Cyclic exotropia associated with retinitis pigmentosa

Alteration Ocular Motility in Retinitis Pigmentosa: Case-Control Study

Purpose

To evaluate ocular motility (OM) disorders and strabismus in a sample of patients with retinitis pigmentosa (RP) and a control sample.

Methods

In this cross-sectional retrospective analysis, we studied a sample of RP patients with a mean age of 48.74 years and an average visual acuity of 7/10 based on Snellen optotype and a sample of control patients with similar mean age (49 years [men], 47 years [women]) and sex and an average visual acuity of 9.9/10, with the aim of assessing correlations between alteration of OM and strabismus in RP patients based on age, high refractive defect, or severely impaired binocular vision. The examination followed a protocol of testing for anamnesis and best-corrected visual acuity, as well as a complete eye examination, corneal reflex, cover test, OM, Hess screen, and Lang test.

Results

At the first orthoptic evaluation, 45.16% of patients showed strabismus, 41.93% exotropia (25% of cases intermittent), 3.22% esotropia, and 6.45% vertical deviation. Later evaluation showed strabismus in 25.80% of patients, exotropia in 19.35% (9.67% intermittent), esotropia in 3.22%, and vertical deviation in 3.22%. Assessment of eye motility study showed 51.6% overaction of the inferior oblique and hypofunction of the superior rectus, and 18% overaction of the lateral rectus and hypofunction of the medial rectus. According to our results, alterations in OM and strabismus in RP patients are not correlated with age or high refractive defect. Therefore, motility disorders and strabismus are attributed to a genetic factor to which men are more susceptible.

Conclusion

The incidence of OM disorder was 77.42%, and strabismus was present in 45.16% of patients.

Retroequatorial myopexy in the management of adult-onset cyclic esotropia

A 65-year-old otherwise healthy female, with bilateral normal visual acuity, presented with a unique pattern of strabismus. She complained of esotropia and diplopia occurring after every 24 h. There was no history of previous injury or ocular surgery. Other differentials were ruled out and the patient was diagnosed as adult-onset cyclic esotropia. The patient underwent right eye medial rectus retroequatorial myopexy, which tackled both diplopia and strabismus, without causing exotropia on nonsquint days.

Role of Botulinum Toxin Type A in Cyclic Esotropia: A Long-Term Follow-up

PURPOSE

To describe two patients with childhood cyclic esotropia 8 and 9 years after they underwent botulinum toxin type A treatment to report its long-term outcome.

METHODS

Two patients with sudden onset cyclic esotropia aged 2 and 4 years were included. Botulinum toxin type A injections were performed on the appropriate muscles.

RESULTS

The first patient was a 2-year-old boy with left dominant alternating esotropia on a cyclic basis. His strabismus ranged from 25 to 45 prism diopters (PD) at near and distance. A botulinum toxin type A injection into the left medial rectus muscle revealed orthotropia at near and distance with a stereopsis of 60 seconds of arc (arcsec). During the 9 years of follow-up, he remained stable. The second patient was a 4-year-old girl who complained of double vision and strabismus. Her deviation was 40 PD at near and 35 PD at distance on a cyclic pattern. She became orthotropic with glasses after a bimedial botulinum toxin A injection. During the 8 years of follow-up, she remained stable with a stereo-acuity of 120 arcsec.

CONCLUSIONS

Considering the consecutive and recurrent deviations with surgical treatment in previous reports, botulinum toxin type A is an appropriate first-line option for the treatment of cyclic deviations, despite its limitations. The results suggest that botulinum toxin type A is an effective method to break the cycle in cyclic esotropia permanently. [J Pediatr Ophthalmol Strabismus. 2019;56(6):360-364.].

Argus II Retinal Prosthesis Implantation in a Patient With a History Of Strabismus Surgery:A Surgical Technique

BACKGROUND AND OBJECTIVE

The authors describe a modified surgical technique for Argus II retinal prosthesis implantation.

PATIENTS AND METHODS

The modified surgical technique was performed in a 43-year-old male with retinitis pigmentosa (RP) who underwent strabismus surgery in that eye at age 8.

RESULTS

During Argus II implantation, the lateral rectus (LR) was noted to be 10 mm posterior to its original insertion due to prior strabismus surgery. The authors placed three 5-0 nylon mattress sutures at the expected location of the LR to support the external portion of the prosthesis, specifically the coil. The band was then passed through the mattress sutures, underneath the inferior, and medial recti with temporal placement of the coil.

CONCLUSION

Placement of three mattress sutures allowed proper positioning of the device and enabled fixation of the suture tabs, thus minimizing the risk of postoperative conjunctival erosion and device exposure. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:116-119.].

Acquired Adult Onset Cyclic Esotropia in Patients With Myopic Strabismus Fixus and Intraocular Lens Implantation

PURPOSE/BACKGROUND

Cyclic esotropia is a rare condition that mostly occurs in children, characterized by patterns of straight and strabismic days with a regular cycle of 24 to 96 hours. In this report, 2 patients of cyclic esotropia in adults who showed a regular 48-hour cycle of mild deviation on 1 day followed by a more severe deviation on the second day are presented.

METHODS

Clinical reports, clinical features, imaging findings, and surgical outcomes are presented.

RESULTS

In patient 1, a 42-year-old male with high myopia was diagnosed with progressive esotropia for 2 years. A medial and lateral rectus (LR) recession/resection was performed 9 months before. On day 1 after this surgery, a relatively mild esotropia was present which developed into a severe esotropia on day 2. Being diagnosed as cyclic esotropia with myopic strabismus fixus, he underwent a 4 mm re-recession of the medial rectus combined with a half-Jensen procedure in his right eye. After the second surgery, the cyclic pattern was no longer present. In patient 2, a 39-year-old female with high myopia had concomitant esotropia for 20 years. At 6 months following bilateral intraocular lens implantation for her high myopia, she demonstrated a cyclic strabismus. On day 1, a 25 prism dioptres esotropia was present, which increased to a 45 prism diopters esotropia on day 2. A 4 mm recession of the medial rectus and 6 mm resection of the LR was performed in her left eye. After surgery, the cyclic pattern disappeared.

CONCLUSIONS

Cyclic esotropia can occur in adults with myopic strabismus fixus subjected to horizontal strabismus surgery and with concomitant strabismus following intraocular lens implantation for high myopia. Their cyclic strabismus consisted of a mild squint on day 1 which increased in severity on day 2. The extent of surgery required for correction was based upon the "severe esotropia" experienced on day 2 and resulted in an excellent therapeutic outcome.

Cyclic strabismus in adults

Cyclic strabismus is a rare condition that usually occurs in children and is characterized by alternating intervals of straight and strabismic eyes. In adults with the condition, strabismus surgery often eliminates the cycles. We report a case of adult-onset cyclic esotropia that was converted into a cyclic exotropia.

Cyclic (alternate day) vertical deviation--possible forme fruste of ocular neuromyotonia

PURPOSE

Cyclic ocular deviations are relatively uncommon and are seldom seen in adults. We report 3 adult patients with cyclic hypotropia that has clinical characteristics similar to neuromyotonia, suggesting a possible common etiology.

METHODS

Three consecutive patients with 48-hour cyclic hypotropia underwent full neuro-ophthalmologic, oculoplastics, and orthoptic evaluations as well as appropriate medical and neurologic studies. Examinations were arranged on consecutive days on multiple visits to document the cyclic pattern.

RESULTS

All 3 patients had sustained contraction of a vertically acting extraocular muscle lasting 24 hours and demonstrated characteristics of ocular neuromyotonia. The contraction was absent for the next 24 hours. Two of the patients had thyroid eye disease; the third patient had unilateral ophthalmoparesis and had subsequent frameless robotic radiosurgery for a cavernous sinus schwannoma. Regular cycles lasting 6, 9, or 14 months were documented by all 3 patients. In 2 patients, treatment with carbamazepine and gabapentin effectively reduced or eliminated the cycle. The cyclic deviation in the third patient resolved spontaneously.

CONCLUSIONS

On the basis of the response of these patients to membrane-stabilizing medications and the behavior noted as the cycle broke each day, we propose that cyclic vertical strabismus and ocular neuromyotonia may be related conditions with similar underlying physiology.

Adult-onset cyclic esotropia: a case report

PURPOSE

This case report presents the diagnosis and management of an adult patient with cyclic esotropia, a rare and poorly understood form of strabismus, that is characterized by alternating periods of manifest strabismus and orthotropia. Few cases of adult-onset cyclic strabismus have been reported. The etiology, pathogenesis, and treatment for this condition are reviewed.

CASE REPORT

A 37-year-old man with high unilateral myopia and anisometropic amblyopia in his left eye developed cyclic esotropia 2 months after a scleral buckle procedure for a retinal detachment. A 48-hour cycle that consisted of a 24-hour period of orthotropia followed by a 24-hour period of constant left esotropia was present. Magnetic resonance imaging, electromyography, electroencephalography, and ocular and orbital echography were unremarkable, as was a neurological assessment that included fatigue and edrophonium testing. The patient was successfully managed with muscle surgery.

CONCLUSIONS

The etiology and pathogenesis of adult-onset cyclic esotropia remain unknown. Cyclic esotropia should be considered in the differential diagnosis when an individual presents with a history of intermittent strabismus that is present some days and not others.

Cyclic exotropia in a child

Cyclic strabismus is an uncommon disorder in which strabismus alternates with orthotropia in alternating 24-hour periods, although cycles of other lengths have also been described. Alternate-day exotropia is a rare form of cyclic strabismus which, to date, has been reported in few patients. We describe a case of alternate-day exotropia in a child who had previously undergone surgical correction of constant esotropia.

Alternate day exotropia

INTRODUCTION

Cyclic strabismus is a rare disorder in which manifest strabismus and controlled latent deviation (heterophoria) alternates on a regular pattern which is usually over a 48-hr period. During the "straight" period the patient has a fully controlled heterophoria for all distances, with very good fusion and stereopsis. During the "squinting" period the patient has a constant manifest strabismus for all distances, with no demonstrable fusion and stereopsis.

METHOD

We describe 2 cases of alternate day exotropia. One patient requires strabismus surgery to obtain constant binocularity. The second patient underwent surgery for an intermittent exotropia and subsequently developed an alternate day exotropia. The condition very gradually reduced over the years and the patient is now fully binocular.

CONCLUSION

We report the first 2 cases of cyclic exotropia in non-Japanese female children presenting from about 1 to 3 years of age, without ocular or systemic pathology.

Acquired cyclic exotropia and hypotropia

Cyclic exotropia, a very rare condition, consists of periods of exotropia and orthotropia alternating on a regular, most commonly 48-hour, cycle. Cyclic vertical deviations, including cyclic oculomotor nerve palsy, also are extremely uncommon. Cyclic esotropia, which is more common than cyclic exotropia, has been reported to occur more frequently in children than adults. We describe an adult patient who developed cyclic exotropia and hypotropia associated with monocular loss of vision.

Consecutive cyclic exotropia after surgery for adult-onset cyclic esotropia

Cyclic esotropia--periods of esotropia alternating with periods of orthotropia, most commonly on a 48-hour cycle--is a rare condition seen mostly in children. Surgical correction of the maximum deviation generally corrects the esotropia without resulting in alternating periods of exotropia, as might be expected if the periodicity continued postoperatively. Unlike cyclic esotropia in children, the few reported adult cases have often been associated with severe acquired monocular visual impairment; however, the response to surgical treatment is reported to be the same as that in children. We report here an exception, in which an adult patient developed cyclic exotropia after surgical correction of her acquired cyclic esotropia.