Improvement of compensatory head postures after strabismus surgery

The impact of strabismus on psychosocial heath and quality of life: a systematic review

Strabismus can hinder an individual's ability to perform daily functions and negatively affect their well-being. I examine the impact strabismus has on psychosocial health and quality of life in children and adults and evaluate the challenges confronted by parents of children with strabismus. Numerous misconceptions exist regarding the impact strabismus has on overall health. Negative attitudes persist toward those affected, resulting in difficulties with self-image. Individuals with strabismus are at increased risk for both visual system and psychiatric disorders. Misinformation regarding available treatment options for children and adults with strabismus continues to exist, resulting in decreased access to care. Improved education of health care providers can increase appropriate referrals and initiation of treatment. Treatment of strabismus is not merely cosmetic and has the potential to improve psychosocial health and quality of life for children and adults with and without diplopia.

Ocular abnormal head posture: A literature review

Purpose:

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Results:

Conclusion:

Management of nystagmus in children: a review of the literature and current practice in UK specialist services

Nystagmus is an eye movement disorder characterised by abnormal, involuntary rhythmic oscillations of one or both eyes, initiated by a slow phase. It is not uncommon in the UK and regularly seen in paediatric ophthalmology and adult general/strabismus clinics. In some cases, it occurs in isolation, and in others, it occurs as part of a multisystem disorder, severe visual impairment or neurological disorder. Similarly, in some cases, visual acuity can be normal and in others can be severely degraded. Furthermore, the impact on vision goes well beyond static acuity alone, is rarely measured and may vary on a minute-to-minute, day-to-day or month-to-month basis. For these reasons, management of children with nystagmus in the UK is varied, and patients report hugely different experiences and investigations. In this review, we hope to shine a light on the current management of children with nystagmus across five specialist centres in the UK in order to present, for the first time, a consensus on investigation and clinical management.

Duane Retraction Syndrome: Clinical Features and a Case Group-Specific Surgical Approach

PURPOSE

To describe the clinical features of patients with Duane retraction syndrome (DRS) and evaluate the outcomes of surgical approaches based on the characteristics of each patient.

METHODS

The records of 38 Caucasian subjects with DRS were retrospectively reviewed. The patients were classified as type I, II, or III based on the Huber Classification. Ten patients underwent unilateral medial rectus (MR) recession due to abnormal head posture (AHP) and/or esotropia. Four patients underwent Y-splitting and recession of the lateral rectus (LR) with MR recession due to AHP and/or esotropia, upshoot, and globe retraction.

RESULTS

There was a preponderance of unilaterality, female gender, left eye, type I, orthotropia, upshoot, and low refractive error. All patients demonstrated globe retraction and fissure narrowing. AHP was only present in unilateral cases. Nine patients had amblyopia. More than half of the patients over 5 years of age had decreased stereopsis. MR recession decreased AHP to less than 8° in all patients. Y-splitting and recession of the LR eliminated upshoot in all four patients. One patient who underwent an 8-mm MR recession demonstrated -2 adduction limitation.

CONCLUSIONS

The DRS patients in our study demonstrated features that are consistent with previous reports in the literature. This study emphasizes the need to consider disease classification in the surgical management of DRS patients.

Ocular Causes of Abnormal Head Position: Strabismus Clinic Data

Objectives:

To determine the most common ocular causes and types of abnormal head position (AHP) and describe their clinical features.

Materials and Methods:

Patients with AHP who had been followed in the strabismus unit were retrospectively reviewed. Demographic features and orthoptic characteristics were recorded.

Results:

A total of 163 patients including 61 women (37.4%) and 102 men (62.6%), with a mean age of 19.9±18.3 were recruited. The most common causes of AHP were determined as fourth cranial nerve palsy (33.7%), Duane retraction syndrome (21.5%), sixth cranial nerve palsy (11%), nystagmus blockage syndrome (9.8%) and Brown syndrome (6.7%). Other less frequent causes were A-V pattern strabismus, comitant strabismus, thyroid orbitopathy and third cranial nerve palsy. The most common types of AHP were head tilt (45.4%) and face turn (36.8%). Out of 142 patients whose visual acuity could be evaluated, 28.2% had amblyopia. The frequency of amblyopia varied depending on the diagnosis (p<0.001), while there was no relation between amblyopia and different types of AHP (p=0.497). Stereopsis and fusion could be tested in 128 patients and 43.8% of them had stereopsis and fusion. The presence of stereopsis and fusion was found to be related with the diagnosis (p=0.001), whereas it was not related with the types of AHP (p=0.580). The presence of amblyopia was not significantly associated with fusion (p=1.000) or stereopsis (p=0.602).

Conclusion:

There are many ocular pathologies that cause AHP. Patients with similar diagnoses may have different types of AHP. Patients may have amblyopia and impaired binocularity despite AHP. Therefore, all patients with AHP should be examined in detail and these points should be considered in the treatment plan.

Effect of strabismus surgery on torticollis caused by congenital superior oblique palsy in young children

Purpose:

To evaluate the outcome of strabismus surgery for congenital superior oblique palsy (SOP) in relation to correction of head tilt and hypertropia. The cohort of patients mainly involved very young children. This is the first study to use a standardized instrument to objectively measure torticollis before and after surgery.

Materials and Methods:

A non-comparative interventional case series of 13 cases of congenital superior oblique palsy with head tilt, who underwent simultaneous superior oblique tuck and inferior oblique recession between Jan 2000 and Dec 2008, were studied.

Results:

The mean duration of SOP until surgery was 36.8 months. Of the 12 unilateral cases, 8 were right-sided. Mean follow-up period was 17 months (range 7-36). The outcome was determined at the last follow-up. Mean pre-and post-operative hypertropia (p.d.) in forced primary position was 19 ± 7 and 2 ± 6, respectively (P < 0.0001). The head tilt reduced from mean of 17 ± 9 to 2 ± 2 degrees (P < 0.0001). Success, defined as hypertropia <5 PD and head tilt less than 5 degrees, was achieved in 69% (9/13. C.I. 42-88%) and 85% (11/13. C.I. 56-96%), respectively. The success rate for achieving both criteria was 61.5% (C.I. 35-88%). Five patients required additional surgery; usually a contralateral inferior rectus muscle recession, which was successful in all cases. One case developed asymptomatic Brown syndrome (7.69% - C.I. 6.7-22.2).

Conclusions:

Simultaneous superior oblique tuck and inferior oblique muscle recession can successfully treat selected cases of congenital superior oblique palsy. About one-third required an additional procedure, which led to total normalization of the head position.

Effects of extraocular muscle surgery in children with monocular blindness and bilateral nystagmus

Background

Monocular infantile blindness may be associated with bilateral horizontal nystagmus, a subtype of fusion maldevelopment nystagmus syndrome (FMNS). Patients often adopt a significant anomalous head posture (AHP) towards the fixing eye in order to dampen the nystagmus. This clinical entity has also been reported as unilateral Ciancia syndrome. The aim of the study was to ascertain the clinical features and surgical outcome of patients with FMNS with infantile unilateral visual loss.

Methods

In this retrospective case series, nine consecutive patients with FMNS with infantile unilateral visual loss underwent strabismus surgery to correct an AHP and/or improve ocular alignment. Outcome measures included amount of AHP and deviation at last follow-up.

Results

Eye muscle surgery according to the principles of Kestenbaum resulted in a marked reduction or elimination of the AHP. On average, a reduction of AHP of 1.3°/mm was achieved by predominantly performing combined horizontal recess-resect surgery in the intact eye. In cases of existing esotropia (ET) this procedure also markedly reduced the angle of deviation. A dosage calculation of 3 prism diopters/mm was established.

Conclusions

We advocate a tailored surgical approach in FMNS with infantile unilateral visual loss. In typical patients who adopt a significant AHP accompanied by a large ET, we suggest an initial combined recess-resect surgery in the intact eye. This procedure regularly led to a marked reduction of the head turn and ET. In patients without significant strabismus, a full Kestenbaum procedure was successful, while ET in a patient with a minor AHP was corrected by performing a bimedial recession.

Unilateral rectus muscle recession in the treatment of Duane syndrome

PURPOSE

To determine the outcome of unilateral single horizontal rectus recession surgery in patients with Duane retraction syndrome.

METHODS

A retrospective review was conducted of 27 medical records of patients with Duane syndrome who underwent unilateral medial rectus recession for esodeviations and lateral rectus recession for exodeviations. The criteria for evaluating surgical success included improvement of abnormal head position, reduction of strabismus deviation, and preservation or improvement of stereoacuity.

RESULTS

Patients had an average recession of 6.3 mm and were followed for an average of 4 years. Of the 27 patients treated with unilateral horizontal rectus muscle recession, 93% had a postoperative head turn of <10° in primary position and 85% an ocular deviation of <10(Δ). An excellent outcome, defined as a combination of stereoacuity of <100 arcsec, head turn <10°, and strabismus of <10(Δ), was achieved by 63% of patients.

CONCLUSIONS

Unilateral single horizontal rectus muscle recession improves or eliminates head turn, corrects strabismus in primary position of gaze, and maintains good stereoacuity in a majority of patients with Duane syndrome.

Kestenbaum procedure with posterior fixation suture for anomalous head posture in infantile nystagmus

BACKGROUND

The purpose of this study was to report the effect of combining the Kestenbaum procedure with posterior fixation suture for infantile horizontal nystagmus with anomalous head posture (AHP) in children.

METHODS

Nine consecutive patients who underwent combined Kestenbaum procedure plus posterior fixation suture to the recessed muscles at the same time were retrospectively studied. All patients were orthotropic before surgery and were followed for at least 6 months. Pre- and postoperative AHP and binocular corrected visual acuity (BCVA), and ocular alignment were assessed.

RESULTS

Mean age at surgery was 4.8 +/- 1.5 years. The average follow-up was 29.7 months. The average head turn preoperatively was 27.4 degrees and postoperatively 7.2 degrees . The average net change in AHP was 24.8 degrees (P = 0.008). Seven of 9 patients (78%) achieved a residual head turn of 10 degrees or less. The average Log Mar BCVA was 0.33 preoperatively and 0.31 postoperatively (P = 0.68). Only 1 patient needed additional surgery for residual horizontal AHP. No patient developed strabismus.

CONCLUSION

Combined Kestenbaum procedure with posterior fixation suture was an effective and stable procedure in reducing AHP of the range of 20 degrees to 35 degrees in children with infantile nystagmus.

A simplified approach to the treatment of Duane's syndrome

INTRODUCTION

To report the results of a large series of patients undergoing treatment for Duane's syndrome.

METHODS

Patients with Duane's syndrome undergoing strabismus surgery of a horizontal muscle recession procedure, medial rectus recession for an esodeviation or lateral rectus recession for an exodeviation, in order to correct an abnormal head position (AHP) and a significant tropia in primary position were identified. Amount of recession varied with the angle of deviation in forced primary position, versions and ductions, and intraoperative forced ductions. Elimination of AHP was used as a criterion for success.

RESULTS

Fifty nine patients were treated with either unilateral or bilateral medial or lateral rectus recession. Mean follow up was 3.1 years. Ninety three percent achieved a postoperative alignment of < or =15 degrees AHP, 66% achieved < or =5 degrees AHP. Only three patients, two from the unilateral Type II group and one from the bilateral combined Types I and II group, went on to have a second procedure for a noticeable residual AHP.

CONCLUSIONS

Success (good to excellent results) of horizontal muscle recession was achieved in 93% of patients. Unilateral or bilateral horizontal rectus muscle recession offers a simple and effective surgical option for eliminating AHP and is our treatment of choice in patients with Duane's syndrome.

A case of different null zones for distance and near fixation

A compensatory head posture (CHP) is a common clinical feature of congenital motor nystagmus. It is usually caused by an eccentric null zone, which is the eye position where the nystagmus intensity (amplitude x frequency) is least. A patient adopts the posture to maximize the binocular visual acuity. Occasionally, a patient may have more than one null zone, leading to the adoption of different CHPs at various times. A 10-year-old boy with congenital motor nystagmus and orthophoria, and with good corrected vision in both eyes, presented with a face turn that had been noted since infancy. For distance fixation, he consistently adopted a left face turn due to a null zone in right gaze. For near fixation, he adopted a right face turn due to a null zone in left gaze. Eye movement recordings confirmed the different locations of the null zones for distance and near fixation. After a trial of base-out prisms to stimulate convergence, which eliminated his head posture at both positions, he underwent artificial divergence surgery. He has had a satisfactory result for 18 months after surgery with a satisfactory head posture and a well-controlled exophoria. Measures to induce convergence, with prisms and then surgery, can be an effective strategy to correct the head postures caused by two different null zones in a patient with congenital motor nystagmus.

Surgical management of anomalous head posture because of horizontal gaze palsy or acquired vertical nystagmus

PURPOSE

To confirm the effectiveness of the Kestenbaum-Anderson principle in the surgical management of compensatory head posture because of horizontal gaze palsy and acquired vertical nystagmus.

METHODS

Nine patients with anomalous head posture because of horizontal gaze palsy, and four patients with acquired vertical nystagmus and oscillopsia and compensatory torticollis underwent surgery according to the Kestenbaum-Anderson principle. As in the treatment of congenital nystagmus, the eyes have to be shifted in the orbits, in the direction of anomalous head posture. Homonymously based prisms were used preoperatively to assess the potential benefit of surgery. At the time of surgery, the clinical conditions of the patients had been stable for at least 1 year.

RESULTS

After surgery, compensatory head posture and visual performances improved in all cases and the results remained stable for at least 2 years.

CONCLUSIONS

Contrary to what is generally believed, the ocular condition of the patients with compensatory head posture secondary to neurological causes can be often improved with surgery. The aim of surgery is obviously not to modify ocular motility, but rather to improve the head position.