Superior Rectus Research Articles

Superior Rectus Transposition With Medial Rectus Recession Versus Medial Rectus Recession in Esotropic Duane Retraction Syndrome.

To compare the results of augmented superior rectus transposition (with or without medial rectus recession) with simple medial rectus recession in the treatment of patients with esotropic Duane retraction syndrome. This was a prospective, randomized, and interventional comparative study of 20 patients with esotropic type 1 Duane retraction syndrome. Patients were randomly divided into two groups. In the first group (superior rectus transposition group), superior rectus transposition with or without medial rectus recession was performed. In the second group (non-superior rectus transposition group), unilateral medial rectus recession was performed. Each group included 10 patients. Esotropia improved from 20.4 prism diopters (PD) preoperatively to 0.6 PD postoperatively in the superior rectus transposition group and from 22.5 PD preoperatively to 0.9 PD postoperatively in the non-superior rectus transposition group. Face turn improved from 11.5° preoperatively to 0.5° postoperatively in the superior rectus transposition group and from 12° preoperatively to 1.5° postoperatively in the non-superior rectus transposition group. Abduction improved in the superior rectus transposition group from -3.9 preoperatively to -3.1 postoperatively and from -3.9 preoperatively to -3.6 postoperatively in the non-superior rectus transposition group. Vertical deviation developed in two cases in the superior rectus transposition group. Both superior rectus transposition and medial rectus recession are effective in the elimination of esotropia and face turn in patients with esotropic Duane retraction syndrome. Superior rectus transposition is more effective in improving abduction, but it can be complicated by vertical deviation. [J Pediatr Ophthalmol Strabismus. 2020;57(5):309-318.].

Eficacia y complicaciones de las transposiciones musculares en el síndrome de Duane con esotropía

ObjectiveTo study the long-term efficacy and the complications of several transposition techniques for the treatment of Duane syndrome. These included, full vertical rectus transposition, partial vertical rectus transposition, transposition without muscle disinsertion, and superior rectus transposition. Material and methodsA retrospective study of the patients diagnosed with Duane syndrome, and who underwent any of the different transposition techniques associated or not to the medial rectus recession with a follow-up longer than 12 months. A good result was considered a final deviation≤10 prism dioptres (pd) in primary position, anomalous head posture<10°, and an improvement of the abduction without diplopia. ResultsSeven cases were included (6 women, 6 unilateral), and a mean age of 37.71 years. Pre-operative central gaze esotropia of 28±11.68pd decreased to 6±4.62pd at the final visit (P=.009). The anomalous head posture decreased in 6 patients, and the abduction improved one degree from −3.14 to −2.14 (mean). An induced vertical deviation≤8pd was observed in 4 cases. None experienced diplopia at the final visit. The percentage of reoperations was 71.42%. Only 28.57% had a favourable outcome with a single surgery, which increased to 71.42% with further surgeries at the final follow-up. Mean evolution time was 52±31.65 months. ConclusionsVertical rectus transpositions in Duane syndrome with moderate or severe clinical signs have only been effective in a small percentage of the cases. Most of them required further surgeries to resolve the complications or the under-corrections.

Incidental Hamartoma in an elderly patient: a case report

BackgroundNeuromuscular hamartoma is a very rare tumor; with only five cases reported in the orbit. It often occurs in infants and young children and involves large peripheral nerves, but there has been only few reports of occurrence in the orbit and adults.Case presentationThis paper describes a 70-year-old man with an incidental orbital mass detected by an imaging test and who later developed associated symptoms. The mass was diagnosed as neuromuscular hamartoma. Superior rectus muscle recession and inferior rectus muscle resection were performed in the right eye for hypertropia secondary to postoperative inferior rectus muscle palsy. Hypertropia in the right eye and diplopia improved after surgery, and regular follow-up is underway.ConclusionThis is the first case of an incidentally detected orbital mass diagnosed by histologic examination as a neuromuscular hamartoma in an older patient whose proptosis progressed after a long period of inactivity.

Congenital Anomaly of Central Nervous System Associated with Antenatal Coinfection with Cytomegalovirus and Toxoplasma: Clinical Case

Background . The development of central nervous system (CNS) malformations may occur due to antenatal infection. Specific pathomorphological changes in CNS structures require further study. Clinical Case Description . The autopsy morphological study of the brain of a child who had antenatal toxoplasma and cytomegalovirus infections and who died at the age of 2 years was performed. Thickening of the pia mater with cloudy surface due to edema and focal sclerosis, generalized thrombosis of superior sagittal sinus, sinus rectus and sinus transverses, absence of corpus callosum, major commissural fibers, opened third ventricle and vermis of cerebellum agenesia, as well as mixed forms of obstructive hydrocephalus were revealed. Diffuse gliosis with glial cysts in the periventricular zones were revealed at histological examination of the alba. Pseudocysts filled with toxoplasms were identified in the cysts’ wall. Signs of productive vasculitis were noted. Comparison of pathomorphological changes in the brain and internal organs with anamnestic data of the patient (toxoplasma and cytomegalovirus infection during recent pregnancy, brain abnormality of the fetus on the second ultrasound screening at 21–22 weeks of gestation) and the results of histological examination of placenta was carried out to prove the correlation of antenatal infection with the development of brain anomalies. Pathognomonic signs of cytomegalovirus infection and toxoplasmosis were revealed in the placenta: cytomegalic cells, vascular thrombosis, white infarcts, fibrinoid necrosis of basal lamina, placental hypoplasia. Toxoplasmic cysts were detected in chorionic villae stroma, parietal thophoblast, amnion, decidual tissue. Conclusion . Antenatal viral-parasitic infection may be the cause of brain anomalies of the fetus. However, the child had no specific signs of cytomegalovirus infection (such as cytomegalic cells — owl eye cells), even when the placenta had pathomorphological changes typical for this infection. It can be assumed that the development of brain anomaly in this child could be associated with toxoplasma infection.

Visual preservation in congenital orbital fibrosis

ObjectiveCongenital orbital fibrosis (COF) is a nonprogressive, unilateral, congenital process in which variable fibrosis is demonstrated in the orbit, resulting in restrictive strabismus, upper eyelid malposition, and axial displacement of the globe. We present 4 new pediatric cases of COF and discuss factors that impact visual development. We also describe a patient with local compressive optic neuropathy/edema who underwent optic nerve sheath fenestration (ONSF) for visual preservation. DesignLiterature review and retrospective case series. ResultsFour male COF patients (mean age of 11 months) were examined. Two patients presented with decreased ocular motility of the affected eye. Two patients presented with exophthalmos, and one presented with enophthalmos. Two patients presented with ptosis, and one presented with eyelid retraction. Two patients presented with optic nerve atrophy, and one presented with optic nerve edema. Magnetic resonance imaging demonstrated involvement of the superior, medial, and inferior rectus and superior oblique muscles in 3 patients and the lateral rectus and inferior oblique muscles in 2 patients. Three patients underwent orbitotomy. Histology was consistent with fibrosis. Three patients demonstrated amblyopia, and 2 responded to treatment. The patient with optic nerve edema underwent ONSF. At 4 months’ follow-up, the edema had resolved. ConclusionsCOF can present with either anterior or posterior globe displacement. Patients must undergo a complete ophthalmic evaluation to identify modifiable factors. Strabismus and ptosis should be addressed for optimal visual development. Amblyopia therapy should be instituted quickly. Patients who present with active optic nerve edema may benefit from ONSF for local compressive optic neuropathy.

Vertical restrictive strabismus associated with proptosis: Similar clinical signs, different etiopathogenetic causes. A report of three patients.

To report the different uncommon pathogenesis of three cases of severe vertical restrictive strabismus associated with progressive unilateral proptosis with similar clinical features. Case series of three patients who presented to the Orbit Outpatient Service of Policlinico Gemelli with a history of left progressive unilateral proptosis, slowly worsening vertical strabismus and the left eye fixed in downward position. A thorough hematologic work up was performed. All patients underwent complete abdomen ultrasonography, orbital contrast enhanced magnetic resonance imaging, forced duction test under general anesthesia, and orbital biopsy. Patients were 30, 60, and 46 years old respectively. MRI showed left inferior rectus enlargement in two cases and superior rectus enlargement in one case, with contrast enhanced combined muscle belly and tendon enlargement in all cases. Patients underwent forced duction test, muscle weakening (in two cases), and muscle biopsy with histopathologic examination. The superior rectus appeared infiltrated by an undifferentiated high-grade pleomorphic sarcoma, whereas the two inferior recti were positive for idiopathic orbital inflammatory disease with fibrosis areas and neuromuscular choristoma, respectively. Although proptosis and acquired vertical restrictive strabismus are most commonly associated with thyroid associated orbitopathy (TAO), they can also be a manifestation of many other conditions and the differential diagnosis can be particularly challenging. The three reported cases presented indeed with similar clinical features but had three distinct underlying orbital etiologies, two of which were extremely uncommon.

Augmented vertical rectus transpositions: Intraoperative measurement of torsion following sequential muscle detachment.

After vertical recti transposition surgery, a torsional change may occur. We hypothesized that step-by-step monitoring of the intraoperative torsional position of the eye can avoid any unexpected complications and identify critical moments of surgery that may have adverse effects. Nine patients with sixth nerve palsy that underwent complete transposition of the superior (SR) and inferior rectus (IR) muscles to the lateral rectus muscle by means of the technique of augmented vertical recti transposition were prospectively included. The torsional position of the eye was recorded at eight stages of the procedure. We observed two distinct patterns of induced torsional deviation during partial disinsertion of a vertical rectus muscle depending on whether disinsertion began medially or laterally, after cutting about 3/4 of the muscle fibers: ¾ nasal disinsertion of the SR and ¾ temporal disinserton of the IR caused intorsion, ¾ temporal disinsertion of the SR and ¾ nasal disinsertion of the IR caused extorsion. Torsion improved after the vertical rectus was attached temporally to the sclera along the spiral of Tillaux with tying of the augmentation suture to the LR. The greatest change in torsion was from ¾ temporal disinsertion of the SR (5°extorsion), to reattachment along the spiral of Tillaux temporally (5°intorsion). The SR and IR have different torsional effects, which only appears when more than half of the fibers are detached. Augmented transposition does not cause any additional torsional effects. This intraoperative monitoring system can be used to detect unintended torsional complications, especially during transposition surgery.

New insights into the lacrimal pump

PurposeTo date, there are many theories about tear transport through the canaliculi of the draining lacrimal system into the lacrimal sac but only few with supportive data. It is certain that the function of the lacrimal part of orbicularis oculi muscle (Horner-Duverney's muscle) is indispensable for the transport of “used” tears. However, the muscle's exact structure and the mechanisms of its functions are as yet unclear. To obtain deeper insights we undertook the present study. MethodsUpper and lower canaliculi (including the entrance into the lacrimal sac) from donor cadavers were dissected. Some of the specimens were prepared for scanning electron microscopy (SEM) to analyze the course of muscle fibers surrounding the canaliculi. Others were sectioned for enzyme- (EHC) and immunohistochemistry (IHC) to learn about the distribution of slow and fast reacting muscle fibers in Horner-Duverney's muscle as well as to analyze the distribution of different neurotransmitters to learn more about the innervation of Horner-Duverney's muscle. Four tear duct systems taken from body donors were cut out en bloc after formalin fixation, serially sectioned and reconstructed using a newly developed technology for 3D reconstruction of histological serial sections named HiD® (Chimaera GmbH, Germany). Patients that had undergone dacryocystorhinostomy (DCR) were video-analyzed endonasally during active blinking, focusing on viewing the temporal wall of the lacrimal sac movement where the canaliculi penetrated the lacrimal sac. ResultsSEM revealed that muscle fibers of Horner-Duverney's muscle surround the vertical parts of the upper and lower canaliculus in a scissor like pattern whereas they ran in parallel to the first two thirds of the horizontal parts surrounding the respective canaliculus. Here, the muscle fibers were embedded in dense connective tissue forming a unique network. At the nasal third, muscle fibers left the canaliculi and ran to the posterior part of the fascia of the lacrimal sac and the lacrimal bone. EHC revealed that Horner-Duverney's muscle contained nearly an equal distribution of type I and type IIb muscle fibers compared to the superior rectus muscle which contains more type I and the masseter and iliopsoas muscles with more type IIb muscle fibers. IHC indicated presence of trigeminal, catecholaminergic and cholinergic nerve endings. 3D reconstructions supported the SEM data. Endonasal video analysis of patients after DCR with a nasally open lacrimal sac revealed bulging of the temporal wall of the lacrimal sac during blinking. On the basis of these findings, a modified lacrimal pump theory is proposed. ConclusionThe results support the hypothesis that contraction of Horner-Duverney's muscle leads to closure of the canaliculi in their first two thirds based on the special arrangement of muscle fibers and connective tissue fibers. This causes the tear fluid in the canaliculi to be pressed/transported towards the lacrimal sac. The medial third of the vertical portions of the canaliculi, the canaliculus communis and the intrasaccal portion of the canaliculus are compressed by the shortening and thickening of the Horner-Duverney muscle from dorsal, which leads to a compression of the canaliculi lumens in this part of the system, thereby pushing the lacrimal fluid further towards the lacrimal sac. The mix of fast contracting and fatigue resistant muscle fibers is ideally suited for the blink mechanism that is complexly regulated by the nervous system.

Orbital Myocysticercosis different Presentation and Management in Eastern Nepal

Ocular cysticercosis is a preventable cause of blindness. It is caused by parasitic infestation caused by the larval form of Taenia solium. Poor sanitation and improper management of food and meat products are the major causes for cysticercosis infestation. Two cases of myocysticercosis presented to our hospital differently. A 12 years boy, first case presented with drooping of right eye (RE) upper lid with recurrent swelling, pain, redness with mild headache and intermittent vomiting for 1 and half months. On examination swelling of RE upper lid, mild ptosis, abaxial proptosis with restricted motility in upgaze was noted. Orbital CT (computer tomography) scan and ocular ultrasound reports showed findings suggestive of myocysticercosis of superior rectus muscle of RE. Routine microscopic examination (RME) of stool demonstrated eggs of Taenia. Complete blood count (CBC) showed eosinophilia. As a suspected case of myocysticercosis and since the patient resided at an endemic zone, empirical therapy with albendazole and steroid was started to continue for 4 weeks. After one week the patient presented with features suggestive of RE orbital cellulitis. With proper counseling about medical therapy and cyst excision, the patient recovered well with only mild RE upper lid ptosis of 2mm. The histopathological examination (HPE) of the excised cyst was suggestive of inflammatory cystic lesion. A 55 years male presented as a second case to us with gradually increasing mass in the RE lower lid with a history of pain, difficulty in opening RE and intermittent swelling of RE 2 months back. On examination RE lower lid mass with exotropia of 15 degree, mild hypertropia was noted. CT scan showed presence of cystic mass 3.5x2x1.5cm in the right orbit involving the right inferior rectus muscle, abutting and displacing the globe superolaterally. CBC showed eosinophilia. Post cyst excision patient recovered well with remaining mild restriction in infraduction most probably due to fibrosis. HPE was conclusive of cysticercus cellulosae. Both the patients improved well with no recurrence until last visit 17 months in 12 years boy and 6 months in 55 years male after which he lost to follow. Myocysticercosis can occur at any age. There is equal importance of clinical, radiological, microbiological and histopathological support for proper diagnosis and management of cysticercosis. Medical therapy along with surgical excision of the cyst with it's content may be needed in the management of myocysticersosis.

Strabismus Surgery in Thyroid-Associated Ophthalmopathy; Surgical Outcomes and Surgical Dose Responses

ABSTRACT Purpose To investigate the success rate and surgical dose responses in strabismus surgery of thyroid-associated ophthalmopathy (TAO). Methods Thirty-three patients (26 men) were included in this study and underwent strabismus surgery. The mean follow-up time was 11.3 ± 6.5 months. Success was defined as the proportion of patients with a horizontal deviation of less than 10 PD, vertical deviation of less than 4 PD, and no subjective diplopia in primary and downgaze. Results After the final follow-up visit, strabismus surgery was successful in 87.8% of patients. Pre-operative factors (age, gender, smoking, corticosteroid usage, radioactive iodine, orbital decompression, optic neuropathy, baseline deviations, extorsion, type of strabismus, TAO duration) were not statistically correlated with success. Dose responses were calculated to be 3.44 ± 0.66 PD/mm of medial rectus recession and 4.83 ± 1.48 PD/mm for vertical rectus recession. Patients with deviation ≥25 PD had significantly larger surgical dose response compared to the group with deviation<25 PD (p value = .003 for horizontal and p-value <0.05 for vertical deviations). In eyes with predominant hypotropia, we found 1.64 ± 1.37 PD decrease in esotropia for each millimeter recession of inferior rectus muscle. Conclusions Surgical dose responses in large deviations were significantly higher than the moderate angle of deviation. The reported mean for vertical dose responses may vary in different patients based on the laterality and involvement of superior rectus muscles. The recession of inferior rectus muscle may correct mild-to-moderate esotropia without the need for horizontal muscle surgery.

Novel compact device for clinically measuring extraocular muscle (EOM) tension

Accurate knowledge of extraocular muscle (EOM) tension is important for the diagnosis of and surgical planning for strabismus, such as choosing which eye to operate or determining the amount of muscle displacement. Previous evaluations of passive EOM tension have relied extensively on the experience and skill of ophthalmic surgeons, who generally perform such evaluations by gripping the eyeball and then pushing and pulling it. This methodology, named the forced duction test, has the significant limitation that the tension is felt subjectively via the forceps, with the results therefore not being quantifiable. Previous quantitative analyses have utilized several different types of equipment with implanted force transducers or have involved connecting the muscle tendon to a strain gauge. However, the associated equipment setups and recording systems are highly complex and rarely used outside research settings. This situation prompted the present study to develop a novel compact, quantifiable and clinically applicable device for measuring the passive tension in human EOMs for use in clinical practice. The device employs locking forceps and a tilting sensor to rule out effects of the gripping force and to compensate for changes in the force due to tilting, which improves the measurement accuracy. The performance of the device was investigated in 60 eyes of 30 consecutive anaesthetized patients immediately prior to ophthalmic surgery. The results showed that the measured EOM tension in each rectus muscles agreed with previous findings: 48.3 ± 14.5 g (0.82 ± 0.28 g/deg, mean ± SD) for the lateral rectus, 45.6 ± 13.2 g (0.82 ± 0.23 g/deg) for the medial rectus, 48.6 ± 14.7 g (0.71 ± 0.21 g/deg) for the inferior rectus and 53.4 ± 13.7 g (0.77 ± 0.25 g/deg) for the superior rectus.

SAT-490 A Case of Unilateral Exophthalmos Due to Thyroid Orbitopathy and Its Association with Chronic Kidney Disease

Graves ophthalmopathy(GO)is the most common extra-thyroidal manifestation of Graves’ disease (GD). Most cases of GO are bilateral which may be asymmetric, whereas unilateral ophthalmopathy is less common and has been observed in 9-15% cases. Association between chronic kidney disease and unilateral Grave’s ophthalmopathy in a clinically euthyroid patient is rare. We report a case of a 24-year-old male with no previous history of any chronic medical illnesses who presented with protruded right eye for the past 6 months. He did not have any other visual symptoms or symptoms related to thyroid disease. Laboratory results revealed low TSH, normal free T3 and free T4. TSH receptor antibodies were positive. He also had elevated serum creatinine at 418 umol/L (normal levels 64 - 110 umol/L). US KUB showed bilateral small sized kidneys and increased parenchymal echogenicity suggestive of chronic kidney disease. MRI Head showed features suggestive of unilateral thyroid associated orbitopathy. Patient received 1-week course of oral prednisolone 10 mg per day after which his exophthalmos improved.Case report: A 24 year old male with no previous history of any chronic medical illnesses, presented to the clinic with protruded right eye for the past 6 months that was progressively getting worse. There was no eye pain, visual changes, ophthalmoplegia, dryness or discharge from eye. Patient did not report any other symptoms, Physical examination revealed a comfortable man with protruded right eye, lid retraction, normal eye movements and no signs of orbital cellulitis. Neck examination was significant for a mild diffuse goitre. Laboratory studies were significant for haemoglobin of 12.1 g/dl (normal 13-17 g/dl). He also had elevated serum creatinine at 418 umol/L (normal 64 - 110 umol/L). Serum electrolytes, liver function tests and lipid profile were within normal range. 24 hr urine collection showed 3.08 gm/24 hr proteinuria. Serum TSH was 0.04 mIU/L (normal 0.45 - 4.5 mIU/L), free T4 was 13.8 pmol/L (normal 9 - 20 pmol/L) and free T3 was 4.56 pmol/L (normal 2.89 - 4.88 pmol/L). Thyrotropin Receptor Ab titre was 4.69 IU/L (normal 0.00 - 1.75 IU/L). ANA, ANCA, C3, C4, Anti thyroid peroxidase and Anti GBM antibodies were negative. Screening for hepatitis B, C and HIV was negative US KUB showed bilateral small sized kidneys and increased parenchymal echogenicity suggestive of CKD. MRI Head was remarkable for proptosis of the right eye with increased retro-orbital fat, thickening and T2 hyper-intensity with sparing of the tendinous insertion involving the right inferior, medial, superior and lateral rectus muscles with crowding at the orbital apex. Features were suggestive of unilateral thyroid associated orbitopathy. Patient received 1-week course of oral prednisolone 10 mg per day after which his exophthalmos improved. An association between CKD and GO in a clinically euthyroid patient is rare.

Standard coronal orbital magnetic resonance imaging is an effective technique for diagnosing sagging eye syndrome.

The aim of this study was to determine the importance and efficacy of the standard coronal magnetic resonance imaging (MRI) analysis method for the correct clinical diagnosis of the sagging eye syndrome. This retrospective study evaluated the standard coronal MRI efficacy by comparing the positions of the orbital pulleys and extraocular muscles in patients with sagging eye syndrome as well as controls. The participants included 50 patients with sagging eye syndrome (aged 73.3 ± 6.7years) and 17 age-matched control patients (aged 70.9 ± 4.3years) that presented optic neuritis. The participants were classified into groups of age-related distance esotropia and cyclo-vertical strabismus. Lateral rectus-superior rectus band condition, lateral rectus vertical angle, lateral rectus tilting angle, and superior rectus-lateral rectus displacement angle were examined. The lateral rectus-superior rectus band was more frequently disordered in the two groups than that in the control. The lateral rectus vertical and tilt angle examinations exhibited a significant difference in the age-related distance esotropia [(- 13.3 ± 10.9°, p < 0.05) and (- 24.1 ± 9.5°, p < 0.01)] and cyclo-vertical strabismus [(- 11.9 ± 6.9°, p < 0.05) and (- 20.8 ± 9.3°, p < 0.01)] groups compared with those in the control group [(- 7.5 ± 5.1°) and (- 12.2 ± 9.1°)]. The superior rectus-lateral rectus displacement angle did not present a significant difference between the patients and control groups. Patients with sagging eye syndrome exhibited disordered orbital pulley and extraocular muscle malposition, as determined by standard coronal magnetic resonance imaging, indicating the effectiveness of the procedure for diagnosing sagging eye syndrome.

Lateral Rectus Superior Compartment Palsy

Lateral rectus palsy with hypotropia constitutes a portion of sixth nerve palsy cases in which only the superior compartment of the lateral rectus is palsied. We present such a case in a 10-year-old girl who presented with a peculiar appearing right esotropia and hypotropia due to acquired lateral rectus palsy along with apparent ipsilateral superior rectus underaction. Neuroimaging confirmed atrophy of the superior part of lateral rectus as compared to the inferior half. Augmented superior rectus transposition to the lateral rectus along with adjustable bimedial recessions and bilateral inferior oblique myectomies were done to restore her cosmetic appearance.

Thyroid eye disease with choroidal folds

ABSTRACT Purpose: To determine the clinical course of patients with chorioretinal folds (CRF) in thyroid eye disease (TED). Methods: A multi-center retrospective case series of patients with TED who developed CRF. Results: Ten patients (17 eyes) with CRF related to TED were identified. The mean age of presentation was 59.3 ± 8.3 years old. The majority of patients were male (70%), hyperthyroid (70%), hyperopic (53%), had a history of radioactive iodine (60%), and currently on methimazole treatment (30%). Three patients (3 eyes) had unilateral involvement of CRF with bilateral TED. The average clinical activity score was 3.6 ± 2.1 at the time of presentation. The most commonly enlarged extraocular muscles were medial (76%), inferior (64%), superior (64%) and lateral rectus (35%). Compressive optic neuropathy was seen in 47% of eyes. Treatment included oral prednisone (70%), orbital decompression (59%), thyroidectomy (20%) and tocilizumab (10%). The CRF did not resolve over a follow up period of 24.7 ± 23.7 months in 70% of eyes. There was no significant difference in average axial length (25.7 ± 4.9 mm) and optic nerve to optic strut distance (37.8 ± 3.9 mm) between patients with CRF and the eight age-and sex-matched TED control patients without CRF (p = 0.81 and 0.65 respectively). A univariable and multivariable analysis found an enlarged inferior rectus as a factor in TED patients with persistent CRF. Conclusions: CRF are often an indicator of visually threatening situations and often do not resolve despite treatment of TED.

The effects of simultaneous operation on dissociated vertical deviation with horizontal and torsional strabismus.

To investigate the therapeutic effects of simultaneous horizontal and vertical operations on dissociated vertical deviation (DVD) associated with other deviations. Forty-five cases of DVD with horizontal and torsional strabismus underwent combined operation were collected retrospectively. All clinical records were analyzed. All patients were followed up for 6 to 24mo. Wilcoxon signed-ranks test was performed to evaluate the changes of vertical and horizontal deviation. χ 2 test was used to evaluate the changes of binocular visual function. Forty-five cases included 36 patients with intermittent exotropia and binocular inferior oblique overaction (IOOA), 5 patients with concomitant esotropia and binocular IOOA, 4 patients with intermittent exotropia and monocular superior oblique palsy. The superior rectus recession (SRR) combined with horizontal rectus recession and the myectomy of inferior oblique or anterior transposition were operated simultaneously to correct all types of strabismus. There were 43 cases who achieved normal eye position in vertical direction, while 2 cases were with undercorrection of 5Δ to 6Δ. In patients with horizontal strabismus, 2 cases of exotropia were with overcorrection of 6Δ to 8Δ, 1 case of esotropia was with undercorrection of 6Δ, and 1 case of monocular superior oblique palsy with compensatory head posture was not significantly improved. The binocular visual function of most patients recovered after operation. The difference of the binocular visual function and eye position were significant compared with that before operation (P<0.05). The simultaneous operation on DVD with horizontal and torsional strabismus is successful.

Management of simultaneous ocular elevation and depression deficit in patients after reconstruction surgery for orbital floor fracture

PurposeTo present and examine the results of surgical correction of simultaneous ocular elevation and depression deficit in patients who underwent reconstruction surgery for orbital floor fracture.MethodsA retrospective analysis of medical records of patients who had undergone surgical correction for diplopia associated with orbital fracture which persisted after orbital reconstruction surgery. All patients underwent orthoptic evaluation before surgery and postoperatively with various times of follow-up.ResultsEight cases of blow-out fracture of the orbital floor were identified. Surgical plan varied from case to case. It included thorough revision of inferior rectus/oblique complex with or without recession of the former or flap tear repair and additional procedures. Postoperatively 4 patients (50%) were diplopia free, 3 (37.5%) presented diplopia in extreme upgaze and 1 (12.5%) in mid-upgaze and adduction. None of the patients reported diplopia in the primary position neither downgaze.ConclusionDiplopia persisting after reconstructive surgery of a fractured orbital floor may be corrected surgically. Our results suggest that at least two surgical procedures are necessary to achieve satisfying outcomes. Contralateral inferior rectus recession combined with superior oblique recession and superior rectus posterior fixation appears to be effective procedures for use.

Anatomical and Histological Study of the Conjoint Fascial Sheath of the Levator and Superior Rectus for Ptosis Surgery

An anatomical and histological study of the conjoint fascial sheath of the levator and superior rectus (CFS) was carried out by using the cadavers for teaching. Three adult Asian cadaver heads fixed in formalin were used. The CFS was exposed by the same surgeon in each case. Then the CFS was observed and measured in vivo and ex vivo. And the CFS, the levator and the frontal muscle were removed from the same eye for histological study. The CFS was located 2.1 ± 0.4 mm posterior to the fornix. A special muscle sheath of the levator was observed. The special muscle sheath and the tendon of the superior rectus were fused to the CFS through loose connective tissue. Hematoxylin-Eosin (HE) staining showed a large amount of connective tissue on examination of the CFS by microscopy. Double staining with Victoria-blue and Masson trichrome staining confirmed elastic fibers and collagen fibers in the CFS tissues. If ptosis correction surgery is performed by looking for the CFS from the upper edge of the conjunctiva, in fact, only a special part of the muscle sheath of the levator in the CFS, but not the integral CFS, is used in the surgery. The histological results confirm that the CFS is a fibrous tissue membrane with both elasticity and toughness. Perhaps the best choice is to recombine the special muscle sheath of the levator in the CFS with the levator muscle tissue during ptosis correction surgery to suspend the eyelids.

The Effect of Absorbable and Non-absorbable Scleral Suture on Strabismus Surgery in the Rabbits

ABSTRACT Purpose: To evaluate and compare the histopathological changes in a rabbit model, following strabismus surgery using either absorbable or non-absorbable suture materials. Methods: Superior rectus muscle recession was performed in rabbits using either an absorbable (Vicryl®) or non-absorbable (Prolene®) suture material. Hematoxylin-eosin staining was performed and histologic changes in the sclera were evaluated at the first, second, fourth, and eighth weeks, postoperatively. Moreover, the postoperative scleral thickness was measured and the postoperative pattern of arrangement of scleral fibers was analyzed. Results: Suture material-induced limited inflammatory reaction and formation of new vessels were observed in the study subjects, in the early postoperative phase, in both the Vicryl® and Prolene® groups. In the Vicryl® group, multinucleated giant cells were dominant during the inflammatory phase, and replacement by fibrotic scar tissues was observed. In the Prolene® group, the suture material was observed to be intact, and the inflammatory reactions around the sutures were observed to be less severe compared to the Vicryl® group. Meanwhile, neither group exhibited reduction in scleral thickness or irregular rearrangement of scleral fibers. Conclusions: The current histological study demonstrated that there was no significant postoperative scleral tissue changes after a strabismus surgery. Furthermore, the absorbable suture material was observed to induce inflammatory reactions of greater severity, compared to the non-absorbable suture material, in scleral tissues.

Inferior rectus displacement in heavy eye syndrome and sagging eye syndrome.

To evaluate if there is a nasal displacement of the vertical rectus muscles in heavy eye syndrome (HES) and/or sagging eye syndrome (SES) compared with age-matched controls. We reviewed the charts of all patients with the diagnosis of HES or SES who were seen at the University of California San Diego (UCSD) between the years 2008-2016 who underwent magnetic resonance imaging (MRI) of the brain and orbits. The control group included patients who had brain and orbital MRIs at UCSD in the absence of known pathology in the orbits or globes. Measurements were taken by 3 separate examiners for all groups. Twenty-four patients (16 with SES and 8 with HES) and 24 age-matched controls were retrospectively reviewed. The superior rectus (SR) of patients with HES and SES was more nasally displaced from the midline compared with that of age-matched controls (p = 0.04, p = 0.03, respectively). The inferior rectus (IR) of patients with HES but not with SES was more nasally displaced from the midline compared with that of age-matched controls (p = 0.04, p = 0.62, respectively). In all groups, the IR nasal displacement from the midline was approximately double compared with the SR. There is a significant nasal displacement of the SR in HES and SES and IR in HES. The observed IR nasal displacement in HES is a new finding and may explain the residual hypotropia and/or esotropia following surgical interventions for HES not involving the IR.