Clinical observation of external rectus muscle amputation in the treatment of divergence insufficiency / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To observe the clinical effect of external rectus muscle amputation in the treatment of divergence insufficiency. <p>METHODS: A retrospective analysis of 37 cases of insufficiency in our hospital from February 2011 to October 2017. The clinical manifestations were hyperopic esotropia with ipsilateral diplopia, myopia implicit esotropia without diplopia, and the monocular and binocular movements were normal. Preoperative refractive, strabismus, near stereopsis, negative fusion force examination, and then single or double external rectus muscle surgery.<p>RESULTS: Double vision disappeared after all cases, and there was no recurrence in diplopia after one year of follow-up. The preoperative long-term internal strabismus was +15△-+28△, with an average of 18.4△±5.7△, the near-internal strabismus was +5△-+16△, the average was 10.3△±3.6△, The difference value of long distance and short distance strabismus was 8.1△±2.3△; one week after surgery, the distance strabismus was -5.4△±1.5△, the near-distance squint was -7.2△±1.6△, the difference value was 1.8△±0.6△; the one year postoperative strabismus was -1.9△±1.2△, the close squint was -3.4△±1.4△, the difference value was 1.5△±0.8△. The long-distance strabismus one week after operation and one year after operation was significantly lower than that before operation(<i>P</i><0.05). The difference of distance and strabismus between one week and one year after operation was statistically significant. Preoperative the difference between near and far squint one week and one year after operation was statistically significant(<i>P</i><0.05). The difference was statistically significant between the preoperative and postoperative one week. The difference was statistically significant 1 week after surgery and 1 year after surgery. The long-distance negative fusion force before surgery was 3△-9△, with an average of 5.1△±1.8△, and the near-negative fusion force was 15△-24△, with an average of 19.4△±3.2△. The long-near negative fusion force was 10.1△±3.3△, 19.7△±4.1△ at 1wk after operation, and the long-distance negative fusion force was 11.2△±3.6△, 20.2△±4.8△ for one year after operation. There was a statistically significant difference between the patients with preoperative and one week postoperative negative fusion(<i>q</i>=4.551, <i>P</i>=0.013). There was no significant difference between the one week and one year after surgery(<i>q</i>=0.713, <i>P</i>=0.115).There was no significant difference in the patients' brachytherapy before and after one week and one year after operation(<i>P</i>>0.05).<p>CONCLUSION: Divergence insufficiency of external rectus muscle surgery can effectively reduce the difference of long-distance strabismus after surgery, eliminate the symptoms of diplopia in patients, and improve the near stereoscopic sharpness and long-distance negative fusion force.

Improvement of divergence insufficiency with treatment of thyroid disease: A case report

@#This is a case that showed improvement of divergence insufficiency after treatment of thyroid disease. A 50-year-old man developed horizontal diplopia a few days prior to presentation while driving a car. On ophthalmologic examination, prism and alternate cover test revealed an esotropia of 8 prism diopters (PD) at distance and exophoria of 2 PD at near in the primary position. He did not show limitation on ductions, or any signs of conjunctival injection, ptosis, eyelid edema, lid lag and proptosis. Orbit and brain magnetic resonance (MR) imaging and MR angiography revealed no abnormal findings in the extraocular muscles and brain. Serum free T4 level was normal and thyroid stimulating hormone (TSH) level was slightly low, while increased levels of thyrotropin-binding inhibitory immunoglobulin (TBII) and antithyroid microsomal antibody were detected. He was managed with glasses of 4 PD base-out prisms in both eyes. Two months later, serum free T4 was elevated and TSH was markedly reduced. TBII was highly elevated and thyroid stimulating immunoglobulin was positive. After 3 weeks of antithyroid treatment with methimazole, his diplopia improved, and prism and alternate cover test showing orthotropia at distance and exophoria of 10 PD at near in the primary position. This case highlights the importance of thyroid function tests and TSH receptor antibodies in patients with acute onset of divergence insufficiency. Divergence insufficiency could be improved with antithyroid treatment.

Clinical Characteristics and Course in Divergence Paralysis

PURPOSE: To improve the understanding of divergence paralysis by identifying its clinical characteristics. METHODS: We performed a retrospective chart review analysis of patients diagnosed with divergence paralysis that were followed up for at least 6 months. Clinical features, including disease onset, course, neurological examinations, and imaging studies were evaluated. RESULTS: Fifteen patients were included in the present study and the average age was 55.6 years. Thirteen patients had an acute onset and 2 had an insidious onset. The initial distance deviation ranged from 4 to 14 prism diopters (PD) of esotropia (mean, 8 PD esotropia) and near deviation ranged from 6 PD exophoria to 10 PD esophoria (mean, 1.2 PD esophoria). None of the patients developed additional neurological disorders associated with divergence paralysis during the follow-up period. Eleven of 13 patients with primary divergence paralysis continued to depend on the prism glasses with the same diopters. In the 2 patients with secondary divergence paralysis, distant diplopia disappeared as the underlying disease improved. CONCLUSIONS: In our study, the majority of divergence paralysis was not associated with neurological diseases and the patients had an acute onset. Primary divergence paralysis lasted for an extended period. However, secondary divergence paralysis was resolved quickly as the underlying disease improved.

Clinical Characteristics and Course in Divergence Paralysis

PURPOSE: To improve the understanding of divergence paralysis by identifying its clinical characteristics. METHODS: We performed a retrospective chart review analysis of patients diagnosed with divergence paralysis that were followed up for at least 6 months. Clinical features, including disease onset, course, neurological examinations, and imaging studies were evaluated. RESULTS: Fifteen patients were included in the present study and the average age was 55.6 years. Thirteen patients had an acute onset and 2 had an insidious onset. The initial distance deviation ranged from 4 to 14 prism diopters (PD) of esotropia (mean, 8 PD esotropia) and near deviation ranged from 6 PD exophoria to 10 PD esophoria (mean, 1.2 PD esophoria). None of the patients developed additional neurological disorders associated with divergence paralysis during the follow-up period. Eleven of 13 patients with primary divergence paralysis continued to depend on the prism glasses with the same diopters. In the 2 patients with secondary divergence paralysis, distant diplopia disappeared as the underlying disease improved. CONCLUSIONS: In our study, the majority of divergence paralysis was not associated with neurological diseases and the patients had an acute onset. Primary divergence paralysis lasted for an extended period. However, secondary divergence paralysis was resolved quickly as the underlying disease improved.

A Case of Pediatric Idiopathic Intracranial Hypertension Presenting with Divergence Insufficiency

An 11-year-old female presenting diplopia only at distance was found to have comitant esotropia of 20 prism diopters (PD) at distance and normal alignment at nearer proximity. Other ocular movement, including abduction, was normal and a thorough neurologic examination was also normal. The deviation angle of esotropia was increased to 35 PD in 6 months, and a brain magnetic resonance imaging with venogram at that time demonstrated no intracranial lesion. A lumbar puncture showed increased opening pressure but the cerebrospinal fluid composition was normal. The patient was diagnosed as having idiopathic intracranial hypertension and treated with oral acetazolamide. Three months after treatment, the deviation angle decreased to 10 PD. This is a case report of divergence insufficiency in pediatric idiopathic intracranial hypertension, with an increasing deviation angle of esotropia. Although sixth cranial nerve palsy is a common neurologic manifestation in intracranial hypertension, clinicians should be aware of the possibility of divergence insufficiency. Also, ophthalmoparesis may not be apparent and typical at first presentation, as seen in this case, and therefore ophthalmologists should be aware of this fact, while conducting careful and proper evaluation, follow-up, and intervention.