Preoperative Horizontal Deviation Research Articles

Strabismus surgery outcomes without removal of scleral buckle in patients with previous retinal detachment repair

To report the motor and sensory outcomes of strabismus surgery following scleral buckle procedure for retinal detachment (RD) without removal of the scleral buckle. The medical records of patients who underwent strabismus surgery without removal of scleral buckle following RD surgical repair at a tertiary referral center between 2002 and 2015 were reviewed retrospectively. Demographic data were recorded, and rates of surgical motor success (defined as horizontal deviation of ≤10Δ and vertical deviation of ≤4Δ) and sensory success (resolution of diplopia) were calculated. A total of 23 patients (mean age, 58.4±24.4years; 12 males) were included. The average time between the RD surgery and onset of strabismus was 11.05±10.95months (range, 1-42months). The strabismus was horizontal in 6 patients, vertical in 2, and combined in 15. Eighteen patients (78%) presented with diplopia. Adjustable sutures were used in 18 patients. Final motor surgical success was achieved in 17 of 23 patients (74%), and diplopia improved in 17 of 18 patients (94%) who had preoperative fusional capability. There was no statistically significant difference in age, number of RD surgeries, macular status, time to strabismus surgery, visual acuity in the worse eye, or magnitude of preoperative horizontal and vertical deviation with regard to motor success rate and with persistence of diplopia postoperatively. In our study cohort, strabismus surgery without removal of the scleral buckle resulted inmotor success and alleviated diplopia in the majority of patients with prior RD repair.

Improvement in Both Primary and Eccentric Ocular Alignment After Thyroid Eye Disease-Strabismus Surgery With Tenon's Recession.

To evaluate the improvement in primary and eccentric gaze ocular alignment in thyroid eye disease (TED) patients undergoing horizontal strabismus surgery with Tenon's recession. This is an Institutional Review Board-approved retrospective analysis of TED patients undergoing horizontal strabismus surgery for esotropia. The study included all patients from 2007 to 2016 operated on by a single surgeon at Columbia University Medical Center. Surgical success was defined as the ability to fuse at both near and distance either without prismatic correction or with less than 10 prism diopters (PD) of correction. Measurements of ocular alignment were also made in eccentric fields of gaze. This study was Health Insurance Portability and Accountability Act compliant with protection of individually identifiable information. Thirty-eight patients with TED and restrictive horizontal strabismus underwent unilateral or bilateral medial rectus recession to relieve diplopia. All patients underwent Tenon's recession with dissection of Tenon's from the overlying conjunctiva permitting it to retract into the orbit. Overall the success rate was 87% with a reoperation rate of 7.9%. The improvement in horizontal deviation in both primary and eccentric gaze was statistically significant (p < 0.001). The change in vertical deviation in the 5 cardinal positions of gaze was not statistically significant. The postoperative change in vertical deviation was not proportional to the preoperative horizontal deviation or the amount of horizontal recession. Due to the preoperative incomitance of ocular deviations in TED patients, persistent postoperative eccentric misalignment is expected. The addition of Tenon's recession to TED-horizontal strabismus surgery led to statistically significant improvement in ocular alignment in both primary and eccentric gaze. This is the first study of TED-strabismus surgery to analyze the postoperative results in positions outside of primary and reading gaze. The authors postulate that the release of scar tissue by the addition of Tenon's recession contributes to these improvements.

Horizontal Deviations in Congenital Brown Syndrome.

To report the incidence of horizontal deviations requiring surgical correction in patients with congenital Brown syndrome. In a retrospective study, the medical records of all children who underwent a surgical correction of congenital Brown syndrome at Schneider Children's Medical Center of Israel from 1998 to 2016 were reviewed, analyzing the presence of preoperative primary position horizontal misalignment. Overall, 19 eyes (8 right and 11 left eyes) of 16 patients (7 males, 9 females; mean age: 4.2 ± 2.6 years) were included in this study. Fourteen patients (88%) had surgery for correction of a compensatory head position, including 8 patients (50%) with a head tilt and 6 patients (38%) with a chin-up position, and 2 patients had surgery for primary position hypotropia. All of them underwent a weakening procedure of the superior oblique tendon, by either Z-tenectomy (81%, n = 13) or suture elongation of the superior oblique tendon (19%, n = 3). Fifty-six percent of patients (n = 9) had primary position horizontal deviation before surgery, including 50% (n = 8) exodeviations, ranging from exophoria of 4 prism diopters (PD) to exotropia of 30 PD, and one esotropia of 14 PD. Fifty percent of patients (n = 8) had surgery to correct the horizontal deviation by a recession of either one (31%, n = 5) or two (19%, n = 3) muscles. Mean preoperative horizontal deviation (9.3 ± 3.4 PD) decreased significantly following surgery (1.7 ± 1 PD, P = .001) (paired t test). Significant horizontal misalignment is often present in patients with congenital Brown syndrome and its correction should be considered at the time of surgery. [J Pediatr Ophthalmol Strabismus. 2018;55(2):113-116.].

Simplified approach of Gokyigit's technique for complete cranial nerve third palsy.

To evaluate a simpler approach of the medial transposition of split lateral rectus technique in patients with complete third nerve palsy. All eyes with complet third nerve palsy were followed in our Strabismus Department between 2014 and 2016. All patients had complete oculamotor nerve palsy. All patients assed routine ophthalmologic examination. Also the ocular deviation, horizontal and vertical ocular alignments were measured at 6 m and at 1/3 m using the Krimsky corneal reflection test and alternate prism cover test with best optical correction. Same surgeon (BG) performed all procedures in general anesthesia. In this procedure, same Gokyigit's technique except upper and lower part of lateral rectus muscle was passed under the superior oblique tendon and inferior oblique tendon. Final deviation from 0 to 14PD was considered a successful result. Eight patients were included in the study. The average ages were 39.4years and male to female ratio 5:3. Patients had a preoperative horizontal deviation -42.5±2.7 PD and postoperative horizontal deviation -1.7±2.6 PD. All patients follow-up time were at least 6months. Achieved to acceptable alignment in primary position, manage to diplopia and cosmetical appearance are the main aims of patients with third nerve palsy.

Surgical management of strabismus following choroidal melanoma plaque brachytherapy

To characterize intraoperative findings, surgical approach, and postoperative outcomes inpatients undergoing strabismus surgery following plaque brachytherapy for ocular melanoma. The records of all patients who underwent plaque brachytherapy for choroidal melanoma between May 2007 and June 2016 were reviewed retrospectively to identify those who subsequently required strabismus surgery. Of the 461 patients who underwent plaque brachytherapy during the study period, 13 (2.8%) met inclusion criteria. Visual acuity of the affected eye was 20/40 or better in 9 patients (69%). Preoperative horizontal deviation ranged from 0Δ to 52Δ; vertical deviation, from 2Δ to 25Δ. At final follow-up mean horizontal deviation ranged from 0 to 4Δ; vertical deviation, from 0Δ to 12Δ. Intraoperatively, all muscles directly adjacent to the treated area appeared macroscopically thicker than normal despite being functionally underacting. Magnetic resonance imaging showed enlarged muscles adjacent to the plaque radiotherapy. Microscopic examination of muscles in 2 patients showed reactive enlargement of the muscle fibers, granulation tissue, and inflammation. Persistent strabismus after plaque brachytherapy is rare. Typical findings include enlarged, underacting rectus muscles adjacent to the area of the plaque, restrictive connective tissue, and incomitant strabismus. Previously disinserted muscles may be found in abnormal locations. In this patient cohort scar tissue removal in conjunction with tightening procedures on the muscle adjacent to the plaque combined with recession of the antagonist muscle frequently resulted in good anatomical outcome.

A Valid Indication and the Effect of Bilateral Inferior Oblique Transposition on Recurrent or Consecutive Horizontal Deviation in Infantile Strabismus.

PurposeTo evaluate the effects of bilateral inferior oblique transposition (BIOT) on horizontal deviation from primary position among patients with bilateral dissociated vertical deviation (DVD) associated with inferior oblique overaction (IOOA) in infantile strabismus.MethodsRetrospective chart review was conducted among 19 patients with infantile strabismus. All patients had DVD and IOOA with consecutive or recurrent horizontal deviation and underwent modified BIOT surgery. Patients were divided into three subgroups: patients who underwent BIOT (BIOT group, n = 9) alone, BIOT with medial rectus recession or lateral rectus resection simultaneously (ET BIOT group, n = 6), or BIOT with lateral rectus recession or medial rectus resection simultaneously (XT BIOT group, n = 4). Postoperative angle of horizontal deviation (prism diopter, PD) and corrected magnitude of horizontal deviation (PD) at final visit after surgery were analyzed in each group.ResultsThe mean age was 55.11 ± 21.05 months (range, 32 to 115). The mean follow-up period was 8.68 ± 2.87 months (range, 6 to 18). Preoperative horizontal deviation was 4.23 ± 5.99 PD (range, 0 to 16) in BIOT, −17.33 ± 6.76 PD (range, −30 to −10) in ET BIOT, and 17.50 ± 2.52 PD (range, 14 to 20) in XT BIOT. Esodeviation is represented by negative values. DVD and IOOA were reduced less than +1 in all patients. The corrected amount of horizontal deviation was 3.56 ± 5.18 PD (range, 0 to 16) in BIOT surgery alone and larger in XT BIOT (18.50 ± 3.41 PD) than in ET BIOT (12.33 ± 5.57 PD, p = 0.004).ConclusionsMinimal exodeviation was corrected by BIOT alone. In addition, secondary eso- or exodeviation at great magnitudes should be corrected with proper horizontal muscle surgery along with BIOT.

Impact of Superior Oblique Transposition on Primary Position Deviation, a Pattern and Intorsion in Third Nerve Palsy

ABSTRACTPurpose: To evaluate the role of superior oblique transposition on primary position alignment, A pattern, and intorsion in third nerve palsy.Methods: Ten patients with isolated, unilateral third nerve palsy were included in this prospective study. The patients were treated by conventional surgery on horizontal recti together with superior oblique transposition by Scott’s procedure in the paretic eye.Results: Pre-operative primary horizontal deviation was 60-80 PD (mean 70.00±7.45 PD). Pre-operative primary hypotropia was 15-22 PD (mean 18.80±2.48 PD). Mean A-pattern was 17.80±2.65 PD. All patients included in the study had some degree of objective torsion as measured by Guyton’s method. One patient had grade I objective intorsion, 2 had grade II, 6 had grade III, and 1 had grade IV objective intorsion.Primary position horizontal alignment (up to ±8 PD) was achieved in 9 patients. Primary position vertical alignment (up to ±8 PD) was achieved in all 10 patients.Only 2 of 10 patients had A-pattern of 10 PD, in the remaining 8 patients it was eliminated (P<0.05). Postoperatively, 5 patients had no objective intorsion and 5 had grade I intorsion, and none of the patients had hypertropia or paradoxical eye movements.Conclusion: Superior oblique transposition by Scott’s procedure along with conventional surgery on horizontal recti in third nerve palsy results in better horizontal and vertical alignment, and improves A-pattern and intorsion, thus leading to better binocular interaction.

Enlargement of the superior rectus and superior oblique muscles causes intorsion in Graves’ eye disease

PurposeTo review the prevalence of preoperative and postoperative intorsion in patients with strabismus and Graves’ eye disease (GED), and to correlate the intorsion with coexisting superior rectus (SR) and superior...

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.

Adjustable nasal transposition of split lateral rectus muscle for third nerve palsy.

Third nerve palsy causes disfiguring, incomitant strabismus with limited options for correction. To evaluate the oculomotor outcomes, anatomical changes, and complications associated with adjustable nasal transposition of the split lateral rectus (LR) muscle, a novel technique for managing strabismus associated with third nerve palsy. Retrospective medical record review appraising outcomes of 6 consecutive patients with third nerve palsy who underwent adjustable nasal transposition of the split LR muscle between 2010 and 2012 with follow-up of 5 to 25 months at a tertiary referral center. Adjustable nasal transposition of the split LR muscle. The primary outcome was postoperative horizontal and vertical alignment. Secondary outcomes were (1) appraising the utility of adjustable positioning, (2) demonstrating the resultant anatomical changes using magnetic resonance imaging, and (3) identifying associated complications. Four of 6 patients successfully underwent the procedure. Of these, 3 patients achieved orthotropia. Median preoperative horizontal deviation was 68 prism diopters of exotropia and median postoperative horizontal deviation was 0 prism diopters (P = .04). Two patients had preoperative vertical misalignment that resolved with surgery. All 4 patients underwent intraoperative adjustment of LR positioning. Imaging demonstrated nasal redirection of each half of the LR muscle around the posterior globe, avoiding contact with the optic nerve; the apex of the split sat posterior to the globe. One patient had transient choroidal effusion and undercorrection. Imaging revealed, in this case, the apex of the split in contact with the globe at an anterolateral location, suggesting an inadequate posterior extent of the split. In 2 patients, the surgical procedure was not completed because of an inability to nasally transpose a previously operated-on LR muscle. Adjustable nasal transposition of the split LR muscle can achieve excellent oculomotor alignment in some cases of third nerve palsy. The adjustable modification allows optimization of horizontal and vertical alignment. Imaging confirms that the split LR muscle tethers the globe, rotating it toward primary position. Case selection is critical because severe LR contracture, extensive scarring from prior strabismus surgery, or inadequate splitting of the LR muscle may reduce the likelihood of success and increase the risk of sight-threatening complications. Considering this uncertainty, more experience is necessary before widespread adoption of this technique should be considered.

Risk factors influencing the outcome of strabismus surgery following retinal detachment surgery with scleral buckle

To determine factors associated with surgical success in patients undergoing strabismus surgery after retinal detachment repair with scleral buckle. The medical records of consecutive patients who underwent strabismus surgery after repair of retinal detachment with scleral buckle were retrospectively reviewed. A successful "motor" outcome was defined as horizontal deviation <10(Δ) and vertical deviation <4(Δ) in the primary position; successful "sensory" outcome was no diplopia in the primary position. Various factors such as removing the scleral buckle at the time of strabismus surgery, the macula structural status, size of the preoperative deviation, presence of restriction to passive movement, and whether the eye with the scleral buckle was the operated eye were compared among groups based on motor success. A total of 25 patients were included. The overall motor success rate was 72% after 1.8 ± 0.9 operations, with 62% of patients diplopia free in the primary position. Horizontal deviation <10(Δ) (P = 0.005) and minimal restriction on forced duction test were associated with motor success after the first surgery (P = 0.05). Partial or entire scleral buckle removal (n = 15) and fellow-eye surgery were not significantly correlated with motor success in our cohort. There were no retinal redetachments after scleral buckle removal. A small preoperative horizontal deviation, and minimally restricted ocular rotations wereassociated with better results. Removing the scleral buckle did not improve results.

Medial transposition of a split lateral rectus muscle for complete oculomotor nerve palsy

To evaluate the effect on ocular alignment of Y splitting the lateral rectus muscle and then reattaching the 2 ends near the medial rectus muscle insertion in patients with complete oculomotor nerve palsy. All eyes with oculomotor nerve palsy treated between May 2008 and February 2010 with Y splitting and transposition of the lateral rectus muscle to the medial rectus muscle were prospectively studied. In this procedure, the lateral rectus muscle was split: the upper half was transposed to the superior border and the lower half to the inferior border of the medial rectus insertion. For the muscles that had lost the ability to stretch and strain due to fibrosis, a hang-back technique was used. In some patients, the medial rectus muscle of the same eye was subsequently strengthened or the lateral rectus muscle of the fellow eye was recessed. Final deviation from 0(Δ) to 10(Δ) was considered a successful result. A total of 10 patients were included. Patients had a preoperative horizontal deviation >45(Δ) (range, 45(Δ)-90(Δ)). Of the 10 patients, 5 attained stable results following surgery, and 5 with postoperative undercorrection between 20(Δ) and 30(Δ) required further surgeries. Postoperatively, 2 patients improved their sensorial status in a very limited range of gaze and 2 patients had symptomatic diplopia. Acceptable aesthetic results can be achieved in the treatment of complete oculomotor nerve palsy with the transposition of the split lateral rectus muscle to the medial rectus muscle area.

The effect of previous orbital decompression on results of strabismus surgery in patients with Graves' ophthalmopathy

To evaluate the effect of previous orbital decompression on the success of strabismus surgery in patients with Graves' ophthalmopathy. The medical records of patients who underwent strabismus surgery for Graves' ophthalmopathy were retrospectively reviewed. Patients were divided into two groups according to whether they had previously undergone orbital decompression. Success was defined as no diplopia in primary and downgaze or no diplopia with prisms no more than 8(Δ) horizontally and 4(Δ) vertically. The effect of strabismus surgery on the amount of proptosis was also evaluated. A total of 56 patients with Graves' ophthalmopathy were included. Of these, 27 had undergone orbital decompression before strabismus surgery and 29 patients had not. The two groups did not differ in terms of the average angle of preoperative horizontal or vertical deviations and the average numbers of muscle that underwent surgery. The postoperative exophthalmometric value decreased an average of 0.4 mm in the decompression group and 0.2 mm in the nondecompression group. The success rate of the surgery was 92.6% in patients who had previous decompression and 93.1% in patients who had not. Previous orbital decompression surgery had no significant effect on the outcomes of strabismus surgery or on postoperative change in proptosis in patients with Graves' ophthalmopathy.

Long-Term Follow-Up of Strabismus Surgery for Patients With Ocular Myasthenia Gravis

Patients with ocular myasthenia gravis (OMG) may develop strabismus and diplopia. We completed a retrospective observational case series to evaluate long-term surgical outcomes in patients with OMG. The medical records of all patients with OMG who underwent strabismus surgery with at least 6 months of postoperative follow-up were reviewed. Nine patients met the study inclusion criteria. The main outcomes, including ocular alignment, number of surgeries, and sensory status were evaluated. Of these patients, initially 2 had horizontal strabismus alone, 3 had vertical strabismus alone, 3 had both vertical and horizontal strabismus, and 1 patient had vertical and torsional strabismus. The length of preoperative stability was 2.0 ± 2.5 years (range: 0.1-8.0 years). The mean preoperative horizontal and vertical deviations were 40.5 ± 32.5 prism diopters (PD; range: 0-90 PD) and 25.6 ± 36.7 PD (range: 0-120 PD), respectively. The average length of the follow-up after the first surgery was 5.7 ± 4.2 years (range: 0.7-10.6 years). Four patients (44%) underwent 2 operations. For patients requiring a second operation, the time to second operation was 2.3 years (range: 0.4-5.0 years). Six patients (67%) were within 10 PD of orthotropia at distance in primary position at the final visit. Five patients (55%) had single vision after their surgeries. Strabismus surgery can achieve good long-term binocular alignment in patients with OMG.

Rectus muscle resection in Graves' ophthalmopathy

In the treatment of Graves' ophthalmopathy, rectus muscle resections generally are avoided because of the concern of reaggravating inflammation and creating excessive extraocular muscle restriction. In patients with large-angle strabismus and in patients with residual strabismus after maximal recession surgery, however, rectus muscle resection may be considered. We report a series of 8 patients with Graves' ophthalmopathy who underwent rectus muscle resections. The records of 270 patients with Graves' ophthalmopathy who had undergone strabismus surgery were retrospectively reviewed. Data from subjects who had undergone rectus muscle resections were collected, including age at surgery, duration of disease, duration of diplopia, previous eye or strabismus surgeries, history of radioactive iodine or corticosteroid treatment, current thyroid medications, current use of corticosteroids, tobacco use, and signs and symptoms used to diagnose Graves' ophthalmopathy. Eight patients (5 females) were identified (mean age, 51.1±17.6 years). Preoperatively, 4 patients had a horizontal deviation and 4 patients had both horizontal and vertical deviations in primary gaze. Mean preoperative horizontal deviation was 27.9(Δ) ± 15.2(Δ) and mean vertical deviation was 6.3(Δ) ± 5.4(Δ). At final follow-up examination, 7 patients were orthotropic in primary gaze; 1 patient had a larger deviation from slippage as the result of a broken suture within the first postoperative week. None of the patients were overcorrected or developed atypical inflammation. In this series, patients with Graves' ophthalmology were successfully treated with the use of rectus muscle resections as part of the surgical plan. Careful ocular motility assessment and patient selection is critical if this option is contemplated.

Surgical treatment of myopic strabismus fixus by modified Yokoyama's surgery

To evaluate the surgical results of modified Yokoyama's procedure for treating myopic strabismus fixus. Retrospective analysis of records of 5 patients (7 eyes) with high myopic strabismus. Pre- and postoperative orthoptic measurements were recorded and analyzed. Anatomic relationships between the muscle cone and globe were analyzed using MRI or CT scan. The surgical procedure is a modification of Yokoyama's technique and medial rectus muscle was also recessed. The average axis length of 7 eyes was 32.62 mm (SD1.84). The mean preoperative horizontal deviation was 82.86 PD (SD 37.62) esotropia and mean vertical deviation was 20 PD (SD 7.91) hypotropia. All patients had marked limitation of elevation and abduction. Displacement of the lateral rectus inferiorly and superior rectus medially was demonstrated in each patient by CT or MRI scan of the orbits and by observation during surgery. After surgery, the supertemporal dislocation of globe was improved. Both the horizontal and vertical deviations decreased significantly, and the abduction and sursumduction motility were also improved gradually. The average follow-up was 5 months, all patients achieved satisfactory results and remained stable. In high myopic patients, if the deviant paths of the LR and SR muscles were demonstrated by MRI or CT scan, the surgical procedure to restore the dislocated globe back into the muscle cone by uniting muscle bellies of the superior rectus and lateral rectus muscles is effective and recommended.

Treatment of “heavy eye syndrome” using simple loop myopexy

To describe our results using a technique modified from that described by Yokoyama in 1991 for treating heavy eye syndrome with high myopia by restoring the normal anatomical relationship of superior rectus and lateral rectus. We perform a simple loop myopexy between superior rectus and lateral rectus without concurrent muscle splitting, medial rectus recession, or scleral fixation. Retrospective analysis of records of all patients with heavy eye syndrome who underwent our modified simple loop myopexy procedure between 2005 and 2008. Pre- and postoperative orthoptic measurements were recorded and analyzed. Surgical complications were noted. Success was deemed patient satisfaction. A total of 5 patients were identified who underwent the procedure for heavy eye syndrome. All patients requested surgery for aesthetically unacceptable strabismus. The mean preoperative horizontal deviation was 13(Delta) esotropia and the mean vertical deviation was 21.8(Delta) hypotropia. The mean postoperative horizontal deviation was 0(Delta) and vertical deviation was 4.4(Delta) hypotropia. Thus there were large improvements in both the vertical (17.4(Delta)) and the horizontal deviations (13(Delta)) following surgery. There were no surgical complications. Follow-up was 6 months. All patients have aesthetically acceptable deviations and have been discharged from care. A simple loop myopexy can be an effective treatment in these difficult patients. We encourage a staged approach to these patients, with simple myopexy being the first line of approach.

Surgery for Strabismus Secondary to Ethmoid Sinus Surgery

To review the outcome of surgery for strabismus due to ethmoid sinus surgery. The series comprised 13 cases, 1 of inferior rectus paresis, 1 of superior oblique paresis, 6 of medial rectus paresis, and 5 of medial rectus muscle palsy due to third nerve palsy. In the cases of paresis of the rectus muscle, resection of the rectus muscles was mainly performed. In the cases of palsy of the rectus muscle, transposition of the extraocular muscle with simultaneous recession of the lateral rectus muscle was performed. The major aim of surgery was to bring both eyes into alignment and to eliminate diplopia in the primary position. The mean preoperative horizontal deviation of 18.1 degrees of exotropia in the paresis cases was reduced to 1.4 degrees of exotropia after surgery. The mean preoperative vertical deviation of 3.8 degrees of hypertropia was reduced to 1.4 degrees of hypertropia postoperatively. The mean preoperative horizontal deviation of 35.6 degrees of exotropia in the palsy cases was reduced to 9.4 degrees of exotropia after surgery. The mean preoperative vertical deviation of 2.0 degrees of hypertropia was increased to 2.6 degrees of hypertropia postoperatively. Postoperatively, diplopia was absent in 11 cases with a slightly compensatory head posture. Surgery for strabismus due to sinus surgery induces improvements in eye position and diplopia.

Strabismus surgery in congenital third nerve palsy

BACKGROUND. Congenital third nerve palsy is a rare condition that usually presents with a large-angle incomitant strabismus and is often associated with ptosis and amblyopia. METHODS. We present the results of strabismus surgery in seven consecutive patients. RESULTS. All the palsies developed before the age of 6 months and the age at surgery ranged from 3 to 24 years. The operations performed included horizontal recti resection/recession (7), supra-placement of the insertions (6), superior oblique weakening (4) and traction sutures (4). The preoperative and postoperative horizontal deviations consisted of seven exotropias and one esotropia due to a combined sixth and partial third nerve palsy. The preoperative vertical deviation consisted of 7 hypotropias and one hypertropia; postoperatively, 5 remained hypotropic and 2 were hypertropic. All patients underwent ptosis surgery. CONCLUSION. Patients with congenital third nerve palsy often achieve reasonable cosmesis with strabismus and ptosis surgery.

An approach to the surgical management of total oculomotor nerve palsy

The goal of the procedure was to keep the eyes of patients with total oculomotor palsy in the straight ahead position by means of surgery on the horizontal and inferior rectus muscles in one session, without involving the superior oblique muscles. Six patients underwent surgery for total oculomotor nerve palsy. All of the surgical procedures were carried out on the muscles of the paralytic eye. We performed hemi-hangback recession of the lateral rectus and resection of the medial rectus for exotropia in all patients. Depending on the magnitude of vertical deviation, the insertions of the horizontal rectus muscles were moved upward, alone or in combination with hemi-hangback recession of the inferior rectus. The mean preoperative horizontal deviation was 66.6 PD. Two years after the operation, the horizontal deviation was measured to be 11.6 PD. Similarly, the mean preoperative vertical deviation of 16 PD decreased to 6.6 PD in two years. This procedure did not disturb normally functioning superior oblique and lateral rectus muscles. Subjectively, all of the patients were satisfied with their alignment two years after the operation. We are of the opinion that this technique is a safe, simple and effective procedure and can be regarded as a first-choice operation in total oculomotor palsy. If one fails to maintain the eye position with this procedure, one can still perform a second operation on the superior oblique muscle, which remains untouched in our procedure.