Improvement In Ocular Motility Research Articles

Outcome of extraocular muscle transpositions in various types of strabismus

Background: Transposition surgery of extraocular muscles helps in paralytic strabismus by altering the direction of force in relation to the center of rotation of the eye. Hence, the study was done to report the outcome of muscle transpositions. Materials and Methods: This was a prospective interventional study of 20 patients conducted at our tertiary ophthalmic institute over a period of 2 years and included ten patients with “V” pattern and four patients with “A” pattern strabismus, two patients with monocular elevation deficiency (MED), two patients with third nerve palsy, and one patient each with Duane’s retraction syndrome (DRS) and Crouzon’s syndrome. Fourteen patients underwent correction of horizontal strabismus with vertical transposition of horizontal recti, four patients underwent upward transposition of lateral rectus (LR) muscle, one patient underwent modified Knapp’s procedure, and one patient had “Y” split of LR muscle with transposition. Results: Ten patients with “V” pattern strabismus and four patients with “A” pattern strabismus had satisfactory collapse of pattern postoperatively with <10 prism diopters (PD) and 15 PD of mean residual horizontal strabismus, respectively. Both patients with MED had good improvement in primary position alignment. Upshoot in DRS patient was corrected. Two out of six patients who had preoperative limitation of duction had improvement postoperatively. Conclusion: Extraocular muscle transposition resulted in alignment of eyes, collapse of alphabet pattern, and improvement in ocular motility in these patients. Proper patient selection and planning of the suitable type of transposition surgery helps in achieving the desired outcome.

Outcomes and risk factors of surgical management of thyroid eye disease-related diplopia.

To evaluate the outcomes of strabismus surgery in patients with thyroid eye disease (TED) and to assess the influence of preceding treatments such as steroid administration, orbital decompression and radiotherapy. Retrospective study on a cohort of patients with TED undergoing strabismus surgery. Data collection included clinical features, smoking status, preceding steroid therapy, orbital radiation therapy and orbital decompression. Qualitative evaluation, assessing diplopia and quality of life and quantitative evaluation, assessing the eye misalignment were analysed 1 year after the last squint surgical procedure. Seventy-nine patients were identified. Ninety-five surgical procedures were performed on 92 eyes. A significant overall improvement of ocular motility was registered (p < 0.001, paired t-test). Forty-five (57%) patients had excellent outcomes, twenty-three (29%) had good outcomes and eleven (14%) had poor outcomes. The average number of muscles operated was significantly greater in patients who underwent orbital bone decompression (1.58 ± 0.63; p = 0.0082; 95% CI 1.413-10.214). Quantitative and qualitative outcomes were not associated with the preceding therapy: steroid (p = 0.75), radiotherapy (p = 0.95) or orbital bone decompression (p = 0.25). The success rate was no different between adjustable and fixed sutures (p = 0.8). Strabismus surgery in TED patients resulted in a high success rate in reducing diplopia and improving ocular motility. The success rate was not negatively associated with previous therapies. Indeed, resolution of diplopia required more squint procedures in patients who have previously undergone to orbital decompression.

Correlation between surgical timing and postoperative ocular motility in orbital blowout fractures.

The study reports the correlation between surgical timing and postoperative ocular motility in orbital blowout fractures. This was a retrospective study of 191 patients that underwent surgical repair for unilateral orbital fractures. All patients included in the study had symptomatic diplopia from the fracture. Patients were classified into one of three groups according to the time of surgery after injury: (1) Early (within 14days of surgery), (2) intermediate (between 15 and 30days), and (3) late (greater than 30days). Ocular motility was measured presurgery and at 3 and 6months postsurgery by Hess chart with calculation of the Hess area ratio (HAR%). Surgery was conducted at a mean of 24.7 ± 45.0days (range: 1-283days) postinjury. There were 120 patients in the early surgery group (surgery at 6.8 ± 3.8days), 38 in the intermediate surgery group (20.7 ± 4.1days), and 33 in the late surgery group (95.1 ± 75.0days). Overall the HAR% improved significantly from a mean of 74.2% preoperatively to 90.8% at 6months postoperatively (p < 0.01). In the early and intermediate groups, the postoperative HAR% improved significantly with all fracture regions (orbital floor, medial wall, and combined orbital medial wall and floor) (p < 0.05). However, in the late groups, the postoperative HAR% only improved significantly with orbital floor fractures. Pre- and postoperative the HAR% give objective evidence of ocular motility improvement with early orbital floor fracture repair surgery. However, observation can be deployed, as a significant improvement in ocular motility can also be achieved with reconstructive surgery conducted 30days or more after depressed floor-fragment fractures. Early intervention should be prioritized for symptomatic medial wall fractures, as late surgery does not improve motility.

Clinical Research on the Efficacy of Modified Surgery for Esotropia Fixus With High Myopia.

To investigate the efficacy of a modified surgical procedure for esotropia fixus with high myopia. Thirteen patients (15 eyes) with esotropia fixus and high myopia who underwent the Jensen procedure for superior and lateral rectus muscles at Southwest Hospital between February 2014 and December 2015 were retrospectively analyzed. Intraoperatively, the superior rectus and lateral rectus muscles were separated up to 12 to 14 mm posterior to their respective insertion. A medial rectus large recession or rectus tenotomy was performed based on the degree of fibrosis of the medial rectus muscle. Postoperative examinations were performed at 1 day, 2 weeks, 3 months, and 6 months. On the first postoperative day, 12 eyes (10 patients) were in the primary position (80.0%), 2 eyes (2 patients) exhibited 5° to 10° esotropia (13.3%), and 1 eye (1 patient) exhibited 15° esotropia (6.7%). At the 2-week follow up, 1 eye (1 patient) was lost to follow-up, 9 eyes (7 patients) were in the primary position (64.3%), 3 eyes (3 patients) exhibited 10° esotropia (21.4%), and 2 eyes (2 patients) exhibited 15° to 20° esotropia (14.3%). At the 3-month follow-up, the patient whose ocular alignment was 20° esotropia at 2 weeks was found to have developed 30° esotropia; no change was observed in the other patients. A remarkable improvement in ocular motility was observed in all patients. The Jensen procedure for the union of the superior rectus and lateral rectus muscles, using two pairs of sutures applied 12 to 14 mm posterior to their respective insertions, yielded favorable outcomes. [J Pediatr Ophthalmol Strabismus. 2018;55(4):219-224.].

Ocular motility disorders: unusual presentation of pituitary adenoma

Background The aim of this study was to describe ocular palsies as a rare presentation of pituitary adenomas and their relation to the size, type, and extension of tumor. Patients and methods Patients who presented with acquired onset of diplopia or ptosis during the period from February 2014 to January 2017 were included. Patients were referred to the neurology unit for transphenoidal removal of the gland. Full ophthalmologic and neurologic examinations were performed preoperatively and postoperatively. Results This study included 15 (12 men and three women) patients. Nine (60%) patients had isolated third nerve palsy; four (26.6%) patients had isolated sixth nerve affection; and two (13.3%) patients had total external ophthalmoplegia. Ocular motor disorders occurred more in nonfunctioning macroadenomas (73.3%) with grade 3 paraseller extension (60%). Apoplexy occurred in 46.7% of the cases. After surgical removal of the tumor, ocular motor improvement started within 3 weeks postoperatively. Full recovery occurred in seven (46.6%) patients within 6 months; five (33.3%) patients showed partial recovery; and three (20%) patients showed no improvement. Conclusions Acquired ocular motility disorders should raise the possibility of pituitary adenoma. The third nerve is the most affected, followed by the sixth nerve. The majority of the cases occurred in nonfunctioning macroadenoma. Transphenoidal tumor excision has a favorable outcome regarding the improvement of ocular motility.

Orbital adherence syndrome: clinical characterization and risk factor tracing (retrospective clinical research)

Background: Titanium mesh is one of the most used reconstruction material in the management of orbital floor fracture, with successful reported outcomes. Few reports describe unfavorable tissue reaction to titanium mesh with subsequent diplopia and lid retraction secondary to periorbita adhesions, or as mentioned in literature, orbital adhesion syndrome (OAS). However, there is no accurate description of such condition and how to avoid it.Aim: This manuscript was made in an attempt to review characterization of this syndrome, associated risk factors, and recommendations to avoid it.Patients and methods: A thorough revision of orbital floor fracture cases treated with titanium mesh in oral and maxillofacial surgery units in both Cairo University and Ain Shams University between 2015 and 2017 was done according to criteria described by Lee (2009).Results: Only six cases of 100 cases treated with titanium mesh in the orbital floor and/or medial wall were diagnosed clinically and radiographically as OAS. All cases underwent removal of implant (3–6 months) after primary repair with replacement by polydaxon sheet. Four cases showed clinical improvement in ocular motility within 2 weeks, whereas two cases did not improve.Conclusion: OAS is an unfavorable tissue reaction to rough surface of titanium mesh, where delayed primary repair and use of large mesh with wide pores in an un-intact periorbita extending to inferior orbital rim are main risk factors. Early detection of this rare complication with removal of titanium mesh is essential for successful management.

Use of bioresorbable implants for orbital fracture reconstruction

PurposeBioresorbable implants offer several advantages over permanent implants and serve as a useful alternative in the reconstruction of orbital fractures. Our aim of the study was to evaluate the clinical...

Efficacy of Subantimicrobial Dose Doxycycline for Moderate-to-Severe and Active Graves' Orbitopathy.

Aim. To study the efficacy and safety of subantimicrobial dose (SD) doxycycline(50 mg/d) in patients with active and moderate-to-severe Graves' orbitopathy (GO). Methods. Thirteen patients with active and moderate-to-severe GO received once daily oral doxycycline (50 mg/d) for 12 wk. Treatment response at 24 wk was used as the primary outcome, measured by a composite of improvement in Clinical Activity Score (CAS), diplopia, motility, soft tissue swelling, proptosis, and eyelid aperture. Secondary outcome was the change of quality of life score (QoL, including visual functioning subscale and appearance subscale). Adverse events were also recorded. Results. Overall improvement was noted in eight out of 13 patients (61.5%, 95% CI 31.6%–86.1%). Both CAS and soft tissue swelling significantly ameliorated in eight patients at 24 wk. Five patients (38.5%) had improvement in ocular motility of ≥8 degrees. Eyelid aperture (46.2%) also decreased remarkably. For QoL, a significant improvement in appearance subscale (P = 0.008) was noted during the study, whereas no difference was observed in visual functioning subscale (P = 0.21). Two patients reported mild stomachache at 12 wk. Conclusions. SD doxycycline appears to be effective and safe for the treatment of active and moderate-to-severe GO. It might serve as a new promising therapeutic strategy for GO. This trial is registered with NCT01727973.

Methotrexate as a Corticosteroid-Sparing Agent for Thyroid Eye Disease.

Thyroid eye disease (TED) is generally treated with oral corticosteroid therapy. A steroid sparing drug could be a useful adjunct. We reviewed our experience with methotrexate as a corticosteroid sparing agent to treat TED. Retrospective chart review from two eye inflammation clinics. Patients with TED who were unable to discontinue prednisone therapy without disease recurrence were included. 14 patients who were receiving an average of 32 mg/day of prednisone were treated with methotrexate, usually 15 mg/week orally or 20 mg/week subcutaneously. Five patients discontinued therapy for a lack of benefit or intolerance. Of the 9 patients who remained on methotrexate, all were able to discontinue prednisone completely after an average duration of 7.5 months. Improved visual acuity by at least two lines on the Snellen chart was achieved by 7 of 12 patients with reduced acuity and partial improvement in ocular motility was achieved in 5 of 14 patients. Methotrexate provided an effective steroid sparing effect in a subset of patients with TED.

Surgical Procedure Joining the Lateral Rectus and Superior Rectus Muscles With or Without Medial Rectus Recession for the Treatment of Strabismus Associated With High Myopia

To evaluate the outcomes of a surgical procedure involving the muscle union of the superior rectus (SR) and lateral rectus (LR) muscles with or without medial rectus (MR) recession for the treatment of strabismus associated with high myopia and the anatomic changes from before and after surgery. Thirty-five eyes of 20 patients who had undergone a muscle union of the SR and LR muscles with or without MR recession for treatment of acquired strabismus associated with an inferior displacement of the LR and nasal displacement of the SR in magnetic resonance imaging of the orbit due to axial high myopia were observed prospectively. Main outcome measures were the angles of the dislocation of the globe, angles of horizontal or vertical deviations, abductions, and supraductions. The angles of the dislocation of the globe were analyzed using magnetic resonance imaging (1.5 Tesla Magnet; Siemens Symphonia, Munich, Germany). The axial lengths ranged from 26 to 36 mm (mean: 30.6 ± 2.8 mm). The angle of dislocation of the globe changed from 178º ± 10º to 101º ± 6º, the angle of esotropia changed from 58.6 ± 2.5 to 6.8 ± 1.4 prism diopters (PD); and the angle of hypotropia changed from 12.5 ± 1.3 to 3.3 ± 1.1 PD postoperatively. Abduction and supraduction improved significantly after surgery. At the 4-year follow-up, the postoperative outcomes were stable. In the treatment of strabismus caused by high myopia, the surgical procedure involving the muscle union of the SR and LR muscles with or without MR recession was effective on both the restoration of the dislocated globe into the muscle cone and the improvement of ocular motility.

Profile of Gaze Dysfunction following Cerebrovascular Accident

Aim. To evaluate the profile of ocular gaze abnormalities occurring following stroke. Methods. Prospective multicentre cohort trial. Standardised referral and investigation protocol including assessment of visual acuity, ocular alignment and motility, visual field, and visual perception. Results. 915 patients recruited: mean age 69.18 years (SD 14.19). 498 patients (54%) were diagnosed with ocular motility abnormalities. 207 patients had gaze abnormalities including impaired gaze holding (46), complete gaze palsy (23), horizontal gaze palsy (16), vertical gaze palsy (17), Parinaud's syndrome (8), INO (20), one and half syndrome (3), saccadic palsy (28), and smooth pursuit palsy (46). These were isolated impairments in 50% of cases and in association with other ocular abnormalities in 50% including impaired convergence, nystagmus, and lid or pupil abnormalities. Areas of brain stroke were frequently the cerebellum, brainstem, and diencephalic areas. Strokes causing gaze dysfunction also involved cortical areas including occipital, parietal, and temporal lobes. Symptoms of diplopia and blurred vision were present in 35%. 37 patients were discharged, 29 referred, and 141 offered review appointments. 107 reviewed patients showed full recovery (4%), partial improvement (66%), and static gaze dysfunction (30%). Conclusions. Gaze dysfunction is common following stroke. Approximately one-third of patients complain of visual symptoms, two thirds show some improvement in ocular motility.

Challenges of Managing Orbital Floor Blow–out Fracture in a Developing Country

Background: Orbtal blow-out fracture can be associated with ocular injuries which may involve the anterior or posterior segments of the eye. This can present significant morbidity to patients which can impact on the quality of life. Objective: To evaluate cases of orbital floor blow-out fractures seen at two centres. Methodology: A retrospective study of patients seen with a diagnosis of orbital blow-out fracture between July 2009 and March 2010 was done. Diagnosis was based on history, clinical examination and computerised tomography (CT) scan. The patients had lower lid incision – transcutaneous or transconjunctival. Silicone and bone implants were used to reconstruct the defects. Results: Five patients – 3 males and 2 females were reviewed, age range between 21 to 26 years. The fracture occurred as a result of road traffic injury in 3 patients (60%), and the involved eye had poor visual acuity on presentation, but no associated ocular injury was noticed in 3 (60%) of the patients. The interval between injury and presentation ranged from 9 to 120 days. Vertical limitation of ocular motility and significant enophthalmos were noticed in all the 5 patients; 2 had diplopia and hypoesthesia in the distribution of the infraorbital nerve. The average time interval between injury and surgery were 49 days and 3 of the patients (60%) had repairs after 14 days of presentation. Postoperatively, slight improvement in ocular motility was observed. Conclusion: The challenges of managing orbital fracture include late presentation, lack of synthetic implant materials, increased morbidity with graft harvesting, and poor cosmetic outcome. Keywords: Challenges, enophthalmos, road traffic injury

Amniotic Membrane Transplantation for Restrictive Strabismus

To report the use of amniotic membrane transplant in patients with restrictive strabismus. Retrospective, interventional case series. Patients with restrictive strabismus treated with amniotic membrane transplantation. Chart review of 7 consecutive patients (8 eyes) who developed restrictive strabismus after periocular surgery and were treated with surgical removal of restrictive adhesions and placement of an amniotic membrane transplant. Intraoperative findings to explain the mechanism of restrictive strabismus, and clinical postoperative results, including ocular alignment, ductions and versions, symptom relief, and resolution of diplopia. Restrictive strabismus occurred after surgery for pterygium, retinal detachment, orbital floor fracture, dermoid cyst, and dermatochalasis. Restrictive strabismus was due to a combination of conjunctival contracture, fat adherence, or rectus muscle contracture. All patients developed postoperative scarring, with failed additional standard surgery to remove the adhesions, including 1 patient treated with mitomycin C for recurrent scarring after pterygium. Reoperation using amniotic membrane transplantation was associated with improvement of ocular motility in 6 of the 7 patients; 1 patient had recurrence of scarring with persistent diplopia. The remaining 6 of 7 patients had no significant recurrence of scarring, and motility remained stable during the follow-up period of 5 to 13 months. Amniotic membrane transplantation seems to help prevent recurrence of adhesions in patients with restrictive strabismus caused by conjunctival scarring, fat adherence syndrome, or rectus muscle contracture. Use of an amniotic membrane transplant should be considered as a treatment option for these difficult cases of restrictive strabismus. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Bilateral multiple extraocular muscle metastasis from breast carcinoma

We report a rare presentation of an initially misdiagnosed case of a pseudotumor, which on histopathology was diagnosed as bilateral breast metastases of lobular carcinoma involving multiple extraocular muscles. A 61-year-old lady presented with external ophthalmoplegia and diplopia. Incisional biopsy was performed using a lid crease approach and the patient received radiotherapy and hormonal therapy. Following prolonged hormonal therapy, complete remission was achieved, with improvement in ocular motility and resolution of diplopia, about 18 months after the initial presentation. Multiple extraocular muscle involvement by breast carcinoma metastasis is very rare and should be considered in the differential diagnosis, especially in patients with a prior history of breast carcinoma.

Bone and Cartilage Wedge Technique in Posttraumatic Enophthalmos Treatment

To evaluate a new surgical method, using calvarial bone graft combined with a wedge of irradiated homologous costal cartilage, for the revision repair of posttraumatic enophthalmos. This retrospective study was performed from January 1, 2003, through December 31, 2007. Eight patients were diagnosed as having unilateral posttraumatic enophthalmos. All the patients had previously undergone insufficient primary repair of their orbital fractures. In the revision surgery a calvarial bone graft was placed in the area of the defect using a transconjunctival approach. In combination with this technique, a wedge of irradiated rib cartilage was placed on the bone graft behind the globe. Patients were assessed preoperatively and postoperatively by ophthalmologists and maxillofacial surgeons. Standard follow-up examinations were performed at 2 and 4 weeks and at 3 and 6 months after surgery. Computed tomographic scans were obtained preoperatively and postoperatively from all patients. For all 8 corrected orbits, favorable cosmetic results were obtained regarding the position of the globe. The mean preoperative Hertel exophthalmometer showed a difference of 3.1 mm and 0.7 mm postoperatively. Improvement of ocular motility and reduction of diplopia were achieved in only 1 patient; in the others, motility and diplopia remained unchanged. No postoperative complications were observed. The bone and cartilage wedge technique seems to be a useful surgical technique for the cosmetic correction of posttraumatic enophthalmos.

Endoscopic Endonasal Management of Medial Orbital Blowout Fractures

This study demonstrated that endoscopic endonasal sinus surgery is a successful technique for reducing medial orbital blowout fractures and does not cause complications. Twenty-three patients with isolated medial blowout fractures that did not involve the inferior wall underwent reduction surgery using the endoscopic endonasal approach. Surgery was indicated if the patient experienced persistent diplopia, ocular motility limitation, or enophthalmos. Septoplasty and submucous resection of the inferior turbinate bone were performed to access the fracture site safely in 3 and 15 patients, respectively. The bone fragments entrapping the orbital content or adhesions between the orbital contents and the sinus mucosa were dissected carefully from the fracture site. An ophthalmologist used the eye traction test to verify improvement in ocular motility. A temporary Silastic sheet was applied in three patients, but no permanent supporting material was used in any patient. No surgical or late complications were seen. Preoperative symptoms were resolved in 22 of the 23 (95.5%) patients 6 months after surgery. We concluded that the endoscopic endonasal reduction based on endoscopic endonasal sinus surgery techniques is safe, accurate, and an appropriate surgical intervention for medial orbital blowout fractures.

The spectrum of nystagmus following cerebro-vascular accident

Aim: To report the features of nystagmus documen­ted following a confirmed diagnosis or cerebro­vascular accident (stroke). Methods: A multi-centre prospective observational study was undertaken in 14 acute Trust hospitals. Stroke survivors with suspected visual difficulty were recruited. Standardised screening/referral forms and investigation forms were employed to document data on visual impairment, specifically assessment of visual acuity, ocular pathology, eye alignment and movement, visual perception (including Inattention) and visual field defects. Results: Of 323 patients, 38 were found to have nystagmus following cortical, brain stem or cerebel­lar stroke. Twenty were male and 18 female, with a mean age of 65 years. Acquired nystagmus accounted for 84% of the types documented. Four patients had oscillopsia and 3 had vertigo. Associated ocular motility deficits were found in 84% of patients and treatment was largely aimed at alleviating diplopia but also reading difficulties or blurred vision. Improvement was noted in 42%. Conclusion: Twelve per cent of stroke survivors with suspected visual difficulties had nystagmus documen­ted. Most had associated ocular motility defects. Symptoms relating to the nystagmus of oscillopsia and vertigo were reported in 18%. Improvement of ocular motility was recorded in 42%.

Surgical Treatment of Strabismus Fixus Associated with High Myopia

A 55-year-old woman had convergent strabismus fixus associated with high myopia. Bilateral medial rectus recession and loop myopexy of lateral and medial rectus muscles was performed. The clinical characteristics and the possible surgical treatment modalities were discussed. This surgery seems effective on both the restoration of dislocation of the eyeball and the improvement of ocular motility.

Tetracycline delays ocular motility decline in chronic progressive external ophthalmoplegia

Chronic progressive external ophthalmoplegia (CPEO) is a mitochondrial cytopathy characterized by bilateral ptosis during adolescence, followed later by limitation of extraocular muscle movement and diplopia.1 The biochemical defect consists of mutations or deletions of mitochondrial DNA genes that encode respiratory chain enzymes involved in adenosine triphosphate (ATP) generation and its subsequent translocation from the mitochondria.1 To date, there is no definitive treatment that reverses or halts the progression of the muscle weakness. Herein, we report improvement in ocular motility in a patient with CPEO following treatment with tetracycline. The retrospective review was approved by the institutional review board. A 47-year-old woman, with bilateral upper eyelid ptosis since childhood, underwent ptosis repair in 1987, at age 28. There was a gradual return of the ptosis over the ensuing years. By age 33, she began experiencing diplopia. She had otherwise enjoyed excellent health. Her family history was significant for six brothers and three sisters with ptosis. We initially evaluated her in October 1997, at age 38, for diplopia and ptosis. Her visual acuity was 20/20 for both eyes. There was 6- to …

Diplopia secondary to endoscopic sinus surgery

Objective—Diplopia after endoscopic sinus surgery (ESS) is rare but very serious. In this study, we investigated the characteristics, prognosis and treatment of diplopia occurring after ESS.Material and Methods—A retrospective analysis was carried out to investigate three patients with diplopia after ESS referred to us from other hospitals.Results—In one case, an improvement in ocular motility was seen after surgical treatment. In the other cases, no improvement was observed, despite surgical treatment.Conclusion—In order to prevent diplopia after ESS, the surgeon must possess a complete anatomical knowledge obtained by means of cadaveric dissection, the ability to carefully read preoperative CT scans and the necessary surgical experience.