of the inferior rectus muscles in both eyes. After 12 days, she complained of rapid progression of diplopia. Adduction and down gaze were limited in the left eye, and left hypertropia and exotropia were presented. Steroid pulse therapy was administered, and eye movements and strabismus improved at one month after treatment, and there were no recurrences until 9 months after symptom onset.Conclusions: Thyroid eye disease was accompanied by third cranial nerve palsy. If ocular movement is not consistent with the extraocular muscle involved or the forced duction test result in thyroid eye disease, the possibility of combined cranial nerve palsy should be considered.

Characteristics of Guyton's exaggerated forced duction test (FDT) and torsional FDT in congenital superior oblique palsy

Objective: To investigate the characteristics of Guyton's exaggerated forced duction test (FDT) and torsional FDT in patients with congenital superior oblique palsy (CSOP) and their correlation with clinical features. Methods: This cross-sectional study included single-eye CSOP patients and intermittent exotropia (IXT) patients scheduled for strabismus correction surgery at Tianjin Eye Hospital from September 2021 to March 2022. Prior to surgery, measurements of fovea-disc angle (FDA) and maximum cross-sectional area of the superior oblique muscle (max-CSA) were obtained in both eyes of the patients. The Guyton's exaggerated FDT and torsional FDT were performed intraoperatively to assess the degree of superior oblique muscle relaxation. The characteristics of the two FDT tests and their correlation with vertical strabismus angle, FDA, and max-CSA were analyzed. Statistical analyses were conducted using t-test, ANOVA, Tukey's test, Mann-Whitney U test, and chi-square test. Results: A total of 42 patients (84 eyes) were included in the study, including 19 IXT patients (38 eyes) and 23 CSOP patients (46 eyes, 23 eyes with palsy and 23 eyes without palsy). There were no statistically significant differences in gender composition or age between the IXT and CSOP patients (all P>0.05). The degrees of superior oblique muscle relaxation measured by the Guyton's exaggerated FDT were (-2.52±1.20), (-0.35±0.71), and (-0.03±0.16) for the palsy eye, non-palsy eye, and IXT eyes, respectively, showing significant differences (F=88.10, P<0.001). The torsional FDT measurements yielded external rotation angles of 48.70°±9.67°, 37.39°±5.40°, and 38.95°±2.88° for the palsy eye, non-palsy eye, and IXT eyes, respectively, showing significant differences (F=16.67, P<0.001). There was no statistically significant difference in internal rotation angles (F=2.36, P=0.100). The FDA values were-12.11°±7.42° for IXT patients and-19.02°±4.95° for CSOP patients, while the max-CSA values for the palsy eye and non-palsy eye of CSOP patients were (7.59±4.69) mm² and (11.63±3.64) mm², respectively, all showing significant differences (all P<0.001). The degree of superior oblique muscle tendon relaxation assessed by the Guyton's exaggerated FDT was negatively correlated with the external rotation angle measured by the torsional FDT (r=-0.64, P=0.001). They were positively correlated with max-CSA (r=0.45, P=0.030) and negatively correlated with max-CSA (r=-0.52, P=0.011). However, there was no correlation with vertical and rotational strabismus angle (r=-0.12, P=0.579; r=0.33, P=0.126) and FDA (r=-0.02, P=0.921; r=-0.23, P=0.309). Conclusions: Guyton's exaggerated FDT and torsional FDT can both assess the degree of superior oblique muscle relaxation in patients with CSOP. Furthermore, these two tests are correlated with changes in superior oblique muscle morphology. However, FDT cannot reflect the degree of vertical and rotational strabismus in patients.

Extraocular muscle enlargement of indeterminate cause in pediatric patients: case series and literature review

To specify the clinical characteristics of enlarged extraocular muscles of indeterminate cause in pediatric patients based on a case series and literature review. The medical records of pediatric patients who presented between January 2019 and January 2022 with enlarged extraocular muscles, where the underlying cause could not be determined, were retrospectively reviewed. Four patients were included. The main reason for presentation was evaluation of abnormal head posture. Head tilt or turn with duction deficit was observed in all patients. The age of onset ranged from 6 months to 1 year. Two patients presented with esotropia and hypotropia; the other 2 patients, with large-angle esotropia. Orbital imaging was performed in all cases and revealed unilateral rectus muscle enlargement sparing the muscle tendon. All 4 patients were found to have enlarged medial rectus muscle. In the 2 patients with hypotropia, the inferior rectus muscle was also involved. No underlying systemic or orbital disease was found. There were no changes in the orbit or extraocular muscles on follow-up imaging test. The intraoperative forced duction test revealed severe restriction in the direction of gaze opposite to the primary field of action of the enlarged muscles. Enlargement of extraocular muscles should be considered in the differential diagnosis when large-angle incomitant vertical or horizontal misalignment and abnormal head posture are observed in infancy.

Restrictive medial rectus myositis in orbital sarcoidosis

Sarcoidosis is a systemic multiorgan granulomatous disease of unknown etiology in middle age group women. Orbital sarcoidosis is uncommon and the most common orbital manifestation is dacryoadenitis (70%). Extraocular muscle involvement is rare; if present, the superior rectus/levator complex and lateral rectus are most commonly involved. We report a 57-year-old male, a known case of biopsy-proven sarcoidosis, with medial rectus myopathy and lacrimal dacryoadenitis in the left eye, and angle closure with raised intraocular pressure (IOP) in both eyes. Imaging by computed tomography (CT) also confirmed the above findings. The forced duction test was positive confirming restrictive myopathy of the left medial rectus muscle. Orbital sarcoidosis has a highly diverse presentation; medial rectus involvement is a rare occurrence.

SUCCESSFUL MANAGEMENT OF HYPERTROPIA RELATED THYROID EYE DISEASE WITH HEMI HANG-BACK PROCEDURE

Introduction: Hypertropia in thyroid eye disease (TED) is uncommon condition which may cause visual and aesthetical problem with quality of life disturbance. Case Illustration: A 44-year-old woman presented with a squint on the right eye with bilateral diplopia for 18 months. She had history of hyperthyroidism for two years which had been treated with thiamazole and propanolol for 1 year and methylprednisolone for 6 months. Visual acuity of both eyes was 20/20 with no sign of active inflammation and optic neuropathy. Ocular motility showed restriction in lateral and down gaze. Inferior restriction was found in forced duction test. Hypertropia of 40 prism diopters was remarkably seen in Krimsky test. We performed strabismus surgery after patient was in inactive stage and reach euthyroid state without treatment for 6 months. During surgery we found muscle enlargement and fibrous tissue of superior rectus muscle. Superior rectus recession for six milimeters with additional hemi-hang back procedure for two milimeters had been performed with significant improvement of diplopia. Ocular motility exercise was suggested to reach binocular vision. Discussion: Hypertropia in TED was caused by extraocular muscle fibrosis due to inflammation and lymphocytic infiltration. Strabismus surgery was aimed at diplopia correction in primary position. Surgical procedure, extra ocular muscles in which surgery must be done and its surgical dosage should be considered carefully. Conclusion: This case showed restrictive hypertropia in TED with distressing symptoms and challenging management. Hemi hang-back procedure is should be considered in difficult case.

Malposition of the Resorbable Sheet in Medial Orbital Wall Fractures: Frequency and Techniques for Prevention.

The aim of this report is to discuss malposition of the resorbable sheet in medial orbital wall fractures and how to prevent this problem. After making an incision through the skin and orbicularis oculi muscle, a skin-muscle flap was elevated just superficial to the orbital septum, extending to the arcus marginalis. Dissection was extended just below the anterior lacrimal crest to increase the exposure. Fracture site in medial orbital wall was visualized. A resorbable sheet (poly- l -lactide, d -lactide sheet, 0.5-mm thickness) was trimmed and molded in an L shape, with the vertical portion used to cover the medial wall defect and the horizontal portion for stability in the orbital floor. An extended part, measuring roughly 1cm, was bent across on the infraorbital rim, and this part was fixed with absorbable screws to prevent the sheet from crumpling. After the molded plate was put in position, the periosteum and skin were closed. From 2011 to 2021, the authors operated on 152 orbital floor or medial wall fractures. Among 152 patients who underwent surgery to reconstruct orbital floor or medial wall fracture, of whom 27 patients had both floor and medial wall fractures, the authors experienced 2 cases of medial orbital wall fractures where the resorbable sheet was malpositioned, requiring reoperation. To prevent malposition of the sheet in medial wall reconstruction, the inferomedial angle of the vertical portion and the horizontal portion of the sheet should be about 135°. Before fixing the sheet on the bony part, a complete tension-free forced-duction test is mandatory.

Post-ROCM restrictive strabismus: A challenge for strabismus surgeon

Abstract Restrictive strabismus is characterized by extraocular motility restriction, which is confirmed by performing forced duction test. It can be congenital because of various syndromes or acquired after thyroid eye disease, after long-standing strabismus, after sinus surgery, or after trauma. Recently, we have faced a devastating epidemic of rhino-orbito-cerebral mucormycosis (ROCM) during the second wave of COVID-19 pandemic, which was treated by both surgical (sinus surgery) and medical (antifungal agents) modalities. Diabetes mellitus and the inadvertent use of systemic steroid were the leading risk factors for ROCM outbreak. India being the diabetic capital of the world favored this condition. We are reporting a challenging case of ROCM with diabetes mellitus, who presented to us with troublesome diplopia with extraocular motility restriction. He had a history of right-sided ROCM treated by sinus surgery and systemic antifungal agents 1 year back, followed by a good residual vision and restrictive strabismus leading to the symptoms. A previous history of sinus surgery and post-ROCM scarring and narrow surgical field posed a great challenge for strabismus surgery. In spite of all odds, a good postoperative alignment was achieved by a single-stage strabismus surgery, and the patient was asymptomatic after 3 months of follow-up.