Forced Duction Test Research Articles

Pseudo-Duane’s retraction syndrome: a rare clinical entity

<p class="abstract">Studies of sequelae of isolated medial orbital wall fractures show that the majority of patients with this condition are often asymptomatic, which makes the diagnosis based only on clinical grounds difficult. One of the rare complications of this entity is Pseudo-Duane’s retraction syndrome, which is characterised by horizontal diplopia, restricted abduction with or without limited adduction, accompanied by narrowing of the palpebral fissure, globe retraction and pseudo ptosis on abduction. This is a case report of a 46-year-old female who developed Pseudo-Duane’s retraction syndrome following trauma to her left orbit. She presented with left eye pain, diplopia, horizontal gaze restrictions, left eye ecchymosis and enophthalmos. Careful history taking and thorough ophthalmic examination including forced duction test along with radiological imaging helped clinch this diagnosis. Timely intervention by an endoscopic approach to release the medial rectus muscle entrapped within the fracture resolved the patient’s symptoms.</p>

Estudio de correlación en las medidas de ducciones pasivas oblicuas y de ciclorrotación

PurposeTo evaluate intraoserver and inteobserver repeatability of the “exaggerated forced duction test” or “oblique traction test” and the “excyclo and incyclo passive rotation test” or “cyclorotation traction test”. Methods44 eyes of 22 patients were evaluated under deep general anesthesia. Passive duction was tested on supraduction and infraduction by the “exaggerated duction test”. The limitation on movement was graduated from 0 to - 4. Passive cyclorotation test was evaluated with retropulsion of the globe until the first resistance is noted. We used the Mendez ring and blue dots marked on the limbus to measure the amount of cyclorotation. The results obtained of excyclo and incyclorotation were recorded. All measurements were made in duplicate for each of the two observers. ResultsThe intraclass correlation of the “oblique traction test” coefficient between the two observers was for the IO was 0,738 (95% confidence interval, 0,62-0,83) and 0,910 for the superior oblique (SO) (95% confidence interval, 0,85-0,94). The “cyclorotation traction test” intraclass correlation coefficient of the between the two observers was 0,827 (95% confidence interval, 0,74-0,89) for exclycloduction and 0,792 (95% confidence interval, 0,67-0,85) for inclycloduction. The percentage of patients within 5° of rotation interobserver was 84,1% for excyclorotation and 81,8% for inclyclorotation. Both tests had better correlation on the intraobserver than interobserver evaluation. ConclusionsEvaluation of the “oblique traction test” and “cyclorotation traction test” had moderate to good correlation between the two observers and good to excellent on the intraobserver evaluation.

Enhanced adjustable nasal transposition of split lateral rectus muscle for surgical management of oculomotor nerve palsy

Lateral rectus transposition to the medial rectus muscle has recently generated interest in the management of oculomotor nerve palsy. We report 4 cases of complete oculomotor nerve palsy with a large-angle exotropia that were treated with a modified adjustable nasal transposition of the split lateral rectus muscle. Forced duction testing for the lateral rectus muscle showed good adduction in all 4cases. Postoperative alignment within 10Δ in straight-ahead gaze was achieved in all 4 cases; adjustment was required in 2 cases.

Brown Syndrome from Local Anesthesia for Inferior Orbital Fat Decompression

Patient: Female, 36-year-oldFinal Diagnosis: Acquired Brown syndromeSymptoms: Diplopia • vertical diplopiaMedication: —Clinical Procedure: Local anesthesia • orbital fat decompressionSpecialty: OphthalmologyObjective:Unusual or unexpected effect of treatmentBackground:Vertical diplopia that follows local anesthesia is usually due to inferior rectus muscle fibrosis. Here, we report a rare case of acquired Brown syndrome following local anesthesia.Case Report:A 36-year-old woman underwent right inferior orbital fat decompression under local anesthesia. On the first postoperative day, she developed vertical diplopia. She had left hypertropia, which increased on left gaze, with limitation of elevation of the right eye on attempted adduction. Forced duction test of the right eye revealed resistance on elevation in adduction. Magnetic resonance imaging showed signal alteration, thickening, and irregularity involving the right superior oblique tendon and trochlea region. The diagnosis of iatrogenic Brown syndrome was made. Then, a single dose of 10 mg triamcinolone injection was given near the intratrochlear region. On follow-up, complete resolution of diplopia on primary gaze occurred 12 weeks after the incident.Conclusions:The reported case highlights that local anesthesia carries a risk of Brown syndrome. We believe bupivacaine-induced superior oblique hypertrophy is the underlying mechanism. The patient showed excellent outcome after medical management, with no surgical intervention required after 3 months of follow-up.

Study of clinico-etiological profile of patients with paralytic and restrictive strabismus

Incomitant strabismus typically results in intractable diplopia, blepharoptosis, ocular motility disturbance, disturbance in pupil reaction and an unacceptable compensatory head or face posture. A complete clinico etiological profile is necessary for identifying the underlying risk factors and etiology pertaining to paralytic and restrictive strabismus which is imperative in prevention , early detection, managing the etiology and timely recovery in these patients.To study the clinico-etiological profile of patients with paralytic and restrictive strabismus in a tertiary eye hospital. Patients reporting to a tertiary eye hospital in north India and diagnosed with paralytic and restrictive strabismus, over a period of one year , were enrolled in the present study . Patients were subjected to detailed ocular examination and evaluated for ocular motility or related disorders. This included detailed clinical history, ophthalmic examination, orthoptic workup , sensory evaluation, diplopia charting, Hess charting, slit lamp examination and fundus examination . In patients of suspected restricted strabismus, forced duction test was performed. Relevant systemic investigations including blood pressure , blood sugar and lipid profile were carried out . M.R.I orbit was done in every patient. Neuroimaging was advised in those patients where indicated. 48 patients were diagnosed with incomitant strabismus and enrolled in the study. 81.3%were of paralytic strabismus while 18.8 % were of restrictive strabismus. In the group of paralytic strabismus, 43.8 % patients had sixth nerve palsy , 27.1% patients had third nerve palsy , 6.3% patients had fourth nerve palsy and combined nerve palsy patients were 4.2%. Analysing the etiology, out of total patients of paralytic strabismus, 48.7% of cases were idiopathic, 25.6% were post traumatic, 15.4% were due to microvascular causes , 5.1% of cases were due to intracranial anomalies and rest 5.1% were due to inflammatory causes. In restrictive strabismus group, 66.7% were congenital and rest 33.3% were acquired. Our study has reflected the prevalence, distribution , etiological and clinical profile of patients presenting with incomitant strabismus . It is helpful for ophthalmologists and other physicians in guiding diagnosis and evaluation and is useful for proper and timely intervention and timely recovery in these patients.

The surgical effect of secondary esotropia with diplopia after orbital decompression for thyroid-associated ophthalmopathy

Objective: To evaluate the effect of extraocular muscle surgery in treating secondary esotropia with diplopia after orbital decompression for thyroid-associated ophthalmopathy (TAO). Methods: Retrospective case series study. Eleven secondary esotropic patients with diplopia after orbital decompression for TAO who underwent extraocular muscle surgery during March 2016 and October 2018 in Tianjin Eye Hospital were included. All patients had new onset esotropia after decompression surgery and underwent strabismus surgery. Deviation angle, diplopia, and ocular movement were observed preoperatively and postoperatively. Surgeries were carried out under the monitored anesthesia care combined with local anesthesia, and the eye alignment was adjusted to orthotropia with no diplopia in the operation with the technique of intraoperative adjustable suture and forced duction test results. All the patients were followed up. Results: The ages of the patients were from 26 to 42 years (1 male and 10 females). The deviation angles were 10-98 prism diopter. Orbital CT scan showed that the horizontal rectus thickness was increased at different levels, and the thickness of the medial rectus was increased more than that of the lateral rectus. Two patients had monocular medial rectus recession only, 2 had bilateral medial rectus recession only, 2 had monocular medial rectus recession combined with lateral rectus resection, and the other 5 had bilateral medial rectus recession with monocular lateral rectus resection. The recession of medial rectus muscle was 3.5 to 7.5 mm in 11 patients and 2.0 to 6.0 mm in 7 patients with the resection of lateral rectus muscle. Diplopia of the 11 patients disappeared with orthotropia at primary gaze position after the extraocular muscle surgery. The limitation of abduction changed from preoperative (-1.91±1.04) to postoperative (-0.64±0.81). All the patients were satisfied with the surgical results. At the end of the follow-up (6 to 24 months), the results of the patients were stable, and no over-correction was found. Conclusion: Extraocular muscle surgery with intraoperative adjustable suture technique can effectively treat TAO patients with secondary esotropia with diplopia after orbital decompression. (Chin J Ophthalmol, 2020, 56: 183-188).

Extraocular muscle insertion shift after disinsertion during strabismus surgery

ABSTRACT Purpose To quantify the amount of insertion shift after disinsertion of the rectus muscles and identify factors that may influence the shift. Methods Patients who underwent rectus muscle surgery between November 2018 and April 2019 were included. During surgery, the limbal-insertion distance (LID) distance was measured in millimeters with calipers from the limbus to the center of the insertion at the anterior border of the rectus muscle prior to and after disinsertion. The primary outcome was the shift of the rectus muscle insertion after disinsertion. This was calculated by subtracting the LID after disinsertion from the LID before disinsertion. The secondary outcome was the identification of preoperative and intraoperative factors that influenced insertion shift. Randomization was performed to select one rectus muscle per patient. Patients with a history of prior scleral buckle procedure, glaucoma drainage device, orbital wall fracture and strabismus surgery in the same rectus muscle were excluded. Results 110 patients were included. The median (Q1, Q3) LID before disinsertion was shortest for the medial rectus muscle [5.0 (4.5, 6.0)], followed by lateral rectus muscle [6.0 (6.0, 7.0)] and inferior rectus muscle [6.0 (5.5, 7.0)]. The overall median (Q1, Q3) insertion shift was 1.0 (0.8, 1.0) mm (p < .001), which did not significantly differ between each rectus muscle subgroup (p = .158). Factors that influenced the amount of shift were moderate to severe restriction on forced duction testing (FDT) (B = 0.320, SE = 0.105, p = .003) and longer LID before disinsertion (B = 0.172, SE = 0.036, p < .001). Conclusions We found a significant anterior insertion shift after disinsertion of rectus muscles. Moderate to severe restriction on FDT and longer LID before disinsertion can result in larger insertion shifts.

Management of stretched scar\u2013 induced secondary strabismus

BackgroundTo determine characteristics and management of consecutive or recurrent strabismus secondary to stretched scar.MethodsThis is a retrospective review of all patients diagnosed with late secondary consecutive or recurrent strabismus due to stretched scar from 2012 to 2017. The diagnosis of stretched scar was made in any case of late (≥ 1 month) consecutive or recurrent strabismus associated with underaction of the previously operated muscle. The diagnosis was confirmed intraoperatively by negative forced duction test and the characteristic appearance of the scar tissue. Surgical correction involved excision of the scar tissue with muscle re-attachment to the sclera using non-absorbable sutures. Study parameters include improvement in secondary deviations, degree of muscle underaction and diplopia.Results21 consecutive and 6 recurrent cases of stretched scar –induced strabismus were identified and all cases were associated with variable degrees of limited ocular duction. After surgical correction of the stretched scar, consecutive deviations in the form of consecutive esotropia and exotropia were corrected by means of 26.1PD and 65.6PD while recurrent deviations in the form recurrent exotropia and recurrent hypertropia were corrected by means of 34.3PD and 11PD respectively with significant improvement of limited ocular ductions. 21 patients had diplopia at presentation and all were improved after surgery.Conclusionmanagement of stretched scar –induced secondary strabismus by excision of the stretched scar and muscle fixation to the sclera using non-absorbable sutures significantly corrects secondary deviations and improves limitation of ocular duction.

Periorbital Entrapment in a Minimally Displaced Medial Wall Fracture

I experienced periorbital entrapment in a minimally displaced medial wall fracture. An 18-year male was hit in the left eye by a fist. He had decreased horizontal ocular motility with pain. Exophthalmometry of both eyes were same. Computed tomography (CT) demonstrated a minimally displaced medial wall fracture with herniation of orbital fat. Decreased horizontal ocular motility and pain persisted until the fifth post-trauma day. On exploration, entrapped soft tissue was found and dissected from the fractured site, but the bony displacement was minimal. After release, the forced duction test became normal and postoperative CT demonstrated reduced herniated orbital fat. In cases of a minimally displaced medial orbital wall fracture, if the patient feels pain while gazing horizontally, precise inspection of the CT scan is needed. If the pain persists for several days, despite the absence of diplopia, periorbital entrapment should be suspected and exploration can be considered.

Diffusion Tensor Imaging of the Lateral Rectus Muscle in Duane Retraction Syndrome.

This study aimed to assess metrics of diffusion tensor imaging in evaluating microstructural abnormalities of the lateral rectus muscle in Duane retraction syndrome (DRS). A prospective study was conducted on 27 patients with DRS and 16 age- and sex-matched controls who underwent diffusion tensor imaging of orbit and forced duction test (FDT). Fractional anisotropy (FA) and mean diffusivity (MD) of the lateral rectus were calculated by 2 observers. Fractional anisotropy of the lateral rectus in patients (0.62 ± 0.07 and 0.59 ± 0.06) was significantly higher (P = 0.001) than that in controls (0.49 ± 0.06 and 0.51 ± 0.06). Selection values of 0.53 and 0.52 as cutoff points of FA of the lateral rectus to differentiate patients from controls revealed areas under the curve of 0.92 and 0.86 and accuracy values of 84.8% and 80.4% by both observers, respectively. Mean diffusivity of the lateral rectus by both observers in patients (1.19 ± 0.13 and 1.23 ± 0.19 × 10 mm/s) was significantly lower (P = 0.001) than that in controls (1.54 ± 0.18 and 1.49 ± 0.16 × 10 mm/s). Selection values of 1.35 and 1.40 × 10 mm/s as cutoff points of MD of the lateral rectus to differentiate patients from the control groups revealed areas under the curve of 0.93 and 0.85 and accuracy values of 91.3% and 80.4% by both observers, respectively. Interobserver agreement for MD and FA of the lateral rectus by both observers were excellent (r = 0.870 and, 0.959). Diffusion tensor imaging metrics of the lateral rectus muscle did not differ significantly between patients with unilateral and bilateral disease (P = 0.05) and patients with DRS type I and type III (P = 0.05). Diffusion tensor imaging metrics of the lateral rectus muscle differed significantly between FDT grades I and II versus grades III and IV, and these metrics were well correlated with the degree of FDT. Diffusion tensor imaging metrics are valuable noninvasive tools in evaluating the microstructural abnormalities of the lateral rectus in DRS and are well correlated with degree of FDT.

Partial scleral buckle removal during strabismus surgery after retinal detachment repair

To describe outcomes after partial scleral buckle removal at the time of strabismus surgery. The medical records of consecutive patients with symptomatic diplopia who underwent strabismus surgery after scleral buckling by two surgeons were reviewed retrospectively. All patients underwent forced duction testing and had a segment of the scleral buckle removed intraoperatively. Pre- and postoperative ocular motility and alignment were compared. The outcome was considered successful if residual horizontal deviation was ≤8Δ, vertical deviation ≤2Δ, and cyclotropia <5°. A total of 12 patients (mean age, 51years; range, 14-71years) with a mean horizontal deviation of 16Δ (range, 2Δ-40Δ) and mean vertical deviation of 10Δ (range, 2Δ-20Δ) were included. Three patients underwent 2 strabismus surgeries. All patients underwent intraoperative removal of a segment of the scleral buckle near a muscle being advanced or recessed at the time of surgery. An adjustable suture technique was used in 13 of 15 surgeries (86%). Orthotropia was achieved in 7 patients (58%); surgical success, in 11 (92%). Subjective resolution of diplopia was achieved in all patients, in 2 with the aid of prisms. Mean follow-up was 12.4months (range, 1-75). No patient had retinal redetachment. In this case series, removal of a segment of the scleral buckle facilitated advancement or recession of a rectus muscle and was associated with good outcomes without retinal redetachment.

Management of restrictive strabismus

Aim of the study This study aimed to target a special type of strabismus, the restrictive type, with prediction of its problems, diagnostic, management, and results. Patients and methods This is a prospective randomized study performed in Alexandria. The participants of this study were 42 patients having restricted strabismus, with different diagnostic criteria, such as abnormal ocular deviation with the movement of the globe defective and not reaching the midline, abnormal position of the head, forced duction test, and anatomical changes found during surgery. Results The cases of restrictive strabismus included congenital cases including monocular elevation deficit, Brown’s syndrome, congenital fibrosis of extraocular muscles, oculomotor nerve palsy, and long-standing strabismus, especially unilateral presenting in old age. Cases needed specific diagnostic procedure such as forced duction test to be performed preoperatively and intraoperatively, and postoperative results were satisfactory in most cases except cases that underwent previous surgery with muscle resection, aggravating the condition and leading to more restrictions. Conclusion Cases of restrictive strabismus, when properly diagnosed, with special considerations, could arrive at a postoperative satisfactory outcome.

Clinical features and surgical treatment of double elevator palsy in young children.

To describe the clinical features of congenital double elevator palsy (CDEP) and to evaluate various surgical outcomes between the standard Knapp and augmented Knapp procedures, based on improvements in primary eye position and ocular motility. Twenty-two patients with CDEP at Shanghai Children's Hospital were enrolled from July 2014 to January 2018. The forced duction test (FDT) was negative in 21 patients, aged 8mo to 12y (mean 5.4y). Patients were divided into two treatment groups: 16 patients underwent the standard Knapp procedure (group A), with or without horizontal squint procedure; and 5 patients underwent the augmented Knapp procedure (Foster procedure; group B). One patient underwent inferior rectus recession in the affected eye and superior rectus recession in the sound eye because of a positive FDT. The pre- and postoperative vertical deviations in the primary position and ocular motility were compared in the two groups. Twenty-one eyes of the 22 patients (95%) were aligned within 10 prism diopters (PD), and all patients (100%) reached ≥25% elevation improvement after surgery. The average corrected vertical deviation in group B was statistically better than that of group A. For group A, the vertical deviation in the primary position decreased from 24.75Δ±8.35Δ to 4.56Δ±8.07Δ after surgery, for an improvement of 23.06Δ±6.51Δ (P<0.05). In group B, the decrease was from 35.00Δ±5.00Δ (range 30Δ-40Δ) to 1.00Δ±2.24Δ, for an improvement of 34.00Δ±4.18Δ (P<0.05). There were significant differences between the pre- and postoperative elevation in each group (group A, P<0.05; group B, P<0.05). The average scale of improved elevation in group B (1.80±0.45) was not significantly better than that of group A (1.69±0.87; Z=-0.732, P=0.548). The average follow-up periods lasted 21mo in group A and 18mo in group B. For vertical deviations <30Δ, the standard Knapp procedure can be chosen. For deviations greater than 30Δ-40Δ, the Foster procedure should be chosen. Because of our early interference, the inferior rectus (IR) muscle did not show mechanical restriction. Monocular elevation deficiency (MED) should be diagnosed early so that complications will be reduced and the procedure will be easier for the surgeon.

Surgical Management in Type 1 Monocular Elevation Deficiency.

To evaluate the outcome of surgical treatment in patients with type 1 monocular elevation deficiency. Patients who were diagnosed as having type 1 monocular elevation deficiency by forced duction test and exaggerated traction test between 2000 and 2016 were retrospectively reviewed. Epidemiologic and clinical features of the patients were noted. The efficacy of ipsilateral inferior rectus recession to vertical misalignments and limitation of elevation were evaluated. The clinical features of the patients who did not achieve surgical success after inferior rectus recession were determined. The surgical and functional results of contralateral superior rectus recession were evaluated for patients who had residual hypotropia under inferior rectus recession. Thirty-nine patients were included in the study. Preoperatively, vertical deviations were 20.53 ± 4.50 prism diopters (PD) for near and 22.21 ± 5.12 PD for distance. After inferior rectus recession, the amount of vertical deviation corrected was 15 ± 1.14 PD for near and 17.01 ± 2.00 PD for distance. Ten (25.64%) patients did not achieve surgical success (> 6 PD residual hypotropia). Nine patients (preoperative inferior rectus recession measurements = 28.77 ± 7.25 PD for near and 27 ± 7.44 PD for distance) underwent contralateral superior rectus recession as a second surgery. After contralateral superior rectus recession, 7 of 9 (77.78%) patients achieved surgical success. The limitation of elevation significantly improved after both surgeries (Wilcoxon test, P < .05). No diplopia or other complications after surgeries were reported. Inferior rectus recession is the first surgical option for patients with type 1 monocular elevation deficiency. Contralateral superior rectus recession is an effective alternative surgical treatment for residual hypotropia after ipsilateral inferior rectus recession. [J Pediatr Ophthalmol Strabismus. 2018;55(6):369-374.].

Surgical outcomes of unilateral recession and resection in intermittent exotropia according to forced duction test results.

PurposeTo compare the surgical outcomes of unilateral lateral rectus recession–medial rectus resection (RR) according to forced duction test (FDT) results with those of conventional RR in intermittent exotropia.MethodsA total of 129 patients aged 3 to 10 years with intermittent exotropia who underwent RR between 2006 and 2011 were included. The operator compared the tension of the lateral rectus (LR) between both eyes. When FDT results were asymmetric, RR was performed on the eye with more LR tension. RR was performed on the nondominant eye when FDT results were symmetric. Patients were divided into two groups; one group (n = 64) underwent RR without FDT (RR group) and the other group (n = 65) underwent RR considering FDT results (RR-FDT group). Success, recurrence, reoperation rates and cumulative probabilities of success were evaluated in both groups. Surgical outcome was considered satisfactory if the distance deviation in the primary position was between ≤ 10 PD of exophoria/tropia and ≤ 10 PD of esophoria/tropia. Recurrence was defined as an alignment of > 10 PD of exophoria/tropia, and overcorrection defined as > 10 PD of esophoria/tropia. Reoperation for recurrence was recommended for constant exotropia ≥ 14 PD at distance.ResultsThe total follow-up periods were 4.4±2.3 years in the RR group, and 3.9±2.0 years in the RR-FDT group (P = .310). In the RR group, 50 patients (78.1%) were successful, 13 patients (20.3%) had recurrence, and 1 patient (1.6%) had overcorrection at 2 years after surgery. In the RR-FDT group, 58 patients (89.2%) were successful, 5 patients (7.7%) had recurrence, and 2 patients (3.1%) were overcorrected. The recurrence rate at 2 years after operation was significantly lower in the RR-FDT group (P = .045). Recurrence rates during the follow-up period were 5.6% per person-year in the RR group and 2.7% per person-year in the RR-FDT group. Reoperation for recurrence was performed on 7 patients (10.8%) in the RR-FDT group and 16 patients (25.0%) in the RR group (P = .035). Postoperative sensory outcomes were similar between both groups.ConclusionsThe forced duction test was useful in reducing the risk of recurrence at 2 years after surgery when RR was performed on the eye with more passive tension of the LR. Intraoperative FDT may be considered to choose which eye to operate on when planning RR in intermittent exotropia.

Clinical and Histopathologic Features of Consecutive Exotropia

ABSTRACTPurpose: The purpose of this study is to investigate clinical and histopathologic features of consecutive exotropia. Methods: Thirty patients with consecutive exotropia and negative forced duction testing underwent unilateral medial rectus resection and advancement. Abnormal scleral attachment (appearance of stretched scar or slipped muscle) was documented and compared with histopathology results. The term “stretched scar” is used when tendon-like scar appears between muscle fibers and scleral attachment. The term “slipped muscle” is used when a thin capsule is attached to the sclera and the muscle fibers retracted posteriorly in the capsule. Histopathologic results of resected medial rectus muscles of 11 control patients were compared with cases of consecutive exotropia. Surgical success was defined as <10 PD deviation at both distance and near, 6 months after the surgery. Dose–response and risk factors for abnormal scleral attachment were also evaluated. Results: Forty percent of the cases had abnormal scleral attachment. Nineteen patients (63%) showed successful results. The mean dose–responses were for near 4.7 and for distance 4.2 prism diopters per millimeters of resection plus advancement. Preoperative medial rectus underaction was a risk factor for abnormal scleral attachment. The mean muscle percentage in pathology was 10 ± 18.7 in patients with abnormal scleral attachment, 28.3 ± 27.9 in other consecutive exotropia patients, and 26.5 ± 30.6 in 11 control eyes. Conclusion: This study showed surgical success of 63% with one-muscle surgery in consecutive exotropia. Calculated dose–responses could be helpful in surgical planning. In the cases with preoperative medial rectus underaction, risk of abnormal scleral attachment is increased.

Reoperation of strabismus, points to be considered

Purpose The aim was to obtain the best results when dealing with previously operated cases of strabismus, as regards the restoration of ocular alignment, regaining ocular motility at least in the central field and at the same time aiming at preserving equal vertical width of the palpebral fissure in both the eyes. Participants and methods Effective strategies for strabismus reoperations are controversial, and should be tailored to each patient, depending on the specific history and findings. The first decision is to operate on previously operated muscles or fresh muscles. This should be influenced by many factors, in part by whether we are treating an undercorrection or an overcorrection, limitations of rotations, and incomitance, and by the vertical width of the palpebral fissure in the two eyes. Also many important decisions should be made intraoperatively based on the muscles integrity, whether slipped, lost, tight, hypertrophied, and also according to forced duction test. Results The total number of cases included in this study were 175 patients. Most of them were exotropic, 102 (58.3) cases, 67 women and 35 men, most of them (80 cases, 78.5%) were residual or recurrent. Esotropia constituted 59 (33.7%) cases, most of them were residual (46 cases). New types of deviation presented in 8% of cases. Management decision depended on the presenting deviation, its angle, ocular motility and any limitation, forced duction test, vertical width of the palpebral fissure, and modified according to the anatomical findings during the surgery. Conclusion A proper plan for a strabismus reoperation takes into consideration a number of factors preoperatively, and the surgeon should be prepared to modify his plans in each patient according to the intraoperative findings.

Diagnosis and treatment of strabismus caused by nasal endoscopic surgery

Objective: Strabismus with diplopia is the main orbital complication of functional endoscopic sinus surgery (FESS). This study was to analyze clinical findings, treatment and outcomes of such cases. Methods: Retrospective case series. Twenty-three cases were divided into 3 groups based on the disease severity: group A, partial transection of the medial rectus muscle, group B, complete transection of the medical rectus, group C, transection of the medial rectus combined with the other orbital injuries. Complete ophthalmology examinations, including eye alignment, eye motility, force duction test, force generation test, general eye exam, and medical imaging (orbital CT or MRI), were performed for each case. The treatment included botulinum toxin (Botox) injection to the lateral rectus muscle, transposition of the vertical rectus muscle, and orbital surgery if needed. Results: In group A with Botox injection, all the cases achieved single vision in primary position, but still remained some adduction weakness. In group B treated by vertical transposition surgery combined with Botox, 22% of the cases got single vision in primary gaze. In group C, even with more efforts of treatment, the cases with orbital injury can only get cosmetic improvement, and diplopia and adduction dysfunction were found in most cases. Conclusions: Due to the variety of the complications of FESS, force duction test is a crucial exam to detect the direction and severity of synechia in the orbit, which will give solid information to surgery approach as well as prognosis. Botox injection at early stage will minimize the contraction of antagonist lateral rectus, helping to postpone the transposition surgery which may cause anterior segment ischemia when performed right after the medial rectus transection injury. Botox may even reduce the synechia by minimizing the scarring process. Partial vertical rectus transposition combined with muscle resection may effectively correct the eye misalignment in primary gaze and improve eye motility. The prognosis of FESS induced orbital complications is quite related with the severity of the injury. Botox combined with surgery may help medial rectus transection cases to achieve single vision in primary gaze, but when there is any other orbital injury, treatment may only improve cosmetic appearance. (Chin J Ophthalmol, 2017, 53: 917-923).

Prognostic Factors of Orbital Fractures with Muscle Incarceration.

BackgroundAmong the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration.MethodsThe medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries.ResultsAll patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1–108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13–36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur.ConclusionsPatients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.

Sequential congenital and acquired presentation of bilateral Brown syndrome

Brown syndrome is an ocular motility disorder characterized by limitation of elevation in adduction of the affected eye that occurs with both voluntary ductions and passive forced duction testing. 1 Wright K.W. Brown’s syndrome: diagnosis and management. Trans Am Ophthalmol Soc. 1999; 97: 1023-1109 Google Scholar The cause is thought to be an abnormality of the superior oblique tendon–trochlea complex. Brown syndrome can be either congenital or acquired, with the congenital form occurring bilaterally in 10% of cases. 2 Wilson M.E. Eustis Jr., H.S. Parks M.M. Brown’s syndrome. Surv Ophthalmol. 1989; 34: 153-172 Google Scholar