Inferior Rectus Muscle Y-Split for Thyroid-Related Vertical Strabismus

Incomitant hypotropia in thyroid eye disease can be difficult to manage, especially in the presence of orthotropia with fusion in down gaze and reading position. Recessing the affected ipsilateral inferior rectus muscle may result in an undesirable downgaze diplopia secondary to a hypertropia in downgaze. Various surgical techniques have been described to manage this potential complication including asymmetric recession of both inferior rectus muscles, posterior myoscleropexy operation, and the Scott recess/resect procedure of the contralateral inferior rectus. In 2004, Hoerantner et al. introduced the y-split recession of the medial rectus muscle for near esotropic deviations. The anterior portion of muscle is split and secured in a y-shaped configuration, which reduces the muscle lever arm and helps minimize incomitance and muscle slippage. Unlike the traditional Cüppers Faden, a y-split recession results in torque reduction in all gaze positions. In addition, a y-split recession does not involve scleral passes posteriorly reducing the risk of globe perforation. We report a patient with incomitant strabismus secondary to thyroid eye disease who underwent a combination of traditional recession and y-splitting recession of the contralateral inferior rectus muscle, resulting in good functional alignment in primary gaze and in the reading position.

Unilateral four muscle surgery for extra-large monocular exotropia

INTRODUCTION

Recurrent exotropia is common following surgery for monocular large angle constant sensory exotropia. Surgery is usually limited to operations on the affected eye. Simultaneous oblique weakening surgery may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting forces. We report the results of simultaneous oblique muscle weakening procedures combined with ipsilateral horizontal rectus muscle surgery constant monocular exotropia greater than 35 prism diopters (PD).

METHODS

Retrospective case series of patients who underwent unilateral lateral rectus recession combined with medial rectus muscle resection and simultaneous weakening of both ipsilateral oblique muscles. Primary outcome measure was ocular alignment in primary position.

RESULTS

Twelve eyes of 12 patients were included. The mean preoperative exotropia improved from 57.9 ± 15.1 (range 35-80; median 60 PD) to 3.3 ± 5.5 (range 0-16; median 0 PD) postoperatively (p < 0.005). Two of 3 patients with a pre-existing vertical deviation had resolution of their vertical misalignment postoperatively. At the last postoperative follow up 92%% of the patients had an exodeviation of 10 PD or less (range 0-16 PD median 0 PD), and 7 (58%) measured near and distance orthotropia. Postoperative abduction measured -0.6 ± 1 (0 to -3) and adduction -0.4 ± 0.7 (0 to -2).

CONCLUSION

Weakening the ipsilateral oblique muscles may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting vectorial forces when operating for a large angle monocular exotropia. As an additional potential advantage, oblique muscle surgery may be used simultaneously to address associated vertical deviations.

Rebound tonometry by iCare 200 (IC200): comparison with Tono-Pen in the operating room and Goldmann applanation in the clinic

BACKGROUND

Tonometry guides decision making in children with known or suspected glaucoma. The iCare IC200 is a recently FDA-approved rebound tonometer that can measure intraocular pressure (IOP) in both supine and upright patients. The purpose of this study was to evaluate this new tonometer against more commonly used standard instruments: Tono-Pen in the operating room (OR arm) and Goldmann applanation in the clinic (clinic arm).

METHODS

The OR arm included sequential children undergoing general anesthesia. The clinic arm included cooperative children seen in clinic. IOP was measured twice (right eye then left eye, repeat) with IC200 and either Tono-Pen (OR arm) or Goldmann (clinic arm).

RESULTS

A total of 99 children were included: 75 for the OR arm and 24 for the clinic arm. There was a strong correlation between the IOP measured by IC200 and each device (R² = 0.81 for Tono-Pen; R² = 0.78 for Goldmann). In the OR arm, the overall mean IOP difference (ΔIOP [Tono-Pen - IC200]) was -1.6 mm Hg. For eyes with corneal edema (n = 12), ΔIOP ranged from -8 to 15 mm Hg. At IOP >20 mm Hg, mean ΔIOP was -3.7 mm Hg. In the clinic arm, the mean ΔIOP (ΔIOP [Goldmann - IC200]) was -1.2 mm Hg.

CONCLUSIONS

In eyes of children under general anesthesia with IOP <20 mm Hg without corneal edema, IC200 and Tono-Pen correlated well. In cooperative clinic patients, Goldmann and IC200 correlated well over the range of IOP studied.

Perforating Peripheral Ulcerative Keratitis in Syphilis

Purpose

To present a case of peripheral ulcerative keratitis with perforation in the setting of syphilis.

Method

A single observational case report in urban USA.

Case Presentation

A patient with multiple sexual partners presented with bilateral peripheral ulcerative keratitis, unilateral corneal perforation, and a pustular rash. Workup was positive for syphilis as well as HSV, HIV, and multiple autoantibody tests. Findings improved after treatment for syphilis.

Conclusion

Bilateral peripheral ulcerative keratitis in syphilis has been reported in one prior case. However, corneal perforation in the setting of syphilis infection has not, to our knowledge, been reported previously.