Clinical manifestations and treatment outcomes in dissociated strabismus complex (DSC) patients.

Objective: To demonstrate clinical manifestations and treatment outcomes in dissociated strabismus complex patients. Methods: Charts of patients who attended the Muscle Clinic at Siriraj Hospital from July 1998 to June 2002 were reviewed. Information regarding the patient’s age, sex, eye deviation, visual acuity, binocular function, head posture, degree of dissociated vertical deviation (DVD), dissociated horizontal deviation (DHD), dissociated torsional deviation (DTD), inferior oblique overaction (IOOA) and the treatments were obtained. Results: Seventy-three subjects from 1,335 strabismic patients were included in the study (5.5% of all strabismic patients attended the Muscle Clinic during the study time). The mean age of DSC patients was 8 years old. Among all DSC patients, 65.8% had esodeviation; 23.2% had exodeviation; and, 11% had isolated DSC. Latent nystagmus was found in 11% of the patients. Abnormal head posture was found in 16.4% of the patients. About fifteen percent of DSC patients had binocular function. All DSC patients had DVD but only 5 patients had DHD; no DTD was found. The treatment of DHD was correction of the horizontal deviation that coexisted with vertical deviation. As for DVD, there were many surgical procedures for correction such as superior rectus muscle (SR) recession, inferior oblique muscle (IO) recession, inferior oblique muscle anteriorization and inferior rectus muscle (IR) resection. Both unilateral and bilateral surgeries were performed. Regardless of the procedures, the total success rate was 78.4% (the residual of hyperdeviation was 10 prism diopters (PD) or less).The group of patients, who had surgical correction in only one eye, had a significant deviation in the non-operated eye after the surgical treatment. Conclusions: DSC was composed of DVD, DHD, DTD and latent nystagmus. DVD was the predominant manifestation in most cases of DSC. DSC was usually bilateral and was seen in subnormal binocular function patients. Esotropia was the most common deviation associated with DSC patients. Many surgical procedures were used to correct DVD such as bilateral large SR recession or IO anteriorization. In unilateral surgery, the manifestation of the deviation in the non-operated eye was always be found. Bilateral surgery was suggested but may be performed in asymmetrical degree. In this study, the overall success rate was 78.4%.

Outcomes of cataract surgery in senile cataract patients at Siriraj Hospital: a prospective observational study.

The present study was done to assess the results of cataract surgery performed in Siriraj Hospital by comparing phacoemulsification and extracapsular cataract extraction techniques in senile cataract patients within a 3-month period. The prospective observational study of a representative sample of 379 patients (409 eyes) who underwent cataract surgery in Siriraj Hospital from January 1, 2004 to March 31, 2004. Identical clinical assessment protocol was used to compare the improvement of postoperative visual acuity and surgical complications between two surgical techniques and different surgeons. Of the 409 eyes, phacoemulsification was performed on 373 eyes (91.2%), and extracapsular cataract extraction was performed on 36 eyes (8.8%). Departmental staff operated on 326 eyes (79.7%) and ophthalmology residents operated on 83 eyes (20.3%). The primary outcome was postoperative visual acuity. Visual acuity was improved > or = 2 Snellen chart lines in 278 of 373 eyes (74.5%) in the phacoemulsification group, and > or = 2 lines in 31 of 36 eyes (86.1%) in the extracapsular cataract extraction group. A small risk of surgical complications was found in the present study. Posterior lens capsule rupture was the most frequent complication found (10/ 409 eyes), followed by corneal injury (9 of 409 eyes). Endophthalmitis was the most severe complication in the present study, occurring in 1 of 409 eyes. There was a significant difference in postoperative visual improvement between phacoemulsification and extracapsular cataract extraction techniques. Final visual acuity in the phacoemulsification group was better than in the extracapsular cataract extraction group.

The outcomes of horizontal strabismus surgery and influencing factors of the surgical success.

OBJECTIVES: To evaluate the surgical outcomes of horizontal strabismus and identify the influencing factors of the surgical success. MATERIAL AND METHOD: The medical records of 304 patients who underwent their first strabismus surgery for treatment of horizontal deviation at Siriraj Hospital were reviewed retrospectively from January 1998 to December 2003. The main outcome measure for successful surgery was defined as eye deviation 10 prism diopters or less at 6 weeks post-surgery. The outcomes of postoperative binocular function and visual acuity improvement were also evaluated. The pre operative deviation, diagnosis, binocular function, visual acuity and age were analyzed as influencing factors of surgical success. The patients were divided into two groups, the first group was 6 years or less (161 cases) and the second group was older than 6 years (143 cases). The statistical methods for analysis the data were Chi-square test, Mann-Whitney U test and Logistic regression. RESULTS: The follow- up period was from 3 to 12 months. 187 patients (61.5%) for esotropia and 117 patients (38.5%) for exotropia were identified. Mean patient's age was 10.5 +/- 10.2 years (median 6, min 0.5, max 53), mean preoperative deviation was 44.9 +/- 16.6 prism diopters and mean VA was 20/30 (no PL, 20/20). The success rate was 62.0% for esotropia and 57.0% for exotropia. There was no statistical difference between the two groups of diagnosis. The average final deviation postoperative in the success group was 6 +/- 4.9 prism diopters. The comparison of difference visual acuity between pre and post-operation showed no statistical significance but the presence of binocular vision was increased in number of patient by two times. The complication rate was 0.7% (2/304), one case showed conjunctival wound dehiscence and the other had globe perforation. Re-operative rate was 12.9% (39/304) after one year. CONCLUSION: The surgical success rate of horizontal strabismus surgery was 60.2% and revealed no statistically significant improvement of visual acuity after surgery. The successful surgery was related to the age younger than 6 years and preoperative deviation less than 30 degrees.

Botulinum toxin treatment of sixth cranial nerve palsy.

Twelve patients with sixth cranial nerve palsy were treated with botulinum toxin injections to the antagonist medial rectus muscle at Siriraj Hospital between October 1995 and June 1996, The angle of esotropia, the extent of abduction and stereopsis were measured in all patients before and after the injections. After the treatment, seven patients (58.3 per cent) who exhibited a short duration of palsy, small angle of esotropia and incomplete paresis of the lateral rectus muscle recovered to achieve orthotropia and re-established fusion in the primary position. Of those seven patients, five demonstrated complete recovery of ocular motility. Botulinum toxin treatment can not only be a safe and effective alternative to conventional surgery but can also restore single binocular vision in primary gaze.

Results of using lyophilized fascia lata for frontalis sling.

This is the first study and report on the effect of lyophilized allogenic fascia lata as the suspension material in the frontalis sling operation. The total cases were 17 eyes. The follow up period from 6 months to 18 months revealed that there were no infection, nor evidence of tissue rejection or granuloma. Post failure due to slippage in two cases was noted within the first few months. All the remaining cases achieved satisfactory cosmetic and functional results.