Cirugía monocular de 4 músculos extraoculares para la exotropía monocular de gran ángulo / Unilateral four muscle surgery for extra-large monocular exotropia

Introducción La exotropía recurrente es común después de cirugía para exotropía sensorial monocular constante de gran ángulo. La cirugía generalmente se limita al ojo afectado. El debilitamiento simultáneo de los músculos oblicuos ipsilaterales puede mejorar el efecto de la cirugía de los músculos rectos horizontales al disminuir las fuerzas de abducción. Presentamos los resultados de la cirugía simultánea de debilitamiento de los músculos oblicuos combinados con cirugía del músculo recto horizontal ipsilateral con exotropía monocular constante superior a 35 dioptrías prismáticas (DP). Métodos Serie retrospectiva en casos de retroinserción unilateral del recto lateral combinada con resección del recto medial, y debilitamiento simultáneo de ambos músculos oblicuos ipsilaterales. La medida de resultado fue la alineación ocular en la posición primaria. Resultados Se incluyeron 12 ojos de 12 pacientes. La exotropía preoperatoria mejoró de 57,9±15,1DP (rango 35-80; mediana 60) a 3,3±5,5 (rango 0-16; mediana 0) postoperatoriamente (p<0,005). Dos (66%) pacientes con desviación vertical preexistente tuvieron una resolución de su desalineación vertical postoperatoriamente. En el último seguimiento postoperatorio, el 92% de los pacientes tenían una exodesviación de 10DP o menos y 7 (58%) midieron ortotropía. La abducción postoperatoria midió −0,6±1(0 a −3) y la aducción −0,4±0,7 (0 a −2). Conclusión El debilitamiento de los músculos oblicuos puede mejorar el efecto de la cirugía de los músculos rectos horizontales al disminuir las fuerzas de abducción en casos de exotropía monocular de gran ángulo. Como ventaja adicional, la cirugía del músculo oblicuo se puede utilizar simultáneamente para abordar las desviaciones verticales asociadas (AU)

Introduction Recurrent exotropia is common following surgery for monocular large angle constant sensory exotropia. Surgery is usually limited to operations on the affected eye. Simultaneous oblique weakening surgery may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting forces. We report the results of simultaneous oblique muscle weakening procedures combined with ipsilateral horizontal rectus muscle surgery constant monocular exotropia greater than 35 prism diopters (PD). Methods Retrospective case series of patients who underwent unilateral lateral rectus recession combined with medial rectus muscle resection and simultaneous weakening of both ipsilateral oblique muscles. Primary outcome measure was ocular alignment in primary position. Results Twelve eyes of 12 patients were included. The mean preoperative exotropia improved from 57.9±15.1 (range 35–80; median 60PD) to 3.3±5.5 (range 0–16; median 0PD) postoperatively (p<0.005). Two (66%) patients with a pre-existing vertical deviation had resolution of their vertical misalignment postoperatively. At the last postoperative follow up 92% of the patients had an exodeviation of 10PD or less (range 0–16PD median 0PD), and 7 (58%) measured near and distance orthotropia. Postoperative abduction measured −0.6±1 (0 to −3) and adduction −0.4±0.7 (0 to −2). Conclusion Weakening the ipsilateral oblique muscles may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting vectorial forces when operating for a large angle monocular exotropia. As an additional potential advantage, oblique muscle surgery may be used simultaneously to address associated vertical deviations (AU)

PTSD in women is associated with a block in conversion of progesterone to the GABAergic neurosteroids allopregnanolone and pregnanolone measured in plasma.

There is a need to identify new and more effective treatments for posttraumatic stress disorder (PTSD). Allopregnanolone and its stereoisomer pregnanolone (together termed ALLO) are metabolites of progesterone that positively and allosterically modulate GABA effects at GABAA receptors, thereby reducing anxiety and depression. Previous research revealed that women with PTSD had low cerebrospinal fluid (CSF) ALLO levels and a low ratio of ALLO to the allopregnanolone precursor 5α-DHP, consistent with deficient activity of the ALLO synthetic enzyme 3α-hydroxysteroid dehydrogenase (3α-HSD). The current study examined ALLO and the ratio of ALLO to 5α-DHP in plasma at rest and in response to psychophysiological stressors in trauma-exposed, medication-free women with and without PTSD. Participants were examined twice in random order during the early follicular phase (eFP) and mid-luteal phase (mLP) of the menstrual cycle. Plasma neurosteroids were measured using gas chromatography-mass spectrometry. Results indicate that the ALLO to 5α-DHP ratio in plasma increases between the eFP and mLP. In addition, women with PTSD have a lower ratio of ALLO to 5α-DHP than trauma-exposed healthy women, as well as blunted increases in this ratio in response to a moderately stressful laboratory procedure, i.e., differential fear conditioning, across the menstrual cycle. Clinically feasible testing for 3α-HSD dysfunction is critical to translating this line of research into clinical care. Measurement of this ratio in plasma could facilitate patient stratification in clinical treatment trials, as well as precision medicine targeting of treatments that address ALLO synthesis deficits in women with PTSD.

Anterior segment ischemia: etiology, assessment, and management.

Anterior segment ischemia (ASI) is a potentially serious but rare complication of strabismus surgery. Among several risk factors, ASI occurs after strabismus surgery because of the nature of the anterior segment circulation. Disinsertion of rectus muscles leads to a decrease in the blood supply to the various anterior segment structures. We report a series of retrospective and prospective studies performed by our group focused on determining the risk of anterior segment ischemia following strabismus surgery, diagnosis, and modifications to surgical techniques to minimize the impact on anterior segment circulation. We found a significant decrease in postoperative anterior segment blood flow when operating vertical rectus muscles. Plication procedures preserve anterior segment circulation, and modifications to the technique allow the performance of adjustable sutures. Small adjustable selective procedures that spare the ciliary vessels have been demonstrated to be effective in patients with vertical and torsional diplopia. Ciliary sparing augmented adjustable transposition surgery decreases the risk of anterior segment ischemia while allowing management of potential post-operative alignment complications. Finally, ocular coherence tomography angiography is a valuable quantitative and qualitative technique to evaluate anterior segment ischemia. Strabismus surgeons should be aware of the risks of anterior segment ischemia when operating vertical rectus muscles. Modifications to standard surgical techniques allow surgeons to perform complex strabismus surgery in patients at risk for anterior segment ischemia.