Persistent Diplopia Research Articles

Incidence of symptomatic vertical and torsional diplopia after superior rectus transposition for esotropic Duane syndrome and abducens nerve palsy

To report the incidence of symptomatic vertical and torsional diplopia after superior rectus transposition (SRT) for esotropic Duane syndrome and abducens nerve palsy. The medical records of patients with esotropic Duane syndrome or abducens nerve palsy seen at Boston Children's Hospital (2006-2018) and treated with unilateral SRT with or without augmentation was performed. The primary outcome was incidence of postoperative vertical or torsional diplopia in primary position. The secondary outcome was induced vertical deviation in affected side gaze. A total of 69 patients met inclusion criteria: 32 with abducens nerve palsy and 37 with esotropic Duane syndrome. Vertical alignment changed in both hyper- and hypotropic directions. Median pre- and postoperative vertical deviation in primary gaze was 1.1Δ (10th-90th percentile, 0Δ-6Δ hypertropia) and 0.4Δ (10th-90th percentile, 6Δ hypotropia to 8 Δ hypertropia), respectively. Postoperative vertical diplopia occurred in 7%, including 4 of 49 treated with loop myopexy (8%), 1 of 13 without augmentation (8%), and 0 of 7 treated with sclera-fixated augmentation. All but one was successfully treated with prism or secondary surgery. Intorsional change predominated, but no patient had torsional diplopia post adjustment. Vertical misalignment in affected side gaze increased from 19% to 45% after SRT (P=0.01). In this largest-to-date review of patients treated with SRT, with or without MR recession, no patient developed persistent torsional diplopia, while 7% developed symptomatic vertical diplopia in primary position, similar to the reported incidence after balanced vertical rectus transposition. Vertical misalignment in affected side gaze increased, however fusion is already limited by unresolved esotropia in this field.

Orthoptic Vision Therapy: Establishing a Protocol for Management of Diplopia Following Orbital Fracture Repair.

Persistent diplopia following orbital fracture is a well-recognized problem. While observation is the standard-of-care, symptoms may be protracted. Orthoptic vision therapy is a form of ocular physical therapy that achieves functional rehabilitation through targeted exercises. This study presents a protocol for post-traumatic orthoptics and describes preliminary results. Protocols for home-therapy/office-assessment were developed using commercial software and exercises targeting motility and fusion. Office-assessment also included validated questionnaire chronicling symptomatology. Healthy-volunteers (n = 10) trailed the protocol three times (n = 30) and normative data was compiled. Comparative measurements were made in chronic (>1year; n = 8) and acute (<2 weeks; n = 4) fracture cohorts. Time-of-therapy was recorded, monetary cost-analysis performed, and side-effects assessed. Severe/moderate motility limitation was found in 3 of 4 acute fracture patients but not in chronic or healthy cohorts. The acute cohort had worse fusion when comparing convergence (mean break/recovery of 8.0/6.5 prism diopters (pd) versus 31.87/21.23pd; P = 0.001/0.015) and divergence (3.00/1.50pd versus 18.37/12.83pd; P = 0.000/0.001) to the healthy cohort. Those with chronic fracture had lower convergence (15.71/5.00pd; P = 0.01/0.001) and divergence (12.29/4.71pd; P = 0.04/0.002) when compared with healthy subjects, but better function than acute patients. Acute fracture patients reported greater symptomatology than chronic (mean score 18.8 versus 4.6; P = 0.003) or healthy (5.0; P = 0.02) groups, but there was no difference between chronic and healthy groups (P = 0.87). Assessment took <10 minutes. Per patient software cost was <$70. Mild eyestrain related to therapy was self-resolving in all cases. Orthoptic therapy may improve fusion and motility following orbital fracture. This protocol serves as basis for prospective work.

Orbital Bony Reconstruction With Presized and Precontoured Porous Polyethylene-Titanium Implants.

Complex bony orbital defects are reconstructively challenging due to loss of intraoperative anatomical landmarks and adjacent support. Presized and precontoured porous polyethylene-titanium implants (Medpor Titan 3D Orbital Floor Implant) are designed to reestablish normal orbital floor and medial wall anatomy and are modeled after anatomically averaged orbits. This is the first study to report clinical outcomes with this implant. This retrospective case series reviewed clinical data and outcomes for patients undergoing orbital reconstruction with a presized and precontoured porous polyethylene-titanium orbital implant from January 2016 to June 2018. A total of 34 orbits of 33 patients were identified (mean age: 43 ± 16 years, 70% men). Most bony defects were a result of trauma and included large orbital floor deformities (100%), medial wall defects (74%), disrupted inferomedial struts (68%), and broken posterior ledges (82%). Symptomatic diplopia (73%) and enophthalmos (89%, mean: 3.7 ± 2.1 mm) were common preoperatively. Many cases were revisions (44%). Mean follow up was 7.8 ± 6.7 months. All patients had improved globe positioning, enophthalmos, and hypoglobus. Seven patients had persistent postoperative diplopia: 6 responded to prism therapy and 1 required strabismus surgery. One patient required retrobulbar hematoma drainage and 1 patient required implant explantation due to chronic infection. Commercially available presized and precon toured porous polyethylene-titanium implants are useful for complex orbital bony defects and can achieve functional improve ments in diplopia, enophthalmos, and extraocular motility with a low incidence of postoperative complications or revisional surgery.

Uveal Melanoma Metastatic to the Cavernous Sinus: A Case Report

A woman in her early 50s previously treated 7 years prior with iodine-125 plaque brachytherapy without a biopsy for gene expression profiling for uveal melanoma in the left eye presented with a 3-week history of intermittent diplopia and headache. Ophthalmic examination was significant for limitation in left eye upward gaze; otherwise, examination revealed a stable, regressed tumor in the left eye, and normal vision, pressure, and pupils in both eyes. Neuroimaging showed a left cavernous sinus lesion, suggestive of a meningioma. Excisional biopsy revealed metastatic melanoma. The patient was treated with radiotherapy, and her diplopia resolved. Slight enlargement of the lesion was noted on neuroimaging 20 months later, and was treated with stereotactic radiosurgery. Serial neuroimaging in the following 6 months did not reveal any recurrences or new metastases. This case demonstrates the importance of investigating persistent diplopia in a patient with a history of uveal melanoma, and the possibility of metastases occurring in organs besides the liver or lung.

ORBITAL FLOOR RECONSTRUCTION WITH TRANS-ANTRAL APPROACH USING ENDOSCOPE

&#x0D; &#x0D; &#x0D; Background and objective: Orbital floor fractures are very common in current day to day scenario. Till date different treatment modalities have been tried to reconstruct the orbital fractures. Conventionally various transorbital approaches have been used. But in cases where there is involvement of posterior part of orbit there is drawback of incomplete accessibility. To overcome this endoscopic assistance tends to get mandatory through trans-antral approach for better visualization, providing a good alternative to conventional approach.&#x0D; Case Report: A 55-year-old male patient with pure blowout fracture along with persistent diplopia and enophthalmos was operated with sub tarsal approach along with trans antral approach using endoscope.&#x0D; Result: The post-surgical results were satisfactory in respect to correction of diplopia and enophthalmos.&#x0D; Conclusion: Conventional approach assisted with endoscope provides a new method of managing Orbital floor fractures improving treatment outcomes.&#x0D; &#x0D; &#x0D;

Association Between Compensatory Overaction of the Non-Injured Eye, Measured by HESS Chart and Postoperative Diplopia in Blow-Out Fracture.

In orbital floor fracture, diplopia often persists post-operatively. This study evaluated the association between pre-operative parameters concerning the extent of the injury and post-operative diplopia, using multivariate analysis. A retrospective computed tomography analysis and chart review was performed for patients with punched out orbital floor fracture, who underwent operations during the period from April 2011 to March 2018. Five parameters were evaluated: the number of upward arrows on the Hess chart (representing compensatory overaction of the non-injured eye), time interval to surgery, muscular subscores, fracture area, and swelling rate of the inferior rectus muscle. Of the 32 patients, 9 (28%) had post-operative diplopia; pre-operative diplopia was completely restored in 23 (72%) patients by 6 months after surgery. Univariate analysis found statistically significant differences in the number of upward arrows on the Hess chart, time interval to surgery, muscular subscores, and fracture area. Logistic regression analysis demonstrated that only the number of upward arrows displayed a significantly increased risk for post-operative diplopia (odds ratio, 15.3; 95% confidence interval, 2.0-117.0; P = 0.008). Excessive overaction of the non-injured eye predicted persistent diplopia by 6 months post-operatively. Surgical intervention may be insufficient to achieve full recovery from diplopia and disturbances of ocular motility in some patients.

Inferior Oblique Entrapment After Orbital Fracture With Transection and Repair.

Extraocular muscle (EOM) entrapment with resulting reduction in motility and diplopia is a known complication of orbital fractures. Less commonly, transection of the EOMs due to trauma, iatrogenic injury, or intentional myotomy may lead to persistent diplopia. The inferior oblique (IO) is often encountered during orbital surgery along the medial wall and floor, and may be disinserted to aid in visualization. The authors present a case of IO entrapment which occurred during zygomaticomaxillary fracture reduction. Intraoperatively, an IO transection was performed and the muscle was reattached within the orbit. Postoperatively, the patient did not develop diplopia or motility disruption. This technique may provide a useful solution to an unusual problem during orbital fracture repair.

Repair of orbital floor fractures via the transantral approach with osteosynthesis plate.

The most common surgical access techniques employed in patients with orbital floor fractures are associated with a risk of complications, such as implant infection, migration, epiphora, lower eyelid retraction, ectropion, diplopia worsening, retrobulbar hematoma, emphysema, "white-eyed" syndrome, enophthalmia relapse, hypoglobus, and persistent diplopia due to periorbital atrophy. Consequently, alternative access techniques precluding these complications have to be found. To assess the efficacy of transantral approach in the surgical treatment of patients with orbital floor fractures based on results of retrospective analysis of our clinical experience. We performed a retrospective study of medical records and X-ray data of 52 patients with fractures of the floor of the orbit, 18 to 68 years old, treated using transantral approach as described in the article. Titanium plates of special shape were used for orbital floor reconstruction. In 94.2% of the cases, adequate restoration of the floor of the orbit was achieved. It led to regression of the ocular signs. In 4 patients, diplopia remained in extreme gaze positions, which did not require surgical correction. The failed cases were related to incorrect positioning of the plate or fixing screws. No inflammatory complications were observed. Transantral access approach may be a technique of choice in treating patients with orbital floor fractures; it is safe, minimally traumatic, and effective in the early posttraumatic period when the injured area is located in the posterior parts of the floor of the orbit.

Otago Glaucoma Surgery Outcome Study: Examining the Development of Strabismus Causing Diplopia in Patients Who Have Received Molteno Implant Surgery

ABSTRACT Objective To evaluate the development of postoperative strabismus causing diplopia in patients who received Molteno implant surgery for the treatment of glaucoma. Methods The Otago Glaucoma Surgery Outcome study (OGSOS) was used to select cases who had undergone Molteno implant surgery to examine the effect on the development of strabismus causing diplopia. Information was collected on treatments provided to correct motility disturbance, and their success, in this retrospective non-comparative study. Results 32 cases (3.3%) were found to have developed diplopia following the Molteno implant surgery from a total of 977 cases. Of these, the strabismus in 23 cases was described in sufficient detail to permit clinical categorization. Most (19/23) demonstrated an exodeviation, hyperdeviation, or a combination thereof, although 2/6 cases with superonasal plate location demonstrated a hypodeviation. Diplopia generally resolved spontaneously (20/32 cases). Treatment was required in eight cases, usually conservative and successful (6/8 cases), but strabismus surgery was required in two cases, and was unsuccessful. Conclusions This study found a low incidence of diplopia developing post-Molteno implant surgery. Strabismus features suggested a restrictive etiology, and spontaneous recovery was common (62.5%). Surgical correction proved unsuccessful – confirming persistent postoperative diplopia after Molteno implant surgery to be a rare but surgically challenging complication.

Efficacy and complications of orbital fat decompression in Graves’ orbitopathy: a systematic review and meta-analysis

In Graves’ orbitopathy, surgical decompression is often needed for functional and aesthetic reasons. This meta-analysis was performed to assess the efficacy and safety of fat removal orbital decompression (FROD) alone to treat exophthalmos in Graves’ orbitopathy. A systematic search was conducted in PubMed/MEDLINE, Web of Science, and Cochrane Library for studies published before August 2018. Random-effects meta-analyses were applied; weighted means and weighted proportions with corresponding 95% confidence intervals (CI) were calculated. Study quality and quality of evidence for each individual outcome were analyzed. Of 1908 records initially identified, 13 observational studies were selected, representing 4820 orbits in 2514 patients. Weighted Hertel exophthalmometry was 23.10mm (95% CI 21.77–24.43mm) preoperative and 19.31mm (95% CI 17.81–20.81mm) postoperative. The weighted mean difference was 3.81mm (95% CI 3.41–4.21mm). Five studies reported an improvement of diplopia after surgery, occurring in 943 of 1172 patients (weighted proportion 0.50, 95% CI 0.15–0.85). Persistent new onset diplopia was reported in five studies, or 124 of 1277 patients (weighted proportion 0.15, 95% CI 0.03–0.27). No serious adverse events were reported. Results support the effectiveness and safety of FROD to treat mild-to-moderate exophthalmos in Graves’ orbitopathy. Prospective and controlled trials are needed to improve the level of evidence.

A retrospective study of pure medial orbital wall fracture management

To describe the clinical presentation of isolated medial orbital wall fractures, the duration of symptoms and their management. Retrospective study of 60 orbits of 60 patients over 18 years of age with isolated medial wall fractures of the orbit at the facial and trauma center of the Pitié-Salpêtrière university hospital of Paris between June 2012 and November 2015. Diplopia, enophthalmos and limitation of extraocular muscle movements were investigated. The location of the fractures was confirmed with three-dimensional computed tomography. Intraocular trauma was ruled out. Incomplete data were excluded. Eighty-three patients were identified (June 2012-November 2015). Sixty patients (39 males and 21 females) had a complete medical record. The mean age was 37 years, ranging from 18 to 75 years. Assault was the most common cause in 45 patients (75%), followed by sports accidents in 8 patients (13%), motor vehicle accidents in 6 patients (10%), and a fall in 1 patient. On presentation, 51 patients (85%) had no symptoms. Diplopia was present in 9 patients (15%). Four of them (6.7%) had associated enophthalmos. The diplopia resolved spontaneously in 5 patients (5.5%) and persisted more than 2 weeks in 4 patients (6.7%), for whom surgical intervention was recommended. Only 4 patients (6.7%) were managed surgically due to the presence of combined persistent diplopia and enophthalmos. The mean time from trauma to surgery was 18 days (15-45 days). At the 45-day postoperative follow-up, persistent diplopia was present in 1 patient out of the four treated surgically, with no residual enophthalmos. Fifty-six patients were managed conservatively. Asymptomatic fractures do not require surgical repair, and conservative management is adequate. Such fractures heal on their own without any consequences.

SAT-579 A Rare Presentation of Ophthalmopathy in a Patient with Hashimoto's Hypothyroidism

Ophthalmopathy is a known disorder that consists of inflammation of the orbits and periorbital tissues that can be commonly seen in systemic autoimmune diseases such as Graves. On the other hand, ophthalmopathy associated with Hashimoto's thyroiditis is a rare presentation that is under-reported in the literature. A 58-year-old female was admitted to the hospital for sudden onset of double vision with subsequent progression of vision loss in her left eye. Prior to admission, she had a known history of hypothyroidism for several years with non-compliance to replacement therapy. On admission, patient's thyroid function tests (TFTs) showed a TSH of 37.95 and a Free T4 of 0.6 along with elevated thyroid peroxidase (TPO) antibodies at 58.3, thus confirming the diagnosis of Hashimoto's hypothyroidism. Upon Ophthalmology consultation, she was noted to have orbitopathy, namely left eye rectus lateralis paralysis, that was attributed to the TPO antibodies. The patient was started on appropriate thyroid hormone replacement with improvement of TFT values within a few days. However, the patient continued to have persistent diplopia despite therapy. At this time, the patient was started on prednisone 20 mg daily for a total of 2 weeks. At the end of the steroid therapy, complete resolution of the orbitopathy with vision improvement was noted. Hashimoto's ophthalmopathy is a rare form of orbitopathy especially when compared to the well-known version in Graves' Disease. In the literature, there has been some case studies that looked at the association of Hashimoto's thyroiditis with diplopia. In one study, the authors noted that both Graves' and Hashimoto's diseases accounted for 6% of thyroid associated eye disease while Graves' disease accounted for the majority of cases. The authors also noted that patients with Hashimoto's thyroid-associated eye disease were: older, had a longer duration of Hashimoto's diagnosis, were less likely to have co-existent other autoimmune disease, had a positive history of tobacco usage, and had elevated values of thyroid stimulating antibodies (TSAb). The authors also established a positive correlation between the occurrence and severity of thyroid associated eye disease in relation to increasing TSAb levels.1 Although Hashimoto's associated ophthalmopathy is a rare presentation of this autoimmune thyroid disorder, it is prudent to have a high index of suspicion in order to institute appropriate anti-inflammatory therapy such as steroid therapy for early resolution of eye symptoms. Early identification and treatment can stop the disease progression and prevent complications such as blindness due to optic nerve compression. 1. Kan E, Kan EK, Ecemis G, Colak R. Presence of thyroid-associated ophthalmopathy in Hashimoto's thyroiditis. International Journal of Ophthalmology. 2014;7(4):644-647. doi:10.3980/j.issn.2222-3959.2014.04.10.

Exploring the effect of streamlining multidisciplinary care pathways on orbital trauma outcomes at a regional referral centre

Introduction Complex orbital fractures require multi-specialty input. The United Kingdom currently has no agreed best practice guidelines. A systematic review and meta-analysis found a significantly increased adverse outcome of persistent diplopia in patients operated on more than 14 days after initial injury. At our tertiary centre, we felt patient outcomes may be affected by investigative and referral pathway limitations so evaluated to assess and attempt to improve these. Methods This was a two-stage service evaluation study of all orbital trauma patients requiring specialist oculoplastic and orbital input. The initial phase included all orbital trauma patients referred to our department in April–November 2014. We assessed relevant key performance indicators and then implemented changes to our referral system, educated referring departments and formed a multidisciplinary team clinic to manage complex trauma. We then re-evaluated, collecting data on all patients referred March–May 2015. Results Most patients were male and victims of assault. Following intervention, there was a significant reduction in the injury to eye clinic review time (3.45 weeks to 2.22 weeks, p = 0.01) and multidisciplinary team review time (3.86 weeks to 2.71 weeks, p = 0.04). Injury to discharge time was significantly reduced from 6.15 weeks to 3.36 weeks (p = 0.002). Discussion Our study shows that a multidisciplinary team approach and structured pathways can improve assessment and intervention times for orbital trauma patients. This may have a beneficial effect on patient outcomes. In the absence of guidelines in the United Kingdom, we believe similar improvements could be implemented by other national centres and outcomes evaluated to assist future guidance formation.

Factors Affecting Persistent Diplopia after Surgical Repair of Isolated Inferior Orbital Wall Fracture

Factors Affecting Persistent Diplopia after Surgical Repair of Isolated Inferior Orbital Wall Fracture

Long-term efficacy of fractionated conformal radiotherapy for the management of primary optic nerve sheath meningioma

Background/AimFractionated conformal radiotherapy (FCRT) is now used to treat vision-threatening optic nerve sheath meningioma (ONSM), but long-term efficacy and safety data are lacking; the purpose of this study was to...

Does vertical incomitance predict the diplopia outcome in orbital fracture patients? A prospective study of 188 patients

ObjectiveTo determine the predictive value of vertical incomitance for diplopia outcome in orbital fracture patients. Patients and methodsA prospective cohort study composed of patients with orbital fractures was designed. The predictor variable was vertical incomitance, and the primary outcome variable was diplopia. Incomitance was calculated in prism diopters (Δ) as the difference of the maximum absolute deviation between the upper and lower three gaze directions. Standard statistics for patient characteristics, the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables were computed. ResultsThe sample was composed of 188 patients grouped as follows: non-operated (n = 124) and operated (n = 64). Fifty-one patients showed vertical incomitance of whom 10 (19.6%) had persistent diplopia at the 1-year follow-up. The mean incomitance was 9.6Δ in the diplopia group versus 2Δ in the non diplopia group (OR = 1.13; p < 0.001). There was a statistically significant association between vertical incomitance of >2Δ and persistent diplopia at 1 year after adjusting for the surgery variable (OR = 1.07; p < 0.04). ConclusionThe present study has demonstrated that in orbital fracture patients, vertical incomitance was associated with (1) persistence of long-term diplopia, (2) the decision to perform surgery, and (3) the severity of the fracture.

Surgical Management of Strabismus in Patients With Orbital Fracture.

Till date, the surgical policy of strabismus in patients with orbital fracture is scarcely described in literature. The purpose of this study was to describe the clinical features and surgical experience in patients with strabismus and persistent diplopia after orbital fracture repair, or in patients who need not receive surgery for orbital fracture. Retrospective review was performed on patients with orbital fracture who received strabismus surgery between 2004 and 2016 in Eye Hospital, Zhongshan Ophthalimc Center, Sun Yat-sen University, China. The following clinical data were recorded from the patients' charts: the nature of fracture, age at surgery, preoperative motor alignment, stereoacuity, surgical methods, surgical outcomes, and complications. Deviations of 10 prism diopter (PD) or less of horizontal angle and deviation of 5 PD or less of vertical angle in the primary position were considered to be a successful outcome. A total of 29 patients (23 males and 6 females) with an average age of 32.4 ± 16.6 years (2-61 years) were recruited in this study. The strabismus was paralytic in 16 patients, restrictive in 2 patients, and both paralytic and restrictive in 11 patients. The surgical methods were quite various in each patient; however, all patients underwent either rectus recession or rectus recession plus resection. With at least 6 months of follow-up, preoperative horizontal deviation of 32.79 ± 22.84 PD was reduced to 6.69 ± 13.01 PD (P < 0.01). The vertical deviation was reduced from 22.76 ± 17.66 PD to 6.59 ± 7.98 PD (P < 0.01). Sixteen patients (55.2%) were considered as success, whereas a surgical undercorrection was observed in 44.8%. There were no surgical complications. The clinical manifestations of strabismus in patients with orbital fracture or after fracture repair are quite complex, often involving both paralytic and restrictive factors. The surgical treatment of each patient needs to be individualized. The rectus muscle recession and resection seems to be predictable, effective, and stable.

Outcomes of undercorrection in surgical management and binocular vision gained of adult intermittent exotropia

PurposeTo study the surgical outcomes of intended undercorrection on adult intermittent exotropia (X(T)) performed to avoid postopertively overcorrected diplopia.Patients and methodsA retrospective chart review was conducted for adult patients (age ≥18 years) with X(T) ≥15 prism diopter (PD) who underwent strabismus surgery by a single surgeon. Inclusion criteria were 1) corrected VA ≥20/40 in either eye; 2) monocular occlusion at least 30 minutes before deviation measurement; 3) difference of ≤10 PD between near and distance deviation; 4) absence of significant A or V pattern or vertical deviation; 5) lateral rectus recession and medial rectus resection procedure were performed unilaterally; and 6) intended surgical number for deviation correction was aimed at 5 PD undercorrection.ResultsOf 234 patients who met the inclusion criteria, 122 were women (52.14%). Average age at the time of surgery was 27.56 years (range, 18–42 years). A total number of 197 patients (84.19%) had postoperative exodeviation under 10 PD. Twenty five (10.68%) and 12 patients (5.13%) had postoperative exodeviation within 10–15 PD and >15 PD, respectively. All patients who had postoperative exodeviation >15 PD exhibited initial deviation of ≥40 PD and had undergone re-operation. In 74 patients (46.25%) out of 160 who had no binocular vision in orthoptic examination before surgery, fusion or stereopsis was gained after good alignment. No postoperative diplopia was found in this study.ConclusionIntended undercorrection in surgical management of adult X(T) showed good functional and cosmetic outcomes. No procedure resulted in consecutive esodeviation or persistent diplopia. Fusion or stereopsis could be gained after successful surgical alignment. Our recommendations are as follows: 5 PD undercorrection if deviation is <40 PD and regular correction if deviation is ≥40 PD.

Delayed surgical treatment of orbital trapdoor fracture in paediatric patients.

Trapdoor fracture is a special type of orbital blowout fracture. Although early surgery is recommended, there still remain some patients delayed by various reasons. In this study, we analysed the clinical characteristics of delayed paediatricpatients, especially those with different levels of ocular motility restriction before surgery. Thirtypatients(3 to 14 years old) whounderwent delayed surgery for trapdoor fractures between January 2008 and September 2016 were enrolled. Their demographics, causes of injury and delay, clinical features, imaging data and follow-up information were collected. Muscular entrapment was found in 17 patients (group A) and soft-tissue entrapment in 13 patients (group B). 12 (7 in group A) presented with severe motility restriction and 18 (10 in group A) with mild restriction before surgery. 41.7% with severe restriction recovered after surgery, compared with83.3% with mild restriction. Four (23.7%) in group A (all with severe restriction) and six (46.2%) in group B (half with severe restriction) presented with persistent diplopia. Long recovery time and a high percentage of persistent diplopia are the main problems of delayed trapdoor fracture inchildren. A prompt surgery within 48 hours is strongly recommended in patients with muscular entrapment even if an urgent treatment is hard to achieve. So are patients with soft-tissue entrapment and significant motility restriction. In the other patients without such indications, even though some recovery might be possible in the long term, a prompt surgery right after diagnosis is still preferable regardless of the entrapped contents.

Rectus Muscle Resection for Vertical Strabismus in Thyroid Eye Disease

ABSTRACTPurpose: Rectus muscle resection in thyroid eye disease (TED) is generally avoided due to the risk of worsening restriction or reactivating inflammation. However, for some patients with large-angle strabismus or diplopia in primary gaze despite maximum recession surgery, rectus muscle resection may be beneficial. We report our surgical experience with rectus muscle resection in the management of vertical strabismus associated with TED.Methods: Retrospective review of eight patients with TED and vertical diplopia who underwent vertical rectus muscle resection by a single surgeon (IBM) at a tertiary referral centre in Liverpool, UK, from 2001 to 2013. The goal of surgery was elimination of diplopia in primary and reading position. Vertical deviations were measured in prism dioptres (∆) before and after surgery at one month, four months and final visit by prism alternate cover testing at ⅓ m and 6 m.Results: The mean ± standard deviation vertical deviation for near and distance reduced significantly from 14.2∆ ± 8.4∆ and 15.8∆ ± 8.8∆ pre-operatively to 5.7∆ ± 4.9∆ and 6.7∆ ± 7∆ at the four-month visit, respectively (p< 0.05). At the four-month follow-up, five (62.5%) patients achieved binocular single vision in primary and reading position with either no prisms or prisms less than 5∆. Further recession surgery, Harada-Ito procedure, or lateral rectus resection were necessary in four (50%) patients with persistent diplopia. No patient developed recurrence of inflammation or increased muscle restriction.Conclusions: Vertical rectus resection could be considered as an additional surgical strategy in the management of TED patients with vertical strabismus without adverse sequelae.