Superior oblique tuck-effectiveness in reducing vertical deviations when performed as a primary versus secondary procedure in superior oblique paresis

PURPOSE

To quantify the effectiveness of superior oblique tuck (SOT) surgery in patients with a hyperdeviation secondary to superior oblique paresis (SOP). Surgical outcomes were compared in patients undergoing SOT surgery as a primary procedure with those who had previously undergone ipsilateral inferior oblique weakening surgery.

METHODS

This retrospective study assessed surgical outcomes from all patients undergoing SOT surgery for SOP between 2012 and 2021 across 2 hospitals. The effectiveness of SOT surgery in reducing the hyperdeviation was assessed in the primary position (PP) and in contralateral elevation and depression. Results were compared between those undergoing primary SOT surgery with those who had previously undergone ipsilateral inferior oblique weakening surgery.

RESULTS

A total of 60 SOT procedures were performed between 2012 and 2021. 7 were removed due to incomplete data. The remaining 53 cases experienced a mean reduction in hyperdeviation of 6.5 prism dioptres (PD), 6.7PD and 12.0PD in the PP, contralateral elevation and contralateral depression respectively. In eyes with previous IO weakening, the reduction of hyperdeviation was larger than in those eyes with no previous IO weakening surgery, with mean reductions of 8.0PD vs 5.2PD, 7.4PD vs 6.2PD and 12.4PD vs 11.6PD in the PP, contralateral elevation and contralateral depression respectively.

CONCLUSION

SOT surgery is a safe and effective procedure with high patient satisfaction and resolution of symptoms in those patients with troublesome diplopia in downgaze secondary to SOP. This is true in both unoperated eyes and in those who have previously undergone inferior oblique weakening surgery.

[The complications of transethmoidal decompressive orbitotomy associated with endocrine ophthalmopathy]

The objective of the present study was the analysis of the results of transethmoidal decompressive orbitotomy (TEDO) with the resection of the bone matrix of the medial and inferior orbital walls in the patients presenting with endocrine ophthalmopathy (EOP) with the purpose of reduction of the risk of development of this pathological conditions. A total of 51 patient with EOP at the stage of complete remission or pharmacotherapeutic compensation underwent transethmoidal decompressive medial orbitotomy in the ENT Clinic of 1 I.M. Sechenov First Moscow State Medical University during the period from 2006 to 2016. Twenty two of these patients presented with the unilateral process and 29 ones with bilateral exophthalmos. The surgical intervention was performed on the total of 80 eye orbits. The main complaints of the treated patients during the post-operative period included difficulties in nasal breathing (33%), dryness of the nose and crust formation (43%), discharge from the nose and along the posterior pharyngeal wall (15%), nasal bleeding (2%), pain in the forehead and maxillary region (8%), headache (2%). As far as the state of eyes and sight is concerned, 14 (27%) patients reported double vision at the primary gaze position while 6 others (12%) complained of the appearance of diplopia upon a change in the gaze position during the post-operative period. The post-operative endoscopic study revealed synechiae of different localization in the nasal cavity (47%), discharge from the maxillary sinuses (16%) and from the frontal sinus (2%). Eight (16%) patients were found to suffer from maxillary sinusitis, one had acute frontitis, and one sphenoidal sinus mucocelle. These complications were eliminated by pharmacotherapy and additional surgical interventions (2%). Analysis of the results of the study has demonstrated that the above complications were associated with the inadequate post-operative care for the nasal cavity, the excessively large size of the bone window formed during transethmoidal decompressive orbitotomy, resection of the inferior orbital wall, intrusion of the medial rectus muscle of the eye into the wide bone window. We evaluated the possible influence of the orbital soft tissues on the physiological parameters of the functioning of the paranasal sinuses in the post-operative period including blockade of the paranasal drainage pathways by the prolapsed orbital tissues. A few possible approaches to the reduction of the risk of post-operative complications are proposed. The authors emphasize the importance of the further improvement of the surgical treatment of endocrine ophthalmopathy.

[Intracranial hypertension and jugular vein thrombosis]

BACKGROUND

Pseudotumor cerebri is an idiopathic increase in intracranial pressure, which commonly affects obese women of fertile age. The diagnostic criteria according to the guidelines of the German Society for Neurology are increased cerebrospinal fluid (CSF) pressure, symptoms of increased CSF pressure, normal results of CSF examination, no relevant medication and a lack of structural and vascular lesions in magnetic resonance imaging (MRI).

CASE REPORT

This article presents the case of a 39-year-old male patient who presented at hospital with visual obscuration and recently occurred double vision. Except for a recently diagnosed thrombosis of the left jugular vein of unknown origin, there was nothing else of note in the medical history. Biomicroscopic examination showed papilledema with hemorrhages and cotton wool spots. The CSF opening pressure was initially > 50 cmH2O. During therapy by lumbar puncture (three times), oral carbonic anhydrase inhibitors and loop diuretics, the abducens nerve palsy and papilledema receded. Anticoagulation therapy (initially with coumarin derivatives, then with low molecular weight heparins) was unsuccessful in eliminating the thrombosis of the jugular vein. Surgical intervention was not recommended by the vascular surgeons.

CONCLUSION

This case report demonstrates the unusual combination of (idiopathic) intracranial hypertension and thrombosis of the jugular vein, which occurred spontaneously and without any detectable coagulation disorders.

The therapeutic outcome to intravenous steroid therapy for active Graves' orbitopathy is influenced by the time of response but not polymorphisms of the glucocorticoid receptor

BACKGROUND

Glucocorticoids are the mainstay of immunosuppression for active moderate-severe Graves' orbitopathy (GO).

AIM

To analyze the response to therapy and the contribution of glucocorticoid receptor (GR) gene polymorphisms to the therapeutic outcome of intravenous glucocorticoids (IVGC) in active moderate-severe GO.

METHODS

we have studied 58 patients treated with 7.5 g i.v. methylprednisolone (cumulative dose). ophthalmological assessment was performed at baseline and at 6-8, 12-16, and 24-30 weeks after the first infusion. Three GR gene polymorphisms, ER22/23EK, N363S, and BCL1, which have been associated to variable sensitivity to steroids, were studied in 43/58 patients. The therapeutic outcomes defined as: i) reduction of the clinical activity score (CAS) ≥2 points or ii) reduction of proptosis ≥2 mm or iii) improvement of diplopia according to the Gorman score were also studied in relation to treatment schedule, age, gender, duration of thyroid or GO, smoking habits, and serum TSH-receptor autoantibodies levels.

RESULTS

In total, 70% of patients responded and had GO inactivation (CAS <4) as early as 6-8 weeks. At 12-16 weeks, the proportion of patients who became inactive increased by another 10% up to a total of 80%. ER22/23EK and N363S polymorphisms were present only in about 7%, while the Bcl1 variant was present in 30% of patients; no significant association of any of the GR polymorphisms with either the therapeutic response or the occurrence of side effects was observed.

CONCLUSIONS

Most patients with active GO respond to IVGC as early as 6-8 weeks of therapy and the analyzed GR polymorphisms do not influence the therapeutic effect of steroids. Questions arise about the need of continuing therapy up to 12 weeks in nonresponders. We suggest that these patients may be switched to other treatments alone or in combination with steroids.

[Difficulties in surgical management of consecutive exotropia]

Difficulties in surgical management of consecutive exotropia. Consecutive exotropia occurs in formerly esotropic patients without binocular vision, either spontaneously or as a result of surgical overcorrection. However, the above cannot provide sufficient explanation in all cases. Patients with consecutive exotropia mostly complain about aesthetic considerations, although a numerous group of patients reports disturbing diplopia. Patients with consecutive exotropia require particular attention of the surgeons, due to the difficulties in pre-operative assessment and, in turn, in planning thesurgery. The prism adaptation test and botulinum toxin injection used in pre-operative diagnostic assessment often fail to provide the fully reliable information concerning the potential cortical vision suppression, anomalous retinal correspondence and the risk of postoperative diplopia (including paradoxical diplopia). Moreover, many surgeons emphasize the role of technical difficulties experienced during the surgery performed in patients with consecutive exotropia, especially during the reoperation. The preoperative assessment in these patients must include the forced duction test in order to determine which eye should actually be addressed during the surgery. The ocular muscle strength must be balanced during the reoperation, which requires extensive surgical experience and often also the intraoperative adjustment of the primary surgical plan. However, listening patients' concerns regarding satisfactory aesthetic results and considering the risk of postoperative diplopia still remain of the utmost importance.

Time course of Graves' ophthalmopathy after total thyroidectomy alone or followed by radioiodine therapy: a 2-year longitudinal study

The findings in hyperthyroid patients with Graves' orbitopathy (GO) of antibodies against antigens shared between the thyroid and orbit, such as the TSH-receptor (TRAb) and a novel protein G2s (G2sAb), suggested a possible common therapeutic strategy. However, the gold therapeutic standard for hyperthyrodism in these patients remains still unsettled and is mainly based on personal experience. Studies on the effect of total thyroidectomy (TT) alone or followed by radioiodine ablation (RAI) of thyroid remnants showed often conflicting results. This longitudinal study was aimed at evaluating the influence of TT alone or followed by post-surgical RAI with respect to methimazole treatment on the activity and severity of GO in patients with hyperthyroidism and GO. Sixty consecutive patients with Graves' disease and mild/moderate GO were studied and grouped as follows: group 1, including 25 patients (16F, 9M) undergoing TT alone; group 2, including 10 patients (8F, 2M) undergoing TT followed by RAI for histological evidence of differentiated thyroid cancer; group 3, including 25 patients (18F, 7M) euthyroid under methimazole therapy, studied as controls. Clinical study of ophthalmopathy and measurements of TRAb and G2sAb were performed in all patients at start of the study (time of TT for group 1 and RAI after TT for group 2 and of the first finding of euthyroidism under methimazole treatment for group 3) and after 6, 12, 24 months. Patients of both groups 1 and 2 showed an early significant decrease and a further progressive reduction of the activity and severity of GO with a disappearance of TRAb and a decrease of G2sAb levels during the follow-up, without statistically significant differences between the two groups. Patients in group 3 showed a much later and less marked improvement of GO with persistence of TRAb and G2sAb positivity, even if with reduction of TRAb levels at 12 and 24 months. Our results suggest that in Graves' patients with large goiter or relapse of hyperthyroidism and mild/moderate GO, TT alone could be an advisable choice to treat hyperthyroidism also improving GO with reduction of cost/benefit ratio.

Efficacy of the intraoperative relaxed muscle positioning technique in thyroid eye disease and analysis of cases requiring reoperation

PURPOSE

In the relaxed muscle positioning technique of treating strabismus for thyroid eye disease (TED), the most restricted muscles, as determined by preoperative assessment of ductions and intraoperative forced ductions, are recessed to the positions where they rest freely on the globe without tension. The purpose of this technique is to identify preoperative characteristics that are predictive of reoperation and evaluate outcomes.

METHODS

Retrospective review of patients with TED who underwent strabismus surgery using the relaxed muscle positioning technique between 1999 and 2009. Preoperative characteristics; surgical outcomes at 2, 6, and 12 months; and the outcomes of reoperations were evaluated. Outcomes were categorized as excellent (no diplopia in primary and reading gazes without prisms), good (diplopia requiring ≤10(Δ) correction), and poor (persistent diplopia in primary or reading gazes despite prism or attempted prism correction).

RESULTS

Of 63 TED patients treated during the study period, 58 met inclusion criteria. Of these, 45 patients (78%) underwent only one strabismus surgery; 10 (17%), 2 surgeries; and 3 (5%), 3. Excellent outcomes were achieved in 48 (83%), good in 4 (7%), and poor in 6 (10%). Mean follow-up was 12.1 months (range, 1.5 months to 11.5 years). There was an increased likelihood for reoperation in patients with multiple treatment modalities for Graves disease (P = 0.03) and larger horizontal deviations (P = 0.03).

CONCLUSIONS

The intraoperative relaxed muscle positioning technique improved ocular alignment and relieved diplopia in most patients with dysthyroid strabismus. Patients with more severe disease were more likely to require reoperation.

Diplopia in Green Tobacco Sickness

This paper examines the first reported case of Green Tobacco Sickness (GTS) in Poland. A 25-year-old man who worked in a tobacco field for 14 hours with no protective measures experienced symptoms of GTS, and additionally, diplopia, after leaving the field. Upon hospital admission, diplopia was no longer observed. Diplopia was most probably caused by disturbances to the cholinergic neuromuscular transmission, secondary to nicotine. These neurological disturbances, the first of their kind observed in the course of GTS, deserve special attention. The case shows a potential adverse health effect related to tobacco harvest, as most Polish tobacco plantations are not mechanized. Polish farmers should be obligated to protect their workers with protective clothing, shoes, gloves and masks. Recommendations for tobacco harvester health are put forth in the paper.

Visual Deficit Interventions in Adult Stroke and Brain Injury

Visual deficits after cerebral injury are common. The variability in the types of injury sustained as well as their impact on function in the environment have produced multiple approaches at corrective intervention. To assess the effectiveness of these vision interventions, an extensive literature search was completed. The analysis of this review revealed some success with visual neglect disorders, but not enough evidence to comment definitively on interventions for hemianopsia, quadrantonopsia, diplopia, or convergence insufficiency. A lack of follow-up also limited efforts to assess the durability of documented gains. Additional research is necessary to clarify, quantify, and measure treatment outcomes for acquired visual dysfunction as well as to link laboratory testing to improvement in actual functioning for individuals in their environment.

[Using pedicled mandibular osteomuscular flap in orbital reconstruction]

Represented the way of orbital floor reconstruction using coronoid process of the mandible pedicled on temporal muscle. The clinical evaluation of vascularised bone graft from coronoid process confirmed their usefulness in the face recon struction surgery.

How to measure slab-off and reverse slab prism in spectacle lenses

It is well known that new spectacle lenses for the correction of anisometropia can induce diplopia with reading. The difference in the powers of the lenses induces a net prismatic effect that can cause double vision through off-center areas of the lenses. This is particularly bothersome when patients try to read, often noting vertical double vision in attempted downgaze, especially through multifocal add segments. This induced prismatic effect can be compensated at one level of downgaze by the use of slab-off or reverse slab prism. Typically the slab-off correction is ground into the stronger minus, or weaker plus lens. Reverse slab is ground into the weaker minus, or stronger plus, lens. Unfortunately, determining the amount of slab-off prism already incorporated into spectacle lenses is nonintuitive and inconvenient. This usually requires the use of a lens clock, which is not widely accessible to many ophthalmology practices. A simple technique, described in the past but poorly known, is illustrated here for quickly measuring slab-off and reverse slab prism prescription lenses in the clinic with a common manual lens meter.

[Correction of secondary anisometropia after retinal detachment and LASIK surgery]

CASE REPORT

A male with cylindrical anisometropia secondary to retinal detachment (RD) surgery in the right eye (OD) was referred for contact lens (CL) fitting. His refraction was OD -1.25 -2.75 x 60 degrees VA 1.0 and OS +0.25 VA 1.2. He was complaining of diplopia with spectacles. Seven years prior to the RD surgery, he had undergone LASIK without complications. The diplopia was eliminated after a CL was fitted according to his corneal topography.

DISCUSSION

RD surgery can cause anisometropic refractive changes. In patients with diplopia and asthenopia, spectacles are not well tolerated. CL fitting according to post-LASIK corneal geometry succeeded in refractive correction with less anisometropic symptoms.

Lymphangioma of the clivus: case report

OBJECTIVE

Different clival lesions have been reported in the literature previously. The lymphangioma reported in the present case seems to be the first lesion localized in the clivus.

CLINICAL PRESENTATION

The patient presented with a history of diplopia and headache. Imaging studies showed a lytic lesion at the cranial base.

INTERVENTION

Transsphenoidal excision of the lesion resulted in total resolution of the patient's complaints.

CONCLUSION

Lymphangioma must be kept in mind for the differential diagnosis of lytic lesions of the cranial base. Surgical removal leads to immediate improvement of the symptoms.

Intraoperative Relaxed Muscle Positioning Technique for Strabismus Repair in Thyroid Eye Disease

OBJECTIVE

To describe the outcomes of a relaxed muscle technique for treatment of dysthyroid strabismus.

DESIGN

Retrospective consecutive case series.

PARTICIPANTS

Twenty-four patients with thyroid-related orbitopathy (TRO) underwent strabismus surgery using a novel relaxed muscle technique.

METHODS

Charts of all patients who underwent rectus muscle recession surgery using a relaxed muscle technique between 1997 and 2004 were reviewed. Twenty-four of 28 patients had more than 2 months of follow-up and were included. The extent of recession was determined by marking where the tendon naturally fell while the relaxed muscle rested freely on the globe with the eye in the primary position. The muscle was sutured to the globe at the mark. Linear regression was used to determine the correlation between the degree of strabismus and the amount of recession required to eliminate diplopia.

MAIN OUTCOME MEASURES

Surgical outcomes were analyzed 2 months, 6 months, and 1 year after strabismus repair. Excellent success was defined as no diplopia in primary and reading gazes without prisms. Good outcome was defined as no diplopia in primary and reading positions with the use of <10 prism diopters. Poor outcome was defined as persistent diplopia in primary or reading positions despite prisms, or the inability of the patient to tolerate the necessary prisms.

RESULTS

Twenty-four patients underwent 60 muscle recessions. Nine had diplopia without a history of orbital decompression, 8 had diplopia before decompression, and 7 developed diplopia only after orbital decompression. Twenty-one patients (87.5%) had an excellent final outcome. A clinically acceptable (excellent or good) final outcome was achieved in 24 of 24 patients (100%) after an average of 1.08 surgeries. All 7 patients who developed diplopia only after decompression had an excellent outcome. Linear regression did not show good correlation between the degree of strabismus and the amount of recession required to eliminate diplopia (maximum R2 = 0.7292). There were no complications.

CONCLUSIONS

The relaxed muscle technique provides excellent ocular alignment and relief from diplopia in a majority of patients with TRO-associated strabismus. Patients who develop diplopia only after orbital decompression may have a higher success rate.

Preseptal transconjunctival approach for orbital floor fracture repair: ophthalmologic results in 209 patients

CONCLUSIONS

The transconjunctival approach to orbital floor fractures permits excellent exposure of the inferior orbit and provides a good surgical outcome, especially with regard to ocular motility.

OBJECTIVE

Surgical access to orbital floor fractures can be accomplished via the transconjunctival approach. The majority of studies on this subject deal with surgical aspects and complications. The purpose of this study was to report the ophthalmologic outcome after transconjunctival orbital floor fracture repositioning in a significant number of patients.

MATERIAL AND METHODS

In a retrospective study, the data of 209 patients with orbital floor fractures treated via the transconjunctival approach with (n=181) and without (n=28) lateral canthotomy were analyzed.

RESULTS

The commonest cause of injury was forms of violence (32%). An isolated fracture of the orbital floor had occurred in 62 cases, while concomitant facial fractures were present in the remaining 147. A total of 24 patients (11%) had an exophthalmos and 13 (9%) an enophthalmos. Most patients (69%) complained of infraorbital dysesthesia. When elevating the eyeball, the majority of patients showed a marked or severe disturbance of ocular motility (53% in abduction; 51% in adduction) and diplopia (37% in abduction; 36% in adduction). Thirteen patients required repeat surgery. After a follow-up period of 2 years, infraorbital dysesthesia was observed in only three patients, one of whom presented with a considerable persistent enophthalmos of 4 mm, and only four patients had persistent reduced motility and diplopia.

Transforniceal Lateral Deep Bone Decompression—A Modified Technique to Prevent Postoperative Diplopia in Patients with Disfiguring Exophthalmos Due to Dysthyroid Orbitopathy

BACKGROUND/PURPOSE

Postoperative diplopia remains a significant complication of orbital decompression in dysthyroid orbitopathy. This study evaluated the results of orbital decompression treatment using a transforniceal approach to sculpt the lateral orbital deep bone area.

METHODS

The two areas of bone in the deep lateral orbit (the basin of the inferior orbital fissure and the sphenoid door jamb) were exposed using a transforniceal swinging eyelid approach. An electric drill was used to sculpt these deep bone areas of the lateral orbit, and approximately 1 mL intraconal fat was removed simultaneously. Between October 1999 and March 2003, transforniceal lateral deep bone decompression was performed in 35 consecutive patients (62 orbits) with disfiguring dysthyroid orbitopathy. Data on proptosis reduction effect, new-onset diplopia and other complications of lateral wall decompression were analyzed.

RESULTS

The average preoperative Hertel value was 21.2 +/- 1.3 mm (range, 18-23 mm) and decreased to 17.4 +/- 1.2 mm (range, 15-19.5 mm) postoperatively. The mean decrease in proptosis 3 months postoperatively was 3.8 +/- 0.91 mm (range, 1.5-4.6 mm). New-onset downgaze diplopia occurred in two (5.7%) of the 35 patients. Persistent trigeminal paresthesia was noted in one patient (2.8%). No cerebrospinal fluid leak, globe injury or vision deterioration was noted during 9.5 +/- 1.7 months of follow-up. The cosmetic appearance was improved in all patients after surgery.

CONCLUSION

Transforniceal lateral deep bone decompression produces less new-onset, persistent diplopia than traditional inferomedial wall decompression, and provides good cosmesis by using a hidden small incisional wound. This approach appears to be a safe and effective procedure for patients with disfiguring exophthalmos, especially for Asian patients without crease fold.

The removal of the deep lateral wall in orbital decompression: its contribution to exophthalmos reduction and influence on consecutive diplopia

PURPOSE

To evaluate the contribution of maximal removal of the deep lateral wall of the orbit to exophthalmos reduction in Graves' orbitopathy and its influence on the onset of consecutive diplopia.

DESIGN

Case-control study.

METHODS

The medical records of two cohorts of patients affected by Graves' orbitopathy with exophthalmos > or = 23 mm, without preoperative diplopia, were retrieved at random from the pool of patients decompressed for rehabilitative reasons at our institution (01/1990 to 12/2003), and retrospectively reviewed. They had been treated with an extended (cases, group 1, n = 15) or conservative (controls, group 2, n = 15) 3-wall orbital decompression performed through a coronal approach. The deep portion of the lateral wall had been removed in the extended decompression group while preserved in the conservative decompression group. Demographics, preoperative characteristics, and surgical outcome were compared. The difference in mean exophthalmos reduction between groups 1 and 2 was considered to be the contribution of the deep lateral wall to reduction of exophthalmos.

RESULTS

Groups 1 and 2 were drawn from a pool of 37 and 335 patients, respectively. Demographics and preoperative characteristics of the two groups were not significantly different. The mean contribution of the deep lateral wall to exophthalmos reduction was 2.3 mm. The onset of consecutive diplopia was not significantly different between the two groups (case n = 2/15, controls n = 5/15; P = .203). Diplopia resolved spontaneously in all the patients of group 1, while all the patients of group 2 required surgery.

CONCLUSIONS

Removal of the deep lateral orbital wall as part of a coronal-approach, 3-wall decompression, enhances the degree of exophthalmos reduction without increasing the risk of consecutive diplopia.

Paranasal Sinus and Midfacial Reconstruction

Midface defects pose the most difficult of the facial reconstruction problems. Current reconstruction relies heavily on microsurgical techniques, among which there are numerous possibilities. Although midface defects frequently extend to the upper and lower face, often an awareness of the midface subunits most involved can be of critical importance. This article presents an approach that will help the surgeon to identify the defect-related problems, prioritize the reconstructive goals, and select the best surgical option in the total patient context.

Role of Hyaluronidase in Diplopia after Peribulbar Anesthesia for Cataract Surgery

OBJECTIVE

To determine the protective action of hyaluronidase on peribulbar anesthesia-related diplopia in patients undergoing cataract surgery.

DESIGN

Single-center observational case series.

PARTICIPANTS

All patients undergoing elective phacoemulsification and intraocular lens implantation under peribulbar anesthesia between February 2001 and January 2003.

METHODS

We compared the incidence of postoperative diplopia between 2 periods--February 2001 to January 2002 (P1) and February 2002 to January 2003 (P2)--which differed by the presence (P1) or absence (P2) of hyaluronidase in the anesthetic solution.

MAIN OUTCOME MEASURES

All patients were examined on the first and fifth postoperative days during both periods. When diplopia was diagnosed, we recorded the characteristics of the patient, peribulbar anesthesia, and diplopia (orthoptic examination, and magnetic resonance imaging in some cases).

RESULTS

Seven thousand two hundred five patients were studied. During P1, 3582 patients received peribulbar anesthesia, and no cases of diplopia occurred. During P2, 3623 patients received peribulbar anesthesia, and 27 cases of diplopia occurred (incidence, 0.75%; P = 0.0002 vs. P1). Diplopia involved the inferior rectus (40%) and the external rectus (37%) muscles. Diplopia was persistent in 54% of the cases.

CONCLUSIONS

Peribulbar anesthesia-related diplopia was significantly more frequent when hyaluronidase was not added to the anesthetic solution.