Diplopia following cataract surgery: a review of 150 patients.

AIM: To study the motility pattern, underlying mechanism, and management of patients who complained of double vision after cataract surgery. METHODS: A retrospective case note analysis of 150 patients presenting with diplopia after cataract surgery to an orthoptic clinic over a 70-month period. Information was retrieved from orthoptic, ophthalmological, and operating room records. RESULTS: A total of 3% of patients presenting to the orthoptic clinic had diplopia after cataract surgery. We grouped these according to the underlying mechanisms which were: (1) decompensating pre-existing strabismus (34%), (2) extraocular muscle restriction/paresis (25%), (3) refractive (8.5%), (4) concurrent onset of systemic disease (5%), (5) central fusion disruption (5%), and (6) monocular diplopia (2.5%). Twenty per cent of the patients could not be categorised with certainty. After infiltrational anaesthesia, extraocular muscle restriction/paresis was the commonest presentation, while decompensation of preexisting strabismus was commonest with topical anaesthesia.For the 150 patients seen, prisms were the commonest form of treatment prescribed (64%) either in isolation or in combination with other treatment, including surgery (19%). Convergence and divergence insufficiency/paresis patterns were also common. A changing motility pattern was noted in some patients who had early documentation, with increasing comitance over time (spread of comitance). Partial resolution made it difficult to clearly identify the underlying mechanism in patients with late documentation. CONCLUSION: Double vision is a troublesome complication of otherwise successful cataract surgery. The use of topical anaesthesia does not abolish this surgical risk.

Congenital trigeminal anesthesia in two siblings and their long-term follow-up.

PURPOSE: To alert ophthalmologists to congenital trigeminal anesthesia as a cause of corneal scarring and amblyopia and its effective treatment with tarsorrhaphies. METHODS: Case reports. A 2-month-old infant presented with bilateral corneal erosions and complete corneal anesthesia. Her sister presented at age 3 years with a corneal ulcer and corneal hypoesthesia (sensation markedly decreased). The father and paternal grandmother of the siblings also had corneal hypoesthesia. RESULTS: Further investigation of the infant revealed bilateral hearing loss, swallowing difficulties, and decreased sensation in the trigeminal nerve distribution. A diagnosis of congenital trigeminal anesthesia was made. The corneal erosions of the patient resolved with bilateral two-thirds width tarsorrhaphies. The girl continues to do well now at 10 years of age with ocular lubrication and superficial corneal scar removal. Her older sister initially required antibiotic ointment for her corneal ulcer but now requires only ocular lubrication for congenital trigeminal anesthesia. CONCLUSION: This study describes the earliest reported use of tarsorrhaphies in an infant with congenital trigeminal anesthesia. The presence of this condition in her sister and relatives makes it one of the few reports of congenital trigeminal anesthesia in more than two generations. Early recognition of this condition is essential in the preservation of useful vision.

Pathologic causes of the superior oblique click syndrome.

PURPOSE: To describe the clinical features in two patients with superior oblique click syndrome and the pathologic causes of their symptoms. DESIGN: Two observational case reports. PARTICIPANTS: Two patients. METHODS: The clinical histories, results of physical examinations, treatment, and pathologic findings in two patients with superior oblique click syndrome are reviewed and analyzed with reference to the literature. MAIN OUTCOME MEASURES: Relief of symptoms. RESULTS: Both patients were operated on; one was found to have a schwannoma and the other a giant cell tumor of tendon sheath as causes of their symptoms. Symptoms were relieved by removal of the lesions and have not recurred. CONCLUSION: Definite pathologic lesions may cause the superior oblique click syndrome.

Tumors metastatic to the orbit: a changing picture.

Clinical characteristics of tumors metastatic to the orbit are related to primary tumor biology, and vary substantially among the various primary types. Common known primary sites include breast, lung, prostate, and melanoma. Tumor presentations can be classified into four generalized syndromes of mass, infiltrative, inflammatory, and functional effects. We found the infiltrative syndrome of presentation to be more common than for other types of orbital neoplasm. Accurate diagnosis often depends on recognition of the types of clinical syndromes and on the use of diagnostic modalities such as computed tomography, magnetic resonance imaging, fine needle aspiration biopsy, and open biopsy. Special histologic techniques are often useful in determining the origin of these often poorly differentiated tumors, and can provide a basis for specific hormonal therapy. Ophthalmologists play a vital role in the diagnosis of metastatic cancer; the orbital tumor was the presenting sign of systemic cancer in 42% of the cases reviewed. Although the overall prognosis for patients with metastatic cancer is quite poor, specific therapy is available for a growing number of cancers. Timely intervention based on accurate diagnosis can dramatically improve the duration and quality of life with selected tumors.

Amblyopia and strabismus.

Strabismus and amblyopia, two of the most common problems in children's vision, can be prevented only by early recognition, diagnosis, and treatment. Strabismus, a misalignment of the eyes that causes one eye to deviate from its normal position, is the most common cause of amblyopia. Amblyopia is impaired vision in one eye caused by disuse. The author describes diagnostic tests, common causes, and frequently used treatment for both conditions.

Oblique muscle palsies fixating with the paretic eye.

Palsy of the superior oblique muscle is one of the most commonly occurring entities in strabismus; the clinical characteristics are easily recognizable. Isolated inferior oblique muscle palsy, although anatomically enigmatical, is also known to ophthalmologists. When a patient with an oblique muscle palsy chooses to fixate with the paretic eye, characteristic patterns of motility may be obscured. Patients with superior oblique muscle palsy or isolated inferior oblique muscle palsy who habitually fixate with the paretic eye, may present with limited elevation or depression respectively. In each case, limited motility exists secondary to decreased innervational input to the contralateral antagonist of the paretic muscle, or to a mechanical restriction caused by prolonged contracture of the yoke of the paretic muscle. Inhibitional palsy of the contralateral antagonists and the fallen and rising eye syndromes may present diagnostic dilemmas unless the underlying oblique muscle palsy is recognized. Proper diagnosis may be obtained with three clinical tests; the 3-step test, the comparison of ductions to versions, and forced ductions.

Long-term follow-up of Jensen procedures.

Jensen procedures were performed on 29 eyes of 26 patients with lateral rectus palsy between January 1972 and July 1985. The cases were reviewed retrospectively to assess efficacy of the procedure and long-term stability. The patients were evaluated preoperatively with prism cover test, versions, forced auctions, saccadic velocities, and diplopia fields. All patients were observed preoperatively for at least 6 months and had no further recovery of function. Eighteen eyes had less than 20% of normal abduction saccadic velocity; nine eyes had 20% to 40%; two could not be assessed with saccadic velocities. The procedure was a Jensen's union combined with a medial rectus recession on adjustable suture. The average follow-up was 4 years. Twenty-four patients had good head positions and fusion with a functional area of single binocular vision, averaging 41 horizontally. All patients demonstrated improved saccadic velocities, with similar improvement for those beginning with less than 20% abduction saccadic velocity and those with 20%-40%. A single case of anterior segment ischemia is reported.

The relationship between therapist behaviors and outcome for middle- and lower-class couples in marital therapy.

Treated a sample of 77 distressed middle- and lower-class couples by 19 therapists using conjoint therapy. Batteries of tests that assessed marital satisfaction and communications skills were given pre- and posttherapy plus 3 and 6 months later. Couple and therapist therapy behavior were assessed using audio tapes of interview sessions. A variety of sex and social class differences were found that correlated with therapy outcome. The overall thrust of the findings suggests that no one marital therapy technique will be appropriate for the different sexes and with those of different SES backgrounds.

Enophthalmos: a clinical review.

Twenty-six cases of enophthalmos were reviewed. The causes in order of frequency were: orbital asymmetry (8); trauma (5); orbital metastasis (4); microphthalmos (2); orbital varix (2); maxillary mucocele (2); localized scleroderma (1); absence of sphenoid wing (neurofibromatosis) (1); post irradiation atrophy (1). Only six of the patients (23%) were referred with the diagnosis of enophthalmos, suggesting the sign maybe subtle and is frequently missed or misdiagnosed. The nature of the causes underscore the need for careful and thorough diagnosis. In particular, the therapeutic implications of diagnosing metastatic disease, maxillary mucocele, and orbital varices is noted. A review of etiology and mechanisms of enophthalmos point to the diversity, importance and conditions causing this sign.