Muscle Surgery Research Articles

SURGICAL OUTCOME OF THREE MUSCLES SURGERY IN ONE SINGLE PROCEDURE OF LARGE-ANGLE EXOTROPIA: A CASE REPORT

Introduction : The management of large-angle horizontal strabismus poses special difficulties. Literature has outlined large-angle strabismus in a variety of ways. A threshold of 40 to 60 PD has been employed to determine large-angle strabismus.
 Case Illustration : A 19-year-old male with complaint of right eye that had been crossed outward since he was 12 years old. There was 90 prism diopter exotropia in near, distance, upgaze, and downgaze. The patient underwent bilateral lateral rectus recession of 10 mm and unilateral medial rectus resection of 6.5 mm in the right eye. Post-operative outcome revealed orthophoria without any misalignment of prism diopter examination in 1 day, one week, and two weeks follow-up.
 Discussion : When the deviation exceeds 50 prism diopter, there is no established consensus regarding the number and quantity of extraocular rectus muscles for surgery. The lack of uniform criteria and suggested surgical dosage is the greatest obstacle in using three muscles surgery. In this case, we used surgical dose according to Kenneth Wright exotropia binocular surgery table. We performed bilateral rectus lateral recession of 10 mm and a right rectus medial resection of 6.5 mm. This surgical dose gives good outcome. Moreover, this option can leave one horizontal rectus muscle unharmed.
 Conclusion : Determination of the surgical dose is essential in the management of large-angle exotropia. Appropriate surgical dose results in excellent outcomes with low risk of residual deviation.

Changes in ocular extorsion after horizontal muscle surgery in patients with intermittent exotropia coexisting with hypertropia and mild inferior oblique overaction.

To investigate changes in vertical strabismus and extorsion in patients with intermittent exotropia and mild unilateral inferior oblique muscle overaction (IOOA) who underwent horizontal muscle surgery without vertical or oblique muscle surgery. The medical records of 41 patients were retrospectively analyzed. The patients were followed up for at least 6 months after surgery. Fundus photography was performed before and after surgery, and the sum of the angles of torsion in both eyes was used to measure changes in extorsion using ImageJ software. The enrolled patients were divided into two groups according to the degree of IOOA: patients with grade 1 IOOA were placed in +1 IOOA group and those with grade 2 IOOA in +2 IOOA group. The pre- and postoperative angles of horizontal and vertical strabismus and extorsion were compared between the two groups. The +1 IOOA and +2 IOOA groups included 24 and 17 patients, respectively. The angle of preoperative exotropia did not differ significantly: 25.54 ± 5.68 prism diopters (PD) and 25.65 ± 8.11 PD in the +1 IOOA and +2 IOOA groups, respectively. In the +1 IOOA and +2 IOOA groups, hypertropia was 2.67 ± 1.52 PD and 2.82 ± 1.13 PD, respectively, and extorsion angles were 7.14 ± 2.77° and 7.94 ± 2.87°, respectively. As the IOOA degree increased, the extent of hypertropia and extorsion also increased. However, there were no significant differences between the two groups. Postoperative angles of hypertropia and extorsion significantly decreased in both groups (p < 0.001) after surgery. The degree of change in hypertropia and extorsion was not significantly different between the two groups (p = 0.563 and p = 0.354, respectively). Hypertropia and extorsion improved significantly after horizontal muscle surgery in patients with mild unilateral IOOA and intermittent exotropia. There was no significant difference in the improvement in hypertropia or extorsion between IOOA grades I and II.

Visual acuity improvement in children with albinism beyond the first decade of life.

To determine if visual maturation continues beyond the first decade of life in children with albinism and whether this is related to albinism type, presence of nystagmus, eye muscle surgery or refractive errors. Case series based on retrospective study of children with confirmed genetic diagnosis of albinism. Clinical data were obtained from medical files of children examined during school years, including albinism type, visual acuity, eye muscle surgery, nystagmus, and others on different visits (Visit 1: ages 7-9; Visit 2: ages: 10-12; Visit 3: ages 13-16; Visit 4: ages >16). Seventy-five children with albinism were included in the study. Patients were divided into different groups according to the albinism type including OCA1A: 17; OCA1B: 28; OCA2: 26; HPS: 3; OCA4: 1. Follow-up ranged from 3-13 years. Progressive visual acuity improvement was seen in all three main groups. T-test paired samples showed a statistically significant improvement when comparing vision from Visit 1 and Visit 3 in both OCA1A and OCA2 groups, with a mean vision improvement of 2 lines. There was no correlation between visual improvement and refractive error, eye muscle surgery or nystagmus. An improved visual performance was seen in a large percentage of children with albinism during the second decade of life. The reason for this late improvement in vision is not clear but may be related to late foveal maturation or improvement in nystagmus with time. This information is useful for clinicians of these patients and when counseling parents.

Outcomes of Strabismus Surgery Following Teprotumumab Therapy

PurposeTo investigate the results of patients undergoing surgical treatment for strabismic diplopia in thyroid eye disease (TED) following teprotumumab. DesignMulticenter, retrospective, case series. MethodsWe report 28 patients who underwent extraocular muscle surgery for strabismic diplopia after treatment with teprotumumab at 7 different academic centers. Elapsed time from last teprotumumab dose to the date of surgery, previous orbital decompression, primary preoperative horizontal and vertical deviation, surgical procedure, and 2-month postoperative results were collected from the patient records. ResultsSixteen (57%) patients were diplopia-free after one surgery. Three (11%) chose prism spectacles to correct residual diplopia, 2 (7%) used compensatory head posture to resolve diplopia, and 1 (4%) had intermittent diplopia and was functionally improved (choosing no prisms or further surgery). These were considered treatment successes. Three (11%) patients required reoperation, and all were diplopia-free after their second procedure. ConclusionsMost patients requiring surgery for strabismic diplopia following teprotumumab achieve good outcomes with success rates comparable to series published before the availability of teprotumumab.

How Age Affects Graves' Orbitopathy-A Tertiary Center Study.

Graves' orbitopathy (GO) is an autoimmune disorder leading to inflammation, adipogenesis, and fibrosis. The severity of GO can vary widely among individuals, making it challenging to predict the natural course of the disease accurately, which is important for tailoring the treatment approach to the individual patient. The aim of this study was to compare the clinical characteristics, course, treatment, and prognosis of GO patients under 50 years with older patients. We reviewed the medical records of a random sample of 1000 patients in our GO database Essen (GODE) comprising 4260 patients at our tertiary referral center. Patients were divided into two groups: Group 1 (≤50 years) and Group 2 (>50 years). Only patients with a complete data set were included in the further statistical analysis. The results showed that younger patients (n = 484) presented significantly more often with mild GO (53% vs. 33%, p < 0.0001), while older patients (n = 448) were more likely to experience moderate-to-severe disease (44% vs. 64%, p < 0.0001). Older patients showed more severe strabismus, motility, and clinical activity scores (5.9 vs. 2.3 PD/310° vs. 330° both p < 0.0001, CAS: 2.1 vs. 1.7, p = 0.001). Proptosis and occurrence of dysthyroid optic neuropathy (DON) showed no significant difference between groups (both 3%). Multiple logistic regression revealed that the need for a second step of eye muscle surgery was most strongly associated with prior decompression (OR = 0.12, 95% CI: 0.1-0.2, p < 0.0001) followed by orbital irradiation and age. The model showed good fitness regarding the area under the curve (AUC = 0.83). In conclusion, younger GO patients present with milder clinical features such as a lower rate of restrictive motility disorders and less pronounced inflammatory signs. Therefore, older patients tend to need more steroids, irradiation, and lid and eye muscle surgery. Still, the risk of DON and the necessity of secondary eye muscle surgery are not or only slightly associated with age, respectively.

Concurrent adjacent strabismus surgery with glaucoma drainage device placement in childhood glaucomas

BackgroundDetermine outcomes of concurrent strabismus surgery with placement of a glaucoma drainage device (GDD) in children.MethodsRetrospective review of pediatric patients who underwent simultaneous lateral rectus (LR) muscle surgery with superotemporal GDD placement. Strabismus and GDD success were defined as residual horizontal misalignment < 10 prism diopter (PD) and intraocular pressure (IOP) < 21 mmHg, no visually devastating complications, and no additional IOP-lowering surgeries.ResultsFifteen eyes of 13 patients (69% male) underwent LR surgery (14 recessions, 1 resection) for exotropia or esotropia simultaneous with GDD placement (13 Baerveldt, 2 Ahmed) at 8.34 ± 5.26 years. Preoperative visual acuity (VA) in operative eye (0.89 ± 0.54) was worse than non-operative eye (0.23 ± 0.44, p = 0.0032). Preoperative horizontal deviation was 38.3 ± 9.4 PD and LR recession was 7.4 ± 1.1 mm. At final follow-up, VA in operative eye (0.87 ± 0.52) was unchanged from preoperative (p = 0.4062). Final IOP was significantly decreased (12.4 ± 4.7 mmHg vs. 31.1 ± 11.4 mmHg, p = 0.0001) as was number of glaucoma medications (2.7 ± 1.7 vs. 1.1 ± 1.3, p = 0.0037). Five (38%) and 9 patients (69%) met criteria for strabismus and GDD success, respectively. Two eyes required tube revision and endoscopic cyclophotocoagulation and 2 eyes had additional strabismus surgery.ConclusionsConcurrent strabismus and GDD surgery decreased horizontal deviation and obtained IOP control. It is important to consider correction of strabismus at time of GDD placement to maximize visual development and improve cosmesis in children with glaucoma.

Surgical outcome of inferior oblique anteriorization in unilateral superior oblique palsy with large angle hypertropia

Purpose The aim of this study was to assess the effect of unilateral inferior oblique (IO) anteriorization as a single muscle surgery for treatment of unilateral superior oblique palsy (SOP) with large angle hypertropia. Patients and methods This is a retrospective study that included 28 patients, for whom IO anteriorization was performed for treatment of ipsilateral SOP with large angle hypertropia more than or equal to 20 prism diopters (PD). The patients were evaluated preoperatively and 3 months postoperatively for the vertical deviation (VD) in primary position and in adduction. Residual hypertropia less than or equal to 6 PD in primary position postoperatively was considered a successful outcome, together with improvement of the abnormal head tilt. Results The mean age of the patients was 30.75±17.05 years. The mean preoperative VD in the primary position was 25.29±4.50 PD. It significantly decreased postoperatively to 5.54±5.25 PD (P&lt;0.001). The mean preoperative VD in adduction was 30.57±7.89 PD and decreased postoperatively to 8.50±5.27 PD (P&lt;0.001). The preoperative IO overaction grade was 2.61±0.99 and decreased postoperatively to 0.39±0.50 (P&lt;0.001). Successful outcome was reported in 75% of the cases and improvement of head tilt occurred in 78% of the patients. Conclusion IO anteriorization could be a simple one muscle surgery to correct large angle VD associated with unilateral SOP with a favorable outcome.

Variation between surgeons in reoperation rates following vertical strabismus surgery: Associations with patient and surgeon characteristics and adjustable sutures.

To quantify inter-surgeon variation in vertical strabismus surgery reoperation rates, and to explore associations of reoperation rate with practice type and volume, surgical techniques, and patient characteristics. Fee-for-service payments to providers in a national database for Medicare beneficiaries having vertical strabismus surgery between 2012 and 2020 were retrospectively analyzed to identify reoperations in the same calendar year. Predictors of the rate of reoperation for each surgeon were determined by multivariable linear regression. Among 73 surgeons, the reoperation rate for 1-vertical muscle surgery varied from 0.0% to 40.7%. Due to the presence of high-volume surgeons with high reoperation rates, just 11% of surgeons contributed over half of the reoperation events for 1-vertical muscle surgery. Use of adjustable sutures, surgeon gender, and surgical volume were not independently associated with surgeon reoperation rate. Associations of reoperation with patient characteristics, such as age and poverty, were explored. Patient poverty was independently associated with a lower surgeon reoperation rate (p = 0.03). Still, the multivariable model could explain only 14.2% of the variation in surgeon reoperation rate for 1-vertical muscle. Patient-level analyses which ignore inter-surgeon variation will be dominated by the practices of a small number of high-volume, high-reoperation surgeons. There are order-of-magnitude variations in reoperation rates among strabismus surgeons, the cause of which remains largely unexplained.

Outcomes for maximal bilateral lateral rectus recession in large-angle exotropia

Surgical treatment for large-angle exotropia can be challenging. The aim of this study was to evaluate short-term surgical outcomes of patients with large-angle exotropia (≥50Δ) undergoing maximal bilateral lateral rectus muscle recession of 10 mm. This was a retrospective study of consecutive patients at our institution who underwent maximal bilateral lateral rectus muscle recession for exodeviation ≥50Δ from January 1, 2008, to July 22, 2022. We subdivided the cohort into large-angle exotropia (largest amount of exodeviation at near and/or distance ≥50Δ and <65Δ) and very large-angle exotropia (largest exodeviation ≥65Δ). Patients with a history of prior eye muscle surgery, neurologic deficits, and three- or four-muscle surgery were excluded. A total of 22 patients were included. Mean preoperative exodeviation at distance was 51.9Δ in the large-angle group and 67.5Δ in the very-large-angle group (P = 0.001). Outcomes for the large-angle and very-large angle groups were, respectively, as follows: mean follow-up, 31.1 weeks and 11.8 weeks (P = 0.97); success, 75.0% and 16.7% (P = 0.02); undercorrection rates, 18.7% and 83.3% (P = 0.01); and mean postoperative exodeviation at distance, 3.7Δ ± 6.3Δ and 28.0Δ ± 13.5Δ (P = 0.001). Our study identified good surgical outcomes (75%) with maximal bilateral lateral rectus muscle recession of 10 mm in treating patients with large-angle exotropia between 50Δ and <65Δ. Other surgical techniques such as recession-resection and three- or four-muscle surgery may result in better outcomes when treating patients with exotropia ≥65Δ.

Clinical Results after Release of Sternocleidomastoid Muscle Surgery for Neglected Congenital Muscular Torticollis-Unipolar vs. Bipolar Release Surgery.

Although the surgical release of the sternocleidomastoid muscle (SCM) is required for residual congenital muscular torticollis (CMT), the surgical outcomes between bipolar and unipolar SCM release remained unclear. The purpose of the present study was to assess surgical outcomes after bipolar and unipolar release of SCM in adolescent/adult patients with neglected CMT. Twenty-one consecutive adolescent/adult patients with neglected CMT who underwent surgical treatment were enrolled. Clinical and radiographic outcomes were evaluated at preoperative and final follow-up. The bipolar release of SCM was performed in 3 patients (B group; males, n = 1, females, n = 2) and the unipolar release of SCM in 18 patients (U group; males, n = 6, females, n = 12). The mean age at surgery was 40.0 ± 17.0 years in Group B, and that was 32.3 ± 13.1 years in Group U (p = 0.47). The mean follow-up period was 16.0 ± 5.7 months in Group B and 10.4 ± 7.6 months in Group U (p = 0.22). Cervicomandibular angle correction rates were comparable at 75.4 ± 2.4% for the B group and 73.1 ± 11.7% for the U group (p = 0.62). There was no significant difference in clinical outcome according to the modified Cheng and Tang score between the two groups (p = 0.89). No major complications arose, although one patient exhibited a transient neurological deficit of the greater auricular nerve, and one patient developed a hematoma in the B group. The unipolar SCM release appeared to be a non-inferiority and less invasive procedure, minimizing surgical scars and avoiding potential auricular nerve damage in adolescent/adult patients with neglected CMT.

Acquired comitant esotropias – comparison of surgical outcomes of accommodative vs non-accommodative types

ABSTRACT Purpose: To compare the motor and sensory outcomes of strabismus surgery and the factors affecting surgical success in acquired acute non-accomodative esotropia (ANAET) and partially accommodative refractive esotropia (pARET). Methods: A retrospective chart review of patients with ANAET and pARET who underwent unilateral or bilateral horizontal rectus muscle surgery between January 2020 and December 2021 was conducted. Patients with postoperative follow-up of at least six weeks were included. Patients with pattern deviation, lateral incomitance, and near-distance disparity were excluded. Motor success was defined as a postoperative deviation within eight prism diopters of orthophoria. Sensory success was defined as presence of binocular single vision (BSV) for both distance and near (Worth four dot test). The effect of factors like age at onset, age at surgery, amblyopia before surgery, duration of squint before treatment, presence or absence and magnitude of vertical deviation, preoperative angle of deviation, and spherical equivalent on the motor and sensory success in each group were analyzed and compared. Results: 38 patients with ANAET and 33 patients with pARET were included. The mean age of onset of esotropia was 8.55 ± 4.65 years and 4.39 ± 2.27 years (p < .001) and the mean age at surgery was 10.62 ± 4.99 years and 7.89 ± 2.84 years (p = .006) in the ANAET and the pARET group respectively. The mean duration of the final follow-up was 38.51 weeks in the ANAET and 48.68 weeks in the pARET group (p = .089). Patients were successfully aligned for both distance and near in 81.5% of patients in the ANAET and 78.9% of patients in the pARET group at the final follow-up (p. 0.775). A BSV for both distance and near at the final follow-up was seen in 81.2% vs 66.6% of patients in the ANAET and the pARET group respectively (p = .25). A good near stereoacuity (<120 arcsecs) was seen in 60.6% and 41.9% of the ANAET and the pARET groups respectively (p = .175). The percentage of patients in the ANAET group who had orthophoria, any esodeviation, and any exodeviation for distance at the final follow-up was 63.1%, 34.2% and, 2.6%. The percentage of patients in the pARET group in similar categories was 36.3%, 42.4% and, 21.2%. None of the demographic and preoperative factors were found to affect the surgical outcomes in the two groups. Conclusions: The motor and sensory outcomes were similar in the two groups. A higher proportion of ANAET patients remained orthophoric during the follow-up. The patients in the pARET group showed a tendency toward exodrift.

Coding and noncoding RNA profile of human heterotopic ossifications - Risk factors and biomarkers.

Heterotopic ossification (HO) means the formation of bone in muscles and soft tissues, such as ligaments or tendons. HO could have a genetic history or develop after a traumatic event, as a result of muscle injury, fractures, burns, surgery, or neurological disorders. Many lines of evidence suggest that the formation of HO is related to the pathological differentiation of stem or progenitor cells present within soft tissues or mobilized from the bone marrow. The cells responsible for the initiation and progression of HO are generally called HO precursor cells. The exact mechanisms behind the development of HO are not fully understood. However, several factors have been identified as potential contributors. For example, local tissue injury and inflammation disturb soft tissue homeostasis. Inflammatory cells release growth factors and cytokines that promote osteogenic or chondrogenic differentiation of HO precursor cells. The bone morphogenetic protein (BMP) is one of the main factors involved in the development of HO. In this study, next-generation sequencing (NGS) and RT-qPCR were performed to analyze the differences in mRNA, miRNA, and lncRNA expression profiles between muscles, control bone samples, and HO samples coming from patients who underwent total hip replacement (THR). As a result, crucial changes in the level of gene expression between HO and healthy tissues were identified. The bioinformatic analysis allowed to describe the processes most severely impacted, as well as genes which level differed the most significantly between HO and control samples. Our analysis showed that the level of transcripts involved in leukocyte migration, differentiation, and activation, as well as markers of chronic inflammatory diseases, that is, miR-148, increased in HO, as compared to muscle. Furthermore, the levels of miR-195 and miR-143, which are involved in angiogenesis, were up-regulated in HO, as compared to bone. Thus, we suggested that inflammation and angiogenesis play an important role in HO formation. Importantly, we noticed that HO is characterized by a higher level of TLR3 expression, compared to muscle and bone. Thus, we suggest that infection may also be a risk factor in HO development. Furthermore, an increased level of transcripts coding proteins involved in osteogenesis and signaling pathways, such as ALPL, SP7, BGLAP, BMP8A, BMP8B, SMPD3 was noticed in HO, as compared to muscles. Interestingly, miR-99b, miR-146, miR-204, and LINC00320 were up-regulated in HO, comparing to muscles and bone. Therefore, we suggested that these molecules could be important biomarkers of HO formation and a potential target for therapies.

Long-Term Surgical Outcomes of Bilateral Symmetrical Superior Oblique Nasal Tenotomy in Patients of Large A-Pattern Exotropia.

To report the long-term outcomes of bilateral symmetrical superior oblique (SO) nasal tenotomy in patients with large A-pattern exotropia (≥25 prism diopter [PD]). This retrospective study was conducted on 15 patients (aged: 4-28 years) of large A-pattern exotropia. An A-pattern was defined as >10 PD difference between up and down gaze at 6 m by use of the alternate prism cover test. Objective ocular torsion was assessed by fundus photography and subjective torsion by double Maddox rod test. All patients underwent horizontal muscle surgery according to the primary position horizontal deviation and bilateral symmetrical SO nasal tenotomy for A-pattern. Surgical success was defined as postoperative A-pattern of ≤10 PD, the absence of vertical and torsional diplopia, and the absence of V-pattern. The minimum follow-up period was 24 months. A total of 15 patients of large A-pattern exotropia (7 males and 8 females) with a mean age of 17.09 ± 7.9 years were included in the study. All patients had bilateral SO overaction of grade +3 or +4 with a mean preoperative A-pattern of 30.3 ± 3.9 PD. At 24 months of follow-up, esotropia in down gaze (V-pattern) was present in four patients with a mean of 11.25 ± 2.5 PD, (range, 10-15 PD). The rest of the 11 patients maintained successful alignment with a mean A-pattern of 3.18 ± 1.17 PD, (range, 2-5 PD). There was significant A-pattern collapse with a mean of 31 ± 9.1 PD after 2 years of follow-up, which was significantly associated with preoperative A-pattern (Pearson correlation, r = 0.7; t[15] = 4.0; P = 0.002). The mean of pre- and postoperative objective ocular torsion was found to be -0.5 ± 4° and -4.8 ± 3.8° with a mean extorsion effect of 4.67 ± 3.85°. There was a statistically significant difference between pre- and postoperative ocular torsion (°) (t [30] = 5.42; P < 0.001), the change in ocular torsion was significantly associated with preoperative torsion (Pearson correlation, r = 0.5; t [30] = 7.2; P < 0.001). None of the patients had subjective torsion on the double Maddox rod test pre- and postoperatively. Bilateral symmetrical SO nasal tenotomy is effective in cases with large A-pattern (>25 PD). The reduction of A-pattern and postoperative change in fundus torsion have a positive correlation with preoperative A-pattern and preoperative torsion, respectively.

Changes in retinal and choroidal blood flow after one or two horizontal rectus muscle surgeries by optical coherence tomography angiography

Purpose To evaluate the retinal and choroidal microvasculature after one or two horizontal rectus muscle surgeries in strabismus patients using swept-source optical coherence tomography angiography (SS-OCTA). Methods 30 eyes of 26 patients who underwent horizontal rectus muscle surgery were included in this study. Group A, A’ and Group B , B’ respectively consisted preoperative and postoperative measurements of patients who underwent one or two horizontal rectus muscle surgeries. We analyzed the vessel density (VD) of the superficial vascular complex (SVC), the deep vascular complex (DVC), the choriocapillary layer (CC), choroidal vascular index (CVI), choroidal thickness (T-Ch) and retinal nerve fiber layer thickness (T-RNFL) preoperatively, and one week postoperatively. Results Only in the nasal sector of the perifoveal zone, the VD in SVC demonstrated a significant increase in Group A’ (p = 0.027). There was a statistically significant difference in the VD changes of SVC between Group A and Group B (p = 0.043). The VD in DVC did not change significantly in the whole macular compared with the preoperative. Moreover, in both Group A’ and Group B’, the VD in CC showed a reduction in a single sector of the parafoveal area (p < 0.05). Group A’ have increased CVI in the nasal sector of the perifoveal region (p = 0.008). In addition, the T-Ch increase in the perifoveal region was more significant in Group B’ than in Group A’ (p < 0.05). Group A’ showed statistically significant decreases in T-RNFL in the foveal and parafoveal regions (p < 0.05). Conclusion This study revealed that the increase in choroidal thickness was more significant after two rectus muscle surgery. In addition, there were microvascular changes in sectional macular regions after strabismus surgery. OCTA is an excellent way to study the impact of strabismus surgery on the macular structure and blood flow.

Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye

PurposeTo describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy. MethodsA retrospective study of 9 cases between 2017−2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD). ResultsThe mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology). ConclusionSupra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

Evaluation of the effects of strabismus surgery on corneal backward light scattering

BackgroundInvestigation of the effects of conventional strabismus surgeries on corneal densitometry (CD). MethodsPatients who had strabismus surgery between May 2022 and July 2022 were included in the study. CD software with a Pentacam device was used to determine corneal backward light scattering. CD data were analysed preoperatively and 1 month postoperatively. Patients were classified as those who had single muscle and two-muscle surgery. ResultsThe study included 33 eyes of 28 patients. The mean age of the patients was 20.51 ± 8.22 (5–35) years. Of the eyes, 19 underwent single muscle recession surgery. Two-muscle surgeries (recession and resection combination) were performed in 14 eyes. In the 1st month postoperative, the mean CD value decreased statistically significantly only in the total cornea apical 0–2 mm zone among the layers examined (p = 0.039). There was no significant change in the other layers (p > 0.05 for all). Single-muscle and two-muscle surgery groups were similar in the amount of CD reduction, except for one layer. ConclusionsCD did not change in most of the corneal layers examined in the first month postoperatively. Single muscle and two-muscle horizontal rectus surgeries did not impair corneal clarity in the postoperative 1st month.

Study 3: Anterior segment optical coherence tomography-guided surgical approach in slipped medial rectus muscle.

To discuss the novel swept-source anterior segment optical coherence tomography (SS-ASOCT)-guided surgical approach in slipped medial rectus muscles. Prospectively (between February 2020 and July 2022), six patients with a clinical suspicion of slipped medial rectus muscle were recruited. After complete ophthalmic and orthoptic evaluation, the missing medial rectus muscle is screened using Anterior Segment Optical Coherence Tomography (ASOCT). In presence of a traceable muscle, its morphology, depth, and distance from a fixed anatomical landmarks were noted; in its absence, the status of other recti was noted. Intraoperatively, the features were confirmed and the intended intervention was performed. The mean age of six patients was 25.66 ± 9.72 years, two with surgical trauma and four with penetrating trauma (66.66%). In five patients, the ASOCT traced the slipped medial rectus muscle successfully (83.33%); intraoperatively, the same was confirmed (within 1-2 millimeters) with favorable outcomes. ASOCT made a significant contribution in all subjects by reducing the number of interventions and muscle surgeries. In eyes with slipped medial rectus muscle, especially those which are within a finite distance from the angle can be traced using ASOCT. This approach impacts the outcomes in many ways.

Miopexia supra-ecuatorial del recto lateral en el tratamiento del síndrome «sagging/heavy eye» miópico

PurposeTo describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with lateral rectus myopexy. MethodsA retrospective study of 9 cases between 2017 and 2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered successful if the diplopia was improved or eliminated and a final vertical deviation≤5prism diopters (PD). ResultsThe mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33PD (SD 3.16), and the mean final VD 3.44PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another 3. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation≤5PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (3 with macular pathology). ConclusionSupra-equatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye is a therapeutic option if hypotropia is less than 12PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

Oestrogen therapy for treating pelvic organ prolapse in postmenopausal women.

Pelvic organ prolapse (POP) is the descent of a woman's uterus, bladder, or rectum into the vagina. It affects 50% of women over 50 years old who have given birth to at least one child, and recognised risk factors are older age, higher number of births, and higher body mass index. This review assesses the effects of oestrogen therapy, alone or in combination with other treatments, on POP in postmenopausal women. To assess the benefits and harms of local and systemic oestrogen therapy in the management of pelvic organ prolapse symptoms in postmenopausal women, and to summarise the principal findings of relevant economic evaluations. We searched the Cochrane Incontinence Specialised Register (up to 20 June 2022), which includes CENTRAL, MEDLINE, two trials registers, and handsearching of journals and conference proceedings. We also checked the reference lists of relevant articles for additional studies. We included randomised controlled trials (RCTs), quasi-RCTs, multi-arm RCTs, and cross-over RCTs that evaluated the effects of oestrogen therapy (alone or in combination with other treatments) versus placebo, no treatment, or other interventions in postmenopausal women with any grade of POP. Two review authors independently extracted data from the included trials using prespecified outcome measures and a piloted extraction form. The same review authors independently assessed the risk of bias of eligible trials using Cochrane's risk of bias tool. Had data allowed, we would have created summary of findings tables for our main outcome measures and assessed the certainty of the evidence using GRADE. We identified 14 studies including a total of 1002 women. In general, studies were at high risk of bias in terms of blinding of participants and personnel, and there were also some concerns about selective reporting. Owing to insufficient data for the outcomes of interest, we were unable to perform our planned subgroup analyses (systemic versus topical oestrogen, parous versus nulliparous women, women with versus without a uterus). No studies assessed the effects of oestrogen therapy alone versus no treatment, placebo, pelvic floor muscle training, devices such as vaginal pessaries, or surgery. However, we did identify three studies that assessed oestrogen therapy in conjunction with vaginal pessaries versus vaginal pessaries alone and 11 studies that assessed oestrogen therapy in conjunction with surgery versus surgery alone. There was insufficient evidence from RCTs to draw any solid conclusions on the benefits or harms of oestrogen therapy for managing POP symptoms in postmenopausal women. Topical oestrogen in conjunction with pessaries was associated with fewer adverse vaginal events compared with pessaries alone, and topical oestrogen in conjunction with surgery was associated with reduced postoperative urinary tract infections compared with surgery alone; however, these findings should be interpreted with caution, as the studies that contributed data varied substantially in their design. There is a need for larger studies on the effectiveness and cost-effectiveness of oestrogen therapy, used alone or in conjunction with pelvic floor muscle training, vaginal pessaries, or surgery, for the management of POP. These studies should measure outcomes in the medium and long term.

Clinical features of Helveston syndrome and discussion of individualized surgical design.

Reasonable personalized surgical design can achieve good treatment results for Helveston syndrome in one surgery, reducing the psychological and economic burden on patients. This article aims to explore the clinical characteristics of Helveston syndrome and the clinical effectiveness and feasibility of individualized surgical design. In this retrospective case series study, 28 patients who underwent strabismus correction for Helveston syndrome at the Affiliated Hospital of Yunnan University from June 2018 to December 2020 with complete follow-up data were enrolled. Preoperatively, all patients received standard assessment of vision, intraocular pressure, slit lamp, fundus and refractive status, excluding other eye diseases, as well as detailed special examination of strabismus. These patients were divided into two groups according to the surgical modality: the horizontal muscle surgery alone group and the horizontal muscle surgery combined with superior oblique muscle surgery (combined surgery) group. We used SPSS software for data analysis and compared the postoperative eye position, eye movement, success rate, and reoperation rate between these two groups. Clinical measurement data were compared and analyzed with Fisher's exact test for count data, the t-test for normally distributed measurement data, and the Mann-Whitney U test for non-normally distributed measurement data. P<0.05 was considered statistically significant. This study included a total of 28 patients with Helveston syndrome, including 20 males and 8 females. The average age at the time of surgery is 12.04 ± 8.67 years (range, 4-43 years). The postoperative A-pattern degree was significantly greater in the group undergoing horizontal muscle surgery alone [6.23±1.31 prism diopters (PD); range, 0-10 PD] than in the group undergoing combined surgery (0.53±0.32 PD; range, 0-4 PD; P=0.002). Superior oblique muscle overactivity was significantly reduced in the combined surgery group (0.20±0.11+; range, 0-1+) compared to the horizontal muscle surgery alone group (1.31±0.26+; range, 0-2+; P=0.002). However, there was no significant difference in success rate or reoperation rate between the two groups. Additionally, after combining the recession of the superior rectus muscle with the horizontal muscle, the number of A-pattern degrees was greatly reduced. Helveston syndrome can be improved using a personalized surgical design according to the degree of external strabismus A-pattern, superior oblique muscle overaction, and dissociated vertical deviation (DVD) degree, which improves the success rate of single surgery.