Evaluation of three superior oblique surgical weakening procedures for A-pattern strabismus / Avaliação de três tipos de cirurgia de enfraquecimento dos músculos superiores oblíquos no estrabismo com padrão em A

ABSTRACT Purpose: To evaluate three superior oblique surgical weakening procedures for correcting A-pattern strabismus: tenectomy, superior oblique hang-back recession, and that involving the use of superior oblique suture spacers. Methods: The inclusion criteria were A-pattern strabismus ≥10Δ and horizontal deviation ≥10Δ, with no other ocular abnormality and a follow-up period of ≥6 months. The 24 patients (mean age, 16.3 ± 8.1 years; mean postoperative follow-up, 9.63 ± 3.11 months) were randomly divided into three groups of 8 patients each. Sigmascan® Pro 5.0 software was used to measure the degree of torsion pre- and postoperatively. Results: Preoperatively, the mean angles of A-pattern deviation were 19.33Δ° ± 3.53Δ° (tenectomy group), 15.71Δ° ± 1.11Δ° (hang-back recession group), and 14.62Δ° ± 1.18Δ° (suture spacers group); these values did not differ significantly. At the final follow-up examination, the mean angles of A-pattern deviation were 4.67Δ° ± 0.67Δ° (tenectomy group), 6.29Δ° ± 1.48Δ° (hang-back recession group), and 4.38Δ° ± 1.03Δ° (suture spacers group), with no statistically significant difference in the correction in A-pattern strabismus among the three groups. Preoperatively, the mean torsional angles were +5.4° ± 3.9° (tenectomy group), +5.6° ± 4.9° (hang-back recession group), and +6.0° ± 3.3° (suture spacers group); these values did not differ significantly. At the final follow-up examination, the mean torsional angles were + 0.3° ± 5.6° (tenectomy group), +0.5° ± 4.6° (hang-back recession group), and +0.2° ± 5.2° (suture spacers group), with no statistically significant difference in the intorsion correction among the three groups. Conclusion: All three superior oblique weakening procedures were effective for correcting A-pattern strabismus and fundus intorsion.

RESUMO Objetivo: Avaliar três procedimentos de debilitamento dos músculos oblíquos superiores para a correção de estrabismo com padrão em A: tenectomia, sutura em rédea (hang-back recession) e o uso de espaçadores de sutura oblíqua superior. Métodos: Os critérios de inclusão foram estrabismo padrão em A ≥10Δ e desvio horizontal ≥10Δ, sem outras anormalidades oculares e tempo de acompanhamento ≥6 meses. Os 24 pacientes (média de idade de 16,3 ± 8,1 anos; média de seguimento pós-operatório de 9,63 ± 3,11 meses) foram divididos aleatoriamente em três grupos de 8 pacientes cada. O programa Sigmascan® Pro 5.0 foi utilizado para medir o grau de torção no pré e pós-operatório. Resultados: No pré-operatório, a média e o desvio padrão dos ângulos de padrão em A foram de 19,33Δ° ± 3,53Δ° (grupo da tenectomia), 15,71Δ° ± 1,11Δ° (grupo da sutura em rédea), 14,62Δ° ± 1,18Δ° (grupo de espaçadores de sutura); esses valores não diferiram significativamente. No exame pós-operatório, a média e o desvio padrão dos ângulos de desvio do padrão em A foram de 4,67Δ° ± 0,67Δ° (grupo da tenectomia), 6,29Δ° ± 1,48Δ° (grupo da sutura em rédea), 4,38Δ° ± 1,03Δ° (grupo de espaçadores de sutura), sem diferença estatisticamente significativa na correção do estrabismo padrão em A entre os três grupos. No pré-operatório, os ângulos médios de torção foram de +5,4o ± 3,9° (grupo de tenectomia), +5,6° ± 4,9° (grupo da su­tura em rédea), e +6,0° ± 3,3° (grupo de espaçadores de sutura), esses valores não diferiram significativamente. No pós-operatório, os ângulos médios de torção foram de +0,3° ± 5,6° (grupo da tenectomia), +0,5° ± 4,6° (grupo da sutura em rédea), e +0,2° ± 5,2° (grupo de espaçadores de sutura), sem diferença estatisticamente significativa na correção da intorção entre os três grupos. Conclusão: Os três procedimentos de debili­tamento dos músculos oblíquos superiores foram efetivos para a correção do estrabismo com padrão em A e da intorção ocular observada na fundoscopia.

Inestabilidad de la polea como causa de estrabismo / Pulley instability as a cause of strabismus

RESUMEN La caracterización de las poleas de los músculos extraoculares ha sido de gran trascendencia en la fisiopatología del equilibrio óculo-motor. El efecto mecánico de la polea funcional es cambiar el eje de acción del músculo de acuerdo con la orientación que el globo ocular presente. Los trastornos en la localización o estabilidad de las poleas pueden crear patrones de estrabismo incomitante. Es importante el conocimiento de estas anomalías porque los procedimientos quirúrgicos estándar no corrigen los desplazamientos de las poleas. Se realizó una búsqueda del tema de los últimos 10 años utilizando la plataforma de infomed(AU)

ABSTRACT Characterization of extraocular muscle pulleys has had great relevance in the physiopathology of ocular motor balance. The mechanical effect of the functional pulley is to change the axis of action of the muscle in keeping with the orientation of the eyeball. Pulley location or stability disorders may create incomitant strabismus patterns. It is important to be aware of these anomalies because standard surgical procedures do not correct pulley displacement. A search was conducted on the Infomed platform of papers published about the topic in the past ten years(AU)

Determinación y cuantificación de subpoblaciones de linfocitos T y células natural killer en sangre periférica de individuos sanos por citometría de flujo / Detection and quantification of T-cell subpopulations and NK cells in peripheral blood from healthy individuals

Resumen Introducción: La determinación de las diferentes subpoblaciones de los linfocitos T en las diversas patologías y el monitoreo postratamiento ayuda a que el médico tome decisiones terapéuticas teniendo como referencia la cinética de los linfocitos T localizados en sangre periférica. Métodos: Se realizó la estandarización de un perfil de moléculas de superficie para la caracterización de subpoblaciones de linfocitos T: naïve, activados y de memoria, así como las células natural killer o asesinas naturales (CD3− CD56+) en sangre periférica de individuos clínicamente sanos. Resultados: Se identificaron las subpoblaciones de linfocitos: naïve (CD3+, CD4+ o CD8+, CD45RA+, CD62L+, CCR7+), activados (CD3+, CD4+ o CD8+, CD45RA+ o CD45RO+, CD69+ y/o CRTAM+), efectores (CD3+, CD4+ o CD8+, CD45RA+, CD62L−, CCR7−), de memoria central (CD3+, CD4+ o CD8+, CD45RO+, CD62L+, CCR7+) y de memoria efectora (CD3+, CD4+ o CD8+, CD45RO+, CD62L−, CCR7−) en las poblaciones de linfocitos T CD4+ y CD8+. Se integraron los datos obtenidos con estadística descriptiva (valores mínimos, valores máximos, media, mediana). Conclusiones: Este panel será de gran utilidad para monitorear pacientes en quienes se requiera valorar el estado inmunológico desde el punto de vista celular. Particularmente, puede apoyar en el seguimiento de los pacientes en los que se requiera evaluar la reconstitución inmunológica (componente celular de estirpe T).

Abstract Background: The knowledge of the participation of different subpopulations of T lymphocytes in various pathologies helps to make therapeutic decisions, having as reference the presence of the different subpopulations of the T lymphocytes associated with the disease. Methods: A profile standardization of surface molecules for the characterization of subpopulations of T cells was conducted: naïve, activated and memory, as well as natural killer (CD3− CD56+) cells in peripheral blood of clinically healthy individuals. Results: Naïve (CD3+, CD4+ or CD8+, CD45RA+, CD62L+, CCR7+), activated (CD3+, CD4+ or CD8+, CD45RA+ or CD45RO+, CD69+ and/or CRTAM+), effectors (CD3+, CD4+ o CD8+, CD45RA+, CD62L−, CCR7−), central memory (CD3+, CD4+ o CD8+, CD45RO+, CD62L+, CCR7+), memory effectors (CD3+, CD4+ or CD8+, CD62RO+, CD62L−, CCR7−) subpopulations were analyzed by flow cytometry. Descriptive statistics parameters were calculated (minimum values, maximum values, mean values, median). Conclusions: This panel can be very useful for monitoring patients in whom the immunological status from a cellular perspective is needed. Particularly, it can support the follow-up of patients who require an immunological reconstitution (T-cell component) evaluation.

Implante de pesa de oro palpebral en el tratamiento del lagoftalmo paralítico / Palpebral gold weight implantation in the paralytic lagophthalmos treatment

El lagoftalmo secundario a daño del nervio facial trae como consecuencia alteraciones funcionales y estéticas que pueden tributar a serias complicaciones corneales y eventualmente a la ceguera. El correcto manejo depende de su severidad y del tiempo de recuperación. El implante de pesas de oro en el párpado superior juega un importante papel en el tratamiento a mediano y largo plazo de esta afección. Se presenta un paciente masculino de 74 años con síntomas y signos de parálisis facial periférica derecha, incluyendo lagoftalmo ipsilateral con gran deterioro corneal. Se le implantó una pesa de oro pretarsal en el párpado superior para corregir el lagoftalmo paralítico y se obtuvieron excelentes resultados funcionales y estéticos. Mientras novedosas modalidades de tratamiento se encuentran en el horizonte con gran potencial para alterar el algoritmo de tratamiento actual, este proceder continúa siendo una técnica confiable, segura y efectiva para la rehabilitación permanente del párpado superior(AU)

Lagophthalmos secondary to facial nerve damage brings about functional and esthetic alterations which may result in serious corneal complications and eventual blindness. Appropriate management depends on severity and recovery time. Gold weight implantation in the upper eyelid plays an important role in the medium- and long-term treatment of this condition. A male 74-year-old patient presents with signs and symptoms of right-side peripheral facial paralysis, including ipsilateral lagophthalmos with great corneal deterioration. A pretarsal gold weight was implanted in the upper eyelid to correct the paralytic lagophthalmos, and excellent functional and esthetic results were obtained. While novel treatment modes lie in the horizon with great potential to alter the algorithm of current treatment, this procedure continues to be a reliable, safe and effective technique for the permanent rehabilitation of the upper eyelid(AU)

Retroceso bilateral de rectos laterales comparado con retroceso/resección unilateral para el tratamiento de la exotropia intermitente básica / Bilateral lateral rectus recession versus unilateral recession/resection for basic intermittent exotropia

Resumen INTRODUCCIÓN: En determinadas circunstancias clínicas, la exotropia intermitente básica requiere resolución quirúrgica. Existen dos técnicas para ello: el retroceso bilateral de rectos laterales y el retroceso/resección unilateral. Aunque el retroceso bilateral es la técnica más utilizada, no está claro cuál de estas técnicas tiene mejores resultados. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyeron siete estudios primarios, de los cuales tres son ensayos aleatorizados. Concluimos que el retroceso/resección unilateral podría tener un mayor éxito quirúrgico y probablemente disminuiría la tasa de subcorrección/recurrencia, cuando se le compara al retroceso bilateral de rectos laterales.

Abstract INTRODUCTION: Intermittent exotropia requires surgical resolution under some clinical circumstances. The main techniques are bilateral lateral rectus recession and unilateral recess/resection. Although bilateral recession is the most widely used, it is not clear whether it leads to better results. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews including seven studies overall, of which three were randomized trials. We concluded unilateral recess/resection might achieve greater surgical success and probably decrease the rate of undercorrection/recurrence when compared to bilateral lateral rectus recession.

Epidemiology of strabismus surgery in a public hospital of the Brazilian Federal District / Epidemiologia da cirurgia de estrabismo em um hospital público de Brasília, Distrito Federal

Abstract Purpose: to determine the prevalence of different types of strabismus submitted to a surgical procedure in a public hospital in the Brazilian Federal District. Methods: Retrospective cross-sectional review of medical records of patients who underwent strabismus surgery performed by the same surgeon from 2004 to 2014. Incomplete records were excluded from the study. Variables included sex, age, type of strabismus, type of surgery, and re-surgeries. Strabismus was classified into three main types (esotropia, exotropia, and pure vertical deviation), and their subtypes. The type of surgery was determined by the number of muscles operated on (up to two, or more than two), the involvement of oblique and vertical rectus muscles, and muscle displacement. Results: 563 patients were reviewed and 531 were included in the study. The average age was 12.7 years, and females accounted for 54.4% of total patients. Esotropia was the most frequent type of strabismus (74%), followed by exotropia (23.7%) and pure vertical deviation (2.3%). The most frequent subtype of esotropia was infantile (49.1%), with 16.1% of these surgeries performed before the age of 2. Constant exotropia was the most frequent subtype of exotropia (27.8%). The prevalence of esotropia decreased with age, whereas that of exotropia increased. 52.3% of surgeries involved more than two muscles. An association between different types of deviation was found in 58.9% of patients. In cases of paralytic strabismus, the sixth nerve was the most affected (46%). Re-surgeries accounted for 10.7% of total surgeries. Conclusion s: Esotropias were the most common types of strabismus, especially infantile esotropia. Most cases were associated with other types of deviation, and needed more complex surgeries, involving more than two muscles. This study expects to contribute to the planning of health measures that may effectively improve the assistance provided to the population.

Resumo Objetivo: Determinar a prevalência dos diferentes tipos de estrabismo submetidos a intervenção cirúrgica em um hospital público de Brasília, Brasil. Métodos: Estudo retrospectivo de corte transversal de prontuários médicos dos pacientes submetidos a cirurgias de estrabismo por um mesmo cirurgião, de 2004 e 2014. Foram excluídos prontuários incompletos. Variáveis pesquisadas incluíram sexo, idade, classificação do estrabismo, tipo da cirurgia e reoperações. Os estrabismos foram classificados em três tipos principais (esotropia, exotropia e desvio vertical puro) e seus subtipos. Avaliação do tipo da cirurgia considerou o número de músculos operados (intervenção em até 2 ou em mais músculos), o envolvimento de músculos oblíquos, retos verticais e transposição muscular. Resultados: Foram avaliadas 563 pacientes e 531 foram incluídas na análise. A média de idade foi 12,7 anos e o sexo feminino respondeu por 54,4%. A esotropia foi o tipo de estrabismo mais frequente (74%), seguido pela exotropia (23,7%) e desvio vertical puro (2,3%). O subtipo de esotropia mais frequente foi o infantil (49,1%), com 16,1% destas cirurgias realizadas antes dos 2 anos de vida. A exotropia constante foi o subtipo mais observado (27,8%) de exotropia. A proporção de esotropia diminuiu com a idade, enquanto a de exotropia aumentou. 52,3% das cirurgias envolveram mais de dois músculos. Associação de diferentes tipos de desvio foi observada em 58,9% dos pacientes. Dentre os estrabismos paralíticos, o VI nervo foi o mais acometido (46%). Reoperações corresponderam a 10,7% do total. Conclusão: As esotropias foram os estrabismos cirúrgicos mais comuns, especialmente a esotropia infantil. A maioria dos casos estava associada a outras formas de desvio e necessitaram de cirurgias mais complexas, envolvendo mais de 2 músculos. Espera-se que dados do estudo possam contribuir no planejamento de ações de saúde efetivas para melhorar a assistência à população.

Antielevation Syndrome after Bilateral Anterior Transposition of the Inferior Oblique Muscles

No abstract available.

Comparison of Postoperative Exodrift after First Unilateral and Second Contralateral Lateral Rectus Recession in Recurrent Exotropia

PURPOSE: To compare postoperative exodrift of the first unilateral lateral rectus (ULR) muscle recession with the exodrift of the second contralateral ULR muscle recession in patients with recurrent small-angle exotropia (XT). METHODS: We evaluated the results of a second ULR muscle recession in 19 patients with recurrent XT with deviation angles under 25 prism diopter (PD), following a first procedure of ULR muscle recession for small-angle XT. Recession of the lateral rectus muscle ranged from 8 to 9 mm. The postoperative motor alignment and degree of exodrift were investigated after the first ULR muscle recession and the second ULR muscle recession in the same patients. RESULTS: Observed differences in postoperative ocular alignment between the first ULR muscle recession and the second ULR muscle recession were statistically significant at follow-up periods of six months (7.84 +/- 4.43 vs. 3.89 +/- 3.47 PD), one year (9.58 +/- 4.97 vs. 5.21 +/- 4.94 PD), and at a final follow-up (21.11 +/- 2.98 vs. 7.52 +/- 4.06 PD) after surgery (p = 0.006, 0.013, and 0.000). Postoperative exodrift was statistically different between the first and second ULR muscle recessions at three to six months (2.89 +/-3.75 vs. 0.63 +/- 3.45 PD) and one year to final follow-up (11.52 +/- 5.50 vs. 2.32 +/- 3.53 PD) (p = 0.034 and 0.000). All of the first ULR muscle recession patients showed XT with deviation angles of more than 15 PD at the final follow-up. Regardless, the surgical success rate (<8 PD) after the second ULR recession was 63.16% (12 patients) among the total amount of patients with recurrent XT. CONCLUSIONS: This study shows that changes in exodrift after a second ULR muscle recession are less than changes after the first URL muscle recession among patients with recurrent XT. A second ULR muscle recession may be a useful surgery for small-angle XT patients with deviation angles of 25 PD or less after a first ULR muscle recession.

The Stabilization of Postoperative Exo-drift in Intermittent Exotropia after Surgical Treatment

PURPOSE: To investigate the long-term clinical course of intermittent exotropia after surgical treatment to determine whether and when postoperative exo-drift stabilizes, and the required postsurgery follow-up duration in cases of intermittent exotropia. METHODS: We retrospectively reviewed the medical records of patients diagnosed with intermittent exotropia who underwent surgical treatment between January 1992 and January 2006 at Yeungnam University Hospital and postoperatively performed regular follow-up examinations for up to 7 years. We also analyzed the difference in exo-drift stabilization, according to surgical procedure. RESULTS: A total of 101 patients were enrolled in the study. Thirty-one patients underwent lateral rectus recession and medial rectus resection (R&R) and 70 patients underwent bilateral lateral rectus recession (BLR). The postoperative angles of deviation increased significantly during the initial 36 months, but no subsequent significant changes were observed for up to 84 months. Follow-ups for 7 years revealed that more than 50% of the total amount of exo-drift was observed within the first postoperative year. In addition, the angles of deviation at 1 year correlated with those at 7 years postoperatively (Pearson correlation coefficient r = 0.517, p < 0.001). No significant exo-drift was observed after 36 months in patients who underwent BLR, whereas after 18 months in patients who underwent R&R. CONCLUSIONS: The minimum postoperative follow-up required after surgical treatment to ensure stable results is 36 months. In particular, careful follow-up is necessary during the first postoperative year to detect rapid exo-drift. Patients who underwent BLR required a longer follow-up than those who underwent R&R to ensure stable postoperative alignment.

Difference of Self-identity Levels between Strabismus Patients and Normal Controls

PURPOSE: To evaluate differences in self-identity in patients diagnosed with strabismus, patients who underwent strabismus surgery, and healthy control individuals. METHODS: Self-identity testing was done during a military service physical examination. There were three subject groups: subjects with strabismus (group 1), subjects who had undergone corrective strabismus surgery (group 2), and subjects free of strabismus (group 3). The self-identity test was comprised of six sub-sections (subjectivity, self-acceptance, future confidence, goal orientation, initiative, and familiarity). Statistical significance of the sub-sections was compared across the three groups. Correlations in age at the time of surgery and across the six sub-sections were investigated in group 2. RESULTS: A total of 351 subjects were enrolled in the study; 96 subjects were in group 1, 108 subjects were in group 2, and 147 subjects were in group 3. Significant differences were evident in subjectivity, self-acceptance, initiative and familiarity between groups 1 and 3. No significant differences were found between groups 2 and 3. In group 2, statistical significance was evident between age at surgery and initiative and familiarity (r = −0.333, p < 0.001; r = −0.433, p < 0.001, respectively). CONCLUSIONS: Self-identity is greater in non-strabismus subjects than strabismus subjects. Correction of strabismus may increase self-identity levels.

Clinical Outcomes of Individualized Botulinum Neurotoxin Type A Injection Techniques in Patients with Essential Blepharospasm

PURPOSE: To assess the clinical outcomes following botulinum neurotoxin type A (BoNT-A) treatment with an individualized injection technique based on the types of spasms and to compare the results of the individualized injection technique with those of the conventional injection technique in the same patients. METHODS: From November 2011 to July 2013, 77 BoNT-A injections were performed in 38 patients. Eighteen patients were treated with conventional BoNT-A injections before 2011, and 20 patients were referred to our hospital for unsatisfactory results after a conventional injection technique. We classified the patients by spasm-dominant sites: the lateral orbital area, representing the orbital orbicularis-dominant group (ODG); the glabella, representing the corrugator-dominant group (CDG); and the ptosis, representing the palpebral part of the orbicularis-dominant group (PDG). We increased the injection dose into the spasm-dominant sites of the blepharospasm groups. We assessed subjective symptom scores (functional disability score, FDS) after treatment. RESULTS: This study included 38 patients (26 women, 12 men; mean age, 60.6 +/- 10.9 years). There were 21 patients in the ODG, 10 patients in the CDG, and 7 patients in the PDG. Mean ages were 59.7 +/- 12.6, 59.8 +/- 8.5, and 66.8 +/- 9.0 years, and mean BoNT-A injection dose was 38.8 +/- 11.2, 38.8 +/- 11.2, and 38.8 +/- 10.8 U in each group, respectively (p = 0.44, 0.82 Kruskal-Wallis test). Mean FDS after injection was 1.7 +/- 0.7 in the ODG, 1.4 +/- 0.8 in the CDG, and 1.2 +/- 0.3 in the PDG. There were significant differences in reading and job scale among the three groups. In a comparison between the conventional and individualized injection techniques, there was a significant improvement in mean FDS and in the reading scale in the PDG with the individualized injection technique. The success rate was 92.1% in the conventional injection group and 94.1% in the individualized injection group. CONCLUSIONS: The individualized injection technique of BoNT-A according to the spasm-dominant site is an effective and safe treatment method for essential blepharospasm patients.

Comparison of Surgical Outcomes with Unilateral Recession and Resection According to Angle of Deviation in Basic Intermittent Exotropia

PURPOSE: The purpose of this study is to compare the surgical outcomes and near stereoacuities after unilateral medial rectus (MR) muscle resection and lateral rectus (LR) recession according to deviation angle in basic intermittent exotropia, X(T). METHODS: Ninety patients with basic type X(T) were included in this study. They underwent unilateral recession of the LR and resection of the MR and were followed postoperatively for at least 12 months. Patients were divided into three groups according to their preoperative deviation angle: group 1 or =40 PD. Surgical outcomes and near stereoacuities one year after surgery were evaluated. Surgical success was defined as having a deviation angle range within +/-10 PD for both near and distance fixation. RESULTS: Among 90 patients, groups 1, 2, and 3 included 30 patients each. The mean age in groups 1, 2, and 3 was 9.4 years, 9.4 years, and 11.0 years, respectively. The surgical success rates one year after surgery for groups 1, 2, and 3 were 80.0%, 73.3%, and 73.3% (chi-square test, p = 0.769), respectively. The undercorrection rates for groups 1, 2, and 3 were 16.7%, 23.3%, and 26.7%, and the overcorrection rates were 3.3%, 3.3%, and 0%, respectively. The mean preoperative near stereoacuities for groups 1, 2, and 3 were 224.3 arcsec, 302.0 arcsec, and 1,107.3 arcsec, and the mean postoperative near stereoacuities were 218.3 arcsec, 214.7 arcsec, and 743.0 arcsec (paired t-test; p = 0.858, p = 0.379, p = 0.083), respectively. CONCLUSIONS: In basic X(T) patients, the amount of angle deviation has no influence on surgical outcomes in unilateral LR recession and MR resection. The near stereoacuities by one year after LR recession and MR resection for intermittent X(T) were not different among patient groups separated by preoperative deviation angle.

Measurement of ocular torsion variation following superior oblique tenectomy / Medida da variação da torção ocular após a tenectomia do oblíquo superior

Purposes: To objectively evaluate the torsional effect of the superior oblique muscle-weakening surgery using the tenectomy technique proposed by Souza-Dias. Methods: The present prospective study included 10 patients (20 eyes) with horizontal strabismus, bilateral superior oblique overaction and A-pattern of 15 to 30 prism diopters who underwent superior oblique tenectomy. Objective assessment of ocular torsion was performed by retinography immediately before and one month after surgery. The amount of ocular torsion was determined by measuring the angle formed by a horizontal line drawn across the geometric center of the optic disc and a second line connecting this point to the fovea. Results: The median preoperative angle was 5.56° in the right eyes and -3.43° in the left eyes. The median postoperative angle was 1.84° in the right eyes and -3.12° in the left eyes. The angle variation was statistically significant in both eyes (p=0.012 and p=0.01, respectively). Conclusion: The present study suggests that superior oblique tenectomy has an extorter effect, decreasing the intorsion detected on overaction of this muscle. .

Objetivo: Avaliar, de forma objetiva, a torção ocular após a tenectomia do oblíquo superior, proposta por Souza-Dias. Métodos: Estudo prospectivo de dez pacientes (20 olhos) com estrabismo horizontal, hiperfunção bilateral dos oblíquos anisotropia em A de 15 a 30 dioptrias prismáticas, submetidos à tenectomia bilateral dos oblíquos superiores. A avaliação objetiva da torção foi realizada com a retinografia antes e após a cirurgia, determinando-se o ângulo de torção formado entre a linha horizontal que passa pelo centro do disco óptico e a linha que passa pelo centro da fóvea. Resultados: A mediana dos ângulos de torção pré-operatória foi de 5,56° nos olhos direitos e de 3,43° nos esquerdos. Após a cirurgia, o ângulo mediano foi de 1,84° nos olhos direitos e de -3,12° nos esquerdos. Em ambos os olhos, a variação absoluta foi estatisticamente significativa (p=0,012/p=0,01). Conclusões: O presente estudo demonstrou que a tenectomia do oblíquo superior tem ação extorsora, reduzindo de forma significante a intorção encontrada nos casos de hiperfunção deste músculo. .

Recuo assimétrico dos músculos retos horizontais para correção de incomitância alfabética: relato de caso / Asymmetric recession of the horizontal rectus muscles for correction alphabetical incomitance: case report

Os autores relatam o caso de um homem de 21 anos com estrabismo divergente incomitante, anisotropia em "V", hiperfunção de músculo oblíquo inferior direito e hipofunção de obliquo superior direito, no qual foi realizado, sob anestesia tópica, um recuo assimétrico das fibras dos músculos retos horizontais para correção da incomitância alfabética. O resultado cirúrgico imediato foi considerado muito bom (ortotrópico e sem incomitância alfabética), já que pela técnica cirúrgica convencional não se obteve sucesso.

The authors report a case of 21-year-old man with divergent noncomitant strabismus, "V" pattern anisotropy, right inferior oblique muscle overaction and right superior oblique muscle hypofunction, which was performed under topical anesthesia an asymmetrical recession of the horizontal rectus muscles fibers to correct alphabetical incomitance. The immediate surgical outcome was considered very good (orthotropic, no "V" or "A" pattern), since the success was not obtained through conventional surgical technique.

Relationship of Hypertropia and Excyclotorsion in Superior Oblique Palsy

PURPOSE: To evaluate the correlation between hypertropia and excyclotorsion in acquired superior oblique palsy (SOP). METHODS: Thirty-one patients with acquired unilateral SOP were recruited for this study. The torsional angle of each patient was assessed via one objective method (fundus photography) and two subjective methods (double Maddox rod test and major amblyoscope). The patient population was divided into two groups (concordance group, n = 19 and discordance group, n = 12) according to the correspondence between the hypertropic eye (paralytic eye) and the more extorted eye (non-fixating eye), which was evaluated by fundus photography. RESULTS: The mean value of objective torsion was 5.09degrees +/- 3.84degrees. The subjective excyclotorsion degrees were 5.18degrees +/- 4.11degrees and 3.65degrees +/- 1.93degrees as measured by double Maddox rod test and major amblyoscope, respectively. Hypertropia and the excyclotorsional angle did not differ significantly between the groups (p = 0.257). Although no correlation was found in the discordance group, the concordance group showed a significant and positive correlation between hypertropia and excyclotorsion (p = 0.011). CONCLUSIONS: Torsional deviation was not related to hypertropia. However, in the concordance patients in whom the hypertropic eye showed excyclotorsion, a significant positive correlation was found between hypertropia and excyclotorsion.

Contemplation of the Surgical Normogram of Lateral Rectus Recession for Exotropia Associated with Superior Oblique Palsy

PURPOSE: To suggest a surgical normogram for lateral rectus recession in exotropia associated with unilateral or bilateral superior oblique muscle palsy (SOP). METHODS: We retrospectively reviewed the charts of 71 patients with exotropia who were successfully corrected over one year. Each patient had undergone unilateral or bilateral rectus recession associated with uni- or bilateral inferior oblique (IO) 14 mm recession, using a modified surgical normogram for lateral rectus (LR) recession, which resulted in 1 to 2 mm of reduction of LR recession. We divided all patients into 2 groups, the 34 patients who had undergone LR recession with unilateral IO (UIO) recession group and the remaining 37 patients who had undergone LR recession with bilateral IO (BIO) recession group. Lateral incomitancy was defined when the exoangle was reduced by more than 20% compared to the primary gaze angle. The surgical effects (prism diopters [PD]/mm) of LR recession were compared between the two groups using the previous surgical normogram as a reference (Parks' normogram). RESULTS: The mean preoperative exodeviation was 20.4 PD in the UIO group and 26.4 PD in the BIO group. The recession amount of the lateral rectus muscle ranged from 4 to 8.5 mm in the UIO group and 5 to 9 mm in the BIO group. Lateral incomitancy was noted as 36.4% and 70.3% in both groups, respectively (p = 0.02). The effect of LR recession was 3.23 +/- 0.84 PD/mm in the UIO group and 2.98 +/- 0.62 PD/mm in the BIO group and there was no statistically significant difference between two the groups (p = 0.15). CONCLUSIONS: Reduction of the LR recession by about 1 to 2 mm was successful and safe to prevent overcorrection when using on IO weakening procedure, irrespective of the laterality of SOP.

Factors Associated with the Direction of Ocular Deviation in Sensory Horizontal Strabismus and Unilateral Organic Ocular Problems

PURPOSE: To evaluate factors associated with the direction of horizontal deviation in the sensory strabismus of patients with unilateral organic amblyopia. METHODS: The medical charts of 53 patients who had been diagnosed with sensory strabismus between 2000 and 2009 were reviewed retrospectively. The underlying ocular disease, time of onset and the duration of vision impairment, refractive error and axial length of the fixing eye, and the direction and angle of deviation were analyzed to determine the distribution of underlying diseases and any factors relevant to determining the direction of the horizontal deviation. RESULTS: Congenital cataracts were the most common underlying disease, found in 33 patients, followed by acquired cataracts, optic nerve disorders, retinal detachment, glaucoma and lens subluxation. Among the 50 patients with horizontal strabismus, 11 had esotropia and 39 had exotropia. The incidence of esotropia was significantly higher when the fixing eye had hyperopia or emmetropia, than when the eye was myopic. Age of onset of vision deterioration and at diagnosis of sensory strabismus, and the axial length of the fixing eye had no relationship to the direction of horizontal deviation. In addition, the duration of visual impairment had no significant relationship with the direction or extent of horizontal deviation. CONCLUSIONS: The most common cause of sensory strabismus was congenital cataracts and the most frequent type of strabismus was exotropia. With respect to the direction of horizontal strabismus, esotropia occurred significantly more often when the refractive error of the fixing eye was hyperopia or emmetropia than when the fixing eye was myopic.

Postoperative Stabilization of the Strabismic Angle in Intermittent Exotropia

PURPOSE: To analyze the postoperative strabismic angle for five years or more and to investigate when the angle stabilized in intermittent exotropia. METHODS: We retrospectively reviewed the clinical records of 89 patients who had undergone surgery for intermittent exotropia. The postoperative strabismic angles measured were analyzed at one-year intervals up to five years postoperatively. We divided them into two groups according to their age at the time of surgery. Group 1 was less than 5 years of age, while Group 2 participants were 5 years of age or older. RESULTS: For our 89 total patients, average exo-angles were 7.8 +/- 7.26, 7.9 +/- 7.51, 9.5 +/- 7.05, 10.1 +/- 6.87, and 9.4 +/- 6.90 prism diopters at one, two, three, four, and five years postoperatively, respectively. Average exo-angles between postoperative year one and year three, as well as between postoperative year two and year three, were statistically significant (p = 0.015, 0.022). However, the angles were not statistically significant between postoperative year three and year four or between years three and five, respectively (p = 0.707, p = 0.948). The stabilization characteristics of the angle were somewhat different according to age group. In Group 1, the average exo-angle in postoperative years one and three were statistically significant (p = 0.016), but the angle in the same period was not statistically significant in Group 2 (p = 0.203). CONCLUSIONS: There was no significant interval change after three years postoperatively in intermittent exotropia, but if the patient's age at surgery was 5 years or higher, no significant change of exo-angle was found following postoperative year one in this study.

Supermaximal Recession and Resection in Large-Angle Sensory Exotropia

In cases of extropia with an exodeviation angle over 50 prism diopter (PD), a 3- or 4-muscle surgery is a rational option. But, in patients with sensory exotropia, there is usually a strong preference for a monocular procedure to avoid surgery on the single seeing eye. Thus, we confined surgery to visually poor eyes, and performed a medial rectus muscle resection with a mean of 10.3 mm (range, 9-11 mm) and a lateral rectus muscle recession with a mean of 12.8 mm (range, 10-14 mm) in 4 adult sensory exotropia patients who had a mean deviation of 82.3 PD (range, 75-90 PD). The mean postoperative angle of exodeviation was 2.0 PD (range, ortho-8 PD). The limitation on abduction was not disfiguring. Other expected disfigurements, such as narrowing of the palpebral fissure or enophthalmos, were not conspicuous. The mean follow-up period was 4.5 months (range, 3-7 months). In large-angle sensory exotropia, instead of additive surgery on the seeing eye, supermaximal medial rectus resection and lateral rectus recession only on the visually poor eye is a clinically feasible surgical option.

Surgical Correction of Hallermann-Streiff Syndrome: A Case Report of Esotropia, Entropion, and Blepharoptosis

We report a case of surgical treatment for Hallermann-Streiff syndrome in a patient with ocular manifestations of esotropia, entropion, and blepharoptosis. A 54-year-old man visited Yeouido St. Mary's Hospital complaining of ocular discomfort due to cilia touching the corneas of both eyes for several years. He had a bird-like face, pinched nose, hypotrichosis of the scalp, mandibular hypoplasia with forward displacement of the temporomandibular joints, a small mouth, and proportional short stature. His ophthalmic features included sparse eyelashes and eyebrows, microphthalmia, nystagmus, lower lid entropion in the right eye, and upper lid entropion with blepharoptosis in both eyes. There was esodeviation of the eyeball of more than 100 prism diopters at near and distance, and there were limitations in ocular movement on lateral gaze. The capsulopalpebral fascia was repaired to treat the right lower lid entropion, but an additional Quickert suture was required to prevent recurrence. Blepharoplasty and levator palpebrae repair were performed for blepharoptosis and dermatochalasis. Three months after lid surgery, the right medial rectus muscle was recessed 7.5 mm, the left medial rectus was recessed 7.25 mm, and the left lateral rectus muscle was resected 8.0 mm.