Resolution Of Diplopia Research Articles

Management of persistent diplopia after surgical repair of orbital fractures

To present the results of management of patients with persistent diplopia after orbital reconstructive surgery with respect to the type of ocular motility impairment pattern. All patients referred during a 2-year period because of persistent diplopia after surgical repair of orbital fracture were categorized according to the degree and pattern of ocular motility impairment on the basis of orthoptic examination 3-4 weeks postoperatively. Patients were followed for a mean period of 10.5 months (range, 6-12 months), during which adequate treatment was implemented. A total of 52 patients were included in the study (45 males; mean age, 41.8 ± 16.6 years). Most could be divided into 1 of 4 groups according to the type of ocular motility impairment. The follow-up orthoptic examination revealed resolution of diplopia in 9 patients (15%) and persistent but unbothersome diplopia in 26 (43.4%). Significant diplopia was treated conservatively in 3 patients (5%) and with strabismus surgery in 14 (23.3%) cases. The results of this study indicate that in most cases of persistent diplopia after reconstructive surgery for orbital fractures, symptoms resolve over time without treatment; nevertheless, strabismus surgery is unavoidable in some cases.

Comparison of inferior oblique myectomy to recession for the treatment of superior oblique palsy

PurposeTo compare inferior oblique (IO) myectomy with recession for the treatment of superior oblique (SO) palsy.MethodsA retrospective review of medical records identified all patients with SO palsy who underwent IO...

Endoscopic Transcaruncular Repair of Large Medial Orbital Wall Fractures Near the Orbital Apex

To study the suitability of an endoscopic transcaruncular approach (ETA) for repair of large medial orbital wall fractures (MOWFs) near the orbital apex. A retrospective, noncomparative case series with description of the surgical technique. Ninety-three consecutive patients (93 orbits) with large isolated MOWFs near the orbital apex. The isolated MOWFs were determined by computed tomography (CT) scans of the orbit in all patients. All patients underwent fracture repair by an ETA, and the vertical and horizontal dimensions of the defects were measured during surgery. Porous polyethylene sheets (1.0 mm thick) were used to repair the bony defects. Patients were followed for 6 to 15 months. Size of vertical and horizontal fracture defects, rate of complete repair of the fracture defects, correction of enophthalmos, resolution of diplopia, and complications 6 months after surgery. All surgeries were completed uneventfully. The mean postoperative follow-up time was 9.7 ± 3.0 months. Under direct endoscopic visualization, all entrapped and herniated orbital contents were released and reposited, the entire boundary of the fractures were exposed adequately, and the implants were placed to overlie all edges of the fracture stably in all cases. The vertical and horizontal fracture defects measured during surgeries ranged from 16 to 30 mm and from 25 to 34 mm, respectively. Six months after surgery, complete reconstruction of the bony defects was demonstrated by orbital CT scans, and symmetry of the both eyes was acquired in 92 of 93 patients (98.9%). Of 30 patients with significant preoperative enophthalmos of more than 2 mm, 29 (96.7%) were corrected, with a mean improvement of 3.37 ± 0.77 mm. Diplopia within the 30° visual field of the gaze was resolved in 40 of 43 patients (93.0%). Three patients (7.0%) had residual diplopia on medial gaze because of presumed paralysis of the medial rectus muscle. Intraorbital hemorrhage occurred in 1 patient the day after surgery and resolved with conservative treatment. The ETA seems to be a useful method for recovery of the normal anatomic features of the orbits for patients with large MOWFs near the orbital apex.

Endoscopic Orbital Decompression: When and How?

Objective: 1) Identify acute and chronic indications for orbital and/or optic nerve decompression. 2) Review known techniques for endoscopic orbital decompression. 3) Evaluate the necessity to include inferior orbital wall/orbital floor. 4) Compare and contrast the endoscopic technique in comparison to various open methods. Method: Retrospective review of all patients that underwent endoscopic orbital decompression procedures between 2009 and 2011. Data analysis included review of perioperative clinical findings, operative technical details, radiology data, and outcomes. Results: A total of 15 orbital decompressions were performed. All patients underwent endoscopic medial orbital wall decompression, 2 included the orbital floor. The majority of the patients had allergic fungal sinusitis as their primary diagnosis for surgical indication (n = 7, 47%). Neoplasms (n = 5, 33%) and Graves disease (n = 3, 20%) were the remaining diagnoses. Restricted ocular motility, proptosis, and diplopia were the most common presentations indicating surgery (n = 13, 11 and 8, respectively). Resolution of diplopia was observed in all patients, but delayed in Graves patients (2-3 months). Proptosis improved in 7 patients (64%), without any significant difference among those including orbital floor. Conclusion: The endoscopic technique for orbital decompression is a safe and less invasive alternative to currently used open approaches. Sufficient medial wall decompression may yield sufficient outcomes, precluding the need for including the orbital floor. Further objective outcomes data is needed to compare proptosis among various modes of endoscopic decompression techniques.

Abducens Nerve Palsy Associated With Pseudomeningocele After Lumbar Disc Surgery

Clinical case report and review of the literature. To highlight the importance of including cerebrospinal fluid leak and pseudomeningocele in the differential diagnosis in a patient presenting with diplopia due to abducens palsy after spine surgery and to highlight the possibility of cure after successful surgical repair of the dural defect. Abducens nerve palsy after spine surgery is extremely rare, with only 3 reported cases in the literature. We report the first case of abducens nerve palsy associated with a clinically evident pseudomeningocele, which was completely cured by successful repair of the dural defect. A 53-year-old male patient with diabetes presented 6 weeks after lumbar disc surgery with persistent headache, a fluctuant swelling at the operated site, and diplopia secondary to left abducens nerve palsy. Clinical examination revealed a left abducens nerve palsy and magnetic resonance imaging showed a pseudomeningocele due to dural tear at L4-L5. He underwent exploration, and the dural defect was repaired using 6-0 Vicryl and reinforced with a fibrin sealant. After dural closure, pseudomeningocele and headache resolved completely and diplopia improved partially. At 4-week follow-up, there was complete resolution of diplopia. Clinical examination showed full recovery of the lateral rectus function, indicating resolution of the abducens palsy. Magnetic resonance imaging showed complete resolution of pseudomeningocele. Although uncommon, abducens nerve palsy after cerebrospinal fluid leak should be considered in the differential diagnosis of diplopia developing in a patient who has undergone spine surgery. After confirmation of pseudomeningocele radiologically, early surgical intervention with repair of the dural defect can result in complete recovery of the abducens nerve palsy.

Prisms are Effective in Resolving Diplopia from Incomitant, Large, and Combined Strabismus

To assess the effectiveness of prisms in the management of diplopia in patients with incomitant, large, and combined strabismus. Data were collected retrospectively from the medical records of 64 patients who were prescribed prisms for symptomatic diplopia due to restrictive strabismus. The main outcome measure was resolution of diplopia (diplopia score 1 or 2). Data on the number of patients who continued wearing prisms versus those who opted for surgery were derived based on follow-up records. Among 64 patients, 72% of patients reported complete or partial resolution of diplopia after prism use. In patients who were prescribed =10 PD (n=18) and those with oblique prisms (n=18), 67% and 50%, respectively, reported resolution of diplopia. More patients with vertical prism reported improvement in double vision symptoms (83%) than those who were prescribed horizontal prism (70%, p=0.04). During follow-up, 73% of the cohort continued using prisms while 23% of patients opted for strabismus surgery. Prisms are an effective modality and should be considered in the initial or interim management of patients with diplopia from complex ocular misalignments.

Effectiveness of Prisms in the Management of Diplopia in Patients Due to Diverse Etiologies

To study the effectiveness of prisms in the management of diplopia from different etiologies and over a broad range of ocular misalignment. In this retrospective cohort study, resolution of diplopia in 94 patients who were prescribed prisms was studied. Among 94 patients, 88% reported complete or partial resolution of double vision (95% confidence interval: 84.1% to 95.6%) with highest improvement noted in the divergence insufficiency and skew deviation group (100%) compared to 64% improvement noted in patients with convergence insufficiency. More than 85% of patients who were prescribed greater than 10 diopters of prism and those with oblique prism prescriptions also reported resolution of diplopia. Eighty-nine percent of the cohort continued with prism use and 11% opted for strabismus surgery. In this study, prisms were effective in alleviation of diplopia over a broad range and for different etiologies of double vision.

Does unintentional macular translocation after retinal detachment repair influence visual outcome? Response

We thank Lee et al. for their insightful comments regarding our paper, which explored the phenomenon of macular translocation after retinal detachment repair.1 It is indeed notable that only three of our patients complained of postoperative vertical diplopia despite objective evidence of translocation on fundus autofluorescence imaging. It is not clear as to why some patients with macular translocation are symptomatic and others are not. The degree of foveal displacement and individual variations in vertical fusional vergence are likely factors. In our small series, the postoperative best-corrected visual acuity (BCVA) was worse in those patients who were symptomatic. Fusional vergence was not measured, and the BCVA in the fellow eyes was 6/6 or better in all cases. Of note, in the study by Shiragami et al., none of the 27 patients with proven macular translocation were symptomatic with diplopia.2 Lee et al. correctly observe that the extent of displacement is often not uniform within the macula, and propose that retinal stretch rather than simple displacement may be responsible. This may partially account for the lack of complete symptom relief with prismatic correction; however, retinal torsion may also be involved as fixation at the optic disc allows the retina to rotate inferiorly rather than simple vertical displacement. Of the three patients in our series who were symptomatic, patient 3 had resolution of diplopia at final review and no longer required prismatic correction. Finally, the possible significance of suboptimal face-down positioning postoperatively is raised as a contributing factor to macular translocation. We echo the observations of Shiragami et al. that despite the orders for face-down positioning, this may not actually be achieved in the immediate period after surgery. For example, a patient may be taken from theatre to recovery in a (semi)-supine position before being sat up and then transferred to the ward, where positioning is then enforced. We suspect that this occurred in our five cases. Therefore, we have advocated surgeon-supervised face-down positioning on the operating table to ensure that this is achieved promptly and correctly. We feel that this minimizes the risk of inadvertent translocation, and we are examining this prospectively with postoperative autofluorescence imaging.

Cavernous Malformation of the Trochlear Nerve: Case Report and Review of the Literature on Cranial Nerve Cavernomas

Cavernous malformations (CMs) arising intrinsically to the cisternal segment of the trochlear nerve are extremely rare. This case of a trochlear nerve cavernous angioma is the third to be reported in the neurosurgical literature and the first to be resected by a middle fossa approach. The authors present a case of a 31-year-old woman with progressive left-sided headache and left hemisensory symptoms, whose magnetic resonance imaging showed a solid enhancing tumor in the left ambient cistern at the level of the midbrain-pontine junction causing significant brainstem compression. Intraoperatively, a left trochlear nerve cavernous angioma circumferentially enveloping the nerve was visualized. The angioma was microsurgically resected by a middle fossa approach under frameless stereotactic guidance. Gross total resection of the intrinsic trochlear nerve lesion was achieved, although the trochlear nerve could not be preserved intact. CMs should be considered in a possible differential diagnosis of cisternal trochlear nerve tumors. Surgical resection remains the standard of care, and is indicated for relief of compressive symptoms and prevention of future bleeds. Postoperative diplopia often persists; however, resolution of diplopia reported in the literature can be attributed to either regeneration after direct surgical repair of the sacrificed nerve or a spontaneous adaptation over time.

Bilateral multiple extraocular muscle metastasis from breast carcinoma

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

Orbital Floor Fracture Reconstruction Using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction Using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft

Atypical presentation of an unusual foreign body

A 14-year-old boy presented with intractable diplopia for 10 days following an assault. A thorough history revealed that he was unaware of any penetrating injury. However, imaging demonstrated a radiolucent foreign body between the globe and the orbital floor. On surgical exploration, it was found to be the proximal part of a ball point pen. Its removal resulted in complete resolution of diplopia. Thorough clinical and radiological examination is recommended when a foreign body is suspected in pediatric patients. Prompt diagnosis will aid in early intervention and prevention of long-term complications.

Augmented vertical rectus transposition surgery with single posterior fixation suture: Modification of Foster technique

To describe a modification of the lateral posterior fixation augmentation suture of the vertical rectus muscles that is proposed to enhance the abducting vector while balancing the vertical vectors, therefore limiting stress on the sclera and preventing vertical deviations. Full tendon temporal transposition of the vertical rectus muscles was performed on 5 patients with Duane retraction syndrome and 5 with sixth (abducens) nerve palsy. Augmentation was created by the use of a single lateral fixation suture of 5-0 polyester that incorporated the muscle bellies of both vertical muscles. The lateral rectus muscle was disinserted and attached to the lateral orbital wall in 4 of the patients with Duane syndrome. Four of 5 patients with Duane syndrome and 4 of 5 patients with abducens nerve palsy had successful horizontal alignment, defined as reduction or elimination of head turn, a deviation < or =10(Delta), and resolution of diplopia. Patients with Duane syndrome had improved adduction, elimination of co-contraction, and decreased torticollis. Patients with abducens nerve palsy were noted to have a reduction of esotropia with improved abduction. The modified technique limits stress on the scleral portion of the lateral fixation suture; the opposing vertical vectors are transmitted to the opposite vertical rectus muscle. Patients exhibited improved abduction, adduction, torticollis, and range of single binocular vision with a low risk of vertical deviations induced by surgery. Complications included repeat strabismus surgery (2 cases) and scleral perforation (1 case). A vertical deviation of 3(Delta) developed in 1 patient.

Lateral rectus restriction secondary to traumatic orbital exostosis

Bony exostoses can occur at the site of a fracture but are rare in facial bones. We report a case of lateral rectus restriction secondary to a traumatic exostosis in the lateral orbital wall with resolution of diplopia after surgical removal of the lesion. Although orbital masses may cause extraocular muscle restriction, to our knowledge, restriction secondary to an exostosis has not been previously reported. A bony exostosis should therefore be included in the differential diagnosis of mechanical restriction of extraocular muscle movement, and surgical treatment is recommended in symptomatic patients.

Gradenigo Syndrome

Gradenigo Syndrome

Comparison of Orbital Fracture Repair Performed Within 14 Days Versus 15 to 29 Days After Trauma

To examine whether orbital floor and/or medial wall fracture repair delayed for 15 to 29 days is as effective as early surgery. A retrospective review is reported comparing outcomes of early fracture repairs (performed 1-14 days after trauma) to delayed fracture repairs (performed 15-29 days after trauma). Ocular motility, diplopia, and time to resolution of diplopia postoperatively are the main endpoints. Fifty-eight patients were included in the study: 36 underwent early fracture repair (average 9 days after trauma) and 22 underwent delayed fracture repair (average 19 days after trauma). Ocular motility was equivalent in both groups, both before and after surgery. Patient reports of diplopia and frequency of strabisumus surgery were also equivalent in both groups. The time to resolution or stability of diplopia postoperatively is independent of the time to surgery within the first 29 days after trauma. Although 14 days after trauma is commonly cited as a timeline target for orbital blowout repair, these data show that effective fracture repair can be performed up to 29 days after trauma. Patients with improving diplopia and at low risk for enophthalmos can therefore be observed for 3 to 4 weeks prior to undergoing surgery. This may help prevent unnecessary surgery in some cases. Fourteen days need not be considered a deadline for orbital floor and/or medial wall fracture repair.

C-modified osteotomy for bilateral advancement of the orbital rim in Graveś orbitopathy: a technical note

The authors present a modification of the classical three-wall orbital decompression for the treatment of Graves’ orbitopathy. It consists of two ‘C’ osteotomies for the bilateral projection of the superolateral, lateral and inferolateral orbital rims, associated with the removal of the lateral orbital walls. This technique is performed following a coronal approach. Ultrasound cutting instruments were used for the osteotomies. They avoided lesion of surrounding soft tissues, such as the duramater and the periorbital tissues. Stabilization of the advanced structure was achieved by interposition of autologous bone graft obtained from the outer cortex of the calvaria. An extreme advancement of the orbital rim with resolution of diplopia, ocular pain and eyelid incompetence was obtained. Using this procedure, a good functional and aesthetic outcome was achieved.

Surgical Management of Traumatic Strabismus after Combat-Related Injury

Traumatic strabismus may result from orbital or head injury (closed or open). Patients may have other complex injuries that delay diagnosis and treatment. Twelve consecutive adult patients with persistent (> 3 month) strabismus after combat-related head, orbital, or eye trauma underwent strabismus surgery on one or both eyes. The main outcome measures were ocular alignment and diplopia resolution at least 6 months postoperatively. Seven of 12 patients (58%) had traumatic vision loss (< 20/200) in one eye in addition to the traumatic strabismus. Strabismus procedures were complicated intraoperatively by previous ocular and orbital surgery in the majority of patients. One patient required an additional procedure to obtain a satisfactory result, and all patients achieved resolution of diplopia and/or cosmetic improvement 6 months postoperatively. Acceptable outcomes at 6 months may be obtained by using customary amounts of muscle recession and resection both horizontally and vertically.

Resolution of diplopia with late treatment of post-dural puncture headache and intracranial hypotension

Resolution of diplopia with late treatment of post-dural puncture headache and intracranial hypotension