Augmented bilateral lateral rectus recessions in basic intermittent exotropia.

PURPOSE: To compare the outcomes of conventional surgery with the outcomes of surgeries using augmented amounts of symmetric lateral rectus recessions in the treatment of patients with basic intermittent exotropia. METHODS: One hundred seven patients were enrolled in this study; the patients were followed for more than 6 months. The study group was composed of 41 patients who had undergone conventional surgery, and 66 who had augmented surgery. The amount of recession in conventional surgery was determined according to Parks' formula; the augmented amount ranged from 1.5 to 2.5 mm more per eye in augmented surgery. RESULTS: The success rate was 68.2% in subjects who had undergone augmented surgery, compared with the 43.9% observed in those who had undergone the conventional procedure (p = 0.01). The under correction rate was 53.7% in those who had undergone conventional surgery and 30.3% in those who had undergone augmented surgery (p = 0.02). The overcorrection rate was similar in the two groups (conventional, 2.4%; augmented, 1.5%). CONCLUSIONS: The augmented formula may be preferable to the standard formula for patients undergoing symmetric surgery to correct basic intermittent exotropia.

Extensive persistent pupillary membranes: conservative management.

Extensive persistent pupillary membranes (PPMS) may appear to occlude the pupil so completely as to preclude useful vision. They often motivate aggressive interventions. We present a 6-year-old girl with bilateral extensive densely pigmented pupillary membranes in whom good vision was obtained without pharmacologic, laser, or surgical intervention. There was associated ametropic amblyopia and exotropia in the patient, which were effectively treated with spectacles and occlusion therapy, with the patient responding conventionally. In view of our findings, we recommend a trial of conservative management before surgical intervention even in cases of dense PPMs.

Extraocular muscle damage associated with endoscopic sinus surgery: an ophthalmology perspective.

BACKGROUND: Orbital complications associated with endoscopic sinus surgery are well documented. Damage to the medial rectus muscle results in complicated strabismus and disturbing diplopia. The aim of this study was to characterize the types of extraocular muscle injury and the number of muscles involved that may complicate endoscopic sinus surgery and correlate its occurrence to factors in the surgical procedure itself. METHODS: A retrospective chart review was performed of 14 patients with strabismus after endoscopic sinus surgery. Operative notes of the surgical procedure, pathology reports of the intraoperative specimens, postoperative pattern of strabismus, the extraocular muscle involved, and the type of muscle injury characterized by orbital imaging were reviewed in each patient. RESULTS: In our series, not only the medial rectus muscle but also the inferior rectus and the superior oblique muscles were damaged with multiple muscles being involved in one patient. Extraocular muscle injury varied from hematoma, entrapment of muscle in the fractured orbital wall, damage to the oculomotor nerve entry zone, muscle transection, and partial or complete muscle destruction with entrapment in scar tissue. Use of the microdebrider causes extensive irreparable muscle damage. CONCLUSION: Extraocular muscle damage complicating endoscopic sinus surgery can produce therapeutically challenging complicated strabismus.

Chorioretinitis as a complication of pauciarticular juvenile rheumatoid arthritis.

A girl with pauciarticular juvenile rheumatoid arthritis developed bilateral uveitis complicated by cataract and glaucoma. Sequential fundus photography documented development of extensive choroidal scarring and retinal pigment epithelial atrophy in the left macula. Vision was not impaired. This case suggests uveitis in juvenile rheumatoid arthritis can be associated with chorioretinitis.

Combined adjustable rectus muscle resection--recession for incomitant strabismus.

INTRODUCTION: We sought to report the results of combined adjustable suture resection and recession of a rectus extraocular muscle in a subset of patients who are asymptomatic in the primary position but diplopic in secondary functional gaze positions. METHODS: We undertook a retrospective chart review of 12 patients who underwent a surgical procedure consisting of combined resection and recession of the same rectus extraocular muscle on adjustable suture, the amount of recession being double the amount of resection. RESULTS: The amount of incomitance reduced from a preoperative mean of 11.6 prism diopters (PD) to a postoperative mean of 2.9 PD. All 4 rectus muscles underwent operation No significant change in the primary position alignment occurred. Diplopia was eliminated in 11 of the 12 patients postoperatively. CONCLUSION: The combined adjustable suture resection and recession operation is an effective and easy procedure for treatment of this subset of patients with incomitant strabismus.

Superior oblique muscle involvement in thyroid ophthalmopathy.

BACKGROUND: Rectus muscle involvement in thyroid ophthalmopathy is well documented. The inferior rectus is the most frequently involved, followed by the medial, superior, and infrequently the lateral rectus. This study reports involvement of the superior oblique muscle as a contributory cause of restrictive strabismus in patients with thyroid ophthalmopathy. METHODS: This is a retrospective review of four patients with known thyroid ophthalmopathy who presented with incomitant vertical strabismus, A-pattern, overdepression in adduction, underelevation in adduction, and incyclotorsion. All patients underwent preoperative orbital imaging. Two of the four patients had previous orbital decompressions. All patients underwent surgery on the SO muscle. RESULTS: Preoperative scans showed enlargement of one or both SO muscles in all patients and intraoperative forced duction testing revealed restriction to elevation in adduction in all cases. Preoperative A-pattern ranged from to 6 to 22 prism diopters. All subjects had preoperative incyclotorsion, ranging from 2 and 14 degrees. Improvement of the versions, hypertropia, and cyclotorsion followed surgical weakening procedures on the SO muscle. CONCLUSION: Thyroid ophthalmopathy may involve the SO muscle. Clinical manifestations include preoperative A-pattern strabismus, incyclotorsion, and restrictive limitation to elevation in adduction. Orbital imaging documents SO muscle enlargement. Awareness of SO involvement in thyroid ophthalmopathy assists the surgeon to develop a more precise surgical strategy to correct the hypotropia.

Lateral rectus resections in divergence palsy: results of long-term follow-up.

INTRODUCTION: Lateral rectus resections have been previously advocated as surgical options to treat patients with divergence palsy who do not respond well to prisms. This study was undertaken to review the results and long-term follow-up of patients with divergence palsy who underwent lateral rectus resections at our institution. METHODS: Retrospective review of 29 patients (age 35-83 years) with divergence palsy. Five subjects underwent unilateral lateral rectus resection between 4.5 and 5.5 mm on adjustable suture and 24 subjects underwent bilateral lateral rectus resection between 3 and 7 mm on adjustable sutures. RESULTS: Preoperatively, all patients had diplopia at distance and an esodeviation, which was greater at distance (mean 14.7 +/- 5.1Delta) than at near (mean 4.7 +/- 3.5Delta). Twenty-five subjects had previously been treated with prisms. Postoperative follow-up period ranged from 6 to 96 months (mean 38.7 +/- 27.3 months). The angle of deviation at distance was significantly reduced to -0.1 +/- 3.2Delta postoperatively ( P < 0.0001). The angle of deviation at near reduced significantly to -2.2 +/- 3.3Delta postoperatively ( P < 0.0001). No patient was overcorrected for near. Two patients experienced recurrent postoperative diplopia at distance subsequently at 1 and 4 years, which was corrected with prism glasses and lateral rectus re-resection. CONCLUSION: Lateral rectus resection in patients with divergence palsy is an effective and stable procedure in patients with divergence palsy over long-term follow-up periods, with minimal risk of overcorrections at near.

Strabismic complications following endoscopic sinus surgery: diagnosis and surgical management.

INTRODUCTION: Endoscopic surgical techniques improve the surgeon's view of sinus structures but are subject to extraocular muscle complications that cause permanent diplopia. METHODS: A series of 15 patients with strabismus following endoscopic sinus surgery was reviewed retrospectively to characterize the type of muscle injury and report the results of surgical correction. RESULTS: A variety of insults to the medial rectus (MR) muscle occurred, ranging from contusion, hematoma, oculomotor nerve damage with paralysis, muscle transection, and muscle destruction. Inferior rectus and superior oblique muscle trauma was observed. High-resolution computed tomography and magnetic resonance imaging scans proved essential in determining the extent and nature of muscle injury. Surgical approaches included anterior orbitotomy with muscle recovery and transposition procedures. CONCLUSIONS: Several extraocular muscles may be traumatized. Timing and type of surgical treatment depend on severity, type of injury, and number of muscles involved. If the remaining posterior segment of the MR muscle is longer than 20 mm and is contractile, muscle recovery via anterior orbital approach is suggested. If injury is more severe, muscle transposition procedures may be helpful. In cases where there is coexistent medial and inferior rectus injury, transposition procedures may not be possible. Inactivation of the antagonist and use of an orbital periosteal flap as a globe tether to center it may be options.

Acquired strabismus following cosmetic blepharoplasty.

The purpose of this study was to report on 12 patients with acquired strabismus following cosmetic blepharoplasty and to identify patterns of strabismus related to the surgical procedure. Clinical ophthalmologic examinations were performed to specifically clarify the type of strabismus. Operative reports of the blepharoplasty procedures were reviewed. Patients were followed for a minimum of 3 months after the blepharoplasty procedure before surgical intervention was considered. Operative findings at corrective strabismus surgery were noted and an attempt was made to correlate these findings with the clinical ophthalmologic examination and the blepharoplasty surgical procedure. Twelve cases of persistent vertical strabismus occurred following blepharoplasty procedures. Five patients had clinical findings consistent with the diagnosis of acquired superior oblique palsy; one of these five patients also showed signs of an acquired Brown syndrome. Seven patients developed an incomitant vertical deviation consistent with an inferior rectus paresis. Strabismus occurred after conventional lower lid, upper lid, and four-lid blepharoplasty with or without laser blepharoplasty. Acquired strabismus accompanied by persistent diplopia may occur as a complication of cosmetic blepharoplasty. Extraocular muscle damage resulting in either superior oblique muscle palsy or inferior rectus paresis was noted in these patients. In some cases, patients with inferior rectus paresis also showed mechanical restriction to upward rotation of the globe.