Management of strabismus due to orbital myositis

We report on 5 consecutive patients seen at the botulinum toxin clinic at Moorfields Eye Hospital with an ocular motility disorder secondary to orbital myositis. CT scans demonstrated involvement of one or both of the medial recti in the inflammatory process in all 5 patients. In addition 1 patient had involvement of both the lateral recti and the right superior rectus. Two patients had been treated with oral steroids, 3 with non-steroidal anti-inflammatory agents, and 1 with orbital radiotherapy. Prior to toxin injection 3 patients had an esotropia (ranging from 4 delta to 30 delta) and two an exotropia (52 delta and 85 delta). A vertical imbalance was present in 3, and all 5 patients had symptomatic diplopia. A total of six injections were given to 5 patients, 2 of whom later went on to have surgery. Toxin injection reduced the angle of the deviation to less than 10 delta in 4 patients, all of whom are now asymptomatic. The fifth patient has persistent diplopia despite two operations to correct a large exotropia. We discuss the role of botulinum toxin and surgery in the management of strabismus due to orbital myositis.

Management of VIth nerve palsy--avoiding unnecessary surgery

Unresolved VIth nerve palsy that is not adequately controlled by an abnormal head posture or prisms can be very suitably treated by surgery. It is however essential to differentiate partially recovered palsies, which are amenable to horizontal rectus surgery, from unrecovered palsies, which must be treated initially by a vertical muscle transposition procedure. Botulinum toxin is a valuable tool in making this distinction. It also facilitates full tendon transposition in unrecovered palsies, which appears to produce the best functional outcome of all the transposition procedures, with a reduction in the need for further surgery. A study of the surgical management of 12 patients with partially recovered VIth nerve palsy and 59 patients with unrecovered palsy provides clear guidelines on how to attain a successful functional outcome with the minimum amount of surgery.

[Diplopia in fractures of the orbital floor]

Based on their own experience with surgical treatment of 43 patients with fractures of the orbital floor, the authors discuss the problem of early operation in relation to the development of residual diplopia. They evaluate the functional result by the size of the visual field where diplopia occurred. In confirmed fractures of the orbit they recommend operation as early as possible after the injury. All patients were operated by the method of transantral reposition of the orbital floor. Satisfactory functional results were achieved in all operated patients. None of them had diplopia in the primary position of the eyes. The best results were achieved in patients operated early (residual diplopia in 10%), where none of the patients had diplopia in the visual field beneath 30 degrees.

Early and late botulinum toxin treatment of acute sixth nerve palsy

Ten patients with sixth nerve palsy were treated with botulinum toxin injection to the antagonist nonparetic medial rectus. All patients were followed for a minimum of 14 months after the last injection. Six patients were treated within eight weeks of the onset of the palsy. Within a few days five of the six gained fusion, without the necessity of a marked head turn and none complained of confusing reversal of diplopia. The same five recovered full function. Four patients with no medial rectus contracture on forced duction testing were treated six months or longer after the onset of the palsy and none recovered full function. One of the four patients was permanently over-corrected despite persistent weakness of the lateral rectus. This preliminary report suggests that early botulinum toxin injection of patients with recent onset (acute) sixth nerve palsy is beneficial. Since some patients may recover spontaneously a randomised double-blind study is necessary to more precisely determine the effectiveness of this form of therapy. Botulinum toxin does not appear to be effective in facilitating recovery in those cases with poor lateral rectus function six months or longer after the onset of the palsy, even when there is no contracture of the medial rectus.

[Use of nerve division in oculomotor paralysis]

Sectors have a double interest in an extraocular muscle palsy: to avoid the diplopia and to aid the reeducation of palsied muscles. Patient can alternatively wear the two types of glasses with sectors. Authors decrease sector's size when motility improves. They are stopped if regression, and in other cases, patients can wait surgical time with maximum comfort. Clinical examples are presented: VI, III and IV cranial nerve palsies and generalized diplopia.

Pigmented corneal implants: a surgical treatment for iridectomy related optical complications

Initial evaluation in rabbits demonstrates that corneal implants made from prolene and nylon sutures flattened into strips appear promising as a means of covering diplopia or glare-inducing iridectomies. Two-month follow-up studies showed the implants to be well tolerated in the corneal stroma. Results of the studies suggest that black prolene films of 50 to 70 micrometers in thickness, contoured to follow the corneal curvature, would be the ideal configuration for such implants.

Surgical treatment of orbital floor fractures

This study retrospectively examines 551 patients with 597 orbital floor fractures for sequelae of enophthalmos and diplopia. Ocular injuries are associated with 6.9% of the fractures. Nondisplaced orbital floor fractures have been treated with observation alone, resulting in an incidence of sequelae of zero in 263 patients. Displaced fractures that had not undergone surgery have resulted in an incidence of sequelae of 18 (34%) in 53 patients. Displaced fractures that had undergone orbital floor exploration have resulted in an incidence of sequelae of 29 (10.3%) in 281 patients. Only one mild loss of visual acuity has complicated the 281 surgical procedures. It is concluded that orbital floor exploration is not indicated in patients with nondisplaced fractures of the orbital floor and that orbital floor exploration is a safe and effective means of reducing the complications associated with displaced fractures of the orbital floor.

Bony reconstruction in the orbital region

The author discusses the various problems that can arise in the static or dynamic state in the eyeball, the eyelids, and the lacrymal canals--due to alterations of the bony orbit. Reconstruction techniques in the orbitomaxillomalar, orbitonasal, and frontoorbital regions are dealt with separately, with emphasis on the need for a global and primary solution to all the alterations. Particular attention is payed to some cases of fibrous dysplasia in the frontoorbital region that were treated with reimplantation of the same dysplasic bone after it was remodeled. This is a personal technique that is suggested as an alternative treatment for this kind of lesion.

Superior oblique paresis after blepharoplasty

A case of superior oblique paresis is presented which appeared to be due to cautherization of the superior oblique tendon. The torsional diplopia and head tilt were corrected with recession of the contralateral inferior rectus muscle.