Ocular Alignment In Primary Position Research Articles

Cirugía monocular de 4 músculos extraoculares para la exotropía monocular de gran ángulo

IntroductionRecurrent exotropia is common following surgery for monocular large angle constant sensory exotropia. Surgery is usually limited to operations on the affected eye. Simultaneous oblique weakening surgery may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting forces. We report the results of simultaneous oblique muscle weakening procedures combined with ipsilateral horizontal rectus muscle surgery constant monocular exotropia greater than 35 prism diopters (PD). MethodsRetrospective case series of patients who underwent unilateral lateral rectus recession combined with medial rectus muscle resection and simultaneous weakening of both ipsilateral oblique muscles. Primary outcome measure was ocular alignment in primary position. ResultsTwelve eyes of 12 patients were included. The mean preoperative exotropia improved from 57.9±15.1 (range 35–80; median 60PD) to 3.3±5.5 (range 0–16; median 0PD) postoperatively (p<0.005). Two (66%) patients with a pre-existing vertical deviation had resolution of their vertical misalignment postoperatively. At the last postoperative follow up 92% of the patients had an exodeviation of 10PD or less (range 0–16PD median 0PD), and 7 (58%) measured near and distance orthotropia. Postoperative abduction measured −0.6±1 (0 to −3) and adduction −0.4±0.7 (0 to −2). ConclusionWeakening the ipsilateral oblique muscles may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting vectorial forces when operating for a large angle monocular exotropia. As an additional potential advantage, oblique muscle surgery may be used simultaneously to address associated vertical deviations.

Unilateral four muscle surgery for extra-large monocular exotropia

IntroductionRecurrent exotropia is common following surgery for monocular large angle constant sensory exotropia. Surgery is usually limited to operations on the affected eye. Simultaneous oblique weakening surgery may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting forces. We report the results of simultaneous oblique muscle weakening procedures combined with ipsilateral horizontal rectus muscle surgery constant monocular exotropia greater than 35 prism diopters (PD). MethodsRetrospective case series of patients who underwent unilateral lateral rectus recession combined with medial rectus muscle resection and simultaneous weakening of both ipsilateral oblique muscles. Primary outcome measure was ocular alignment in primary position. ResultsTwelve eyes of 12 patients were included. The mean preoperative exotropia improved from 57.9 ± 15.1 (range 35–80; median 60 PD) to 3.3 ± 5.5 (range 0–16; median 0 PD) postoperatively (p < 0.005). Two of 3 patients with a pre-existing vertical deviation had resolution of their vertical misalignment postoperatively. At the last postoperative follow up 92% of the patients had an exodeviation of 10 PD or less (range 0–16 PD median 0 PD), and 7 (58%) measured near and distance orthotropia. Postoperative abduction measured −0.6 ± 1 (0 to −3) and adduction −0.4 ± 0.7 (0 to −2). ConclusionWeakening the ipsilateral oblique muscles may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting vectorial forces when operating for a large angle monocular exotropia. As an additional potential advantage, oblique muscle surgery may be used simultaneously to address associated vertical deviations.

CASE REPORT OF AN ATYPICAL PRESENTATION OF CONGENITAL FIBROSIS OF THE EXTRAOCULAR MUSCLES (CFEOM)

INTRODUCTION: CFEOM is a disorder that includes multiple extra ocular muscle restrictions. It is a rare, non –progressive, congenital condition and refers to at least eight genetically dened strabismus syndromes. Commonly presented clinical signs and symptoms in CFEOM includes- congenital nonprogressive ophthalmoplegia (inability to move the eyes) with or without ptosis (droopy eyelids) affecting part or all of the oculomotor nucleus and nerve (cranial nerve III) and its innervated muscles. Refractive errors are also common. CASE REPORT: The patient was the rst child of non-consanguineous parents. There was no similar history or any history of ocular motility disorders in family in both paternal and maternal side. There is no prior history of use of glasses, occlusion therapy, surgery or trauma. Typically, binocular vision is absent. The child had difculty looking at objects in downgaze, up gaze and laterally. They also observed outward deviation of both eyes which was more for distance. Child had normal weight for age (30 kgs) Head circumference was within normal range (57 cm) There was absence of lid crease in both eyes and chin up head posture was seen for distance. No facial asymmetry was seen. Patient was able to spontaneously alternate xate in the primary position. Patient had hypertropia of 6 prism diopters in left eye when xing with right eye and hypertropia was same in upgaze and downgaze. No evidence of globe retraction on ocular movements. Patient had history of ocular deviation since birth which had not changed over the years. Mutations in the KIF21A gene are the primary cause of CFEOM1. Patients typically have convergent-type nystagmus movements with attempted up gaze (synergistic convergence) and an A pattern with divergence of the eyes in downgaze. There was no associated neurologic abnormalities and systemic disorders. The patient was found to have bilateral lagophthalmos, limitation of elevation and depression (vertical gazes). The patient underwent two surgeries. In the rst surgery, B/L LR RC (14mm from limbus) and B/L SR RC(11mm)was done. DISCUSSION: Congenital brosis of extraocular muscles is a common condition encountered by pediatric ophthalmologists. If not properly diagnosed, it is often confused with other ocular motility disorders. The treatment of CFEOM must focus on specic pattern of decit and include management of head position, ocular alignment in primary position and maximizing outcome by preventing ambylopia. Currently no treatment has been developed to restore full functionality and range of motion of the extraocular muscles. Patients presenting with CFEOM1 usually require large bilateral inferior rectus recessions, often enhanced with bilateral superior oblique tenotomies to allow the eyes to come to vertical midline. Patient might also need multiple strabismus surgeries like with our patient. CFEOM is often associated with potential complications like strabismus, decreased binocular vision, ambylopia and facial palsy.

Longterm surgery outcome of Möbius syndrome

Objective: To investigate clinical features and the long-term surgery results of Möbius syndrome patients. Methods: This investigation presents a retrospective study of Möbius syndrome in 7 children we found since 2009. All 7 patients had MRI scan, ocular alignment in primary position, the limitation of versions and ductions and forced duction under general anesthesia. Early surgery is done to the 7 esotropia children. The pre-operative and post-operative outcomes, including the ocular alignment, deviation measurements and ocular rotations, were evaluated and compared. Results: MRI showed absence of uni- or bilateral CN6 and CN7 in all 7 patients. All 7 patients underwent extra large recession of medial rectus at the first surgery, (6.17±1.47) mm/eye. Variation of ocular deviation in the primary position within 6 months postoperatively in all patients, demonstrating that strabismus surgical stabilization needs time. Three patients with esotropia deviation≥40° preoperative were under corrected and needed the secondary operations. The average deviation in the primary position was +35.00°±16.58° before surgery and +2.14°±5.67° after surgery(t=6.040, P<0.01). The abduction in affected eye is limited both pre and postoperatively and a smaller limitation of adduction after surgery. Conclusions: Möbius syndrome has been classified to congenital cranial dysinnervation disorders (CCDDs). We recommend MR recession as the first surgical choice because of the lack of abduction ability. Longterm surgical results were considered satisfactory, improving patient self-esteem and the parent satisfaction. (Chin J Ophthalmol, 2017, 53: 897-902).

Superior Oblique Anterior Transposition with Horizontal Recti Recession-Resection for Total Third-Nerve Palsy.

Aims. To report the results of lateral rectus muscle recession, medial rectus muscle resection, and superior oblique muscle transposition in the restoration and maintenance of ocular alignment in primary position for patients with total third-nerve palsy. Methods. The medical records of patients who underwent surgery between March 2007 and September 2011 for total third-nerve palsy were reviewed. All patients underwent a preoperative assessment, including a detailed ophthalmologic examination. Results. A total of 6 patients (age range, 14–45 years) were included. The median preoperative horizontal deviation was 67.5 Prism Diopter (PD) (interquartile range [IQR] 57.5–70) and vertical deviation was 13.5 PD (IQR 10–20). The median postoperative horizontal residual exodeviation was 8.0 PD (IQR 1–16), and the vertical deviation was 0 PD (IQR 0–4). The median correction of hypotropia following superior oblique transposition was 13.5 ± 2.9 PD (range, 10–16). All cases were vertically aligned within 5 PD. Four of the six cases were aligned within 10 PD of the horizontal deviation. Adduction and head posture were improved in all patients. All patients gained new area of binocular single vision in the primary position after the operation. Conclusion. Lateral rectus recession, medial rectus resection, and superior oblique transposition may be used to achieve satisfactory cosmetic and functional results in total third-nerve palsy.

Strabismus Surgery in Congenital Fibrosis of the Extraocular Muscles: A Paradigm

Background: Congenital fibrosis of extraocular muscles (CFEOM) is a rare group of disorders with variable phenotypes that result from aberrant innervation to the EOMs leading to synergistic vertical and/or horizontal deviations. We report our experience with the surgical management of patients with CFEOM.Materials and Methods: We reviewed the clinical findings, the surgical management, and outcomes of 52 consecutive CFEOM patients operated by one surgeon at a university hospital setting between 1993 and 2014. Patients were divided into CFEOM1, 2, or 3 based on clinical and/or molecular genetic findings.Results: Thirty-seven (71.2%) cases were bilateral and 15 (28.8%) were unilateral. Six of the bilateral cases had CFEOM2, and the rest of the patients had either CFEOM1 or CFEOM3. The median age at the first surgery was 10 (1–43) years. Twenty-five were females and 27 were males. Nineteen patients had previous strabismus and/or ptosis surgeries elsewhere. The mean number of operations at our center was 1.6 ± 0.7 (1–4). A temporary stay suture was used in eight patients and permanently in seven. Of the 40 patients with abnormal head position, 18 achieved excellent, 15 good, and seven poor outcomes and ocular alignment in primary position following the latest surgery was excellent in 19, good in 18, and poor in 14 of the patients, as defined in the “Methods” section of the paper.Conclusions: Although patients with CFEOM present significant strabismus surgical challenges because of EOM dysinnervation, fibrosis, and/or heterotopia, satisfactory alignment and improvement of the head posture can be attained in a significant proportion of patients using an individually tailored surgical approach.

Improved Ocular Alignment with Adjustable Sutures in Adults Undergoing Strabismus Surgery

To assess whether outcomes of strabismus surgery are improved by using the adjustable suture technique and to determine which subgroups of strabismus patients benefit most from the adjustable suture technique. A retrospective chart review. A total of 535 adults who underwent strabismus surgery between 1989 and 2010. Success was defined as ≤10 prism diopters (PD) for horizontal deviations and ≤2 PD for vertical deviations. Differences in the proportion of successful strabismus surgery were analyzed using a chi-square test with an alpha of 0.05. Ocular alignment in primary position at a 7-day to 12-week follow-up examination. A total of 491 patients met the inclusion criteria (nonadjustable suture, n = 186; adjustable suture, n = 305). The success rates for the nonadjustable and adjustable groups were 61.3% and 74.8%, respectively (χ(2)=9.91, P=0.0016). Adjustable suture use was particularly beneficial for patients undergoing a reoperation for childhood strabismus (success rate: nonadjustable, 42.4%; adjustable, 65.7%; P=0.0268; n = 100). The differences in outcomes were not statistically significant for patients with childhood strabismus undergoing a primary surgery (nonadjustable, 65.0%; adjustable, 81.4%; P=0.1354; n = 90) or with thyroid orbitopathy (nonadjustable, 76.7%; adjustable, 74.1%; P=0.8204; n = 57). Strabismus surgery using adjustable sutures was associated with improved short-term ocular alignment compared with strabismus surgery without the use of adjustable sutures. Adjustable sutures were most beneficial for patients undergoing reoperations for childhood strabismus.

Suture Fixation System as Globe Tethers in Severe Paralytic Strabismus

almology ith inability duction on mitation to Surgical correction of severe paralytic or re strabismus is challenging. Patients with unre complete third-nerve palsy present with a lar exotropia and a variable vertical deviation. Lat tus muscle weakening is a major componen surgical plan to treat patients with this cond However, surgery usually results in underco because no active adducting force is present to any lateral rectus muscle force. Functional tion of the lateral rectus muscle by attaching i tion to the adjacent periosteum on the latera wall, and globe fixation to the medial perio may be necessary to eliminate diplopia and to ocular alignment in primary position.

A new surgical technique for ocular fixation in congenital third nerve palsy

Purpose To present a new technique of ocular fixation to restore and maintain the ocular alignment in primary position for patients with total third nerve paralysis. Method We fixated the globe (medial rectus muscle insertion) to the medial palpebral ligament insertion at the anterior lacrimal crest by using nonabsorbable 5-0 polyester sutures in a prospective study of 5 patients (5 eyes) with congenital total third nerve paralysis. A large recession of the lateral rectus muscle (12 to 16 mm) was also performed in four patients. Results Four patients achieved satisfactory ocular alignment and one patient had residual exotropia. After an initial exotropic shift, no significant change in ocular alignment was observed during the follow-up period of 6 to 9 months. Mild fullness and congestion over the medial rectus muscle area was observed in the immediate postoperative period in all the patients, which resolved in about two months time. Conclusion This technique of ocular fixation is easy, safe, and effective for the management of exotropia secondary to total third nerve paralysis.

Head tilt–dependent esotropia associated with trisomy 21

Objective To describe a series of patients who used a head tilt to control esotropia. Design Retrospective noncomparative case series. Participants Seven children with esotropia that decreased with their compensatory abnormal head tilt. Six of the patients had trisomy 21. The patients had no other identifiable etiology for their head tilt, including no oblique muscle dysfunction, nystagmus that changed with head tilt, or uncorrected refractive error. Intervention Six patients underwent horizontal extraocular muscle surgery. Preoperative evaluation in 4 patients included assessment of the change in head position with either monocular occlusion or prisms. Main outcome measures Ocular alignment in primary position and improvement in abnormal head tilt after surgery. Results In the 4 patients who underwent preoperative testing, the abnormal head tilt resolved with either monocular occlusion or prisms. The head tilt and esotropia were eliminated or improved in all patients who underwent strabismus surgery. Conclusions Abnormal head tilt may be used as a compensatory maneuver to improve purely horizontal strabismus. This finding appears to be associated with trisomy 21. Horizontal extraocular muscle surgery may improve the head tilt in such patients.