Underacting inferior oblique muscle following myectomy or recession for unilateral inferior oblique overaction.

PURPOSE: To assess the incidence and investigate the functional impact of postoperative overcorrection following primary unilateral inferior oblique muscle recession and myectomy for inferior oblique overaction. METHODS: A retrospective study of 79 consecutive patients undergoing inferior oblique myectomy (43) or recession (36) with a minimum 6 months of postoperative follow-up. All underwent ocular motility examinations preoperatively and postoperatively at approximately 2 weeks and 6 months. The vertical deviation in primary position and on contralateral gaze and inferior oblique versions and ductions on contralateral elevation were analyzed. RESULTS: At 6 months, 51 patients had no inferior oblique underaction (group 1), 23 of 28 who had developed inferior oblique underaction were asymptomatic (group 2), and the remaining 5 were symptomatic (group 3). The mean preoperative hyperdeviation was 12.9 (group 1), 13.1 (group 2), and 15 (group 3) prism diopters (PD) in primary position. Postoperatively, these measured 3.8 (group 1), 3.8 (group 2), and -7.8 (group 3) PD (- indicates deviation reversal). The mean preoperative and postoperative inferior oblique versions for these three groups were +2.7, +2.2, +2.2 units and +0.9, -1.0, -1.4 units, respectively. CONCLUSION: Inferior oblique underaction was common (28 patients, 35.4%), generally mild, persistent, and usually asymptomatic 6 months following surgery. Although uncommon (5 patients, 6.3%), symptomatic inferior oblique underaction required further surgery with a successful outcome. They included 2 patients with a history of head or orbital trauma and one with masked and one with highly asymmetric bilateral inferior oblique overaction.

Periocular changes following long-term administration of latanoprost 0.005%.

This is a case series of 3 patients who presented with periocular changes in the treated eye following chronic administration of unilateral latanoprost 0.005%. The clinical changes included worsening of dermatochalasis, deepening of superior sulcus and hollowness of the lid. This similar observation was previously described in usage of bimatoprost 0.03% and travoprost 0.004%. However this has not been reported in latanoprost instillation. Therefore, patients should be made aware of these potential side effects.

Effect of superior oblique weakening on vertical alignment and horizontal and vertical incomitance in patients with A-pattern strabismus.

PURPOSE: To determine the relationship between the magnitude of preoperative A pattern and the correction of vertical alignment and horizontal and vertical incomitance in patients treated with superior oblique muscle-weakening procedures for A-pattern strabismus. METHODS: The records of consecutive patients who underwent surgery for A-pattern strabismus between 1997 and 2008 were retrospectively reviewed. Both horizontal (from up- to downgaze) and vertical (from right to left gaze) incomitance were assessed. RESULTS: Twenty-six patients were treated with superior oblique muscle-weakening procedures (either tendon spacer or nasal or posterior 7/8 temporal tenotomy, with or without simultaneous rectus muscle surgery). In these patients, the A pattern improved from 36Δ preoperatively (range, 15Δ-75Δ) to 6Δ postoperatively (range, 0Δ-16Δ). The magnitude of the reduction in A pattern correlated strongly with the size of preoperative A pattern (r=0.92), whereas the reduction in the magnitude of the vertical incomitance correlated weakly with the magnitude of the preoperative deviation (r=0.56). There was no significant correlation between the magnitude of the A pattern and the vertical incomitance (r=0.25). Of the 9 patients with preexisting primary position vertical deviation≥6Δ, 5 required additional vertical rectus muscle surgery. CONCLUSIONS: Superior oblique muscle-weakening surgery improved the A pattern but did not reliably improve the primary position vertical deviation and lateral gaze vertical incomitance. Patients with associated primary position vertical deviations of >6Δ preoperatively tended to have a greater likelihood of requiring additional strabismus surgery.

Vitreous phenotype: a key diagnostic sign in Stickler syndrome types 1 and 2 complicated by double heterozygosity.

We describe the clinical findings in two patients with double heterozygosity, both involving Stickler syndrome. In case 1, the proposita had Albright hereditary osteodystrophy which was inherited from her mother and type 1 Stickler syndrome which was a new mutation. The combination of manifestations from the two syndromes had resulted in initial diagnostic confusion. Diagnosis of the latter syndrome was made only following ophthalmic examination which documented the presence of a membranous vitreous anomaly characteristic of type 1 Stickler syndrome. Subsequent confirmation was achieved by mutation analysis of the COL2A1 gene. The propositus in case 2 inherited Treacher Collins syndrome paternally and type 2 Stickler syndrome maternally. The overlap of facial anomalies may have resulted in a more severe phenotype for the patient. The diagnosis of Stickler syndrome in the propositus was confirmed initially by vitreous assessment and later by demonstration of mutation in the COL11A1 gene. These two patients highlight the key role of vitreous examination and vitreoretinal phenotyping in the differential diagnosis of Stickler syndrome and its subtypes in cases where the clinical picture is complicated by double heterozygosity.