Horizontal muscle transposition or oblique muscle weakening for the correction of V pattern?

PURPOSE: To report and to analyze the efficacy of horizontal rectus muscle transposition and inferior oblique muscle weakening in terms of pattern correction for patients with V pattern. METHODS: The review of the medical files identified 55 patients who had esotropia (ET) or exotropia (XT) with V pattern. The primary outcome measure was the amount of V pattern collapse (Δ). RESULTS: Of the 55 patients (mean age 22.1 ± 9.5 years), 27 (49.1%) were males and 28 (50.9%) were females. The type of deviations was XT in 30 patients (54.5%) and ET in 25 patients (45.5%). Inferior oblique muscle weakening was performed in 43 (78.2%) patients, whereas horizontal muscle transposition was carried out in 12 (21.8%) patients in addition to recession-resection procedures. The amount of pattern was significantly reduced in both groups (P=0.01 for the horizontal offset group and P<0.01 for the oblique muscle weakening group). CONCLUSION: Oblique muscle weakening surgery and horizontal muscle offset are effective in the correction of V pattern when the amount of pattern is under 30Δ.

Amblyopia and sensory features at initial presentation of Brown syndrome: an issue to recognize.

PURPOSE: To investigate the frequency of amblyopia and sensory features at initial presentation in patients who had unilateral congenital Brown syndrome (BS) and to identify the potential risk factors for amblyopia in BS. METHODS: The study conducted with patients who had unilateral congenital BS. Patient demographics, visual acuity, refractive errors, amount of horizontal and vertical deviations, abnormal head position, fusion, and stereopsis were all reviewed. The main outcome measure was the frequency of amblyopia at initial presentation. RESULTS: The review identified 44 patients with BS (median age 5 years). The frequency of amblyopia was 15.9% (seven patients) in BS at initial presentation. Patient age (P=0.297), ocular alignment at primary position (P=0.693), anisometropia (P=0.184), and stereoacuity (P=0.061) were found to have no significant relation with amblyopia. The main associated risk factor was the absence of sensory fusion (P=0.013). CONCLUSIONS: Amblyopia may be encountered among patients with BS, and may be related to binocularity of the patient. Its recognition may be a critical step during the treatment planning and may determine presumably the success of future therapies.

Bilateral orbital hemorrhage induced by labor.

We describe a woman in whom bilateral orbital hemorrhage occurred during labor. She developed sudden proptosis and complete loss of vision bilaterally. After a stillbirth, she underwent total hysterectomy because of atonic uterus and postpartum hemorrhage. The location of the hematomas was confirmed by magnetic resonance imaging. Clinical resolution occurred in one month but both eyes remained blind. Fundoscopy revealed bilateral atrophy of the optic discs.

Efficacy and complications of dose increments of botulinum toxin-A in the treatment of horizontal comitant strabismus.

PURPOSE: To investigate the efficacy and complications associated with dose increments of botulinum toxin-A (BTA) for comitant horizontal strabismus patients. METHODS: Twenty-five esotropic (ET) and 45 exotropic (XT) patients received 2.5-20 U of BTA injection. Parameters for achieving less than 10 prism dioptres (pd) of horizontal deviation and percentage correction of the pretreatment deviation were assessed for injections of less than 10 U and more than 10 U of BTA. Induced ptosis and vertical deviation were examined within and after 6 months of follow-up. RESULTS: The mean pretreatment deviations were 38.6 +/- 2.5 pd and 37.6 +/- 1.9 pd for the ET and XT groups, respectively. After receiving 1.6 and 1.5 injections on average, improvement to less than 10 pd at the primary position occurred in 32% of ET and 22% of XT patients; the difference was not statistically significant. The percentage corrections of the ET patients were 41.4 +/- 9.3% and 36.9 +/- 5.6% in those treated with less than 10 U and more than 10 U of BTA respectively; the difference between the two groups was insignificant. For the XT patients the values were 42.1 +/- 7.4% and 28.9 +/- 3.5% respectively, which also were not statistically significantly different. Frequency of induced ptosis was more common in ET than XT patients (p = 0.01) and this difference was more pronounced with increased doses of BTA (7.7% in ET and 5.3% in XT patients with less than 10 U of BTA, and 24.0% in ET and 4.3% in XT patients with more than 10 U of BTA). Ptosis resolved completely within 6 weeks in all cases. Induced vertical deviation with less than 10 U of BTA was encountered in one case of ET (11.1%, 9 pd) and in another case of XT (8.3%, 4 pd), increasing to 60.0% (2-20 pd) and 38.8% (4-16 pd) respectively with more than 10 U of BTA injection. In about a year, induced vertical deviation resolved in approximately 40%, and decreased in 30% of the cases. CONCLUSION: Increasing the dose of BTA is clinically effective in larger deviations, although statistically indifferent, especially in ET compared with XT. However, an increased dose is accompanied by increased incidence of induced ptosis and vertical deviation. Ptosis is temporary, but vertical deviation may persist for a long time and may present a cosmetic problem for some patients when more than 10 U of BTA is used.

Magnetic resonance imaging in evaluation of congenital and acquired superior oblique palsy.

BACKGROUND: According to the recently popularized classification of superior oblique (SO) palsy based on congenital variations of the tendon, the primary pathology is the abnormality of the SO tendon rather than an innervational problem in congenital cases. If this hypothesis is true, denervation atrophy of SO muscle should not occur in patients with congenital SO palsy. METHODS: Eight patients with traumatic and nine patients with definite congenital SO palsy underwent magnetic resonance imaging (MRI) of the orbit. SO muscle width and cross-sectional area measurements were taken from coronal images and compared with the clinically uninvolved superior oblique muscles. RESULTS: Atrophy of varying degrees was observed in the SO muscle both in congenital and acquired cases. No significant difference was found in the appearance of the SO muscle between acquired and congenital SO palsy groups. CONCLUSION: We have been unable to demonstrate abnormalities of the SO tendon in both groups. The MRI appearance of the SO muscle suggested that in congenital SO palsy, the pathology is not limited to the tendon; there also is an abnormality of the muscle itself.

Factors influencing the successful outcome and response in strabismus surgery.

In this retrospective study based on 140 esotropic and 51 exotropic patients, the factors influencing successful outcome and response to strabismus surgery were investigated. Thirteen independent variables were chosen. The pre-operative deviation was found to be the only discriminant factor for early and late successful surgical outcomes in esotropic patients. For exotropic patients the visual acuity of the left eye was the discriminant factor for early successful surgical outcome. In esotropic patients the response to surgery increased with increasing amounts of pre-operative deviation. It was lower for patients with older age of onset and larger amounts of medial rectus recession. For exotropic patients the response to surgery was higher for larger pre-operative deviations. Eliminating possible sources of error when determining the pre-operative deviation will improve the predictability of the response to surgery and surgical outcome.

Factors influencing success and dose-effect relation of botulinum A treatment.

Botulinum toxin type A (BTA) treatment is an alternative to strabismus surgery. In this retrospective study the data on 45 esotropic and 49 exotropic patients with concomitant strabismus who were treated with BTA were analysed for dose-effect relationship, the effect of repeat doses and amblyopia on success of botulinum treatment. The esotropic patients were treated with a total of 80 and exotropic patients with 91 injections. The deviations were corrected within 5 degrees of straight in 33% of esotropic and 18% of exotropic patients. In esotropic patients the effect was dose dependent. This relation was not shown in exotropic patients. The repeat doses of BTA corrected the deviation to the same extent as the primary ones for both esotropic and exotropic patients.

Evaluation of congenital Brown's syndrome with magnetic resonance imaging.

The magnetic resonance (MR) findings in congenital Brown's syndrome were investigated. Sixteen involved eyes of 12 patients were compared with 20 eyes of 10 controls. An enlargement of the tendon-trochlea complex was observed in congenital Brown's syndrome. In addition, the appearance of the tendon-trochlea complex was irregular in shape and of intermediate signal intensity. The MR appearances in patients with a satisfactory or poor response to surgery did not show any significant differences from each other or from those in patients who had not undergone surgery. This was also the case for the patient with spontaneous improvement. The MR examination in congenital Brown's syndrome suggested that the abnormality was located at the tendon-trochlea complex but clinically it does not give a clue about the outcome of the disease.

Congenital Brown's syndrome: clinical and surgical approach.

Brown's syndrome is a well-recognized clinical disorder of ocular motility consisting mainly of a restriction of active and passive elevation in adduction. We report a series of 17 patients with true Brown's syndrome and discuss the clinical features and results of surgical intervention. Surgery should be considered carefully for the treatment of this syndrome as reoperation may be necessary and spontaneous resolution is seen during long-term follow-up of some patients.

High myopia causing bilateral abduction deficiency.

We present two cases of degenerative myopia with abduction deficiency. Three mechanisms can explain the defect in the abduction: (a) the size of the long globe filling the space of the orbits, (b) the tightness of the medial recti due to long axis of the globe, and (c) longstanding esotropia becoming decompensated later in life. We believe that high myopia is not a well-known cause of abduction deficiency, and it should be considered in the differential diagnosis.

Unilateral enophthalmos in systemic scleroderma.

Atrophy of orbital fat is a reported complication of localized scleroderma but not of systemic scleroderma. Here we present a case of systemic scleroderma with unilateral enophthalmos. Orbital fat atrophy was the presumed cause on computerized tomography.

A comparison of various methods of treatment of amblyopia. A block study.

The results of conventional occlusion, minimal occlusion and CAM treatment in the management of amblyopia have been investigated in two disparate populations from Cambridge, England and Ankara, Turkey. Each of these methods of treatment was equally effective as an initial therapy. However, if one form of therapy was ineffective or only partially successful, then further improvement can be obtained by using an alternative method. A quarter of the patients showed no improvement in vision at all despite vigorous and active treatment. It is suggested that minimal occlusion should be the first method of treatment but if this fails either or both conventional occlusion and CAM treatment should be used and therapy should not be abandoned until all these methods have been attempted.