Restrictive Strabismus Research Articles

SAT-500 Response to Tocilizumab Retreatment in Refractory Thyroid Eye Disease

Background: The current standard of care for moderate to severe thyroid eye disease (TED) is intravenous methylprednisolone (IVMP), though alternative immunosuppressive options are emerging. In a recent randomized trial, Tocilizumab (TCZ), an anti-IL-6 receptor antibody, demonstrated improved efficacy for corticosteroid-resistant TED compared to placebo. Clinical response to TCZ retreatment, however, has not been previously reported.Clinical case: A 64-year old man presented with progressive diplopia, eyelid retraction and edema and retrobulbar pain. Initial labs revealed TSH 0.221 uIU/mL, free thyroxine (FT4) 1.11 ng/dL, total T3 172 ng/dL and a thyroid stimulating immunoglobulin (TSI) index of 329 (normal < 140). The patient was a former cigarette smoker who had recently transitioned to e-cigarettes. He was treated with 12 weeks of IVMP with improvement in ocular redness and swelling. Three months following completion of treatment, he presented with worsening left sided proptosis, restrictive strabismus, and compressive optic neuropathy (CON) evidenced by deteriorating central acuity and color vision. He underwent urgent surgical decompression for CON with full restoration of visual acuity. He then received a second 12-week course of IVMP with concomitant orbital radiation. Of note, his hyperthyroidism was well controlled with methimazole. Two months after his second IVMP course, he had a third flare of ophthalmic symptoms. He was then treated with TCZ 8 mg/kg (800mg) IV monthly for six months. The patient’s Clinical Activity Score (CAS) improved from 4 to 2 and TSI index decreased from 610 to 92 (normal). He had significant improvement in periorbital edema, caruncle/plica swelling, and conjunctival injection. However, ten months following completion of the TCZ course he again complained of worsening diplopia and left proptosis. Of note, relapse of his TED symptoms was preceded by an increase in TSI from 92 to 300 two months prior. Orbital CT demonstrated progression of left orbitopathy and increased orbital apex crowding. Following these CT findings he was restarted on TCZ, of which he has now completed 5 additional infusions. His CAS has improved from 3 to 2 and TSI index has decreased from 284 to 100.Conclusion: This is the first reported case of response to successive courses of TCZ in relapsing, severe, corticosteroid-resistant TED. TCZ can be an effective option for refractory TED though retreatment may be necessary for recurrent inflammation. Further study of TCZ is required to determine its role in relapsing TED and the optimal duration of therapy needed.

Current trends of strabismus surgery in a tertiary hospital

Abstract Objective to analyze the strabismus surgeries and the outcomes during a year and a half in a tertiary hospital. Material and methods a retrospective study of patients who underwent strabismus surgery. The mean age, sex, diagnosis, diplopia, surgery, anesthesia, adjustable sutures, results, reoperations and follow-time from surgery were analyzed. A good outcome was considered when the final horizontal deviation was less than 10 prism diopters (pd) and the vertical deviation, less than 5 pd without diplopia. Results a total of 153 cases were operated on, mean age: 43.14 ± 25.58 years (61.4%: women). The 74.5% was ≥18 years (33.33%≥ 60). The 51% had diplopia. The most frequent deviation was horizontal: 83.6%. The most frequent diagnosis was cranial nerve palsies: 32% (VI nerve: 12.4%), restrictive strabismus: 7.2%, and the aged related distance esotropia: 6.5%. Adjustable sutures were used in the 19.7% and topical anesthesia in 65.4%. The 79.2% had good outcomes at the end of follow-up. Reoperations were needed in 25.5%. Follow-up evolution time was 11.87 months ± 6.5. The sex female (P = 0.012) and the oblique superior surgery (P = 0.017) were associated to a bad result. Conclusion the adult strabismus surgery was three times more frequent than the children strabismus surgery; the third of the adults that were operated on were ≥ 60 years. The cranial nerve palsies were the most frequent diagnosis. Adjustable sutures were rarely used. The good outcomes were obtained in most of the patients at the end of follow-up.

Study of clinico-etiological profile of patients with paralytic and restrictive strabismus

Incomitant strabismus typically results in intractable diplopia, blepharoptosis, ocular motility disturbance, disturbance in pupil reaction and an unacceptable compensatory head or face posture. A complete clinico etiological profile is necessary for identifying the underlying risk factors and etiology pertaining to paralytic and restrictive strabismus which is imperative in prevention , early detection, managing the etiology and timely recovery in these patients.To study the clinico-etiological profile of patients with paralytic and restrictive strabismus in a tertiary eye hospital. Patients reporting to a tertiary eye hospital in north India and diagnosed with paralytic and restrictive strabismus, over a period of one year , were enrolled in the present study . Patients were subjected to detailed ocular examination and evaluated for ocular motility or related disorders. This included detailed clinical history, ophthalmic examination, orthoptic workup , sensory evaluation, diplopia charting, Hess charting, slit lamp examination and fundus examination . In patients of suspected restricted strabismus, forced duction test was performed. Relevant systemic investigations including blood pressure , blood sugar and lipid profile were carried out . M.R.I orbit was done in every patient. Neuroimaging was advised in those patients where indicated. 48 patients were diagnosed with incomitant strabismus and enrolled in the study. 81.3%were of paralytic strabismus while 18.8 % were of restrictive strabismus. In the group of paralytic strabismus, 43.8 % patients had sixth nerve palsy , 27.1% patients had third nerve palsy , 6.3% patients had fourth nerve palsy and combined nerve palsy patients were 4.2%. Analysing the etiology, out of total patients of paralytic strabismus, 48.7% of cases were idiopathic, 25.6% were post traumatic, 15.4% were due to microvascular causes , 5.1% of cases were due to intracranial anomalies and rest 5.1% were due to inflammatory causes. In restrictive strabismus group, 66.7% were congenital and rest 33.3% were acquired. Our study has reflected the prevalence, distribution , etiological and clinical profile of patients presenting with incomitant strabismus . It is helpful for ophthalmologists and other physicians in guiding diagnosis and evaluation and is useful for proper and timely intervention and timely recovery in these patients.

Multidisciplinary Frontotemporal Orbitozygomatic Craniotomy for Spheno-orbital Meningiomas: Ophthalmic and Orbital Outcomes.

Advances in surgical approaches have improved access for total or near-total resection of spheno-orbital meningiomas (SOM). Herein, the outcomes of multidisciplinary resection and reconstruction of SOM via frontotemporal orbitozygomatic craniotomy at a single institution are evaluated. A retrospective chart review was performed of all patients with SOM who underwent joint neurosurgical and oculofacial plastic resection via frontotemporal orbitozygomatic craniotomy between January 1999 and December 2018. Demographic data, clinical presentation, risk factors for meningioma, radiographic imaging, pathology results, postoperative outcomes, and surgical complications were reviewed. The outcome measures assessed included visual acuity, pupillary function, color vision, ocular motility, visual fields, and proptosis. A total of 48 patients were identified having had multidisciplinary frontotemporal orbitozygomatic craniotomy for SOM of which 43 met inclusion criteria. A mean follow-up period of 23.9 ± 20.4 months (range 1-60) was observed. There were 35 patients who underwent primary resection and 8 patients who had prior surgical resection. The main presenting complaints were proptosis (88%), headache (44%), and reduced vision (12%). Gross total resection was achieved in 15 patients (35%) while near-total or subtotal resection was achieved in the remainder. Histologic analysis revealed World Health Organization grade I meningioma in 72% of tumors, grade II in 23%, and grade III in 5%. Mean visual acuity (Logarithm of the Minimum Angle of Resolution) improved from 0.24 ± 0.46 preoperatively to 0.09 ± 0.13 postoperatively (p = 0.03). Surgery improved proptosis, with a reduction in mean Hertel exophthalmometry from 22.37 ± 3.78 mm to 17.91 ± 3.84 mm (p < 0.001), of which 80% had no residual proptosis or developed subsequent recurrence. Exophthalmic index calculated by radiologic evaluation also improved from a mean preoperative value of 1.32 ± 0.19 to 1.12 ± 0.13 at the 6-month interval after surgery (p < 0.001). Before surgery, 19 (45%) patients had a relative afferent pupillary reaction with improvement in 9 (24%) after surgery. Of the 14 (33%) patients with preoperative ocular motility deficit, 7 (16%) had resolution of ocular motility deficit postoperatively. The most common surgical complications were temporalis muscle atrophy with temporal hollowing (14%), wound infection (7%), neurogenic strabismus secondary to trochlear nerve palsy (5%), restrictive strabismus (5%), and aponeurotic blepharoptosis (5%). Multidisciplinary frontotemporal orbitozygomatic for resection of SOM is a safe and effective means of tumor removal. It can provide improved visual acuity and proptosis metrics, as well as relief of optic neuropathy and ocular motility deficits.

Tendencias actuales de la cirugía de estrabismo en un hospital terciario

ObjectiveTo analyze the strabismus surgeries and the outcomes during a year and a half in a tertiary hospital. Material and methodsA retrospective study of patients who underwent strabismus surgery. The mean age, sex, diagnosis, diplopia, surgery, anesthesia, adjustable sutures, results, reoperations and follow up time from surgery were analyzed. A good outcome was considered when the final horizontal deviation was less than 10prism diopters (pd) and the vertical deviation less than 5pd without diplopia. ResultsA total of 153 cases were operated on, mean age: 43.14 ±25.58years (61.4%: women). 74.5% of patients were ≥18years (33.33% ≥60). Diplopia was present in 51% of patients. The most frequent deviation was horizontal: 83.6%. The most frequent diagnosis was cranial nerve palsies: 32% (VI nerve: 12.4%), restrictive strabismus: 7.2%, and the aged related distance esotropia: 6.5%. Adjustable sutures were used in 19.7% of cases and topical anesthesia in 65.4%. Good outcomes was present in 79.2% of cases at the end of follow-up. Reoperations were needed in 25.5%. Follow-up evolution time was 11.87 months ±6.5. The sex female (P=.012) and the oblique superior surgery (P=.017) were associated with bad outcome. ConclusionThe adult strabismus surgery was three times more frequent than the children strabismus surgery. The third of the adults that were operated on were ≥60 years. The cranial nerve palsies were the most frequent diagnosis. Adjustable sutures were rarely used. Good outcomes were obtained in most of the patients at the end of follow-up.

Adjustable Versus Nonadjustable Sutures in Strabismus Surgery-Who Benefits the Most?

Background: Adjustable sutures have been used in strabismus surgery for more than 40 years, but controversy remains regarding their application. This review sought to analyze studies comparing the efficacy of adjustable sutures (AS) and nonadjustable sutures (NAS) in the treatment of different ocular deviations. Materials and Methods: The PubMed literature database was searched using the keywords ‘adjustable sutures’ and ‘strabismus surgery’, yielding a total of 209 results. Only comparative studies were extracted, and the results were divided into three categories: Adult comitant strabismus, childhood comitant strabismus, and paretic/restrictive strabismus. Results: The search revealed eleven comparative studies on AS versus NAS in adult strabismus, including only one randomized controlled trial. Five of these studies analyzed just the postoperative success rate, three studies analyzed just the reoperation rate, two studies analyzed both the postoperative success and reoperation rates, and one study evaluated achievement of the postoperative target angle. Three of seven studies analyzing postoperative success reported the statically significant superiority of AS over NAS, while four of five studies analyzing reoperation rate indicated a significantly smaller percentage of reoperations with the use of AS. The study covering postoperative target angle as an outcome favored the AS technique. Separately, the search revealed three comparative studies on AS versus NAS in childhood strabismus, one of which reported a statistically significant advantage with AS. Only four comparative studies on AS versus NAS in paretic or restrictive strabismus were found; all showed a tendency for better results with the use of AS but not in a statistically significant fashion. Overall, out of 18 studies analyzed in this review, 17 suggested better clinical results followed the application of AS versus NAS; however, only a minority had statistically significant results. Conclusion: The analysis of available research failed to support AS as the preferable surgery technique over NAS in cases of simple and predictive strabismus. Further research is needed to more precisely determine the group of patients able to benefit the most from AS.

Strabismus and oculomotor disorders induced by injection anesthesia for cataract surgery

To analyze diagnostic and treatment outcomes in patients with strabismus and oculomotor disorders induced by injection anesthesia for cataract surgery. The study included 11 patients (7 women and 4 men) aged 61 to 85 years (the mean age of 66±7.1 years) who complained of diplopia in the early post-op period after cataract phacoemulsification and elastic IOL implantation under retrobulbar anesthesia. Prior to further surgical treatment, all of the patients underwent functional multispiral computer tomography of the orbits. Prismatic spectacle correction was also used independently or in addition to surgical treatment. Eight out of eleven patients underwent one- or two-step surgical treatment (3 and 5 cases, respectively). In 2 patients, hypotropia did not exceed 10 prism diopters, and thus, diplopia could be compensated with prismatic spectacle correction alone. In 5 cases, binocular vision was achieved throughout the whole field of gaze. In 3 cases, surgical treatment enabled elimination of heterotropia in the primary gaze and compensation of diplopia within a radius of 40º from the center of gaze and within the entire horizontal range of eye-movement in the downward gaze. The limitation of ocular mobility decreased from 2.36 to 0.55 points leading to an associated decrease in the area of binocular diplopia - from 98% to 29%. In one case, spectacle occlusion was used. The inferior rectus restriction is the morphological substrate of anatomical and functional changes induced by retrobulbar anesthesia. As treatment options for restrictive vertical strabismus and binocular diplopia, both surgical (extraocular muscle surgery) and optical (prismatic correction, occlusion) methods should be considered.

Current Understanding of the Progression and Management of Thyroid Associated Orbitopathy: A Systematic Review.

Thyroid associated orbitopathy (TAO) is a common diagnosis encountered by ophthalmologists and oculoplastic surgeons. TAO has a varying clinical presentation that can include upper eyelid retraction, restrictive strabismus, proptosis, exposure keratopathy, and optic neuropathy. In this review, we discuss the most recent literature on and the current understanding of the pathophysiology of TAO. We also review available and potential future treatment options for the management of TAO.

The development of inflammatory eye diseases in patients with endocrine ophthalmopathy after the removal of restrictive strabismus

AbstractResearch objectiveIs to show the ways of prevention of corneal complications that patients with endocrine ophthalmopathy (EOP) may have after restrictive strabismus removal.MethodsA patient with an acute keratouveuitis, a purulent helcoma of the left eye against the background of EOP of both eyes after left eye restrictive strabismus removal was examined. The patient underwent biomicroscopic examination with staining solution of fluorescein, beta scanning, anterior segment optical coherence tomography and anti‐inflammatory, antibacterial, keratoprotective treatment was prescribed. There was done bacteriological conjunctival test. Design of the research – case series.ResultsAn important point of intraoperative case management in patients with EOP was to prevent corneal complications. It was related to the duration of surgical intervention, risk of damage to the corneal epithelium during its contact with expander as a result of significant vertical eye rotations during the surgery. We use more frequent irrigation of cornea with normal saline solution or instillation of viskoelastics as keratoprotectors. After surgery, the patient does not have the ability to close the eyelids. It also increases the risk of corneal damage. The cause may be the contact of the cornea with a sterile gauze bandage applied and its non‐moisturizing due to the lack of blinking. In addition, the preoperative hypotropia created protection of the cornea by its contact with the conjunctiva of the lower eyelid. The eye level achieved after the surgery deprives the patient of this “protection”. Therefore there wasn’t applied a gauze bandage but a perforated convex plastic occluder. The cornea is irrigated with keratoprotectors till the ability to close eyelids is reached.ConclusionsSuggested intraoperative and postoperative strategies to manage cases in patients with EOP are the most effective. As long as they allow to reduce all possible corneal complications.

Severe Acquired Restrictive Strabismus Fixus in Patients with Trisomy 21

ABSTRACTAcquired strabismus fixus is a rare form of severe esotropia described most frequently in patients with high axial myopia and infrequently associated with other conditions. Refractive errors, cataracts, and ocular motility disorders are common in patients with trisomy 21. We report two unusual cases of patients with trisomy 21 who developed severe acquired restrictive strabismus fixus. Both patients were successfully treated with medial rectus recession followed by lateral rectus and superior rectus myopexy combined with additional medial rectus weakening, including free tenotomy in one case.

Amniotic membrane in the surgical treatment of post-blepharoplasty diplopia

Two consecutive cases are presented of vertical diplopia after blepharoplasty. They concern two women aged 41 and 63 years with vertical binocular diplopia after bilateral lower blepharoplasty using a trans-conjunctival approach. The diplopia was presented in both cases in the immediate postoperative period, being stable in one of the cases and progressive in the other. With the suspicion of restrictive strabismus, it was decided to explore the affected extra-ocular muscles, eliminate adhesions and coat the muscular bellies with amniotic membrane. Post-blepharoplasty diplopia is an uncommon, but very serious complication, given the expectations of these patients. The current literature reports unsatisfactory results in its management. In this study, it is considered that the muscular covering with amniotic membrane can provide better results in the surgical management of these patients, due to its anti-inflammatory and anti-adherence effect.

Difficult problems in strabismus

To summarize the collective experience of our panel in the management of Difficult Problems in Strabismus in a case-based format. This workshop will address difficult cases strabismus secondary to cranial nerve palsy, restrictive strabismus, prior strabismus surgeries or orbital deformity, to fill a potential knowledge gap for the practicing ophthalmologist.

The role of muscle forces in elite athletes before and after ACL surgery while performing a drop landing task

To report the characteristics of patients with restrictive diplopia following pterygium excision and a successful treatment approach for the strabismus.Retrospective interventional case series.This study was set in a single academic institution and included 15 patients with restrictive diplopia after pterygium excision. Patients with any other reason for strabismus were excluded. Patients were evaluated for deficits with special attention to diplopic measures. The intervention was a combined procedure by a strabismologist and oculoplastic surgeon to correct the diplopia. The primary outcome measurements were subjective and objective improvement of diplopia.Fifteen patients (mean age = 49 years) who developed diplopia after pterygium excision were included. Mean time to diplopia was 6 months. All patients had limited abduction in the previously operated eye causing esotropia in the abductive field (mean deviation = 18 prism diopters). After intervention, all patients were no longer diplopic in primary gaze. In the abductive field, 11 (73%) patients had residual small angle esotropia (mean = 7 prism diopters) in ipsilateral extreme end-gaze only. Only 2 patients required additional surgical intervention for scar tissue removal. No patients underwent medial rectus recession.Restrictive diplopia is a potential complication after pterygium excision, particularly for patients with a history of recurrent pterygia requiring multiple excisions and previous amniotic membrane graft placement with fibrin glue. However, diplopia after pterygium excision in primary position is surgically correctable with scar tissue removal and ocular surface reconstruction, without needing medial rectus recession. Given the high volume of pterygium excision, awareness of postoperative restrictive strabismus and the potential for correction is critical.

Membrana amniótica en el tratamiento quirúrgico de diplopía posblefaroplastia

Two consecutive cases are presented of vertical diplopia after blepharoplasty. They concern two women aged 41 and 63 years with vertical binocular diplopia after bilateral lower blepharoplasty using a trans-conjunctival approach. The diplopia was presented in both cases in the immediate postoperative period, being stable in one of the cases and progressive in the other.With the suspicion of restrictive strabismus, it was decided to explore the affected extra-ocular muscles, eliminate adhesions and coat the muscular bellies with amniotic membrane.Post-blepharoplasty diplopia is an uncommon, but very serious complication, given the expectations of these patients. The current literature reports unsatisfactory results in its management. In this study, it is considered that the muscular covering with amniotic membrane can provide better results in the surgical management of these patients, due to its anti-inflammatory and anti-adherence effect.

Strabismus Is Correlated with Gross Motor Function in Children with Spastic Cerebral Palsy

ABSTRACTPurpose: To investigate the correlation between clinical features of strabismus and motor dysfunction classified according to the Gross Motor Function Classification System (GMFCS) in patients with spastic cerebral palsy (CP).Methods: In this retrospective, cross-sectional study in single tertiary medical center, 62 patients who are diagnosed with spastic CP who had an ophthalmic examination between 2006 and 2014 were included. Only patients with vision sufficient to fixate were included and patients with restrictive or paralytic strabismus were excluded. The types of CP were classified as diplegia, hemiplegia, or quadriplegia for distribution of motor impairment. The GMFCS was used to grade gross motor dysfunction, which was then classified as mild (grade 1, 2 and 3) or severe (grade 4 and 5) motor impairment. Strabismus was investigated in terms of direction, constancy, and deviation angle. The relationship between strabismus characteristics and the level of GMFCS and type of CP were assessed.Results: Thirty-eight and 24 patients had mild or severe motor deficit, respectively. Forty patients had strabismus, which was more frequent in patients with severe motor impairment.(P = .014) Exotropia and esotropia occurred with similar frequency. Constant and large-angle strabismus was frequently observed in patients with severe motor impairment.(P < .005, 0.027) The topographical subtype of CP was not related to clinical features of strabismus.Conclusions: The prevalence of strabismus is higher in severe motor impairment. The constancy and angle of strabismus was related to the severity of motor impairment while the topographical subtype of CP has no significant relationship.

Innovative techniques for the treatment of adult strabismus

Adult strabismus is often characterized by surgical complexity. In recent years, several innovative techniques for the management of complex strabismus have been developed. Strabismus surgeons should understand the indications for various strabismus surgical techniques in the management of these difficult cases. This workshop describes several new surgical techniques to manage complex strabismus, including small-angle incomitant and very large-angle strabismus, torsional diplopia, and restrictive, paralytic, and secondary strabismus. Because strabismus surgery is an ever-evolving field, it is important to continue to refine our surgical armamentarium. Strabismus surgeons may wish to add these techniques to their surgical repertoire for select cases.

SAT-607 "Eye" Spy with My Big Eye: Thyroid Ophthalmopathy Secondary to Hashitoxicosis

Introduction: Hashitoxicosis is the transient hyperthyroid phase of chronic autoimmune thyroiditis, common in children. It is characterised by mild-moderate symptoms of hyperthyroidism, small painless goiter and normal or slightly increased uptake on thyroid scintigraphy. It is differentiated from Graves’ Disease (GD) by its shorter course and absence of thyroid ophthalmopathy (TAO). We present a rare case of TAO associated with Hashitoxicosis in an adult. Case Presentation: A 55 year-old gentleman, with current tobacco use and family history of thyroid disease, presented with complaints of a bulging left eye and double vision for 3-6 months. He endorsed pain and fatigue of eye muscles, and dry eyes. Additionally, he endorsed weight gain, increased appetite, and flat affect. Examination revealed a 5 mm proptosis and restrictive strabismus of the left eye with a normal fundus bilaterally. The thyroid gland was normal to palpation. Laboratory tests revealed a TSH of 0.016 mcIU/ml (normal 0.358-3.800 mcIU/ml), total T3 of 90 ng/dl (normal 60-181 ng/dl) and total T4 8.2 mcg/dl (normal 4.7-13.3 mcg/dl). A TSH receptor antibody (TRAb) was normal (1.35 IU/l, normal <1.75 IU/l), while a thyroid peroxidase (TPO) antibody titre was elevated (5780.7 U/ml, normal <60.1 U/ml), confirming Hashitoxicosis. Thyroid scintigraphy showed normal uptake (4.25% at 4 hours, 24.1% at 24 hours) with a focal photopenic area in the left lower lobe suggesting a non-functioning nodule. A thyroid ultrasound showed mild generalised enlargement of the thyroid gland with hypervascularity and multiple 1 cm hypoechoic solid nodules bilaterally. Magnetic Resonance Imaging (MRI) of the orbit confirmed left sided TAO due to markedly enlarged inferior rectus and mildly enlarged medial and lateral recti. The patient was diagnosed with TAO due to Hashitoxicosis. He is currently awaiting an orbital decompression and strabismus surgery. Discussion: Initial release of preformed thyroid hormones from the inflamed thyroid gland leads to Hashitoxicosis. Traditionally, bilateral TAO with hyperthyroidism is considered pathognomonic for GD. In patients with unilateral TAO, Hashitoxicosis should also be considered. The pathophysiology of TAO due to Hashitoxicosis is not well-understood. Presence of low level TRAb may be implicated, however, more research is required to clarify the natural history of this condition. Current practice suggests that steroids and other immunosuppressive agents such as Rituximab may alleviate symptoms of TAO. Decompression surgery is considered for cases not responding to medical management.

Early Buckle Migration and Restrictive Strabismus after Successful Medical Management of Scleral Buckle Infection

ABSTRACTWe report a case of restrictive strabismus caused by early scleral buckle (SB) migration within 1 month of surgery after successful medical management of SB infection. A 24 year-old man underwent scleral buckling surgery for left eye inferior retinal detachment (RD). A solid silicone buckle element was placed inferiorly along with an encircling silicone band. Two days after surgery, he presented with SB infection. Methicillin resistant Staphylococcus aureus was cultured from the exudate at conjunctival suture sites. Since the retina was well attached and it was only the second postoperative day, it was decided to retain the buckle. SB infection was treated with intravenous cefotaxime and topical fortified cefazolin and successfully eradicated. One month thereafter, anterior SB migration was noted on slit lamp biomicroscopy. Restrictive strabismus and diplopia were also noted. Eventually, SB removal was performed at 2 months. This case report highlights the role of infection and subsequent inflammation as a cause for buckle migration and restrictive strabismus in the early post-operative period. These changes can be seen as early as 1 month after primary surgery and may occur even after successful medical management of the SB infection.

Identification and Correction of Restrictive Strabismus After Pterygium Excision Surgery

To report the characteristics of patients with restrictive diplopia following pterygium excision and a successful treatment approach for the strabismus. Retrospective interventional case series. This study was set in a single academic institution and included 15 patients with restrictive diplopia after pterygium excision. Patients with any other reason for strabismus were excluded. Patients were evaluated for deficits with special attention to diplopic measures. The intervention was a combined procedure by a strabismologist and oculoplastic surgeon to correct the diplopia. The primary outcome measurements were subjective and objective improvement of diplopia. Fifteen patients (mean age= 49 years) who developed diplopia after pterygium excision were included. Mean time to diplopia was 6months. All patients had limited abduction in the previously operated eye causing esotropia in the abductive field (mean deviation= 18 prism diopters). After intervention, all patients were no longer diplopic in primary gaze. In the abductive field, 11 (73%) patients had residual small angle esotropia (mean= 7 prism diopters) in ipsilateral extreme end-gaze only. Only 2 patients required additional surgical intervention for scar tissue removal. No patients underwent medial rectus recession. Restrictive diplopia is a potential complication after pterygium excision, particularly for patients with a history of recurrent pterygia requiring multiple excisions and previous amniotic membrane graftplacement with fibrin glue. However, diplopia after pterygium excision in primary position is surgically correctable with scar tissue removal and ocular surface reconstruction, without needing medial rectus recession. Given the high volume of pterygium excision, awareness of postoperative restrictive strabismus and the potential for correction is critical.

Management of restrictive strabismus

Aim of the study This study aimed to target a special type of strabismus, the restrictive type, with prediction of its problems, diagnostic, management, and results. Patients and methods This is a prospective randomized study performed in Alexandria. The participants of this study were 42 patients having restricted strabismus, with different diagnostic criteria, such as abnormal ocular deviation with the movement of the globe defective and not reaching the midline, abnormal position of the head, forced duction test, and anatomical changes found during surgery. Results The cases of restrictive strabismus included congenital cases including monocular elevation deficit, Brown’s syndrome, congenital fibrosis of extraocular muscles, oculomotor nerve palsy, and long-standing strabismus, especially unilateral presenting in old age. Cases needed specific diagnostic procedure such as forced duction test to be performed preoperatively and intraoperatively, and postoperative results were satisfactory in most cases except cases that underwent previous surgery with muscle resection, aggravating the condition and leading to more restrictions. Conclusion Cases of restrictive strabismus, when properly diagnosed, with special considerations, could arrive at a postoperative satisfactory outcome.