[Three-muscle surgery for large angle esotropia]

BACKGROUND

Bilateral medial rectus muscle recession with or without Cüppers' posterior fixation suture and recess and resect surgery are used to correct for large angle esotropia. There are only few reports on three muscle surgery (3MS). We analyzed the results of 3MS.

PATIENTS AND METHODS

Between June 2016 and May 2020, 61 patients received 3MS for esotropia ≥ 27° (50 PD) together with oblique muscle surgery, if needed. Angles of strabismus were measured by simultaneous prism and cover testing (SPCT) and alternating prism and cover testing (APCT) at 5 m and 0.3 m. Grading was around 0.51 mm/degree (at 5 m). Medium-term results of 57 patients were available.

RESULTS

Medians and ranges (min-max) were: age, 6 years (3-56 years). Preoperative APCT, far 34° (27-45°), near 36° (27-50°). Amount of surgery, 17 mm (15-21 mm), oblique muscle recession in 21 cases. The APCT after 5 months (3-24 months), far 2° (-10-18), near 2° (-8-18). Success rates (absolute deviation ≤ 6° [10 PD]), APCT far 68%, near 67%, SPCT far 79%, near 74%. Exotropia > 6° occurred in 4 cases (7%) at far and 3 (5%) at near, esotropia > 6° in 14 cases (25%) at far and 16 (28%) at near.

CONCLUSION

The use of 3MS is a suitable first step procedure to correct for large angle esotropia.

Wall-Eyed Monocular Inter-Nuclear Ophthalmoplegia (WEMINO) Syndrome, A Rare Decisive Manifestation Of An Isolated Unilateral Pontine Stroke

Isolated unilateral pontine infarction is an uncommon occurrence. It may bring a complex neuroophthalmic manifestation to the clinicians, making the on-spot-diagnosis a hard challenge. Wall-eyed monocular inter-nuclear ophthalmoplegia (WEMINO) syndrome is a rare variant of inter-nuclear ophthalmoplegia which also includes ipsilesional exotropia. The literature seems deficient in documenting WEMINO syndrome the primary presentation of isolated unilateral pontine stroke. The location of the causative lesion of WEMINO syndrome is a hot topic. Here, we discuss a case of WEMINO syndrome, a rare presentation of limited unilateral pontine stroke and its responsible lesion. To the best of our knowledge this is the first reported case from Pakistan. A short literature review has also been presented on the anatomy, pathophysiology and various manifestations of isolated unilateral pontine lesion in the region of medial longitudinal fascicules (MLF). Hence, this article enhances the understanding of clinicians regarding the responsible lesions limited to pons and its various manifestations, in order to enable clinicians to pick them in the early opportunity.

Subnormal Binocular Contrast Sensitivity Summation in Patients with Intermittent Exotropia

BACKGROUND

To evaluate binocular summation ratio using contrast sensitivity (CS) testing and correlation between binocular summation and stereoacuity, and control scale in intermittent exotropia (IXT).

METHODS

We conducted a prospective case-control study. Thirty-seven IXT and 41 controls were evaluated with both monocular and binocular CS testing. We compared the binocular summation ratio of IXT to that of controls. Near and distance stereoacuity was assessed and office-based control scale was evaluated. We investigated correlation between binocular CS summation ratio and stereoacuity, and control scale in IXT, respectively.

RESULTS

IXT had lower binocular CS summation ratio than controls at 1.5 and 3.0 cycles/degree (1.01 ± 1.02 vs. 1.62 ± 1.88 and 1.17 ± 0.96 vs. 1.86 ± 1.75, Both P < 0.05). We found significant correlation between binocular CS summation ratio at 3.0 cycles/degree and both near and distance stereoacuity (r = -0.411, P = 0.012 and r = -0.624, P = 0.005), and ratio at 1.5 cycles/degree also correlated significantly with distance stereoacuity (r = -0.397, P = 0.034) in the IXT. Binocular CS summation ratio was correlated to control scale at 1.5 and 3.0 cycles/degree (r = -0.327, P = 0.041 and r = -0.418, P = 0.028), and the ratio significantly differed in control scale groupings analysis at the same frequencies (Both P < 0.05).

CONCLUSION

Our findings of subnormal binocular CS summation ratio in IXT had correlation with stereoacuity and control scale suggest that binocular CS testing may be a useful method in assessing binocular visual function in IXT.

Congenital Brown's Syndrome: Clinical and Surgical Approach

Brown's syndrome is a well-recognized clinical disorder of ocular motility consisting mainly of a restriction of active and passive elevation in adduction. We report a series of 17 patients with true Brown's syndrome and discuss the clinical features and results of surgical intervention. Surgery should be considered carefully for the treatment of this syndrome as reoperation may be necessary and spontaneous resolution is seen during long-term follow-up of some patients.

Type 4 Duane syndrome

PURPOSE

To identify cases of synergistic divergence whose characteristics suggest that this entity is a form of Duane syndrome.

METHODS

The records of all patients with a Duane syndrome diagnosis, including standardized eye position photographs, from the E-Consultation program of Cybersight, Orbis International were analyzed.

RESULTS

A total of 350 Duane syndrome cases were identified. Of these, 19 (5%) had features consistent with synergistic divergence, or type 4 Duane syndrome. Of the 19, 16 (84%) were male, 15 (79%) had palpebral fissure narrowing, all had anomalous head posture, and 18 (95%) were exotropic. Only 9 (47%) patients were reported to have undergone surgery.

CONCLUSIONS

Synergistic divergence is a rare entity with features similar to those of Duane syndrome. We suggest that this entity be classified as type 4 Duane syndrome, because it has unique findings and an innervation pattern that differs from the other 3 recognized types.

[Long-Term Follow-up of Age-related Strabismus Patients 50 Years-old and Over]

PURPOSE

To characterize age-related strabismus by long term observation.

METHODS

Clinical Characteristics were collected at two institutions from patients 50 years-old and over with age-related strabismus, who complained of diplopia and were followed up longer than 2 years without surgical intervention.

RESULTS

The cohort consisted of one case of near exotropia (convergence insufficiency, exotropia angle at near was 11.3 degrees), eight cases of distance esotropia (divergence insufficiency, average esotropia angle at distance was 5.8 degrees), and 15 cases of hypertropia (average hypertropia angle at distance was 3.6 degrees). In 14 patients more than one year passed from the onset of diplopia to date of visiting one of the two clinics. The strabismus angle slowly increased (0.3 per year in average; Wicoxon signed-rank test, p < 0.01). 17 patients successfully used prism incorporated glasses. Diplopia was intermittent at first and became more frequent in most cases. Hypertropic patients often showed extorsion of the lower eye.

CONCLUSION

Age-related strabismus eyes slowly develop diplopia and very slowly get worse in deviation angle. Prism incorporated glasses are useful in this condition.

Slanted medial rectus recesection for treatment of exotropia with convergence insufficiency strabismus: a report of results in 15 cases

PURPOSE

To evaluate the surgical and functional results of slanted medial rectus resection for treatment intermittent exotropia of the convergence insufficiency type.

METHODS

Fifteen patients with near vision asthenopia and intermittent exotropia of the convergence insufficiency type were included in this prospective study. The upper edge of the MR was resected more than the lower edge. Slanted bilateral or unilateral medial rectus resection was performed. The mean length of follow-up was 14.9 months.

RESULTS

Slanted medial rectus resection(s) caused a significant postoperative reduction in the mean distance exodeviation from 11.40 to 4.53 PD, as well as a change in the mean near exodeviation from 23.93 to 10.73 PD. Although mean near-distance difference reduced from 12.53 to 6.2 PD. In final examination, 11 patients showed surgical success rate and recurrent exotropia occurred in 4 cases. On the other hand, 13 cases had experienced significant relief from their symptoms.

CONCLUSION

Slanted medial rectus resection is useful in decreasing the symptoms of intermittent exotropia of the convergence insufficiency type. However, it can result in undercorrection in larger deviations.

Rick factors for secondary exotropia following a retroequatorial myopexy of the medial rectus muscle with recession for esotropia. A retrospective study of 448 cases

PURPOSE

To determine which factors are important in the development of secondary exotropia and the incidence of secondary exotropia occurring after a retroequatorial myopexy of the medial rectus muscle with recession in the treatment for partially accommodative esotropia associated with convergence excess.

METHODS

In this retrospective study, the patients that underwent retroequatorial myopexy on both medial rectus muscles with recessions for partially accommodative esotropia associated with convergence excess were included. The incidences and angles of secondary exotropia at near and distance fixation were evaluated and the risk factors for secondary exotropia were analyzed.

RESULTS

Four hundred forty-eight patients had retroequatorial myopexy on both medial rectus muscles with recessions. Three hundred forty-nine of 448 patients maintained satisfactory near and distance binocular alignment at the final follow-up. Secondary exotropia occurred in 37 of these patients and residual esotropia occurred in 62 patients. There were no significant differences between the incidences and angles of secondary exotropia at near and distance fixation. The preoperative absence of binocularity was the only independent risk factor for developing secondary exotropia after a retroequatorial myopexy of medial rectus muscle with recession.

CONCLUSION

We determined that secondary exotropia was not a common result of retroequatorial myopexy of the medial rectus muscles with recession. We determined that the preoperative absence of binocularity was the only independent risk factor identified in this study.

Inferior oblique muscle palsy with "paradoxical" v-pattern strabismus

BACKGROUND AND PURPOSE

A- and V-patterns are commonly encountered with cyclovertical muscle palsies. Inferior oblique (IO) muscle palsy produces and A-pattern caused mainly by the decreasing abducting action of the IO in upgaze and an increasing abduction action of the superior oblique in downgaze. V-pattern association with an IO palsy has not been, to our knowledge, reported before. The purpose of our paper is to report on a patient iwth IO palsy and a paradoxical V-pattern and explain the proposed pathophysiology behind the V-pattern.

CASE REPORT

We report a 67 year old female with a 3 year history of diplopia. She met the Bielschowsky/Parks three step test to identify an IO muscle palsy, and she showed all the usual criteria of an IO muscle palsy except for a paradoxical V-pattern.

CONCLUSION

Many forces affect patterns in cyclovertical muscle palsies. A V-pattern in IO palsy can be explained by the spread of comitance resulting in inhibitional innervational pseudo-palsy of the superior rectus muscle resulting in V-exotropia or in inhibitional palsy of the contralateral superior oblique muscle resulting in V-esotropia.

Diagnosis and surgical treatment of dissociated horizontal deviation strabismus

PURPOSE

Obtaining satisfactory binocular alignment in patients with Dissociated Horizontal Deviation (DHD) requires a proper diagnosis and a specific surgical strategy. Clinical characteristics, surgical treatment and the results obtained in 20 patients with DHD are reported with a mean of 35 months postsurgical follow up.

PATIENTS AND METHOD

Retrospective record review of patients with DHD who underwent surgery between 2000 and 2007. Patient data were recorded, including age, sex, history of prior surgery, visual acuity, pre-operative angle with each eye fixing, Reversed Fixation Test (RFT) when available, type of operation performed, and final binocular alignment.

RESULTS

Twenty patients were identified, mean age 11.7 years old, all of them with age less than 12 months at the time of strabismus onset. Ten of them had had prior surgery for congenital esotropia. Nine showed exotropia (XT), 9 esotropia (ET) and 2 had ET when fixing with OS and XT when fixing with OD. All of them also had an associated Dissociated Vertical Deviation (DVD). Seven patients had amblyopia in the non-dominant eye. Six patients underwent a single operation, 13 underwent 2 operations and 1 needed 3 surgeries to obtain satisfactory binocular alignment.

CONCLUSIONS

Patients with DHD also exhibit bilateral and, very often, asymmetric DVD. Therefore, a surgical plan for both the horizontal and vertical dissociation drift of the eyes is needed. Bilateral surgery is almost always necessary, even in cases with a strong fixation preference, in order to obtain satisfactory binocular alignment.

Three Similar But Unique Cases Of Isolated Superior Rectus ExtraOcular Muscle (EOM) Palsy Strabismus, Presenting With Large Abnormal Head Tilts (Postures, AHP)

PURPOSE

To report 3 rare cases, seen over 15 years, of isolated superior rectus (SR) palsy in binocularly fusing pediatric patients presenting with appropriate head tilts.

PATIENTS AND METHOD

All 3 children, ages 11, 16, and 34 mos, presented with large right head tilts and secondary overactions of the right inferior oblique indicating LSR palsy. All 3 children received recessions of the antagonist left inferior rectus (LIR) 8 to 9 mm with 3 mm of nasal transposition to prevent exotropia in down gaze.

RESULTS

All 3 children had zero head tilt 4 weeks after their LIR recessions of 8 to 9 mm, but all 3 children developed a significant contralateral left head tilt three months after their LIR recessions. Two of the 3 them three-stepped to produce a pattern of (previously occult) SR palsy. These 2 received recessions of the RIR 5.8 to 6.5 mm. One of the 3 had a pattern that indicated LIR weakness; his LIR was advanced 2.5 mm from a 9 mm recession to a 6.5 mm recession. No significant head tilts remained or developed anew after the second surgery, but two of the three cases eventually developed apparent primary overactions of the inferior obliques and received successful weakening procedures of the inferior obliques. Due to inclusion in each case of special handling of the intermuscular septa and Lockwoods ligament (for details see later text), none of the 3 children had lower lid retraction after the large IR recessions.

CONCLUSIONS

In view of the fact that the superior division of the Third Cranial Nerve also innervates the adjacent levator and these three cases have had no blepharoptosis suggests that these apparently palsied superior rectus muscles may have been congenitally hypoplastic. Classic MRI (Magnetic Resonance Imaging) of the EOM by the techniques of Demer, to confirm this hypothesis, have not been available in these children, because of the current technical limitations of such diagnostic imaging in the case of young children who cannot maintain steady fixation for the time required.

Hereditary wide angle exotropia in a nigerian family

AIM

To present a report of a Nigerian family with wide angle exotropia resulting in amblyopia.

METHODS

A family of two wives and 12 children from Benin City, Edo State, Nigeria were interviewed and examined at the University of Benin Teaching Hospital, Benin City with the aid of a Snellen's chart, pen torch, slit lamp biomicroscope, ophthalmoscope and the pulsair non-contact tonometer.

RESULTS

There was 450 exotropia in the right eye of the 72 year old father, his 36 year old son, his 22 years old daughter and their 24 year old half sister. There was restriction of ocular motility in the right eye medially and some degree of amblyopia in the right eye of all the patients. The father and his 22 years old daughter were myopic of between -4.00 and -6.00 dioptre sphere but the son and his 24 years old half sister had -0.75 and -1.00 dioptre sphere myopia respectively. None of them presented to hospital because of the strabismus.

CONCLUSION

This report highlights the need to screen family members of patients with squint in order to detect the condition early and prevent amblyopia.

Common ophthalmologic concerns in infants and children

Pediatric ophthalmology differs from adult eye care in many aspects. Some disorders are seen only in children although others may be found in adults as well. A major difference between pediatric and adult ophthalmology is the impact that almost any disorder may have on the developing visual system. This article addresses common pediatric eye disorders and their potential effects on the visually impaired immature child. Referral guidelines and vision screening are also discussed.