Long-Term Outcome and Recurrence of Abnormal Head Posture after Surgery in Patients with Nystagmus

PURPOSE: To evaluate the long-term outcome and recurrence of abnormal head posture after modified Kestenbaum surgery in patients with nystagmus. METHODS: The medical records of 46 patients who underwent modified Kestenbaum procedure in horizontal recti muscles for nystagmus with abnormal head turn were retrospectively reviewed. We assessed the effect of surgery by comparing preoperative and postoperative clinical data such as visual acuity (log MAR) and degree of head turn. A reoperation or abnormal head turn of 10degrees or more at final visit were defined as recurrence. Patients were divided into 2 groups according to the presence of recurrence or reoperation. Clinical factors associated with recurrence or reoperation were compared between the 2 groups. RESULTS: The mean visual acuity was 0.38 in the better eye and 0.42 in the worse eye before surgery, which improved to 0.15 and 0.21 after surgery (each p < 0.001), with a mean follow-up period of 124 months. The mean degree of head turn was 41.41degrees preoperatively and was changed to 2.61degrees postoperatively (p < 0.001). The recurrence rate was 23.9% and the reoperation rate was 10.9%. Mental retardation, amblyopia, preoperative visual acuity, degree of head turn, and presence of strabismus were not associated with recurrence or reoperation. The mean age at first surgery was significantly lower in the reoperation group (p = 0.009). The mean visual acuity in the better eye at postoperative 6 months and in better and worse eyes at postoperative 1 year was significantly worse in the reoperation group (p = 0.034, 0.012 and 0.009, respectively). CONCLUSIONS: The visual acuity and head turn was improved after modified Kestenbaum surgery in patients with nystagmus and abnormal head posture. The reoperation rates were associated with earlier age of first operation and worse postoperative visual acuity. However, further prospective studies are necessary to clarify these factors.

Design and Efficacy of Surgery for Horizontal Idiopathic Nystagmus with Abnormal Head Posture and Strabismus / 华中科技大学学报（医学）（英德文版）

The design and efficacy of surgery for horizontal idiopathic nystagmus (HIN) with abnormal head posture and strabismus were investigated.Different surgical procedures were selected according to the angle of head tum in 44 cases of HIN with abnormal head posture and strabismus.For patients with a head turn of 15° or less,the Anderson procedure was used; the yoke muscles were recessed upon slow-phase.For patients with a head turn between 15° and 25°,the surgery was designed as a Kestenbaum 5-4-4-5 procedure.For patients with a head turn of 25° or more,the surgery was designed as a Parks 5-8-6-7 procedure.The surgery to correct the abnormal head posture was performed on the fixating eye while that to correct the deviation was then performed on the non-fixating eye at the same time.The amount of surgery of the horizontal rectus muscles on the non-fixating eye was sum of the angle of head turn and the degree of deviation,which was calculated as follows:recession/resection amount of medial and lateral rectis/2× 5=angle of head turn±degree of deviation.The results showed as follows:(1)Visual acuity:the visual acuity in the primary ocular position increased two lines or more in 35 patients,accounting for 79.55％.Nine patients had no or only one-line improvement,accounting for 20.45％ of the entire study population; (2) The degree of deviation in the primary ocular position:37 cases had a normal primary ocular position or the degree of deviation ≤8Δ after surgery,accounting for 84.09％.Six patients had a residual degree of deviation of 8Δ-15△,accounting for 13.64％.One patient had a residual degree of deviation ＞20Δ,accounting for 2.27％ of the patients examined; (3) Abnormal head posture:34 patients had a normal head posture or a head turn of less than 5°,accounting for 72.27％.Eight patients had a residual head turn of 5°-15°,accounting for 18.18％.Two patients had a head turn of 15°- 25°,accounting for 4.55％.It was concluded that different surgical procedures based on the angle of head tum and the relationship between deviation and null zone can eliminate anomalous head posture,correct deviation,and improve vision acuity in the primary ocular position simultaneously.

Surgical Results in Duane Retraction Syndrome

PURPOSE: To report the clinical characteristics and the results of a series of patients treated with various strabismus surgery techniques for Duane retraction syndrome (DRS). METHODS: Thirty-eight patients with DRS undergoing surgical treatment were retrospectively reviewed. In all patients, ocular alignment, abnormal head posture and ocular motility disturbance were assessed both preoperatively and postoperatively. The patients were treated with appropriate horizontal muscle recession, Y-splitting combined with horizontal muscle recession, medial rectus recession and lateral rectus resection. RESULTS: The incidence of DRS was greater in females and in the left eye. Type 1 was the most common, and esodeviation was seen most frequently in the primary position. The esotropic patients with DRS turned their faces toward the affected eyes, while the exotropic patients with DRS turned away from the affected eyes. The deviation in the primary position was reduced from an average of 15.0 prism diopters (PD) to 1.5PD. The face turn was reduced from an average of 17.5 degrees to 1.2 degrees. CONCLUSIONS: The primary deviation and abnormal head posture found in DRS can be improved by proper preoperative evaluation and adequate choice of surgical methods.

Anterior Transposition of Inferior Oblique Muscle for Treatment of Unilateral Superior Oblique Muscle Palsy with Inferior Oblique Muscle Overaction

Although many weakening procedures for the inferior oblique muscle have been advocated, there is some controversy as to the most beneficial procedure for weakening overacting inferior oblique muscles. This study was undertaken to determine if unilateral anterior transposition of the inferior oblique muscle alone could be a safe and effective procedure for treating unilateral superior oblique palsy from the perspective of hypertropia, inferior oblique overaction, and abnormal head posture. The records of 33 patients, who underwent anterior transposition of the inferior oblique muscle for unilateral superior oblique palsy at our institution between Jan 1995 and Dec 2002, were retrospectively reviewed. The average preoperative inferior oblique overaction was 2.3 +/-0.64, and the hypertropia in the primary position was 12.3 +/-7.69 prism diopter (PD). Twenty-six patients showed head tilt to the opposite direction preoperatively. After the anterior transposition of the inferior oblique, inferior oblique overaction was diminished in 32 patients (97%). Twenty-six out of 33 patients (79%) had no hypertropia in the primary position at last postoperative assessment. Of the 26 patients with head tilt before surgery, 21 patients (81%) achieved full correction after surgery. Satisfactory results were obtained in most of the patients in our study with the exception of three patients who required additional surgery. No patient demonstrated postoperative hypotropia in the primary position. None of the patients noticed elevation deficiency or lower lid elevation. The anterior transposition of the inferior oblique was found to be safe and effective for treating superior oblique palsy with secondary overaction of the inferior oblique muscle.

Surgery for Vertical Abnormal Head Posture in Infantile Nystagmus

PURPOSE: The purpose of this study is to assess the effect of surgical management for infantile nystagmus with vertical abnormal head posture. METHODS: We performed surgical procedures to correct the vertical abnormal head posture of more than 10degrees in 6 patients with infantile nystagmus. One patient with the chin-up head posture was treated with recession of bilateral inferior rectus muscles and resection of bilateral superior rectus muscles, and 5 patients with the chin-down head posture were treated with recession of bilateral superior rectus muscles and resection of bilateral inferior rectus muscles. The pre- and post-operative measurements of the head posture were evaluated and compared with each other. RESULTS: Preoperatively, the degree of vertical head posture ranged from 10 to 30degrees, and 4 patients were with the 20~30degrees abnormal head posture. In the average follow-up period of 35.8 months, 5 patients (83.3%) showed less than 5degrees of chin-up or chin-down head posture. In one case, 20degrees left face turn was noted postoperatively. However, duction was full in all cases. CONCLUSIONS: These results suggest that the surgical management with bilateral vertical rectus muscles was effective for the correction of vertical abnormal head posture in infantile nystagmus.

The Influence of the Head Posture on the Motor Alignment and Sensory Status in the Patients with the Abnormal Head Posture

PURPOSE: To analyze clinical manifestations of the abnormal head posture of ocular origin and to evaluate the effect of the abnormal head posture on the improvement of binocularity. METHODS: In this prospective study 58 patients with abnormal head posture of ocular origin were enrolled. Best corrected visual acuity, Titmus stereotest, Worth four dot test at near and far and the deviations at far were recorded in the abnormal head posture and the forced primary position. Changes of the head postures and the stereoacuity were evaluated postoperatively in the operated cases. RESULTS: The most common cause of abnormal head posture was superior oblique palsy and the most common type of that was head tilt. The deviating angles were significantly decreased in 30 patients (80%) and not changed in 8 patients (20%) of 38 patients with strabismus in abnormal head posture compared to the forced primary position. However, the results of Titmus stereotest improved only in 28% of patients in abnormal head posture. Six among 7 patients with nystagmus showed the disappearance of nystagmus in the abnormal head posture. Twenty (90%) among 22 patients who had surgical procedures showed improvement in the head posture. CONCLUSIONS: The abnormal head posture improved the motor alignment in most of the strabismus patients. However, in many patients it failed to improve the sensory status or binocularity. Most patients who had surgical procedures showed the improvement of abnormal head posture.

Clinical analysis of Superior Oblique Plication Procedure

The purpose of this study is to evaluate retrospectively the surgical results and complications in the patients with unilateral superior oblique palsy using superior oblique plication(SO plication) only or SO plication combined with inferior oblique weakening. Among 22 patients with unilateral superior oblique palsy, there were 13 patients(59.1%) in type III, 5 patients(22.7%) in type IV, 2 patients(9.1%) in type II and 2 patients(9.1%) in type V according to Knapps classification. The mean amount of hypertropia was 18 prism diopters(PD) and 18 of 22 patients(81.8%) showed abnormal head posture(AHP). Nineteen patients (86.4%) showed horizontal strabismus and exotropia was most common. The methods of oblique and vertical rectus operation were SO plication, SO plication combined with inferior oblique weakening, combined with resection of inferior rectus, and combined with recession of contralateral inferior rectus, inferior oblique weakening, and superior rectus weakening. We performed corrective surgery on the patients with horizontal deviation more than 14 PD. Postoperatively the mean amount of hypertropia was 2.6PD. In 7 patients with superior oblique plication only the mean amount of correction in plication was 8.4PD, and hypertropia was corrected 1.2PD per mm. Thirteen of 18 patients(72.2%) with AHP and 15 of 19 patients (78.9%) with horizontal strabismus were corrected after operation. Postoperative complications were residual hypertropia in 7 patients(31.8%) and Brown syndrome in one. We conclude that plication of the superior oblique may be one of the effective procedures for correction of superior oblique palsy and possible its complications may be postoperative undercorrection and Brown syndrom.

Analysis of Abnormal Heal Posture and Surgical Results in the Patients with Duanes Retraction Syndrome

We evaluated retrospectively the clinical records of 46 cases of Duanes retraction syndrome. The purpose of this study is to demonstrate a clinical characteristics of this syndrome and improvement of abnormal head posture and degree of deviation in 14 cases undergoing operation. Unilateral manifestation was in 42 cases and 4 cases were involved bilaterally. Left eye was involved predominantly in 29 cases (63.0%). The frequencies analyzed according to Hubers classification were that Type I was 64.3%, Type II 7.1%, and Type III 28.6% in unilateral cases. Of unilateral cases, compensatory face turn was exhibited in 65.2% of Type I, 100% of Type II, and 60.0% of Type III. In primary position, 44.4% of Type I had esodeviation, and 100% of Type II ad 83.3% of type III had exodeviation. The major concerns of most patients or their parents were the correction of strabismus and gaze limitation, but they hardly recognized abnormal head posture. The correction of abnormal head posture and strabismus was achieved in 78.6% postoperatively.

Fresnel prism in Paralytic strabismus

We performed clinical evaluations on 26 patients who were prescribed glasses with full correction and Fresnel prism for correction of abnormal head posture and/or diplopia due to incomitiant paralytic strabismus. There were 12 cases(46.2%) of superior oblique muscle palsy and 8 cases(30.8%) of lateral rectus palsy in order. Trauma was the most common cause, but non-traumatic cases were mostly caused by vascular disease of diabetes mellitus and/or hypertension. Abnormal head posture with diplopia and/or dissociated diplopia may be one of the causes of less satisfaction level than interval of prescription of Fresnel prism. Decreased visual acutiy happened when prescribed above ten prism prescription on one eye, and patients accepted with more ease when prescription wasdivided on both eyes, in spite of low prism power. We concluded that it is necessary to explain dimness due to decreased visual acuity when above ten prism power prescription is given on one eye even though prism was more effective method for diplopia gteatment.

Clinical and Histological Study of Extraocular Muscle in Congenital Fibrosis Syndrome

The authors analyzed 8 cases of the patients with congenital fibrous syndrome for clinical and histological study. In addition we observed the histological findings for the relationship between the clinical manifestations and fibrosis of the muscles and the cause of the fibrosis. All of the patients had hypotropia and 7 of whom had bilateral tendency, six patients showed exotropia and two patines showed esotropia. Associated ocular problems were amblyopia (88%), ptosis (88%), nisometropia (50%) and nystagmus (62%). The most common abnormal head posture was chin up position (88%). There were improvement of abnormal head position in six patients but no change of abnormal head posture in two patients after operation. In histological study the muscle fiber showed generalized degeneration. Clumping of the nuclei of the muscle fiber was replaced by many nuclei of the fibroblasts in light microscopy. The authors observed the proliferation of the collagen fibers among the fibroblastic nuclei and amorphous diffuse particle stained by lightred color in the intercellular space. In electron microscopy the premature collagen fibers appeared among amorphous particles and some particles had close relationship with collagen fibers. From these findings, it would appear that formation of the collagen fiber occurs in extraocular space and degenerated myofibrils are responsible for the formation of the collagen fiber, and abnormal head posture results from fibrosis of muscle fiber and ptosis.