Associated incomitance in concomitant strabismus. Diagnosis and surgical treatment.

BACKGROUND: The motor deviation in concomitant strabismus may be accompanied by horizontal, vertical and/or torsional incomitance that hinders the development of binocularity. This should be corrected together with the horizontal deviation or in a repeat surgery. PATIENTS AND METHODS: A series of seventeen patients suffering from a major form of incomitance A or V pattern eso- or exotropia was investigated clinically. Incomitance was measured in all directions of gaze, horizontally, vertically and, as far as possible, torsionally. In 8 cases magnetic resonance tomography of the orbits was performed and has shown in particular,the position of the insertion of the lateral recti, relative to that of the medial recti. All the patients underwent surgery. Clinical, radiological and intra-operative data were concordant in all cases. RESULTS: All possible clinical forms or any combination thereof could be defined with precision and corrected according to the motor disorder of each case. After surgery the A or V pattern was reduced to 4° or less in all cases. The vertical deviation was corrected at least between 25° right and left gaze in all cases but 3. DISCUSSION: The most appropriate surgical strategy for the individual clinical form can be determined. The"triple procedure"includes the shift to the horizontal meridian of the insertion combined/or not with a slanted recession or plication of the lateral rectus, and the recession of the overacting oblique muscles. It enables us to correct in a single surgery both horizontal and cyclo-vertical incomitance. CONCLUSION: The correction of associated incomitance significantly improves motor and angle dependent sensory results in the management of concomitant strabismus.

Stereopsis after primary in-the-bag posterior chamber implantation in children.

PURPOSE: The purpose of this study was to evaluate visual acuity and binocular function after primary posterior chamber intraocular lens (IOL) implantation in children. PATIENTS AND METHODS: A retrospective chart review of 39 eyes of 31 children was performed. Fifteen eyes with traumatic, 17 with developmental, and 7 with congenital cataracts without any other ophthalmologic problems were examined before and after cataract surgery (irrigation/aspiration procedure with implantation of a posterior chamber IOL). Twelve eyes also received a posterior capsulorrhexis and anterior vitrectomy. The mean age at surgery was 6.9 +/- 3 years (range, 3-12 years). RESULTS: Twenty (51%) of 39 eyes achieved a best-corrected postoperative visual acuity of 20/40 or better (range, 20/200-20/20). The mean postoperative visual acuity was 20/40 in the traumatic and developmental cataract groups and 20/100 in the congenital cataract group. There was a positive correlation between cataract morphology and visual acuity (P<.05). Bilateral cataracts had a better postoperative visual acuity than unilateral cataracts (P <.005). Nineteen (70%) of 27 eyes in which no primary posterior capsulorrhexis had been performed had posterior capsule opacification. Stereopsis was found in 10 of the 31 patients: 43% of the traumatic cataract group, 30% of the developmental cataract group, and 14% of the congenital cataract group. CONCLUSIONS: After capsular bag-fixated IOL, visual acuity and binocular function in children older than 3 years were favorable and the complication rate, excluding posterior capsule opacification, was low.

[Early treatment of secondary muscle restriction due to orbital blow-out fractures]. / Le traitement précoce des impotences musculaires secondaires aux fractures du plancher de l'orbite.

INTRODUCTION: Orbital blow-out fractures can result in chronic oculomotor restriction. This is the consequence of orbital fasciae or muscle trapped within the fracture. A delayed treatment usually results in incomplete repair. However, when the extrapped tissues are freed by reconstruction of the orbital floor, oculomotor sequelae can be prevented or at least limited. PATIENTS AND TREATMENT: Twelve adults and 2 children were treated for blow-out fracture in the past two years at the Eye Department of Geneva University Hospital. All of these patients had a non regressive oculomotor restriction, an enophthalmus and/or an infraorbital hypoesthesia with evidence of a blow-out fracture on the CT-scan. They were operated on between the second and the sixth week following trauma. Extrapped fasciae were freed under microscope and the orbital floor was reconstructed with a thin plate of biomaterial (PDS). RESULTS: Tissues could be entirely removed and kept separated from the underlying structures by the biomaterial used for reconstruction. Ocular motility returned to normal in 13 cases within 1 to 3 months, without further intervention. Only one patient had to wear a low grade prism with vertical action. DISCUSSION: In case of blow-out fractures, the long term prognosis of the ocular motility depends on immediate management following the trauma. Orbital floor reconstruction is indicated when consecutive oculomotor restriction is likely avoiding in the majority of the cases any residual oculomotor restriction. On the contrary when delayed, treatment is often difficult generally with limited mobility. CONCLUSION: From an ophthalmological point of view, microsurgical extraction of incarcerated orbital fasciae and reconstruction of the orbital floor is indicated for early treatment of oculomotor restriction.