Superior oblique tendon expanders with inferior rectus recessions for chin-up null point nystagmus

Three patients with chin-up head postures caused by a nystagmus null point in downgaze were treated using bilateral superior oblique tendon expanders and inferior rectus muscle recessions. Preoperative chin-up head postures measured from 25 to 45 degrees. Postoperatively, 2 patients had complete resolution of their abnormal vertical head postures, and the third showed improvement.

Treatment of inferior oblique paresis with superior oblique silicone tendon expander

INTRODUCTION

Patients with inferior oblique eye muscle paresis may show hypotropia and apparent superior oblique muscle overaction on the side of the presumed weak inferior oblique (IO) muscle. We report 8 such patients successfully treated using unilateral silicone superior oblique (SO) tendon expanders.

METHODS

Eight consecutive cases over the course of 6 years from the authors' private practice are described. None had a history of head trauma or a significant neurologic event. All patients showed IO paresis by 3-step test, with incyclotorsion and SO overacton of the hypotropic (paretic) eye. Forced ductions of the hypotropic eye were normal in all cases, and the vertical strabismus was treated with placement of a 7- mm silicone SO tendon expander in the hypotropic (paretic) eye.

RESULTS

Mean preoperative primary position hypotropia was 6.5 prism diopters (PD); mean postoperative was 0.5 PD. Seven of 8 patients had resolution of primary position hypotropia, whereas the eighth was reduced. Mean preoperative SO overaction was 3+; all patients had postoperative resolution of SO overaction. Of 4 patients with preoperative ocular torticollis, mean preoperative head tilt was 9.3 degrees; mean postoperative tilt was 2.9 degrees. Two patients' head tilts had resolved, the other 2 showed improvement. All patients showed preoperative incylclotorsion of the hypotropic (paretic) eye; inclyclotorsion resolved in all patients after the placement of a SO tendon expander.

CONCLUSION

The silicone SO tendon expander effectively restores ocular alignment in IO paresis with apparent SO overaction. Associated ocular torticollis can also be improved.

Adult strabismus surgery under propofol sedation with local versus general anesthesia

PURPOSE

To compare operating room and hospital discharge times between adult strabismus surgeries using intravenous propofol sedation with local anesthesia versus those using general anesthesia.

METHODS

Thirty adult patients underwent uncomplicated strabismus procedures performed by one surgeon using propofol sedation and local subtenon's anesthesia. These were retrospectively matched with adult patients undergoing similar procedures by another surgeon using general inhalational anesthesia. Only one muscle had undergone previous surgery, and no adjustable sutures were used. Times from incision closure to leaving the operating room (Out OR time), and to hospital discharge (DC time) are compared.

RESULTS

Propofol/local Out OR times ranged 2 to 8 minutes (mean, 4.8). General anesthesia Out OR times ranged from 3 to 28 minutes (mean, 8.8) (means differ at P<.001). At 10 minutes, 100% of propofol patients left the OR, but only 63% of general patients had done so (P<.001). Propofol/local DC times ranged from 30 to 140 minutes (mean, 64.8). General DC times ranged from 68 to 325 minutes (mean 116.5) (means differ at P<.001). At 60 minutes after completion of surgery, 53% of propofol/local patients had left the hospital, whereas none of general patients had left (P<.001). At 2.5 hours after surgery, 100% of propofol/local patients had left the hospital, but 10% of general patients remained, with two staying more than 5 hours.

CONCLUSIONS

Many adult strabismus surgeries may be performed more efficiently with intravenous propofol sedation and local subtenon's anesthesia than with general anesthesia. Times from the end of surgery to leaving both the OR and the hospital are decreased compared with those of general anesthesia. Extreme delays are rare with propofol/local, but they occurred with general anesthesia.

Poor results after recession of both medial rectus muscles in unilateral small-angle Duane's syndrome, type I

PURPOSE

To eliminate an abnormal face turn in unilateral Duane's syndrome, type I, the medial rectus muscle of the Duane's eye is commonly recessed. Additional recession of the normal contralateral medial rectus muscle has been advocated in selected cases, although little has been published regarding this technique. We present poor results in a small consecutive series.

METHODS

Four consecutive cases of unilateral Duane's syndrome, type I, with small-angle primary position esotropia are retrospectively reviewed with attention to postoperative face turn. In all cases, the medial rectus muscle of the "normal" eye was recessed as was the medial rectus muscle of the Duane's eye.

RESULTS

Two subjects showed little to no improvement in face turn; one subject developed an increased turn; and the last subject developed a consecutive exotropia.

CONCLUSIONS

In small-angle Duane's syndrome, type I, recession of the normal medial rectus may decrease the positive effects of recessing the Duane's medial rectus muscle with respect to face turn as well as increase the risk of consecutive exotropia. An alternate theory of normal-eye Duane's surgery is proposed.

The red eye in childhood

Overall, the primary care physician can diagnose most cases of red eyes in children, if specific attention is paid to which ocular structures are involved. Accurate diagnosis allows appropriate primary care treatment for most disorders and can aid in determining which cases need referral.

20 unusual presentations of accommodative esotropia

PURPOSE

This paper will discuss several unusual presentations of accommodative esotropia.

METHODS

A total of 20 patients with unusual case histories who presented with accommodative esotropia were studied retrospectively. These patients were separated into 3 categories. The first contained children who had their onset of accommodative esotropia after a traumatic event such as head trauma or ocular trauma. The second involved infants between 3 and 5 months of age who presented with accommodative esotropia. The third showed the onset of accommodative esotropia associated with diabetic ketoacidosis. (There were no other metabolic disorders associated with accommodative esotropia.)

RESULTS

All patients resolved their esotropia with glasses initially but 2 did require surgery several years after the onset of the esotropia.

CONCLUSIONS

Children under 5 months of age with intermittent esotropia and/or significant amounts of hyperopia should have the diagnosis of accommodative esotropia considered as the etiology of their esotropia. Children with the onset of esotropia associated with trauma who have significant amounts of hyperopia should also have accommodative esotropia considered as an etiology of their crossing.

Results and complications in 66 cases using a silicone tendon expander on overacting superior obliques with A- pattern anisotropias

PURPOSE

To supplement limited reports in the literature of the results (outcome)and complications of this procedure with our own recent experience.

METHODS

A total of 66 patients with bilateral overaction of the superior oblique and A-pattern strabismus plus 5 patients with a unilateral overacting superior oblique secondary to inferior oblique palsy were treated with a 7 mm silicone expander.

RESULTS

The fist group of 66 patients had an average preoperative A-pattern of 39.6 prism diopters with an average correction of the A-pattern from the surgery of 36.3 prism diopters.

COMPLICATIONS

Of all 137 operations in these 71 patients, three patients had a sterile orbital cellulitis postoperatively successfully treated with steroids. Also, one patient acquired a Brown's Syndrome-like condition postop'. In these four patients, the sub-Tenon's capsule space had been inadvertently entered during surgery. In addition one unilateral superior oblique palsy occurred postoperatively.

CONCLUSION

While this procedure has a very high success rate, special care should be taken with this surgery to avoid entering the sub-Tenon's capsule space.

Unusual presentations of accommodative esotropia

PURPOSE

Most patients with accommodative esotropia are first examined between the ages of 6 months and 2 years. This paper discusses unusual presentations of accommodative esotropia that occur outside of this age-group and/or have a precipitating event that triggered the esotropia. In a series of patients who were from 5 to 11 years of age, trauma was the precipitating event. In some of the patients under 6 months of age, high myopia, as well as a moderate to large amount of hyperopia, was the cause. In 1 teenager, diabetic ketoacidosis precipitated accommodative esotropia.

METHODS

We reviewed all of our records for the past 25 years involving patients with a diagnosis of esotropia, and we found 17 patients who had unusual presentations of accommodative esotropia. Of 8 who were under the age of 6 months, 2 had high myopia and 6 had moderate to large amounts of hyperopia. Nine patients were older than age 5. Eight of the 9 had suffered trauma associated with the presentation of accommodative esotropia, and 1 patient's accommodative esotropia was associated with diabetes. The patients with myopia received their full myopic correction. The children under 6 months of age with hyperopia received their full cycloplegic refraction, and the children over age 5 received the most plus that they were able to accept in a noncycloplegic state consistent with good visual acuity (at least 20/30 in each eye).

RESULTS

In 17 patients, accommodative esotropia was initially controlled with glasses. In a few of the trauma cases, bifocals were required for control of near deviation. Only 2 of the patients, in whom onset was under 6 months of age, came to surgery. One had hyperopia controlled for 2 years with glasses, and the other had myopia controlled for 3 years with glasses.

CONCLUSIONS

Accommodative esotropia can occur prior to 6 months of age. It can also occur in older children (5 to 14 years of age) and can be precipitated by trauma or diabetic ketoacidosis.

Ocular plagiocephaly: ocular torticollis with skull and facial asymmetry

PURPOSE

To observe facial asymmetry in patients with ocular torticollis to better understand its cause.

DESIGN

Observational case series.

PARTICIPANTS

Forty-four consecutive patients with ocular torticollis in one author's (MFG) private practice were examined for facial asymmetry from January 1998 to August 1998. Some of these, as well as selective others before January 1998 were photographed for a total of 53 photos.

METHODS

One author (MFG) examined the frontal, maxillary, and mandibular facial areas of 44 consecutive torticollis patients for appearance of unilateral compression or reduced mass. The laterality of such findings was compared with the side of the head turn or tilt. Photographs of 53 selected ocular torticollis patients were inspected and the direction of nasal tip and columella deviation compared with the direction of head tilt or turn.

MAIN OUTCOME MEASURES

Subjective clinical determination of appearance of unilateral facial compression or reduced facial mass. Subjective photographic determination of nasal tip and columella deviation.

RESULTS

Forty-three patients with 10 types of ocular torticollis examined were included. Forty-one of 43 showed compression or reduced mass on the same side as the head turn or tilt, including 3 with adult-onset strabismus. Eight nonsuperior oblique palsy patients had nasal deviation to the same side as the torticollis. Six of the eight had head tilts. Seventeen nonsuperior oblique palsy patients had nasal tip deviation to the opposite side of the torticollis. All were pure head turns. Eight superior oblique palsy patients had nasal tip deviation to the same side as the torticollis; nine had deviation opposite.

CONCLUSIONS

Patients with multiple types of ocular torticollis, including face turns, show similar appearance of facial compression on the side of the torticollis, suggesting that the tilt or turn itself may cause the asymmetry. This includes face turn strabismus, in which facial asymmetry has not previously been described. Head tilts are frequently associated with nasal tip deviation to the side of the torticollis, head turns with deviation opposite. We refer to such asymmetric facial changes associated with ocular torticollis as "ocular plagiocephaly."

Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis

BACKGROUND

Subperiosteal abscess may accompany orbital cellulitis secondary to sinusitis. Common surgical principles include incision and drainage of all abscesses. Previous evidence suggests that some orbital abscesses may be treatable with intravenous antibiotics, especially in young children. Children's hospital records were reviewed to determine which abscesses may be treated medically.

PATIENTS AND METHODS

Records of patients admitted for orbital cellulitis from 1993 to 1996 were reviewed. Patients with subperiosteal abscess on CT scan were included. Clinical outcomes for initial surgical versus medical management of medial abscesses were compared. Differences in age, hospital stay, and intracranial involvement were analyzed for medial versus nonmedial abscesses.

RESULTS

All patients had abscesses adjacent to infected sinuses. Eighteen young children had medial abscesses. Twelve of 13 were cured by initial medical treatment; 4 of 5 underwent successful initial drainage. Outcomes were not statistically different (P > .490). Seven children with nonmedial abscesses were older (P < .001) and had more complicated courses than those with medial abscess. Three of 6 children with superior orbital abscess also had intracranial abscess. Intracranial complication was more likely with superior versus medial orbital abscess (P < .01).

CONCLUSIONS

Medial subperiosteal orbital abscesses secondary to sinusitis in children 6 years of age and younger are highly amenable to treatment with intravenous antibiotics. Older children and children with nonmedial abscesses may have more complicated infections. Children with superior orbital abscesses are at higher risk for intracranial abscess.

Absence of multiple extraocular muscles in craniosynostosis

The absence of extraocular muscles, particularly the superior rectus1, 2 or superior oblique3, 4 has been recognized to cause strabismus among patients with craniosynostosis. Absence of multiple muscles is less common. In case 1 we note a patient with Pfieffer's syndrome and absent left superior rectus and inferior oblique, with the presence of only a vestigial left superior oblique and an underdeveloped and misinserted left inferior rectus. In case 2 we describe a patient with Apert's syndrome with bilateral absence of the superior rectus and superior oblique muscles. Unsuspected superior rectus absence led to a bilateral elevation deficit after inferior oblique weakening. Also, during the course of treatment, all 3 remaining recti muscles in 1 eye were disinserted. To our knowledge, this is the first report of absent extraocular muscles in Pfieffer's syndrome. Some evidence suggests that collateral anterior segment blood flow exists in cases of absent recti muscles. Further study is needed to determine whether all remaining muscles could be used for strabismus repair. Last, when patients with craniosynostosis require strabismus surgery, we feel that a limited exploration of all extraocular muscles should be carried out.