Clinical Classification of Acquired Concomitant Esotropia.

BACKGROUND: Classification and management of acquired concomitant esotropia is controversial. We sought to establish a simple clinical classification in order to determine in which cases further investigations in search of underlying pathologies are necessary. PATIENTS AND METHODS: Observational retrospective study of the files of 175 consecutive patients examined in our unit between 2009 and 2018 for acute convergent strabismus. One hundred and nine patients were selected, after exclusion of infantile, incomitant, or mechanical esotropias, residual esotropias, and patients examined on a single occasion. All patients received a complete orthoptic and ophthalmological examination. We grouped the patients according to their common characteristics. RESULTS: We established the following categories: 1. Acute esotropia of large angle (20 to 45 prism diopters [PD]), accompanied by mild hyperopia (mean 1.2 D) in children (n = 16) and moderate myopia (mean 3.7 D) in adolescents and adults (n = 13). 2. Decompensated micro-esotropia, which is distinguished from the other categories by the presence of abnormal retinal correspondence (n = 33). 3. Decompensated esophoria, with intermittent deviations of 5 to 30 PD, esotropia being compensated part of the time (n = 25). 4. Esotropia present only at a distance in patients over 50 years of age (n = 20). 5. Small-angle esotropia (< 15 PD) greater at a distance, associated with oculomotor cerebellar syndrome (n = 2). Complementary examinations (MRI or CT scan) were performed on 21 patients, leading to the discovery of a posterior fossa astrocytoma in a 4-year-old boy. CONCLUSIONS: The recognition of decompensated micro-esotropia and esophoria, as well as distance esotropia of the elderly, avoids unnecessary additional investigations, which are indicated in any type of acute comitant strabismus if associated with any neurological sign or symptom (e.g., headaches, nausea, vertigo, imbalance, poor coordination, nystagmus, or papilledema). In the absence of neurological findings, there is no consensus about the indication of neuroimaging in large-angle acquired concomitant esotropia, but long-term follow-up of patients that do not undergo neuroimaging is strongly recommended in order to identify later occurring intracranial diseases. This is of particular importance with children.

[Inferior Rectus Myopexy: Indications and Long-Term Results]. / Myopexie des Musculus rectus inferior: Indikationen und Langzeitergebnisse.

PURPOSE: The rectus inferior myopexy is often used in vertical incomitant deviations without significant deviation in primary position. We analysed the long-term results in different pathologies. METHODS: Retrospective study of patients operated on rectus inferior myopexy between 1984 and 2018. Vertical and torsional deviations were measured in primary position (PP) and 25° downgaze and the field of binocular single vision (FBSV) was evaluated with the Harms tangent screen, establishing a functional score. Postoperative follow-ups took place at 1 month, 6 months and long term (1 - 24 years). RESULTS: 62 patients were included (mean age 41 years, 28 women and 34 men). 47 presented a fourth nerve palsy (group 1) and 15 a reduced depression of other origins (group 2). 31 patients had undergone previous operations and 34 contemporaneous operations with the myopexy. In group 1, preoperative mean vertical deviation was 6.4° in PP and 12.3° on downgaze, postoperative 4° and 7.2°. In group 2, the value decreased from 3.3° in PP and 11.5° on downgaze to 1.2° and 6.6°. Over the years, there has been a decrease in the effect, particularly in group 1. The torsion was hardly influenced in both groups. The median functional score of FBSV improved in group 1 from 10% preoperatively to 39% postoperatively and in group 2 from 25 to 69%. CONCLUSION: The inferior rectus myopexy shows an effective way to reduce the incomitance of vertical deviation without significant influence on torsion. Over the years, there has been a decrease in the effect, particularly in patients with superior oblique paresis. We do not consider inferior rectus myopexy as a classic surgical treatment of superior oblique paresis. We have only used it in special cases.

Nonsurgical treatment of cyclic esotropia.

Cyclic esotropia is characterized by a 24-hour period of straight eye position followed by 24 hours of large-angle esotropia. Possible mechanisms include notably progressive loss of compensation of a latent strabismus. The classic treatment is surgical correction of the angle measured on the days with manifest deviation. We report the first case of cyclic esotropia successfully treated by prismatic correction of the latent strabismus present on "straight" days.

Inferior oblique muscle recession with and without superior oblique tendon tuck for treatment of unilateral congenital superior oblique palsy.

PURPOSE: To compare the surgical results in patients with congenital superior oblique palsy treated with inferior oblique recession (IOR) versus those treated additionally with superior oblique tendon tuck (IOR+SOT). METHODS: A consecutive, nonrandomized series of patients with congenital superior oblique palsy with vertical deviations in adduction between 10° and 20° were retrospectively reviewed. In the first series, patients were treated with IOR; in the second series, patients were treated with IOR+SOT. We examined the effects of surgery on binocular alignment and on the field of binocular single vision. RESULTS: Each group consisted of 20 patients. Preoperative ocular deviations were similar in both groups. Postoperative residual vertical deviations were not different in the primary position or in downgaze; however, significantly better alignment was achieved in the IOR+SOT group in adduction and downgaze in adduction. Consecutive Brown pattern occurred in 18 of 20 patients who underwent IOR+SOT versus 5 of 20 who underwent IOR. Residual torsion was not statistically different. The field of binocular single vision improved to 92% (range, 28%-100%) after IOR and to 96% (range, 64%-100%) after IOR+SOT (P = 0.20). CONCLUSIONS: IOR alone is a suitable procedure for most congenital superior oblique palsies with a moderate-to-large vertical deviation in adduction, resulting in a lower incidence of consecutive Brown pattern than with IOR+SOT.

Novel mutations in FRMD7 in X-linked congenital nystagmus. Mutation in brief #963. Online.

Congenital nystagmus is an eye movement disorder in which one or both eyes are in constant movement. It can be associated with a number of ocular or neurological diseases, or it can be inherited in an autosomal or X-linked fashion. The latter form is called idiopathic or motor nystagmus (CIN). Loci on the X chromosome (NYS1) and on 6p12 (NYS2), 7p11.2 (NYS3), and 13q31-q33 (NYS4) have been identified for CIN. The molecular characterization of NYS1 has recently been solved by Tarpey et al., who identified mutations in FRMD7, a gene of unclear function. We report five novel mutations in FRMD7 and confirm the role of this gene in the pathogenesis of X-linked congenital nystagmus.

[Retro-equatorial myopexy following Hummelsheim transposition in treatment of 6th cranial nerve paralysis]. / Myopexie retro-equatoriale, après transposition selon Hummelsheim, dans le traitement de la paralysie du VIème nerf crânien.

INTRODUCTION: Vertical muscle transpositions are considered as the classic procedures for total VIth nerve palsy, whereas weakening of the controlateral medial rectus muscle requires a residual function of the paretic muscle. The aim of this study is to investigate the cumulative effects of these two different surgical approaches applied to the same patients. PATIENTS AND METHODS: 2 patients (M 48 years and F 55 years) with posttraumatic total VIth nerve paralysis were operated in two steps more than 1 year after trauma. The first procedure consisted of a Hummelsheim transposition of the vertical recti and was followed by a posterior fixation of the controlateral medial rectus. RESULTS: The vertical transposition resulted in the improved position of the paretic eye and in the disappearance of diplopia in primary position. The posterior fixation considerably improved the motility in abduction of the paretic eye and consequently provided the patients with widened binocular field of fusion. CONCLUSION: Posterior fixation of the controlateral medial rectus efficiently complements the vertical transposition in cases of total VIth nerve palsy. This combined effect remained stable during a 2 years follow-up in our patients.