Forced Duction Test Research Articles

Pseudo-Brown Syndrome: A Potential Ophthalmologic Sequela After a Transcaruncular–Transconjunctival Approach for Orbital Fracture Repair

To prospectively assess the incidence of orthoptic anomalies and, more specifically, the possible development of pseudo-Brown syndrome related to inferior oblique muscle (IO) myotomy after the transcaruncular-transconjunctival approach for orbital fracture repair and its effect on the possible development of annoying diplopia. We analyzed the clinical data from 14 patients with severe isolated medial wall or combined medial wall/floor fractures treated using titanium meshes placed using a transcaruncular-transconjunctival approach. All patients were assessed with a pre- and postoperative ophthalmologic examination using the following methods: prisms and alternate cover test in all 9 gaze directions, Hess-Weiss coordimetry, Maddox rod screen testing, and Harms wall deviometry. The Bielschowsky head-tilt and a forced duction test were also performed. The patients were classified into the following 2 groups: IO paretic-underaction group and non-IO paretic-underaction group. Of the 14 patients, 7 (50%) fulfilled the criteria for IO paretic-underaction. All 7 developed double vision limited to the extreme upgaze in adduction. Four patients in the non-IO paretic-underaction group had double vision limited to the extreme upgaze in abduction that was already present preoperatively. Diplopia did not interfere with the daily activities in the patients from either group. The present study has demonstrated that IO myotomy associated with the combined transcaruncular-transconjunctival approach can result in orthoptic complications. Moreover, our study has shown that the development of a pseudo-Brown syndrome related to IO underaction was not uncommon but resulted in sequela restricted to a very limited portion of the binocular field of vision.

Sequential presentation of bilateral Brown syndrome

Brown syndrome, characterized by a limitation of elevation in adduction and positive forced duction testing, is usually unilateral but occurs bilaterally in 10% of all cases. It may present as a congenital condition in one eye and develop in the other eye with no apparent cause. We present a case of bilateral Brown syndrome in which the right eye became involved within 1 year of surgery on the left eye for congenital Brown syndrome.

Duane’s retraction syndrome associated with crocodile tears and hearing loss

Duane’s retraction syndrome (DRS) is a predominately congenital eye movement disorder. We present a 23-year-old female with unilateral DRS, which was diagnosed by magnetic resonance imaging (MRI), and associated symptoms of unilateral crocodile tears and bilateral high-frequency hearing loss. This case highlights that DRS may be associated with various systemic malformations. For children with newly diagnosed DRS, we recommend comprehensive evaluation for any associated abnormalities. For adults with DRS complaining of discomfiture associated with a noncentral head position, we suggest a complete examination, including strabismus tests, the forced duction test, and even MRI, to evaluate the degree of muscle modification and to identify the most suitable treatment strategy.

Retrospective study on clinical characteristics and surgical treatment of bilateral DRS

To investigate the clinical characteristics and surgical treatment of bilateral Duane retraction syndrome. To collect 24 cases with bilateral DRS among 123 cases with DRS from hospital data during 2005.7 to 2009.11. Retrospective study included the clinical types, characteristics, plus diseases and surgical treatments. Fourteen male cases (58.3%) and 10 female cases (41.7%), aging 2 to 23-year-old. 16 cases were type I (66.7%), 1 case was type II (4.2%). 7 cases were type III (29.1%), in which patients with esotropia or exotropia were 3 and 4 cases respectively. 11 cases had up- or down-shoot pre-operation, which disappeared or improved post-operation in 8 cases (73%). 15 cases had abnormal head posture (AHP) and AHP disappeared or improved in all. Seven cases (29%) were associated with other congenital ocular or systemic anomalies. For horizontal deviation, unilateral medial or lateral rectus weakening procedures were performed in 13 cases and bilateral procedures in 11 cases. Post-operation, horizontal deviation was less than ± 10(Δ) in 21 patients (91%), 1 case was under-corrected and 2 cases were overcorrected. Simultaneously, the restriction of ocular motility and global retraction were improved in all the patients. Additional vertical or oblique muscle procedures were performed in 4 patients among 7 with vertical deviation more than 10(Δ) and up- or down-shoot. Bilateral DRS has more frequency in male, obviously horizontal deviation in primary position and more cases with vertical deviation which is related with up- or down-shoot phenomenon. The key point for successful surgery are forced duction test pre- and during operation to conform to relieve the mechanical factor and estimating abnormal innervation in horizontal and vertical rectus.

Open Reduction in Trapdoor-Type Blowout Fractures Using Absorbable Mesh Plates

In many cases of trapdoor-type orbital blowout fracture, the bony segment has a stable hinge consisting of a greenstick fracture and the sinus mucoperiosteum that is attached to the intact orbital wall. If the displaced bony segment opposite the hinge will be reduced into its original position and will be fixed onto the unaffected bone, the orbital fracture may be reconstructed via the internal fixation of the bony segment itself rather than requiring substitution with an alloplastic implant or a bone graft. A retrospective study was conducted from January 2008 to February 2010 in 34 patients with blowout fracture, via retrospective chart review, including detailed preoperative and postoperative evaluations, age, sex, symptoms, and signs, and based on the postoperative complications. The subciliary, transconjunctival, and transcaruncular approaches were used to expose the orbital floor under general anesthesia. The herniated orbital soft tissue was carefully reduced. The displaced bony segment was carefully pulled up and placed in its original anatomic position with a skin hook. A small absorbable mesh plate was inserted between the normal orbital wall and the bony segment, tangential to the edge of the bony defect at the dependent portion. Postoperative examinations such as the traction and forced duction tests showed no eye movement limitation and surgical complications. During the follow-up period, no complications occurred, and the orbital wall was accurately reconstructed in its original anatomic position, as confirmed by postoperative computed tomography scans. The advantages of internal fixation include anatomic reconstruction of the orbital wall, preservation of the original orbital bone and the mucoperiosteum of the sinus resulting in rapid wound healing and normal mucus drainage function of the sinus, simplicity of the procedure, and the absence of surgery-related complications. This technique is presented as one of the preferred treatments for trapdoor-type orbital blowout fracture.

Medial Rectus Recession After Vertical Rectus Transposition in Patients With Esotropic Duane Syndrome

To describe preoperative characteristics and postoperative results among patients with esotropic Duane syndrome who underwent vertical rectus transposition with vs without subsequent medial rectus recession (MRR). Clinical records were compared of patients with esotropic Duane syndrome who underwent vertical rectus transposition with (study group) vs without (control group) subsequent MRR. Twenty-three study group members and 26 control group members were identified. Preoperative characteristics that differed between groups were the mean (SD) primary position deviation (20 [7] prism diopters of esotropia [ΔET] for the study group vs 15 [9] ΔET for the control group, P = .002) and the mean (SD) adduction deviation (1.4 [4.0] ΔET for the study group vs 2.5 [4.0] Δ exotropia for the control group, P = .04). Forced duction testing (FDT) revealed greater restriction to abduction (17 [7]° for the study group vs 23 [6]° for the control group, P = .002). After vertical rectus transposition, study group members had significantly greater mean (SD) ET (16 [7] ΔET vs 0.4 [0.6] ΔET for the control group, P < .001) and torticollis (10 [4]° vs 1 [5]° for the control group, P < .001) and significantly less mean (SD) abduction (-3.0 [-0.6] vs -2.0 [-0.7] for the control group, P = .20). After MRR, no significant difference was observed between groups in primary position deviation, but the study group had significantly less mean (SD) adduction (-1.0 [-0.8] vs -0.4 [-0.6] for the control group, P < .003). Risk factors for requiring MRR after vertical rectus transposition include greater ET in the primary position and in the adducting field of gaze, as well as greater restriction to abduction on intraoperative FDT. Postoperative results of patients who required MRR were similar to those of patients who did not require MRR.

Brownʼs syndrome

To better understand the various causes of Brown's syndrome, provide a historical account of the progression of Brown's syndrome, and to bring attention to clinical characteristics specific to Brown's syndrome. The inability to elevate an eye in adduction is a common problem with a number of possible causes usually pointing to cyclovertical muscle involvement. The specific cause can usually be determined by either the three-step test or forced ductions. Because Brown's syndrome does not involve a paretic cyclovertical muscle but rather a mechanical muscle limitation, forced ductions instead of the three-step test must be used to evaluate a patient of Brown's syndrome and is crucial in the diagnosis. The recognition of true Brown's syndrome can be accomplished by clinical examination and confirming the diagnosis with a positive forced duction test.

Risk factors for consecutive exotropia after vertical rectus transposition for esotropic Duane retraction syndrome

To define risk factors for postoperative exotropia after vertical rectus transposition (VRT) for Duane syndrome. The records of patients with Duane syndrome who underwent augmented VRT were retrospectively reviewed; those with postoperative exotropia (study group) were compared with those with postoperative esotropia/orthotropia (controls). A total of 51 patients were included, of whom 14 were exotropic postoperatively. Of the 14, 6 became exotropic after augmented VRT, and 8 who were initially esotropic became exotropic after subsequent medial rectus muscle (MR) recession. Study subjects were significantly younger (2 ± 2 years vs 6 ± 10 years, P = 0.04) and demonstrated less restriction on intraoperative forced duction testing than control subjects. Subjects who became exotropic after MR muscle recession had significantly less esotropia at near (5.2(Δ) ± 6.5(Δ) vs 18.4 (Δ) ± 7.9(Δ) esotropia, respectively; P = 0.005) and in adduction (1(Δ) ± 2(Δ) exotropia vs 3(Δ) ± 4(Δ) esotropia, respectively; P = 0.02) than control patients who also underwent VRT and MR muscle recession. Forced duction testing was also significantly different among these groups (P = 0.03). Risk factors for exotropia after augmented VRT include younger age and less restriction on forced duction testing. Additional risk factors for exotropia after VRT and subsequent MR muscle recession include preoperative exotropia in adduction and smaller deviation at near. These factors may be useful in distinguishing patients at risk, allowing for consideration of less powerful procedures.

Tenon Recession: A Novel Adjunct to Improve Outcome in the Treatment of Large-Angle Strabismus in Thyroid Eye Disease

Treatment of large-angle strabismus in thyroid eye disease has historically suffered from low success rates. The authors report a novel technique that adds Tenon recession without conjunctival recession to standard extraocular muscle surgery. Twenty-six patients with thyroid eye disease-associated strabismus with preoperative deviations of ≥ 25 prism diopters in horizontal or vertical deviations underwent strabismus surgery. The amount of recession for a given muscle was determined by a combined analysis of the preoperative versions, deviation in primary gaze and in gaze opposite the restricted muscle, and intraoperative forced duction testing. Before conjunctival closure, the underlying Tenon layer and associated orbital tissues were recessed and allowed to retract posteriorally. The overlying conjunctiva was subsequently reapproximated to its anatomic position without tension. The average preoperative measurements for horizontal and vertical deviations were 39.2 ± 13.4 and 45.0 ± 18.9 prism diopters, respectively. Average postoperative measurements for horizontal and vertical deviations were 3.2 ± 6.0 and 11.1 ± 11.9 prism diopters, respectively. Overall, 22 of 26 patients (84.6%) were within 10 prism diopters of intended correction postoperatively and achieved binocular fusion with or without the use of prisms for both distance and near vision. Four had residual deviations that required reoperation, all of which successfully produced binocular vision without the use of prisms. In the authors' experience, Tenon recession improves outcomes in surgery for large-angle strabismus in thyroid eye disease.

Presumed scleral perforation during forced duction testing of the superior oblique muscle

This is a report a case of presumed scleral perforation during globe retropulsion as part of the Guyton exaggerated traction test in a patient with a history of bilateral keratoconus and scleral thinning. Perforation was indicated by the sudden occurrence of hyphema and globe softening. Postoperatively, the hyphema resolved, the intraocular pressure normalized, and the patient regained preoperative visual acuity.

Congenital Isolated Absence of the Inferior Oblique Muscle and Compensatory Aberrant Insertion of the Inferior and Lateral Recti

Absence of various extra-ocular muscles has previously been described. However isolated absence of the inferior oblique has not yet been described.Our patient was found to have a small right esotropia and limitation of right eye abduction with an abnormal head posture. Ocular movements showed a marked adduction overshoot in elevation.Exploration of the musculature revealed an absent inferior oblique with abnormally inserted and tight inferior and lateral rectus muscles.Imaging, forced duction testing and surgical exploration is recomended in cases where the signs do not fit into a clear syndrome.

Situational Restriction: Using Your Physical Exam to Differentiate Pulley Abnormalities from Other Vertical Deviations Secondary to Restrictive Conditions

The description of the orbital pulley system has changed the way we understand eye movements and ocular motility disorders. The presence of abnormalities in the orbital pulley system can complicate the assessment of vertical restrictive conditions. The standard tests for restriction are reviewed. These include version and duction testing, assessing saccades, differential intraocular pressure measurements, forced duction testing, and forced generation testing. We introduce the concept of situational restriction and how to look for it during your physical exam. Situational restriction is a limitation of ocular rotation that is dependent on the path that is taken to try to arrive at a tertiary position of ocular rotation. Specifically, it shows noncommutative movement that breaks Listing's Law. The presence of situational restriction denotes that a pulley abnormality is present.

Management of diplopia in patients with blowout fractures

Purpose:To report the management outcomes of diplopia in patients with blowout fracture.Materials and Methods:Data for 39 patients with diplopia due to orbital blowout fracture were analyzed retrospectively. The inferior wall alone was involved in 22 (56.4%) patients, medial wall alone was involved in 14 (35.8%) patients, and the medial and inferior walls were involved in three (7.6%) patients. Each fracture was reconstructed with a Medpore® implant. Strabismus surgery or prism correction was performed in required patients for the management of persistent diplopia. Mean postoperative follow up was 6.5 months.Results:Twenty-three (58.9%) patients with diplopia underwent surgical repair of blowout fracture. Diplopia was eliminated in 17 (73.9%) patients following orbital wall surgery. Of the 23 patients, three (7.6%) patients required prism glasses and another three (7.6%) patients required strabismus surgery for persistent diplopia. In four (10.2%) patients, strabismus surgery was performed without fracture repair. Twelve patients (30.7%) with negative forced duction test results were followed up without surgery.Conclusions:In our study, diplopia resolved in 30.7% of patients without surgery and 69.2% of patients with diplopia required surgical intervention. Primary gaze diplopia was eliminated in 73.9% of patients through orbital wall repair. The most frequently employed secondary surgery was adjustable inferior rectus recession and <17.8% of patients required additional strabismus surgery.

A New Approach for Management of Monocular Elevation Deficiency

Aim: To show that the classic Knapp procedure when used for treatment of monocular elevation deficiency may not correct it completely especially when associated with pseudoptosis and to suggest a treatment option. Methods: Thirteen patients (2 to 6 years) with congenital monocular elevation deficiency (MED) were studied. All patients had hypotropia, pseudoptosis, absent elevation above the primary position and negative forced duction test of the affected eye. Medial and lateral rectus muscles were elevated via Knapp procedure. Two months later, the inferior rectus muscle of the non-affected eye was resected 6 m for three patients and tucked for the other two patients. On follow up, vertical deviation mar nal reflex dis ance were recorded after each procedure. Results: After Knapp procedure, hypotropia was moderately improved and pseudoptosis appeared worse in three of the five patients. On the other hand, a good lid height and an improvement in hypotropia were achieved after resecting the contralateral inferior rectus muscle for all patients.

Efficacy of Marlex Mesh on Posterior Fixation Suture: An Experimental Study in a Rabbit Model

To develop a novel method of posterior fixation suture augmented by the application of Marlex mesh and to evaluate the surgical results in a rabbit model. Animal study. Prospective, masked-observer, controlled experimental study. Sixty superior rectus muscles of 30 rabbits. Each superior rectus muscle was randomly subjected to posterior fixation suture at a distance of 6 mm from the muscle insertion. The rabbits were divided into 3 groups: conventional posterior fixation suture (Conventional group), and modified posterior fixation suture using a silicone sponge (Silicone group) or using Marlex mesh (Marlex group). Nonabsorbable sutures were used for muscle-sclera (Conventional group) or muscle-implant fixation (Silicone and Marlex group) and absorbable sutures were used for implant-sclera fixation (Silicone and Marlex group). The efficacy of posterior fixation suture was determined by forced duction testing toward the operated-on muscle immediately after the operation and at 8 weeks postoperatively. Eyes were enucleated at 8 weeks after surgery to measure the stability of the bond using a push pull gauge, and finally the histologic findings were evaluated. Immediately after posterior fixation suture and at 8 weeks postoperatively, the restrictive motion during duction toward the operated-on muscle was greater in the Marlex group compared to the other groups (P < .001). The resistance to separation of the myoscleral union was greatest in the Marlex group (P < .001). Posterior fixation suture can be effectively reinforced and stabilized using Marlex mesh.

Update on orbital reconstruction

Orbital trauma is common and frequently complicated by ocular injuries. The recent literature on orbital fracture is analyzed with emphasis on epidemiological data assessment, surgical timing, method of approach and reconstruction materials. Computed tomographic (CT) scan has become a routine evaluation tool for orbital trauma, and mobile CT can be applied intraoperatively if necessary. Concomitant serious ocular injury should be carefully evaluated preoperatively. Patients presenting with nonresolving oculocardiac reflex, 'white-eyed' blowout fracture, or diplopia with a positive forced duction test and CT evidence of orbital tissue entrapment require early surgical repair. Otherwise, enophthalmos can be corrected by late surgery with a similar outcome to early surgery. The use of an endoscope-assisted approach for orbital reconstruction continues to grow, offering an alternative method. Advances in alloplastic materials have improved surgical outcome and shortened operating time. In this review of modern orbital reconstruction, several controversial issues such as surgical indication, surgical timing, method of approach and choice of reconstruction material are discussed. Preoperative fine-cut CT image and thorough ophthalmologic examination are key elements to determine surgical indications. The choice of surgical approach and reconstruction materials much depends on the surgeon's experience and the reconstruction area. Prefabricated alloplastic implants together with image software and stereolithographic models are significant advances that help to more accurately reconstruct the traumatized orbit. The recent evolution of orbit reconstruction improves functional and aesthetic results and minimizes surgical complications.

Clinical Findings and Surgical Results of Duane Retraction Syndrome

To evaluate clinical properties and surgical outcomes of Duan retraction syndrome (DRS). Twenty-one patients with DRS were evaluated. Surgery was indicated for correction of strabismus, abnormal head position, upshoot-downshoot, and globe retraction. Six patients had undergone surgery. In 5 cases, the lateral rectus muscle was recessed from 4.0 to 7.0 mm combined with "Y-splitting" according to deviation in primary position and degree of globe retraction. In case of significantly positive forced duction test on the medial rectus muscle intraoperatively, simultaneous recession of the ipsilateral medial rectus muscle was performed in addition to lateral rectus surgery. Type I DRS was diagnosed in 83.33% of cases. All 6 cases that underwent surgery had type I DRS. After surgery, all patients showed elimination of upshoot-downshoot. Two cases had minimally improved abduction from the midline. Case 1 underwent a second operation and it was observed that the middle split part disappeared and muscular fibers proliferated to the original insertion. To protect against refusion of the middle split part of the muscle due to proliferation, nonabsorbable separation sutures were placed around the split parts of the upper and lower halves without scleral fixation. Separation sutures were placed on both parts of the muscle to protect refusion in the other cases. Y-splitting combined with recession of one or both horizontal recti is an effective procedure in patients with DRS and associated horizontal deviation. Prophylactic separation sutures as part of Y-splitting may protect against recurrence.

Palmaris longus tendon as an autogenous expander for Brown's syndrome: A novel technique

The palmaris longus tendon (PLT) is one of the most commonly used donor tendons in orthopedic and reconstructive surgery. We present a new surgical technique using this autogenous tissue for lengthening the superior oblique tendon in cases of moderate to severe Brown syndrome. Four children with Brown syndrome were selected, and consent was obtained. Preoperative motility assessment and intraoperative forced duction tests confirmed the diagnosis. PLT harvesting was performed under general anesthesia. Follow-up ranged from 12 to 21 months. Preoperatively all patients demonstrated hypotropia of 16Delta to 30Delta with an abnormal head posture. Postoperatively all patients showed an improvement in hypotropia to <3Delta, with complete resolution of abnormal head posture. Improvement of elevation in adduction did not match that of the vertical deviation, but all patients had less restriction of elevation in adduction after surgery. No patients developed any of the complications encountered with a silicone expander (eg, extrusion, tendon-related inflammation, foreign body sensation, or consecutive superior oblique palsy), and none needed further surgery. Wrist function was completely normal in all patients postoperatively. PLT is an autogenous tissue that allowed for controlled weakening of the superior oblique tendon, with minimal complications observed in four patients. More studies comparing PLT tendon expansion with other published methods are warranted.

Surgical outcome of 21 patients with congenital upper eyelid coloboma.

To evaluate the surgical outcome of congenital upper eyelid coloboma repair. All patients underwent complete ophthalmic and general examination before going to surgery, and then examination under anesthesia was performed to assess the site and size of eyelid defect, conjunctival involvement. The status of cornea and ocular motility with forced duction test was also being noted. The surgical procedure was performed according to the size of defect. Out of 21 cases of congenital upper eyelid coloboma, 18 occurred in isolation with upper eyelid medial defect, 13 were bilateral and 5 were unilateral. Others were associated with Goldenhar syndrome and CHARGE syndrome with bilateral upper lid medial defects. All patients were presented for surgical corrections during age of 2.5-4.0 years except one that presented at 25 years of age. Cosmetically surgical results were acceptable, except one that was already presented with opaque corneal. In this study, overall surgical results were satisfactory except one that was presented late with compromised cornea.

A Case of Acquired Brown Syndrome after Surgical Repair of a Medial Orbital Wall Fracture

A case of acquired Brown syndrome caused by surgical repair of medial orbital wall fracture is reported in the present paper. A 23-year-old man presented at the hospital with right periorbital trauma. Although the patient did not complain of any diplopia, the imaging study revealed a blow-out fracture of the medial orbital wall. Surgical repair with a calvarial bone autograft was performed at the department of plastic surgery. The patient was referred to the ophthalmologic department due to diplopia that newly developed after surgery. The prism cover test at distant fixation showed hypotropia of the right eye, which was 4 prism diopters (PD) in primary gaze, 20 PD in left gaze, while orthophoric in right gaze. Eye movement of the right eye was markedly limited on elevation in adduction with normal elevation in abduction with intorsion in the right eye present. Forced duction test of the right eye showed restricted elevation in adduction. Computerized tomography scan of the orbits showed the right superior oblique muscle was entrapped between the autografted bone fragment and posterior margin of the fracture. When repairing medial orbital wall fracture that causes Brown syndrome, surgeons should always be careful of entrapment of the superior oblique muscle if the implant is inserted without identifying the superior and posterior margin of the orbital fracture site.