Dissociated Horizontal Deviation after Traumatic Brain Injury

A 4-year-old boy visited the hospital with exotropia after brain hemorrhage caused by trauma. He had undergone decompressive craniectomy and cranioplasty 18 months prior to presentation at our hospital. An alternate prism cover test showed more than 50 prism diopters (PD) of left exotropia when he was fixing with the right eye and 30 PD of right exotropia when he was fixing with the left eye at near and far distance. On the Hirschberg test, 60 PD of left exotropia was noted in the primary position. Brain computerized tomography imaging performed 18 months prior showed hypodense changes in the right middle cerebral artery and anterior cerebral artery territories. Subfalcian herniation was also noted secondary to swelling of the right hemisphere. The patient underwent a left lateral rectus muscle recession of 7.0 mm and a left medial rectus muscle resection of 3.5 mm. Three weeks after the surgery, the Hirschberg test showed orthotropia. On alternate prism cover testing, 8 PD of left exotropia and 8 PD of right esotropia were noted at distance. We report a patient who developed dissociated horizontal deviation after right subfalcian subdural hemorrhage caused by trauma.

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%.

Operations on Vertical Rectus Muscles: Their Influence on Horizontal Strabismus

PURPOSE: To investigate the change of horizontal deviation after recession or resection of vertical rectus. METHODS: Retrospective analysis of patients who underwent recession or resection of the vertical rectus to correct vertical strabismus or dissociated vertical deviation from January 1997 to December 2001. RESULTS: Of 39 patients who underwent superior rectus recession, 14 showed exodeviation, 18 esodeviation and 7 no change compared to preoperative horizontal deviation. The mean change was 0.4 prism diopter esodeviation, which was not statistically significant(paired t-test, p=0.96). Nor was there any significant change of horizontal deviation after inferior rectus recession or resection(paired t-test, p=0.95). CONCLUSIONS: Recession or resection of the vertical rectus did not influence horizontal deviation significantly.

Clinical Evaluation of Superior Oblique Muscle PalsyAssociated with Horizontal Deviation

PURPOSE: The purpose of this study is to provide useful clinical information for proper diagnosis of the superior oblique muscle palsy (SOP) associated with horizontal deviation. METHODS: The records of 186 patients with SOP treated surgically were reviewed. The patients who underwent surgery for horizontal deviation more than 10 PD were classified into SOP associated with horizontal deviation. RESULTS: Of 186 patients with SOP, 96 (51.6%) patients also showed horizontal deviation. In 59 patients (61.5%) of these 96 patients, chief complaint was horizontal deviation only and 24 patients (25.0%) knew their hyperdeviation. Compensatory head-tilt was shown in 52 patients (54.2%), however only 11 (11.5%) patients complained their head-tilt posture. Of 96 patients, 72 (82.3%) had horizontal deviation in the eye contralateral to the paretic eye and amblyopia occurred in the horizontally deviated eye. The frequency of exodeviation was 82.3 % and was more than that of esodeviation. The mean amount of hyperdeviation was 12.6 +/- 6.77 PD, and that of horizontal deviation was 22.9 +/- 8.13 PD in exodeviation and 22.5 +/- 9.17 PD in esodeviation, respectively ninety three patients (96.9%) showed positive Bielschowsky head-tilt test. All 83 patients who had fundus examination showed foveal extorsion. CONCLUSIONS: This study reveals that Bielschowsky head-tilt test and fundus examination for foveal extorsion are needed to diagnose SOP which is masked by prominent horizontal deviation.

Clinical Analysis of Sensory Strabismus with Fundus Abnormalities in Children and the Effectiveness of Occlusion Therapy

Fifty-nine children (75 eyes) with organic amblyopia were investigated to know the distribution and incidence of the optic nerve or retinal lesion, the type of sensory strabismus, and the effect of occlusion therapy in organicamblyopia. Optic nerve lesion was found more frequently than retinal lesion as causes of organic amblyopia. Among these optic nerve lesions, optic nerve hypoplasia and tilted disc were most frequently found, and in the retinal lesion, ROP (retinopathy of prematurity: macular dragging), foveal dysplasia, and myopic degeneration were frequent.Thirty-nine of 59 children with organic amblyopia (66%)showed strabismus and 74.4% of them had horizontal deviation; 17 eyes had esotropia, and 12 eyes exotropia. No vertical eyeball deviation was found. Myopic anisometropia was accompanied in 19 cases. Better visual outcome was obtained after occlusion therapy in cases with tilted disc and ROP according to the degree of these lesions. However, there was no improvement in other cases. Authors suggest that fundus examination should be included in the routine ophthalmologic examination in chlidren with strabismus.

Dissociated Horizontal Deviation in the Refractive Accommodative Esotropia with Amblyopia

Dissociated horizontal deviation(DHD) is a rare type of dissociative strabismus. It dose not obey the Hering`s law of equal innervation and is expressed in associated with dissociated vertical deviation or asymmetrical nystagmus blockage syndrome. We observed 6 cases of DHD among the patients with refractive accommodative esotropia associated with amblyopia. The mean age of the patients was 3.6 years and the average refractive error was +5.35D in the dominant eyes and +6.29D in the amblyopic eyes. The average visual acuity was 0.38 with the dominant eyes and 0.17 with the amblyopic eyes. The average angle of deviation was 40.0delta with fixation in the dominant eyes and 24.3delta in the amblyopic eyes. The authors speculate that this difference of angle deviation was caused by the weaker accommodative convergence at the time of fixation by the amblyopic eye that appeared to have decreased accommodative amplitudes.