Secondary Exotropia Research Articles

Ocular Torsional Instability-A Neurodiagnostic Sign of Prenuclear Disease.

Accurate diagnosis of efferent visual system disease in neuro-ophthalmology involves the classification of clinical signs as prenuclear, nuclear, or infranuclear in origin. Over many years, I have come to recognize ocular torsional instability as a clinical sign of prenuclear disease. Retrospective chart review of patients in whom ocular torsional instability was diagnosed using indirect ophthalmoscopy. Twenty patients were diagnosed as having ocular torsional instability (OTI). Eight had neuro-ophthalmologic disease caused by structural injury to prenuclear ocular motor areas. Six of these had structural lesions primarily involving the cerebellum, one had a midbrain glioma, and one had traumatic encephalomalacia. Eight additional patients had infantile strabismus (esotropia in 7, exotropia in 1) associated with various combinations of monocular nasotemporal optokinetic asymmetry, latent nystagmus, and dissociated vertical divergence (DVD), indicating prenuclear involvement of subcortical visuovestibular pathways within the brain. Three additional patients presented with intermittent exotropia with DVD signifying early onset, while 2 had acquired esotropia that was noninfantile in origin. One had partially accommodative esotropia with bilateral inferior oblique overaction, and one presented with acquired esotropia followed by spontaneous secondary exotropia. OTI provides a useful clinical sign of prenuclear ocular motor dysfunction. When detected in patients without any signs of infantile or early-onset strabismus, OTI signifies the need for neuroimaging to rule out neurovestibular or cerebellar causes of prenuclear disease.

Cytomegalovirus uveitis in HIV-infected people: possible complications

BACKGROUND: Cytomegalovirus uveitis is an AIDS-marker disease. If typical chorioretinal foci associated with cytomegalovirus viremia, inflammatory diseases of cytomegalovirus etiology of other organs are detected, etiotropic treatment and antiretroviral therapy are prescribed. Later on, the patient continues to be monitored by an ophthalmologist.
 AIM: The aim is to identify the structure of complications, the frequency and the timing of their occurrence in cytomegalovirus uveitis in HIV-infected patients, the relationship with the treatment.
 MATERIALS AND METHODS: The study was performed at the St. Petersburg Center for the Prevention and Control of AIDS and Infectious Diseases and the Department of Ophthalmology of the North-Western State Medical University named after I.I. Mechnikov. The study group consisted of 66 patients (97 eyes).
 RESULTS: The development of complications of the disease was detected in 86.6% of patients. In patients, following complications were reported: retinal detachment, complicated cataract, partial optic nerve atrophy, cystoid macular edema, and secondary exotropia.
 CONCLUSION: Cytomegalovirus uveitis in HIV-infected patients has a predominantly complicated course.

Medial Rectus Advancement for Secondary Exotropia

To determine the preoperative characteristics and surgical results after medial rectus advancement in patients with secondary exotropia. Retrospective, interventional case series. Setting: Tertiary Care University Medical Center. PatientPopulation: 221 patients with a diagnosis of secondary exotropia who underwent medial rectus advancement surgery by a single surgeon. Preoperative demographics, exodeviation and motility, intraoperative findings, and postoperative results were recorded. MainOutcomeMeasure: Success of surgery, defined as Esotropia <15 prism diopters (pd) at postoperative week 1, or any deviation of <8 pd at postoperative month 2 (POM2). A total of 98 patients underwent unilateral medial rectus advancement (UMRadv), 89 underwent UMRadv with lateral rectus recession (LRc), and 34 underwent bilateral medial rectus advancement (BMRadv). POM2 success rates were 66.7% in UMRadv patients, 62.1% in UMRadv+ LRc, and 56% in BMRadv. A total of 117 patients had preoperative adduction deficits, which were significantly associated with the finding of an intraoperative stretched scar (P < .001). Larger preoperative duction deficits were associated with larger stretched scars (P < .001). At POM2, the mean effect of surgery (pd of correction/mm) was 2.3 ± 1.4 pd/mm for UMRadv, 2.5 ± 0.8 pd/mm for UMRadv+ LRc, and 2.8 ± 1.1 pd/mm for BMRadv. Patients with a stretched scar had significantly less correction per millimeter (2.2 ± 1.2 pd/mm) compared with those without (2.6 ± 1.2 pd/mm, P < .001). A total of 38.6% of patients experienced exodrift greater than 10 pd. Exodrift was significantly larger in the BMRadv group (P < .005). These results provide guidance for surgical correction based on preoperative deviation and ductions. Adduction deficits indicate a stretched scar, which must be treated with resection and advancement of the medial rectus. A larger amount of surgery is needed in patients with a stretched scar. Exodrift is common, and therefore aiming for approximately 10 pd of overcorrection at postoperative week 1 can improve final outcomes. Medial rectus advancement results in successful surgical results at POM2 for secondary exotropia.

Хирургическое лечение вторичной экзотропии у пациентов послепроведения эписклерального пломбирования

Хирургическое лечение вторичной экзотропии у пациентов послепроведения эписклерального пломбирования

Хирургия вторичной рестриктивной экзотропии в исходе эписклерального пломбирования

Хирургия вторичной рестриктивной экзотропии в исходе эписклерального пломбирования

Secondary exotropia following H1N1 viral infection (‘swine’ influenza)

The BIOJ is the official journal of the British and Irish Orthoptic Society. The BIOS was founded in 1937. BIOS is a professional and educational body for the UK and Republic of Ireland representing orthoptists. Orthoptics is a world-wide profession, and the BIOS is recognised as being a leader in both education and clinical practice. The BIOJ invites submissions relating to original research, review articles, case reports and scientific letters to the editor in areas related to clinical ocular motility, visual function, amblyopia, binocular vision and strabismus. The journal will accept submissions from a wide variety of disciplines, including orthoptists, optometrists, ophthalmologists, and vision technicians, among others.

Alleviating debilitating photophobia and secondary exotropia caused by increased straylight by widening a small posterior capsulotomy

In a patient with complaints of photophobia and an ocular deviation, straylight was found to be increased to 1.61 (log[s]), which is 5 times the normal value. The only relative clinical finding was the edge of a too small posterior capsulotomy. Visual acuity was normal. Six weeks after the posterior capsulotomy was widened to a diameter of 6.0 mm with a neodymium:YAG laser, the symptoms were resolved and the patient was satisfied. Straylight may manifest clinically as complaints of photophobia. Straylight increase, which can be related to slitlamp findings, may lead to an interventional decision. Our clinical decision-making was also guided by straylight measurements and proved to be crucial in resolving the patient's complaints. More study of clinical situations in which straylight measurement can be used is needed.

Reversal of unilateral medial rectus recession and lateral rectus resection for the correction of consecutive exotropia

Background/aims:To evaluate the effectiveness and dose–effect relationship of unilateral medial rectus advancement to the original insertion and lateral rectus recession in the surgical management of consecutive exotropia.Patients/methods:The charts of 62...

The ultrastructural changes of tendon axonal profiles of medial rectus muscles according to duration in patients with intermittent exotropia

The goal of this study was to investigate the ultrastructural changes of tendon axonal profiles of medial recti in patients with intermittent exotropia at different ages. In addition, we compared the patterns of degeneration with those of secondary exotropia over time. Thirteen patients, with different ages, with exotropia who had undergone surgery were included in this study and divided into two groups. Eight patients had intermittent or constant exotropia; their age ranged from 6 to 45 years and they had exotropia since childhood without amblyopia, these patients were assigned to group A. The other five patients with sensory exotropia ranged in age from 15 to 52 years; they did not have exotropia until a visual insult and had poor vision in one eye, these patients were assigned to group B. All patients had the medial recti resected (3-5.5 mm) to obtain tissue samples. All specimens were examined with an electron microscope. Schwann cell degeneration was observed with increased neurofilament density, axonal vacuoles and hydropic swelling of the Schwann cells in two patients less than 10 years of age in group A. The other six patients were more than 10 years of age in group A, and it was not possible to identify the tendon axonal profiles or neural structures in the medial recti specimens of these patients. For group B, all patients had intact proprioceptor structures including Schwann cells. However, the collagen diameter decreased and density increased within the capsule according to the duration of exotropia. Schwann cell degeneration of tendon proprioceptors in the medial rectus might induce the degeneration of proprioceptors in patients with intermittent exotropia over time.

Amblyopia due to inflamed chalazion in a 13‐month‐old infant

Meibomian gland cysts (chalazia) are very common lesions in childhood and are not thought of as visually threatening lesions. A case is reported of dense amblyopia and secondary exotropia resulting from an upper eyelid chalazion.

Was bringt der Refraktionsausgleich bei Strabismus divergens intermittens und dekompensierender Exophorie?

The aim of this study was to investigate the effect of full correction of the retinoscopic measurements done in cycloplegia in two groups of patients with intermittent exotropia (IE) and decompensating exophoria (DE), respectively. 58 patients (n = 29 each of IE and DE) fulfilled the inclusion criteria: retinoscopy in cycloplegia, follow-up of at least 6 weeks, age more than 2.5 years and reliable visual acuity. Exclusion criteria were all forms of secondary and constant exotropia, A-V incomitance of high amount and eyes with amblyopia (visual acuity in far distance < 0.5). The age median of refractometry was not higher in patients with IE compared to those with DE: 7.4 (3.10; 47.8) vs. 7.3 (3.8; 40.11) years, p = 0.33. Glasses were prescribed in any case of myopia and astigmatism as well as in hyperopia of > + 0.5 dpt. Mean refraction of both eyes (mean value of spherical equivalent of both eyes) was higher for IE compared to DE: 0.7 +/- 1.8 (- 5.13; + 4.75) vs. 0.1 +/- 1.7 (- 5.25; + 2.5) dpt, p = 0.9. Visual acuity improved in both groups significantly: median of visual acuity in IE: 0.9 (0.3; 1.25) vs. 1.1 (0.5; 1.25), p = 0.02; in DE: 1.0 (0.4: 1.25) vs. 1.0 (0.6; 1.25), p = 0.03. Considering only patients aged over 7 years the difference stayed significant only in the group of DE: IE: median 1.0 (0.5; 1.25) to 1.0 (0.5; 1.25), p = 0.2; DE: median 1.0 (0.8; 1.25 to 1.0 (0.8; 1.25): visual acuity was nearly always 1.0 and better, p = 0.009. In hyperopic patients a significant improvement of visual acuity could be seen: in IE from median 0.9 (0.3; 1.25) to 1.1 (0.5; 1.25), p = 0.02 , in DE visual acuity: median 1.0 (0.4; 1.25) to 1.1 (0.6: 1.25), p = 0.02, as well as stereoacuity improved significantly: median 60 (30; 240)'' vs. 60 (15; 240)'', p = 0.03. In patients aged over 7 years the improvement was no longer significant in IE: p = 0.7, but stayed significant in DE: p = 0.03. There was no significant change of the angle deviation in both groups. According to the results of this study, full correction of refractive errors in IE and DE leads to an improvement of the visual acuity mainly due to correction of myopia and astigmatism, but not to a better compensation of the angle deviation.

Long-term results of botulinum toxin in consecutive and secondary exotropia: Outcome in patients initially treated with botulinum toxin

Introduction: Long-term ocular alignment can be difficult to achieve in patients with consecutive and secondary (sensory) exotropia, and botulinum neurotoxin A (BTXA) is a recognized alternative to surgery in this group. Patients and Methods: We reviewed the results of 44 patients aged 15 to 77 years (mean 31 years) who underwent their first BTXA injections from 1989 to 1990. In 30% of cases the choice of toxin treatment was made by the patient. In the remainder BTXA was recommended by the clinician to assess the risk of postoperative diplopia. Thirty-three patients (75%) were consecutively exotropic and 68% of patients had had previous strabismus surgery. The mean preinjection deviation was 41 Δ of exotropia (range 12 to 85 Δ exotropia) and the minimum mean angle change after 1 injection was 27 Δ (range 0 to 57 Δ). The average number of injections was 3 (range 1 to 17). Results: Of the patient group, 59% went on to strabismus surgery, 14% continued to attend for maintenance treatment, and 9% were discharged with a small, stable deviation. The remainder were either followed up elsewhere or failed to reattend. Conclusions: Botulinum toxin appears to be a satisfactory treatment for constant exotropia in patients at risk of postoperative diplopia who have undergone multiple operations but, because more than half the group went on to surgery, surgery as a first therapy may be preferable in uncomplicated cases.

Large-angle exotropia corrected by intraoperative botulinum toxin A and monocular recession resection surgery

Purpose: Surgical correction of large-angle exotropia, greater than 70 PD, traditionally requires operating on three or four horizontal muscles. However, in secondary exotropia from monocular visual loss, it is advisable to operate only on the eye with poor vision. We used intraoperative botulinum toxin as an adjunct to the monocular recession-resection procedure for large-angle sensory exotropia, therefore operating only on the visually impaired eye. Methods: Three patients underwent monocular recession (10 mm) and resection (10 mm) along with intraoperative botulinum toxin A injection of 10 units into the recessed muscle. All had desired cosmetic repair of long-standing large-angle exotropia (range 100 to 110 PD) with amblyopia and vision worse than 20 200 in the deviated eye. Results: Within 4 days after operation all patients demonstrated maximal paresis of the lateral rectus muscle. This lasted 8 to 12 weeks and resulted in stable orthotropia at 2.5 years in case 1 and stable 8 PD exotropia at 4 years in case 2. The third case demonstrated a stable 18 PD exotropia by 7 months with a satisfactory cosmetic result. Conclusion: This technique provides an alternative for the surgical correction of large-angle exotropia by operating only on two horizontal muscles. In sensory exotropia it also avoids subjecting a normal eye to an operative risk.

The long-term use of botulinum toxin for adult strabismus.

To characterize patients choosing repeated botulinum toxin injection as a treatment for their strabismus, and assess their demand for it over time (up to 8 years). Patients who had undergone at least eight injections were identified and their clinical records analyzed for diagnosis, demographic details, and demand for toxin injections with time. To establish any predictive variables, the details for these cases were compared with those of matched controls who had undergone fewer injections. Lastly, a questionnaire was mailed to research patients' views as to the indications and preferences for regular toxin injection as a method of treatment. Ninety-five patients were identified (34 men, 61 women; median age 37 years), of whom 35 had consecutive exotropia and 16 had secondary exotropia. Other diagnoses represented were residual and primary deviations, restrictive exotropias, and oscillopsias. A trend of fewer injections over the attendance period was seen, and the only complication observed was upper lid ptosis in 1% of injections. Cases exhibited similar demographic composition to matched controls, but were more likely to have consecutive exotropia or secondary esotropia as a diagnosis. Univariate analysis showed evidence (p < 0.001) of an association between the number of previous operations and the odds of being a case. No evidence was found that cases and controls lived at differing distances from our hospital. The questionnaire found that 71% of patients stated appearance as the prime reason for seeking treatment, and 37% stated simplicity of toxin therapy as their reason for reattendance. Twenty-six percent of the patients were disillusioned with the results of previous surgery and preferred toxin therapy as a means of controlling their symptoms. Botulinum toxin injection is an appropriate long-term treatment for some strabismus patients who choose not to undergo further surgery. A trend toward fewer injections with time was observed, and no adverse effects were associated with long-term treatment.

Secondary Exotropia

Secondary Exotropia

Surgical indication and results in exotropia with divergence excess

4 patients with primary exotropia of divergent excess type and 6 patients suffering from secondary exotropia and raised AC/A ratio have been operated with combined external rectus recession interal rectus 'Fadenoperation' and, if necessary, internal rectus resection. In all patients, the far-/near angle difference has been diminished, and in most of them microstrabism was achieved. Lateral gaze incomitance or a significant reduction of the motility of the globe did not occur. Thus, this kind of operation can be recommended for both groups of patients.

Photo-Induced Convulsion After Using the Translid Binocular Interactor

A 12-year-old boy with small-angle secondary exotropia and minimal amblyopia experienced photo-induced epilepsy after using the Translid Binocular Interactor, a device designed to treat several of the motor and sensory abnormalities of the eyes alternately with a bright flash at 10 cps. Whether or not the device is effective, it is potentially dangerous to susceptible individuals.

Postoperative Exotropia

One hundred fifty-four cases of infantile esotropia and acquired esotropia surgically treated before the age of seven were followed for a minimum of five years. We found 44% of infantile esotropia and 60% of acquired esotropia were converted to phoria with 20% having postoperative exotropia. Eight to 10 years of age seemed to be the turning point from esotropia to exotropia. Spontaneous decrease of accommodative convergence with age seemed to be the most important causative factor in relation to secondary exotropia. Long-term follow-up revealed the residual angle of deviation decreased with time and undercorrected esotropia resolved spontaneously. Therefore, it is the responsibility of the surgeon to encourage his patients to return regularly for follow-up visits even ten years after surgery for possible spontaneous change of deviation.

The Surgical Treatment of Overcorrected Esotropia

The medical records of 33 consecutive patients who developed secondary exotropia following surgery for esotropia were reviewed. Only six patients (18%) had normal medial rectus function. Lateral rectus recession proved to be an excellent procudure for correcting the deviation in these patients, provided the surgery was limited to the eye with the narrower palpebral fissure. Twenty-seven patients (82%) exhibited limitation of adduction secondary to medial rectus underaction. Of these patients, 75% were successfully corrected following a 12 mm advancement and resection of the underacting medial rectus muscle. The details of the surgical technique performed are discussed.