Vision In Primary Position Research Articles

Clinical Significance of the Inferomedial Orbital Strut in Orbital Blowout Fractures: Incidence of Symptomatic Diplopia in a Fractured vs. Intact Strut.

Background/Objectives: This study aims to compare the clinical findings, particularly symptomatic diplopia, associated with an inferomedial orbital strut fracture versus intact strut and to determine the clinical significance of the inferomedial orbital strut in patients with orbital floor and medial orbital wall fractures. Methods: A 10-year retrospective observational study involving orbital blowout fracture cases was conducted in our institution. Patients with fractures of the orbital floor medial to the infraorbital groove and medial orbital wall, as seen on computed tomography (CT) scans, were included in this study. Patients with concomitant orbital rim fracture and those with old orbital fractures were excluded. Fracture of the inferomedial orbital strut was diagnosed via coronal CT images and patients were classified into those with an inferomedial orbital strut fracture and those without. Results: A total of 231 orbits from 230 patients was included in the study (fractured strut on 78 sides and intact strut on 153 sides). Approximately 2/3 of patients in both groups had the field of binocular single vision in primary position upon first examination (p = 0.717). Patients with strut fractures demonstrated only comminuted or open fractures, while those without strut fractures showed diverse fracture patterns (p < 0.001). Conclusions: Inferomedial orbital strut fracture does not automatically result in diplopia in patients with orbital blowout fractures. The integrity of the orbital periosteum plays a more essential role in hampering extraocular muscle displacement, thereby preventing symptomatic diplopia in these patients.

Phased strabismus surgery under topical anesthesia.

To evaluate the feasibility and outcomes of phased strabismus surgery under topical anesthesia, with intraoperative comparison of ocular alignment in supine and seated positions. This retrospective clinical investigation analyzed the data of patients who underwent phased strabismus surgery with fixed sutures under topical anesthesia. The technique consisted of 2 phases, spaced out with an intraoperative alternate prism cover test (performed in supine and seated positions): (1) surgery on one or two muscles, as defined by a preoperative surgical plan; (2) if judged necessary, a further one-muscle surgery. Surgical success was defined as a residual angle of horizontal and vertical deviation ≤±8Δand ≤5Δ, respectively, and the presence of single binocular vision in primary position in patients with preoperative diplopia. Follow-up visits were scheduled 1 day, 1 month, and 6 months after surgery. The review identified 38 patients (age range: 10-80 years). Surgery was well tolerated by all patients. Twelve (32%) required a second phase. No statistically significant differences were found for intraoperative angles of deviation in supine and seated positions. Surgical success was reached, respectively, in 88% and 87% of cases with horizontal and vertical deviation 6 months after surgery. No patients were reoperated during the follow-up period. Phased strabismus surgery is a feasible technique for various types of strabismus in adults and children. Secondly, intraoperative evaluation of ocular alignment can be performed either with the patient seated or supine, with the same accuracy in terms of surgical success.

Effect of transposition of superior rectus muscle on vertical deviaton and cyclotropia

Objective To analyze the effect of transposition of superior rectus muscle on vertical deviation and cyclotropia. Methods A prospective study. All 16 patients with ocular abduction dysfunction underwent superior rectus transposited to external rectus insertion. The degree of esotropia was measured with synoptophore, and the vertical deviation was measured with Maddox rod plus prism. The subjective cyclotropia was examined with the double Maddox, and the ocular rotation was evaluated objectively with fundus photography (fovea-disc angle, FDA). Results The difference of pre- and post-operative horizontal strabismus and limit of abduction and adduction were statistically significant, from pre-operative 35.00°±2.21° to post-operative 2.19°±0.78° (t=12.776, P=0.000), from -3.62±0.22 to -2.37±0.15 (t=-7.319, P=0.000), and from -0.06±0.06 to -2.12±0.15 (t=10.688, P=0.000). The vertical deviation was improved from 0.69△+ 0.50△ to 0.63△+ 0.73△ (t=0.083, P=0.935). The subjective cyclotropia were improved from 1.25°±0.50°to -0.69°±0.46° (t=3.422, P=0.004); the objective cyclotropia were improved from 8.93°±0.81°to 6.96°±1.08° (t=2.889, P=0.018). Conclusion Transposition of superior rectus muscle is an effective and safe method to treat ocular abduction dysfunction, which can correct esotropia, improve abduction limitation and restore a certain range of binocular single vision in primary position. Key words: Transposition, superior rectus muscle; Abduction nerve disease; Vertical deviation; Cyclotropia

The Value of Fusional Convergence Amplitudes in Esodeviation Surgery Without Adjustable Sutures.

To explore the application of preoperative fusional convergence amplitudes in the selection of a target angle for non-adjustable suture strabismus surgery with deteriorated intermittent esotropia and diplopia. Thirty-one consecutive cases of presumed acquired non-accommodative, deteriorated intermittent esotropia managed surgically between 2005 and 2016 were reviewed retrospectively. For each individual, a target angle (deviation angle for which surgery was based) was selected preoperatively after analysis of fusional convergence amplitudes. Outcomes in patients selected for overcorrection at 6 meters (target angle > angle in primary position at 6 meters) were compared to those who had planned surgery based on a target angle that did not exceed their measured angle (target angle ≤ angle in primary position) at 6 meters. All 31 patients achieved binocular single vision in primary position at both near and 6 meters without prisms, orthoptic therapy, or additional surgery at 4 to 6 months postoperatively. Greater mean correction in the target angle > angle in primary position group compared to the target angle ≤ angle in primary position group was observed, but this difference was not statistically significant (P = .57). Among this diagnostically specific cohort with intermittent esotropia with symptomatic diplopia and measurable binocular single vision preoperatively, targeted surgery based on an analysis of preexisting fusional convergence amplitudes had an outcome that compared favorably to that of documented adjustable suture strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2018;55(6):375-381.].

Surgical Management of Ophthalmoplegia

ABSTRACTSurgical management—depending upon the severity of the ophthalmoplegia—ranges from restorative to palliative. In paresis with reasonable residual muscle function and ductions, the goal of the surgery is not only to restore single vision in primary position but also to provide a relatively normal field of single binocular vision. With complete paralysis of a single muscle or more than one muscle served by a single cranial nerve (third), in addition to conventional recess or resect surgery, the transposition of still-functioning muscles is often needed to obtain a durable result and restore at least some field of single binocular vision. In complete ophthalmoplegia, the benefits of the surgery are limited; but even in these cases, surgery can often reduce the need for an awkward head posture and improve appearance.

Diagnosis and treatment of strabismus caused by nasal endoscopic surgery

Objective: Strabismus with diplopia is the main orbital complication of functional endoscopic sinus surgery (FESS). This study was to analyze clinical findings, treatment and outcomes of such cases. Methods: Retrospective case series. Twenty-three cases were divided into 3 groups based on the disease severity: group A, partial transection of the medial rectus muscle, group B, complete transection of the medical rectus, group C, transection of the medial rectus combined with the other orbital injuries. Complete ophthalmology examinations, including eye alignment, eye motility, force duction test, force generation test, general eye exam, and medical imaging (orbital CT or MRI), were performed for each case. The treatment included botulinum toxin (Botox) injection to the lateral rectus muscle, transposition of the vertical rectus muscle, and orbital surgery if needed. Results: In group A with Botox injection, all the cases achieved single vision in primary position, but still remained some adduction weakness. In group B treated by vertical transposition surgery combined with Botox, 22% of the cases got single vision in primary gaze. In group C, even with more efforts of treatment, the cases with orbital injury can only get cosmetic improvement, and diplopia and adduction dysfunction were found in most cases. Conclusions: Due to the variety of the complications of FESS, force duction test is a crucial exam to detect the direction and severity of synechia in the orbit, which will give solid information to surgery approach as well as prognosis. Botox injection at early stage will minimize the contraction of antagonist lateral rectus, helping to postpone the transposition surgery which may cause anterior segment ischemia when performed right after the medial rectus transection injury. Botox may even reduce the synechia by minimizing the scarring process. Partial vertical rectus transposition combined with muscle resection may effectively correct the eye misalignment in primary gaze and improve eye motility. The prognosis of FESS induced orbital complications is quite related with the severity of the injury. Botox combined with surgery may help medial rectus transection cases to achieve single vision in primary gaze, but when there is any other orbital injury, treatment may only improve cosmetic appearance. (Chin J Ophthalmol, 2017, 53: 917-923).

Strabismus surgery for internuclear ophthalmoplegia with exotropia in multiple sclerosis

Internuclear ophthalmoplegia (INO) is a disabling condition affecting up to 40% of patients with multiple sclerosis (MS). Management of bilateral internuclear ophthalmoplegia (BINO) with exotropia in MS has been controversial because of the uncertain course of MS. Diplopia associated with INO severely impacts the patient's quality of life and, therefore, treatment should be considered. Three patients (ages 28, 62, and 82 years) who had BINO with exotropia and disabling diplopia secondary to MS underwent bilateral medial rectus resections with either unilateral or bilateral adjustable lateral rectus recession(s). Alignment was measured preoperatively and postoperatively, and symptoms were recorded. Preoperative exotropia ranged from 40(Delta) to 64(Delta) for distance fixation and from 50(Delta) to 70(Delta) for near fixation. Preoperatively, all patients had diplopia at distance and near fixation. Immediately after surgery, patients were adjusted to 10(Delta) to 18(Delta) ET at distance fixation with the expectation of an exotropic drift. None of the patients had a tropia at distance and near fixation 6 months after surgery, with single vision in primary position and reading. Two patients had a 2-year follow-up examination; 1 required a small amount of base-in prism for comfortable reading. Three patients who had BINO with exotropia secondary to MS all benefited from surgery. Surgery should be considered as an option for symptomatic patients who have BINO with exotropia caused by MS.

Incidence and treatment of diplopia after three-wall orbital decompression in Graves' ophthalmopathy

The authors reviewed their experience in treating diplopia after orbital decompression in patients with thyroid orbitopathy. Orbital decompression was performed on 102 patients (34 men and 68 women) for either compressive optic neuropathy or disfiguring proptosis. Persistent postoperative diplopia in primary gaze was present in 53 eyes (52%) six months after orbital decompression. Ten patients (9.8%) with no preoperative diplopia developed diplopia in primary gaze after decompression. Among 43 patients with preoperative diplopia in primary gaze, 19 (18.6%) remained unchanged and 24 (23.5%) worsened considerably after decompression. Nine (17%) of 53 patients with postoperative diplopia obtained resolution of postoperative diplopia with prismatic lenses. The remaining 44 patients (83%) underwent adjustable extraocular muscle surgery with the use of viscoelastic substances to gain single vision in primary position. Thirty-one of these patients obtained stable resolution of diplopia in primary gaze after one surgical procedure. Ten of these patients required a second surgery on the oblique muscles six months after the first procedure to eliminate persistent torsional diplopia. Three of these patients required prismatic lenses for full resolution of diplopia after strabismus surgery. Orbital decompression of Graves' orbitopathy is associated with a high incidence of postoperative diplopia that can subsequently be successfully managed with strabismus surgery and prismatic lenses.—Michael D. Wagoner The authors reviewed their experience in treating diplopia after orbital decompression in patients with thyroid orbitopathy. Orbital decompression was performed on 102 patients (34 men and 68 women) for either compressive optic neuropathy or disfiguring proptosis. Persistent postoperative diplopia in primary gaze was present in 53 eyes (52%) six months after orbital decompression. Ten patients (9.8%) with no preoperative diplopia developed diplopia in primary gaze after decompression. Among 43 patients with preoperative diplopia in primary gaze, 19 (18.6%) remained unchanged and 24 (23.5%) worsened considerably after decompression. Nine (17%) of 53 patients with postoperative diplopia obtained resolution of postoperative diplopia with prismatic lenses. The remaining 44 patients (83%) underwent adjustable extraocular muscle surgery with the use of viscoelastic substances to gain single vision in primary position. Thirty-one of these patients obtained stable resolution of diplopia in primary gaze after one surgical procedure. Ten of these patients required a second surgery on the oblique muscles six months after the first procedure to eliminate persistent torsional diplopia. Three of these patients required prismatic lenses for full resolution of diplopia after strabismus surgery. Orbital decompression of Graves' orbitopathy is associated with a high incidence of postoperative diplopia that can subsequently be successfully managed with strabismus surgery and prismatic lenses.—Michael D. Wagoner

Incidence and treatment of diplopia after three-wall orbital decompression in Graves' ophthalmopathy.

To describe our experience treating diplopia after orbital decompression in patients with thyroid orbitopathy. From May 1997 to July 2001, we performed orbital decompression on 102 patients (34 men and 68 women) with severe proptosis. In 10 (9.8%) of these patients who had no diplopia preoperatively, diplopia in primary gaze occurred after decompression. In 19 (18.6%) of the patients with diplopia in primary gaze before surgery, there was no modification of diplopia after decompression. In 24 (23.5%) of the patients with diplopia in primary gaze before surgery, a more severe imbalance occurred after decompression. Forty-four (83%) of these 53 patients underwent adjustable extraocular muscle surgery with the use of viscoelastic substances to gain single vision in primary position. In 9 (17%) of the patients, diplopia was resolved with the use of prismatic lenses. In 31 (70.4%) of 44 patients, we obtained a stable resolution of diplopia in primary position (minimum follow-up, 6 months). In 10 (22.7%) of these patients, a second surgery on the oblique muscles was necessary 6 months after the first surgery to resolve torsional diplopia. In 3 (6.8%) of the patients, diplopia has been resolved with prismatic lenses. Orbital decompression reduces proptosis, but may cause diplopia or worsen it.

Gaze-evoked amaurosis produced by intraorbital buckshot pellet

Objective To report the first case of gaze-evoked amaurosis secondary to an intraocular foreign body and to highlight the characteristic clinical findings of patients with this symptom. Design Case report and review of the literature. Methods Case review, clinical history, electrophysiologic testing, and follow-up. Main outcome measures Visual acuity, automated perimetry, and visual fields. Results A case of gaze-evoked amaurosis as a result of an intraorbital foreign body is described, and 19 additional cases of gaze-evoked amaurosis are reviewed from the English language literature. These cases share certain characteristics including good vision in primary position with deterioration of vision in eccentric gaze; concurrent objective pupillary abnormalities in eccentric gaze; stereotypic onset and recovery of vision; and funduscopic abnormalities consisting of disc edema and chorioretinal folds. Conclusions Gaze-evoked amaurosis is a reliable sign of intraconal mass lesion. We report the first case of gaze-evoked amaurosis secondary to an intraorbital foreign body.

The efficacy of botulinum neurotoxin A for the treatment of complete and partially recovered chronic sixth nerve palsy.

Esotropia from chronic sixth nerve palsy or paresis usually requires surgery. Chemodenervation of the antagonist medial rectus muscle, while popular for the treatment of acute sixth nerve palsies and pareses, has not been used extensively for chronic cases. In this study, 22 patients with sixth nerve palsies or partially recovered palsies of greater than 5 months duration were treated with chemodenervation. The etiologies of the sixth nerve palsies were trauma (n = 7), tumor (n = 4), infection/inflammation (n = 3), nerve compression from aneurysm or increased intracranial pressure (n = 4), congenital (n = 1), ischemia (n = 2), and idiopathic (n = 1). The mean preinjection deviation was 41 prism diopters. A total of 38 injections were administered (mean, 1.7 per patient). Each patient received an injection of 2.5 to 7.5 units (mean, 4.1) of botulinum neurotoxin A to the ipsilateral medial rectus muscle. Treatment success was assessed 6 months after the last injection. A course of chemodenervation significantly improved the alignment of 9 of the 22 patients (41%). The mean postinjection deviation was 8 delta. Seven patients (32%) had single binocular vision in primary position restored. These patients had a mean horizontal binocular field of 70 degrees (range, 40 degrees to 100 degrees). Thirteen patients (59%) had only modest improvement and required surgery. The data suggest that injection of botulinum neurotoxin A is a useful treatment for some patients with chronic sixth nerve weakness. A course of chemodenervation therapy compares less favorably with transposition surgery with concomitant neurotoxin injection for the treatment of these difficult problems.

Approach to Traumatic Sixth Nerve Palsy with Botulinum Toxin A

Trauma is a frequent cause of acquired sixth nerve palsy in adults, either isolated or associated with other cranial nerve palsies and neurologic dysfunctions. The prognosis is rather good, but horizontal incomitance may become seriously disturbing1.2 due to spastic contracture of the ipsilateral antagonist. Histological changes in paretic eye muscles have been shown to appear as early as three weeks after the onset of the cranial nerve palsy. Intramuscular injections of botulinum toxin A into the direct antagonist of the paretic muscle shortly after the onset of the palsy may help to prevent the development of spastic contracture of the ipsilateral antagonist and prevent restriction to abduction. It also assists to reestablish earlier the field of single binocular vision in primary position.