Management of large angle exotropia

Four cases of large angle exotropia secondary to third nerve palsy are presented. An effective technique involving recession of the lateral rectus and splitting and advancement of the medial rectus is presented.     

Treatment of strabismus and nystagmus with botulinum toxin type A. An evaluation of effects and complications

PURPOSE: Injection of botulinum toxin type A into eye muscles leads to a temporary paralysis and the effects have been evaluated in strabismus or nystagmus. METHOD: A total of 112 patients with different types of concomitant and paralytic strabismus and acquired nystagmus were treated with botulinum toxin, according to well-established indications. RESULTS: The lasting effects of the injections on strabismic angle were largest in esotropia, consecutive exotropia and abducens palsy, and amounted to, on an average, 12 prism diopters or 6 degrees. The larger the strabismus the better was the effect. Repeated injections reduced the angle further. In complex nystagmus forms retrobulbar injections could be used. The side effects were mostly due to spread of botulinum toxin to the levator, producing ptosis (8%), or the inferior rectus muscle, causing vertical strabismus (10%). On an average 42% of the patients were later operated for strabismus and nystagmus. CONCLUSION: Injection of botulinum toxin A into eye muscles is a valuable adjunct to surgery in the treatment of strabismus and nystagmus.     

Predictors of postoperative binocularity in adult strabismus

We evaluated postoperative binocularity in a retrospective study of 111 adult strabismus patients in order to identify the factors which influence the success of surgery for horizontal concomitant strabismus in adults. Selection criteria included minimum age of 15 years at time of surgery, and preoperative fusion impairment with both the Bagolini lens test and synoptophore. Logistic regression analysis was used to correlate patient factors and postoperative binocularity. We found that 52 (65%) of 80 patients with exotropia and 23 (74.2%) of 31 patients with esotropia achieved post operative fusion. Significant predictive factors in exotropia were absence of previous surgery; visual acuity of the deviating eye > 0.5; an increase in the spherical equivalent of the deviating eye, and normal retinal correspondence. Significant predictive factors in esotropia were fusion during prism adaptation, absence of infantile esotropia, and an increase in vertical deviation. The majority of adults with exotropia or esotropia can achieve binocularity after surgery for horizontal concomitant strabismus.     

Growth and toxin production by Clostridium botulinum on inoculated fresh-cut packaged vegetables

BACKGROUND: Classic teaching suggests that surgery for intermittent exotropia should be based on distance/near differences. Divergence excess, according to tradition, should be treated with symmetric lateral rectus recessions; simulated divergence excess and basic deviations should be treated with a recess/resect procedure. This teaching, to our knowledge, has not been systematically tested. OBJECTIVES: To evaluate the appropriateness of selective surgery based on distance/near differences and to determine if bilateral lateral rectus recessions affect the distance deviation more than the near deviation. PATIENTS AND METHODS: Patients with basic type intermittent exotropia were randomized to 2 groups, those receiving either unilateral recess/resect procedures or symmetric lateral rectus recessions. Patients with simulated divergence excess intermittent exotropia received symmetric lateral rectus recessions. Outcome was observed 1 year after surgery. RESULTS: Of 19 patients with basic exotropia receiving lateral rectus recessions, 10 patients (52%) had a satisfactory outcome compared with 14 (82%) of the 17 patients who had recess/resect procedures (P<.05). Of the 68 patients with simulated divergence excess, 55 patients (80%) had a satisfactory outcome after bilateral/lateral rectus recessions. This result was significantly better than the outcome for patients with basic exotropia who underwent lateral rectus recessions (P<.05) [corrected]. The decrease in the distance/near difference after surgery was essentially identical for patients with basic exotropia who underwent lateral rectus recessions as for those who received recess/resect procedures (means, 2.4 prism diopters vs 2.1 prism diopters, respectively). CONCLUSIONS: Although this study did not evaluate increasing the amount of symmetric lateral rectus recessions for patients with basic exotropia, these data suggest that patients with basic type intermittent exotropia should be treated with recess/resect procedures. Data also suggest that patients with simulated divergence excess do well with lateral rectus recessions. Recess/resect procedures and symmetric surgery affect distance/near differences equally in patients with basic exotropia.     

Ipsilateral oculomotor nerve palsy and contralateral downbeat nystagmus due to unilateral paramedian thalamopenduncular infarction--a case report

A case of midbrain and thalamic infarction which showed complete oculomotor nerve palsy of the ipsilateral eye and monocular downbeat nystagmus, ptosis, upward movement disturbance and adduction disturbance of the contralateral eye was reported. The patient is a 53-year-old woman who was admitted to our hospital because of sudden onset of double vision. Head magnetic resonance imaging showed unilateral midbrain and thalamic infarction. The midbrain lesion was located in the paramedian area and the bilateral ptosis, bilateral upward gaze palsy and adduction disturbance of the contralateral eye were considered to be caused by the lesion involving the unilateral oculomotor nucleus. This case is considered to be important because the association of contralateral monocular downbeat nystagmus is very rare.     

Botulinum toxin management of childhood intermittent exotropia

OBJECTIVE: Intermittent exotropia is a common form of childhood strabismus that has a late onset and presents a difficult and frustrating management dilemma. Surgical treatments have a high recurrence rate, and multiple surgeries often are required to achieve a desirable motor outcome. This study presents long-term observations on the use of botulinum toxin for the treatment of intermittent exotropia in children. DESIGN: This study is a nonrandomized, case-controlled study of consecutive pediatric patients who had intermittent exotropia. PARTICIPANTS: Thirty-two neurologically normal children ranging from 3 to 144 months in age were diagnosed with intermittent exotropia with a minimum distance deviation of 15 prism diopters (PD). INTERVENTION: Simultaneous bilateral injections of 2.5 units botulinum toxin type A were made into the lateral rectus muscles with the patient receiving nitrous oxide-ethrane inhalation anesthesia. Patients were observed for 12 to 44 months after the initial injection. MAIN OUTCOME MEASURES: A satisfactory outcome was considered to be stable binocular alignment of the eyes to an orthophoric range of +/-10 PD. RESULTS: Bilateral lateral rectus muscle injections of botulinum toxin were effective in reducing the mean preinjection deviation of -29 PD to an average exotropic angle of -6 PD. Stable orthophoria (+/-10 PD) was achieved in 22 patients (69%). Overall, male patients required significantly fewer injections than did female patients. All patients between 24 and 56 months of age, irrespective of gender, required only a single bilateral injection to achieve a favorable motor outcome. CONCLUSIONS: Botulinum toxin is at least as effective as surgical outcomes reported previously for the treatment of intermittent exotropia in children. This treatment method is particularly effective in children between 2 and 4.5 years of age irrespective of the initial strabismic angle and is not associated with any secondary abnormalities.     

Transposition of vertical recti for residual tropias

Transposition of vertical muscles for residual tropia was performed: nasal displacement for exotropia and temporal displacement for esotropia. Five millimeter equal displacement of superior and inferior recti corrected 10 to 14 prism diopter while equal displacement of 7 to 8 mm resulted in correction of 25 prism diopter. Special indications of this procedure may be: (1) residual tropia in cases with severe intractable ambylopia or pathology in one eye where patient and surgeon may be reluctant to operate on the sound eye, or (2) residual tropias of the alternating type in patients who underwent operations in all horizontal muscles of both eyes.     

Déjà vu all over again: the re-analysis of epidemiologic data

BACKGROUND: An extraocular muscle palsy is conventionally characterized by a deviation of the visual axes, this being greater when measured with the affected eye fixing. By definition and illustrating Hering's law, this secondary angle of deviation is greater than the primary one, measured with the sound eye fixing. We present here a comparative study of the amount of subjective excyclodeviation measured in patients suffering from IVth nerve palsy, with the sound or affected eye fixing. METHODS: Two groups of patients were entered into the study: Group 1 (N = 54) for superior oblique palsies studied retrospectively and Group 2 (N = 14), for a prospective study of those recently acquired (post-traumatic) and followed over 6 months. In both groups, measurements were made at two stages, early (1 to 7 weeks after onset) and late (4 to 6 months later). RESULTS: In both groups, the majority of cases showed a greater secondary torsional deviation, the difference between this and the primary deviation lessening on late stage measurements. CONCLUSION: In both groups, the difference between primary and secondary torsional deviation was not statistically significant.     

Endoscope-assisted fixation of mandibular condylar process fractures

PURPOSE: Reduction and plate osteosynthesis of condylar fractures often require a wide extraoral approach with the risk of aesthetic impairment and possible facial nerve palsy. To avoid complications, the purpose of this pilot study was to use an endoscopic device for the treatment of condylar fractures also allowing for endoscopically assisted plate application. PATIENTS AND METHODS: Seven condylar fractures were operated under endoscopic control. In three patients, a newly developed device for endoscopically controlled plate application was clinically tested. The new device and the application technique is described in detail. RESULTS: In two of three cases using this approach, fracture healing was achieved with the condyle in the anatomically correct position. In the third case the plate had to be removed early because of insufficient screw fixation. CONCLUSION: This technique may be helpful to further minimize surgical trauma in head and neck fracture treatment. The newly developed plate application device may also be used to approach other regions of the skull eg, the skull base, the zygoma, or the orbit.     

Clinical features of 201 cases with Duane''s retraction syndrome

OBJECTIVE: To summarize the clinical features of 201 cases with Duane's retraction syndrome (DRS) and discuss its differential diagnosis. METHODS: We retrospectively summarized the 201 cases from 1979 to 1996. The clinical features including chief complaints, sexual distribution, age at first visit, laterality, type of presentation, ocular deviation in the primary position, refractive errors, amblyopia, globe retraction, change of the palpebral fissure, upshoot and downshoot in adduction, binocular single vision, and its associated ocular and non-ocular anomalies were analysed. RESULTS: There were 99 males and 102 females with a female-to-male ratio 1:1. The 65.88% of DRS cases had left eye involvement with two-to-one predilection for the left eye. The most common form of the syndrome was type I (184 patients, 91.54%). Exotropia was the most common deviation in the primary gaze (72 patients, 35.8%). Among 118 patients, most had abduction deficits, globe retraction in adduction, and faceturn as to maintaining single binocular vision. Crocodial tears (26 patients, 11.93%) was the most frequently encounted ocular abnormalities. CONCLUSIONS: Diagnosis of DRS in a typical case is not difficult, however, children with bilateral abduction deficits which may mimic DRS must be differentiated from the following four motility disorders, namely, abducens nerve palsy, Moebius syndrome, congenital oculomotor apraxia, and congenital or infantile esotropia.     

Botulinum toxin A in the treatment of adherence syndrome

The effect of botulinum toxin A is investigated in the treatment of adherence syndrome related to strabismus surgery. An 18-year-old boy with decompensated right congenital fourth nerve palsy underwent ipsilateral superior rectus muscle recession and inferior oblique muscle disinsertion. During the early postoperative period, a right hypotropia with limitation of elevation developed and the result of the forced duction test was positive for passive elevation of the right eye. Botulinum toxin A was injected into the right inferior rectus muscle on the 15th postoperative day and orthophoria was achieved 1 week later. A repeat injection of botulinum toxin A was performed 6 months later. On follow-up 2 1/2 years later, his eyes remained orthophoric with limitation of elevation in the right eye and the patient was satisfied with the result. This case demonstrated that adherence syndrome can be treated successfully by botulinum toxin A injection if it is administered during the acute phase, before the development of fibrous scar tissue.     

Risk factors and follow-up of recurrent laryngeal nerve paralysis after first surgeries of benign thyroid diseases. Results of a retrospective analysis of 1,556 patients

PATIENTS AND METHODS: risk factors of recurrent laryngeal nerve (RLN) palsy after thyroid gland surgery were evaluated retrospectively in 1556 patients who were submitted to an operation because of a benign thyroid disease. Recurrences were also excluded. RESULTS: RLN palsy occurred in 6.6%. In relation to the nerves at risk the incidence of primary postoperative nerve damages was 4.3%. After a long-term follow-up of in total 18 months the incidence of permanent nerve palsy was 1.6% (related to the nerves at risk: 1.1%) as 75.5% of the paralyses were transient in an average of 6.2 months. Substernal goitres especially when sternotomy became necessary, the ligature of the inferior laryngeal artery, serious perioperative complications and total lobectomy in comparison to subtotal resection were important risk factors for primary postoperative RLN palsy (p < 0.05 resp. p < 0.01). The ligature of the inferior laryngeal artery and the extension of resection were indeed significant risk factors also for permanent nerve damages, but the other factors had no influence on the risk of permanent RLN palsy. However, the non-exposure of RLN in subtotal lobectomy was significantly associated (p < 0.01) with permanent, but not with transient nerve palsy. CONCLUSION: The exposure of the RLN is one of the most important procedures during thyroid surgery and particular also during subtotal lobectomy to reduce the rate of permanent RLN damages.     

Ender nailing of acute humeral shaft fractures in multiple injuries

From January 1987 to April 1993, 25 multiply injured patients were treated with closed intramedullary Ender nail fixation of the humeral shaft. Criteria for the procedure were humeral diaphyseal fractures with associated multiple injuries. Seventeen distal and mid-shaft fractures were treated via a modified anterograde approach in which the rotator cuff is not violated. Eight proximal third fractures were treated via the standard retrograde approach. Postoperative follow-up averaged 36 months. Full range of motion was attained 17 of the 25 patients. Of the eight remaining patients, three with a slightly limited range of motion achieved full range of motion following nail removal; three had preoperative radial nerve palsy which resolved within 1 year, and two patients required follow-on plating. In 92 per cent (23 of 25) there were no incidences of infection or non-union. Flexible nails avoid complications of reaming. The modified anterograde approach allows excellent shoulder motion since it does not violate the rotator cuff. Ender nails provide excellent fixation and clinical outcome in the multiply injured patient and are cost effective compared with interlocking nails.     

Increase in height during the first year after bone marrow transplantation reflecting nutritional status of children

We report a 75-year-old hypertensive man presented with unilateral MLF syndrome combined with ipsilateral blepharoptosis and trochlear nerve paresis due to midbrain infarction. He was admitted to our hospital for sudden onset of diplopia. Neurological examination revealed left ptosis, infraduction disorder of the left eye and left MLF syndrome. Horner's syndrome or other focal neurological signs were not observed; convergence was preserved. Hess-charts confirmed left superior oblique paresis and left internuclear ophthalmoplegia. Laboratory data were all normal. T2-weighted images of brain MRIs demonstrated a high-signal intensity lesion in the paramedian dorsal midbrain at the inferior colliculus level, anterior to the cerebral aqueduct. The oculomotor dysfunction and diplopia had disappeared at discharge, although slight ptosis persisted. It is likely that the lesion in our case affected the left MLF, the right trochlear nucleus or its fascicles and the left partial oculomotor fascicles. Cases with MLF syndrome associated with trochlear nerve palsy have been rarely reported. Our case suggests that the fibers controlling for the musculus levator palpebrae superioris are located more caudally in the oculomotor fascicles.     

Surgical weakening of the inferior oblique

1. The inferior oblique may be weakened effectively by recession, disinsertion, or myectomy, disrupting the muscle continuity between Lockwood's ligament and the muscle's insertion. 2. A successful unilateral inferior oblique weakening produces 20 prism diopters less hypertropia or more hypotropia in the field of action and has less effect away from the muscle's field of action; a bilateral weakening of the inferior oblique produces 20 prism diopters less exotropia or more esotropia in upgaze. 3. Complications of inferior oblique weakening are persistent overaction, operation on the wrong muscle, and the adherence syndrome. 4. The adherence syndrome is not related to the myectomy procedure specifically but is probably related to (or caused by) fat rupture with hemorrhage, which may accompany any type of inferior oblique weakening. 5. The adherence syndrome can be avoided by careful surgical technique.     

Diagnostic assays in cytomegalovirus retinitis

The aim of the work is to inspect the influence of the treatment by using hyper-correcting prisms on the vertical deviations of the eyes and on the head's position in persons with nystagmus. We observed 4 persons with nystagmus without strabismus and 3 persons with convergent squint. In persons without strabismus the prismatic correction placed with an edge in the direction of the "calm's zone" (quiet's zone) to obtain the straight position of the head when looking forwards was applied. Twice a day during 10 minutes the patients were making the movement's exercises in the vertical and horizontal direction looking by the prism separately by each eye. This prism (often 35 D prism) was placed with the edge in the direction of greater deviation of the oblique inferior muscles and the left rectus inferior muscle. Patients with convergent strabismus were treated according to the principles of localization method with consideration of the localize exercises by using hyper-correcting prisms in the vertical and horizontal directions. Two patients had a surgery in order to eliminate not aesthetic and strong prisms which were applied because of large horizontal squint. One patient with convergent alternate squint with hyperactivity of both inferior oblique muscles and inferior rectus muscle of the left eye was treated without surgery, only by the conservative treatment with prisms. In all patients we obtained a straight position of the head despite of the nystagmus still existing during the eyes movements in some directions. The treatment by using hyper-correcting prisms can completely replace the surgical treatment or is able to supplement it and prevent relapses.     

Assignment of cDNA encoding hyaluronic acid-binding protein 1 to human chromosome 17p12-p13

PURPOSE: To report unilateral pupil-sparing third nerve palsy after use of sildenafil citrate (Viagra). METHOD: Case report. RESULTS: A 56-year-old man with a history of tobacco abuse was treated for erectile dysfunction. Viagra, 50 mg, was taken once without adverse effect. Three weeks later, the patient took a second dose of Viagra (50 mg); 36 hours later he experienced a complete pupil-sparing third nerve palsy. Erythrocyte sedimentation rate, blood glucose level, magnetic resonance imaging, and magnetic resonance angiography were normal. CONCLUSION: In a patient with microvascular disease, use of sildenafil may be associated with pupil-sparing third nerve palsy.     

Psychogenic pseudoptosis

Three patients with psychogenic pseudoptosis of one eyelid are reported. All showed depression of the eyebrow on the affected side. The clinical course varied: in two patients the symptom resolved spontaneously after positive reassurance; in the third patient it remained unchanged for 2 years.     

The accuracy of experienced strabismologists using the Hirschberg and Krimsky tests

OBJECTIVE: The purpose of the study was to assess the accuracy of a group of strabismologists applying the Hirschberg and Krimsky tests. DESIGN: A clinical trial. PARTICIPANTS: Sixteen very experienced strabismologists participated in this study. INTERVENTION: The participants were asked to evaluate slides of four different patients using the Hirschberg method and to evaluate two of the four patients with the Krimsky method. The slides included a patient with 25 delta left esotropia, a patient with 25 delta right exotropia, a patient with 80 delta esotropia with a positive angle kappa, and a patient with 75 delta infantile esotropia. Alternate prism and cover testing was performed immediately after the photograph was taken and considered to be the actual deviation of the patient. MAIN OUTCOME MEASURE: Measured was the accuracy in assessing the angle of strabismus. RESULTS: With the Hirschberg method, each participant underestimated at least one patient by at least 10 delta. In addition, the participants tended to underestimate both large and small angle esotropic and exotropic patients with greater errors of estimation occurring with larger angles of strabismus. With the Krimsky method, a majority of participants overestimated at least one patient by 10 delta and showed difficulty in appreciating differences of 5 delta. In addition, the authors noted inconsistent responses by each participant. CONCLUSION: The Hirschberg and Krimsky methods are substantially less accurate than the alternate prism and cover test.     

Postcataract ptosis. A randomized, double-masked comparison of peribulbar and retrobulbar anesthesia

PURPOSE: A randomized, double-masked study of 317 patients was conducted to determine if the incidence of postcataract ptosis is greater with retrobulbar or two-injection peribulbar injection anesthesia. METHODS: Surgery consisted of a planned extracapsular extraction with posterior chamber lens implantation, and no superior rectus bridle suture was used. Ptosis was quantitatively documented preoperatively and postoperatively at 1, 2, 5, and 90 days by the surgeon, photographically at 90 days by a masked observer, and subjectively by the patients. Postcataract ptosis was defined as a drop in the lid margin of 2 mm or greater after correcting for any change in the fellow eye. RESULTS: The incidence of ptosis at 90 days in patients given peribulbar anesthesia was 5.8% and in patients given retrobulbar anesthesia 5.5%, and this difference was not statistically significant (P = 0.90). Eighteen percent of patients in both groups reported a change in the appearance of their eyelids. There was a moderate, positive correlation among patients who reported a change in their lid position and objective measurements of ptosis. Preoperative clinical measurements of vertical lid fissure width and levator function, and the appearance of the lid crease or superior sulcus were not predictive for the development of postoperative ptosis at 90 days; the best predictor was the presence of ptosis in the immediate postoperative period. CONCLUSION: The incidence of postcataract ptosis is the same whether two injection peribulbar or retrobulbar anesthesia is used.