Outcome of Perthes'' disease in unselected patients after femoral varus osteotomy and splintage

PURPOSE: To study the incidence, cause, recovery time, and prevention of diplopia following subcutaneous injection of botulinum A toxin for the treatment of facial spasms. METHODS: Patients who experienced diplopia after botulinum A toxin injections had their deviations examined in detail. When the muscle that caused diplopia was identifiable, the injection closest to that muscle was omitted in the next treatment in an attempt to prevent diplopia. RESULTS: Of 250 patients receiving about 1500 sets of injections, 25 (1.7%) incidents of diplopia occurred in 10 patients. Excluding two patients who declined further treatment after having diplopia on their first botulinum A toxin treatment, seven of the remaining eight patients had multiple incidents of diplopia. The most common pattern of diplopia was "uncertain diagnosis." The most common identifiable cause of diplopia was paresis of the inferior oblique muscle. Omission of the injection into the central portion of the lower eyelids in the next treatment prevented recurrence of diplopia in only one of the four patients. No significant correlation between botulinum A toxin doses injected and times to recovery was noted. CONCLUSIONS: Diplopia following botulinum A toxin treatment is uncommon. Seven patients (3% of patients studied) had 22 episodes of diplopia (88% of episodes). When diplopia occurs, it tends to recur on reinjection, sometimes with a prolonged recovery time. This response may not be dose dependent. The extraocular muscles of some patients may be more susceptible to chemodenervation than others, or botulinum A toxin may diffuse to extraocular muscles more easily in some patients than in others.     

Diagnosis and surgical management of strabismus associated with thyroid-related orbitopathy

BACKGROUND: In the healing phase of thyroid-related orbitopathy, fibrosis and contracture of the extraocular muscles may result in restrictive ocular motility. Ocular misalignment may occur in both eyes and along three different axes of rotation. Successful surgical treatment depends on precise identification of the muscles that are restricting motility and producing the misalignment. METHODS: Between 1980 and 1994, 22 patients were surgically treated for restrictive strabismus caused by thyroid-related orbitopathy. Preoperatively, all patients underwent complete neuroophthalmic, oculoplastic, and orthoptic examinations. Analysis of ductions, measurement of torsion, and the use of monocular neutralization techniques were essential additions to the usual motility exam. Patients were placed into diagnostic categories based on the clinical pattern of extraocular muscle restriction. Adjustable recessions were done for all initial surgeries. RESULTS: Patients with unilateral inferior rectus involvement or with ipsilateral inferior rectus-contralateral superior rectus involvement had large vertical deviations (equal to or > 20 prism diopters [delta]). Patients with bilateral inferior rectus involvement had small vertical deviations (< 20 delta). Excyclotorsion correlated strongly with the presence of tight inferior recti. Vertical comitance (upgaze versus downgaze measurement of equal to or < 15 delta) correlated with the ipsilateral inferior rectus-contralateral superior rectus pattern of involvement. Vertical incomitance (upgaze versus downgaze measurement of > 15 delta) correlated with unilateral inferior rectus involvement. Eighteen of 22 patients had excellent postoperative alignment and elimination of diplopia in functional positions of gaze. Those with less favorable results developed reversal of the hypertropia and exotropia in downgaze. Sixteen out of 19 patients who underwent inferior rectus recession had induced inferior eyelid retraction. CONCLUSION: Different combinations of extraocular muscle restriction in this series of patients produced characteristic patterns of misalignment. Appropriate, adjustable, strabismus surgery was successful in restoring binocular vision in 21 out of 22 patients with a minimum of complications.     

Temporary luminal arteriotomy seal for bypass grafting

OBJECTIVE: To compare the effects of botulinum toxin on static and dynamic aspects of eye movements, and thereby elucidate the mechanisms of its action on eye muscles. BACKGROUND: Laboratory evidence indicates that static alignment and saccades are subserved by different extraocular muscle fiber types, and botulinum toxin may cause specific dysfunction of the fibers controlling static alignment. Diplopia is a well-known side effect of periorbital botulinum toxin injections in humans, and may be a clinical correlate of the laboratory findings. METHODS: Search coil recording of eye movements was performed in one patient with systemic botulism, and in three patients with diplopia following periorbital injection of botulinum toxin A. RESULTS: In the patient with acute botulism, eye movement alignment, range, and saccadic velocity profiles were abnormal. In three patients with iatrogenic diplopia, static alignment was abnormal but movement range and saccadic velocities were within normal limits. Edrophonium improved the range of movements and saccadic velocities in the patient with systemic botulism but was ineffective in reversing ocular misalignment in the one iatrogenic patient to whom it was administered. CONCLUSIONS: Precise alignment is subserved by orbital singly innervated muscle fibers, and the effects of botulinum toxin are greatest on these fibers. This predilection is apparent when the toxin dose is very small, as must have been the case in our patients with iatrogenic diplopia. The lack of a response to edrophonium probably reflects structural damage to muscle fibers. In contrast, larger doses of toxin produce an acute dysfunction of all extraocular muscle fiber types, which is responsive to edrophonium and consequently reflects partial blockade at the neuromuscular junction.     

Pneumo-orbital cyst after orbital fracture repair

PURPOSE: To report a case of a respiratory epithelial-lined, air-filled orbital cyst as a late complication of orbital fracture repair. METHOD: Case report. RESULTS: Recurrent episodes of diplopia and hyperophthalmia developed secondary to pneumatic inflation of a respiratory epithelial-lined orbital cyst 6 months after orbital fracture repair. This cyst remained in communication with an ethmoidal air cell and became inflated during pressurization of the ethmoid sinus. Removal of the cyst and orbital implant was curative. CONCLUSION: Air-filled, respiratory epithelial-lined orbital cyst is a rare cause of episodic diplopia and globe displacement after orbital trauma.     

MR imaging in patients with strabismus

The patients with strabismus, including 8 with superior oblique paresis, 1 with inferior rectus paresis, and 1 with congenital constant exotropia, were examined with MR imaging at 1.5 tesla (T) or 0.5T with a surface coil. Abnormal findings of extraocular muscles were identified in 8 of the 10 patients and most of them were consistent with the clinical findings. Deviation of the optic nerves was noted in 5 patients. Coronal short repetition time (RT) and echo time (ET) images were used to measure the concerned extraocular muscles and the optic nerves. The differences in diameters between the concerned extraocular muscles of both the diseased and normal eyes were calculated. MR imaging is considered to be advantageous and can be favorably used to observe and measure the extraocular muscles and other intraorbital structures in patients with strabismus.     

Idiopathic orbital myositis

Idiopathic orbital myositis is a subtype of nonspecific orbital inflammation primarily involving the extraocular muscles. It occurs most frequently in young to middle-aged adults with a 2 to 1 female predominance. The cardinal clinical feature is orbital pain exacerbated by eye movement. Other common findings include diplopia, proptosis (which is generally minimal), conjunctival injection and chemosis, and periorbital edema. Thyroid eye disease is commonly confused with orbital myositis, but the latter is characterized by a more acute onset, more severe pain, and a rapid response to systemic corticosteroid therapy. Echography and CT scanning reveal enlarged muscle bellies and thickened tendons, with low internal reflectivity echographically. Although the cause of orbital myositis is unknown, an immune-mediated pathophysiologic mechanism is likely. This review summarizes recent findings regarding the epidemiology, diagnosis, pathophysiology, and treatment of idiopathic orbital myositis.     

A case of malignant lymphoma with a metastasis to the lateral rectus muscle

We reported a 75-year-old woman with malignant lymphoma who had a metastasis to the right lateral rectus muscle. She was well until two months earlier, when a tumor in the left thigh began to enlarge. Ten days before admission, she noticed medial deviation of the right eyeball. Neurological examination showed the right esotropia with isolated paralysis of the right lateral gaze. She denied double vision. MR imaging demonstrated a swelling of the right lateral rectus muscle. Gallium scanning revealed abnormal accumulation in the right orbit and the left thigh. The tumor in the left thigh was histologically diagnosed as non-Hodgkin's lymphoma, diffuse large cell type. Discrete extraocular muscle metastasis is rare and unreported for malignant lymphoma. Reported cases of breast and thyroid cancers metastatic to the extraocular muscles did not develop diplopia similar to our case. The rapid growth of metastases to the extraocular muscles produces a large visual axes deviation, therefore no diplopia may be elicited.     

Computed tomography in Graves' ophthalmopathy

The CT scan with the 160 x 160 matrix demonstrated both the normal orbital anatomy and the abnormal orbital anatomy of Graves' ophthalmopathy in great detail. In Graves' ophthalmopathy, the cardinal pathologic feature of extraocular muscle enlargement was accurately reflected on the CT scan and was a distinctive, diagnostically reliable finding. Enlargement of the medial and lateral rectus muscles and of the apex of the muscle cone were the most consistent findings. The severity of the CT scan abnormalities correlated well with clinical severity. Because muscle cone abnormality was observed characteristically in those patients with sight loss, we suggest that pressure by the extraocular muscles on the optic nerve may contribute to visual acuity loss in this disease.     

Extraocular muscle involvement in sarcoidosis

BACKGROUND: Sarcoidosis is a granulomatous inflammatory disease that may have a variety of ocular and orbital manifestations. The most common ocular manifestation is uveitis, and the most common orbital manifestation is dacryoadenitis. Extraocular muscle involvement in sarcoidosis has rarely been reported. The authors report a case of sarcoidosis involving the extraocular muscles of a 15-year-old boy with bilateral, painful, external ophthalmoplegia and enlargement of all extraocular muscles on computed tomography (CT) scan. RESULTS: Lateral rectus muscle biopsy and transbronchial lung biopsy showed noncaseating granulomas characteristic of sarcoidosis. Cultures and serologic studies excluded fungal and mycobacterial diseases. Treatment with oral corticosteroids improved symptoms and signs. CONCLUSIONS: The authors report the first case of sarcoidosis in a patient with symptomatic extraocular muscle involvement, and only the third case in which extraocular muscle involvement has been shown histologically.     

High resolution, dynamic, magnetic resonance imaging in complicated strabismus

Strabismus cases, especially after previous surgery or trauma to extraocular muscles, often present diagnostic challenges. Conventional clinical tests are helpful in some cases but may be inconclusive. High resolution, dynamic, orbital magnetic resonance imaging (MRI) may yield additional critical information about orbital and extraocular muscle anatomy and function. We report four complicated strabismus cases for which dynamic surface coil MRI helped formulate a precise diagnosis and the most appropriate surgical plan.     

Prevalence and management of elevated intraocular pressure in patients with Graves' orbitopathy

AIMS: To investigate the prevalence and to discuss the necessity of treating elevated intraocular pressures (IOP) in patients with Graves' orbitopathy (GO). In addition, to study the effects of orbital decompression and extraocular muscle surgery on IOP. METHODS: The records of consecutive patients with GO referred in a 5 year period were studied and those selected, in which glaucoma medication had been prescribed, or a diagnosis of primary open angle glaucoma (POAG) or of ocular hypertension (> or = 22 mm Hg) (OH) had been made. The necessity of treating these patients with glaucoma medication was questioned and the effects of corticosteroids, orbital decompression, and extraocular muscle surgery on the IOP were evaluated. RESULTS: Of 482 patients with GO, 23 (4.8%) met the inclusion criteria. Four patients (0.8%) had POAG, four had elevated IOPs and visual field defects consistent with dysthyroid optic neuropathy, and 15 (3.1%) had only elevated IOPs. Five patients with OH showed a permanent drop of IOP after orbital decompression, two had a marked decrease of their IOP after recession of the inferior rectus muscle. CONCLUSIONS: POAG has the same prevalence in the general Dutch population as in the GO subgroup. The combination of elevated IOPs and visual field defects in GO patients may be attributed to other mechanisms than obstructed aqueous outflow in the trabecular meshwork and should be treated accordingly. Orbital decompression and extraocular muscle surgery may lower the IOP in patients with GO.     

Orbital myopathy in metastatic malignant paraganglioma: a paraneoplastic syndrome?

BACKGROUND: Several disease entities of the orbit are known which display an autoimmunological pathogenesis. Among these disease entities the thyroid-related immune orbitopathy and the idiopathic orbital inflammatory syndrome (orbital pseudotumor). The pathogenesis of these diseases is not well understood; however, an autoimmune inflammatory reaction histologically characterized by a chronic inflammatory cell infiltrate has been suggested. One care of orbital pseudotumor presumably of paraneoplastic origin occurring in a patient with a non-Hodgkin's lymphoma has been reported. We report a patient with a metastatic paraganglioma and a proptosis secondary to enlargement of all extraocular muscles. CASE REPORT: A 52-year-old woman presented with a recent decline in visual clarity of her left eye and diplopia. Two years ago, the diagnosis of a hormonally inactive paraganglioma has been made. Ophthalmologic examination displayed a lagophthalmos caused by a right-sided facial paralysis secondary to a cerebral metastasis and a bilateral enlargement of all extraocular muscles. Curative therapy for the paraganglioma was not available. Palliative therapy as well as a high-dose corticosteroid therapy for the orbitopathy was refused by the patient. The patient died 18 months later. DISCUSSION: Our patient developed orbital changes similar to thyroid-related immune orbitopathy; however, there was no dysfunction of the thyroid. We believe that the orbital changes were a paraneoplastic immune reaction caused by the metastatic paraganglioma. We recommend that in patients who do not conform to the prototypical profile of well-known orbital disease entities should undergo further testing to exclude a remote neoplasm.     

Long-term observation of ablatio-prophylaxis with kryopexy (author''s transl)

Five cases of laceration of an extraocular muscle without involvement of the globe or significant involvement of the adnexa occurred after injury with a pencil, mower blade, screen door, and building nail, and at surgery when the surgeon operated on the wrong muscle. The inferior rectus muscle was involved in three cases, the lateral rectus muscle in one, and the medial rectus muscle in one, Traumatic muscle laceration involves the inferior or medial rectus muscles more often than the other muscles. This may occur for two reasons: these muscles are closer to the corneoscleral limbus, and they are more visible during the protective blink with associated upward and usually outward movement of the globe (Bell's phenomenon). When the lacerated muscle could be found, it was repaired either by reinsertion to the sclera or reunion of the severed muscle segments. When the muscle could not be found, a muscle transfer procedure was carried out. Patients with fusion before injury regained fusion in part of the visual field after muscle repair.     

Transnasal endoscopic approach to expose the medial rectus from the annulus of Zinn to the penetration of Tenon''s capsule

Conventional strabismus surgery employs a conjunctival incision to gain access to Tenon's space where a wide variety of procedures are routinely performed on the tendon and anterior aspect of the extraocular muscles. Recently, transnasal endoscopic surgical techniques have gained acceptance as effective means of decompressing the medial wall and floor of the orbit in patients with thyroid-related orbitopathy. The orbital surface of the medial rectus and inferior rectus are exposed from the annulus of Zinn to a position close to where the muscles penetrate Tenon's capsule. In theory, this technique also provides the exposure necessary to locate and retrieve a "lost" medial rectus when the usual sub-Tenon's approach fails to recover the muscle. Cadaver studies demonstrate the feasibility of exposure and suture placement in the stump of a lost medial rectus with passage of the suture through Tenon's capsule to transmit the force of the muscle to the globe, provided that the lost muscle is retrieved before severe contracture develops.     

Childhood burns in south eastern Nigeria

A case has been presented in this article of congenital absence of bilateral inferior rectus muscles combined with restriction of the lateral rectus muscle and malinsertion of the inferior oblique muscle to the lateral rectus muscle. The surgical procedures for correction of the absence of the inferior rectus muscle and embryogenesis of extraocular muscles were also reviewed.     

Radiotherapy in the management of thyroid orbitopathy. Computed tomography and clinical outcomes

OBJECTIVE: We investigated the long-term outcome of patients with thyroid orbitopathy treated with orbital radiotherapy using quantitative clinical measurements and orbital computed tomographic morphometric changes. DESIGN: Patients who had undergone orbital radiotherapy for thyroid orbitopathy at least 1 year previously were retrospectively recalled for follow-up examination and computed tomography. Controls were patients with similar disease activity but who had not undergone radiotherapy. SETTING: Subspecialty clinic in a university teaching hospital. PATIENTS: Twenty-one patients (42 orbits) who underwent radiotherapy and six clinically comparable patients who had not undergone radiotherapy (12 orbits). INTERVENTION: Standardized, super-voltage, orbital radiotherapy. MEASUREMENTS: Five clinical indexes of orbitopathy and six computed tomographic indexes were examined for interval changes. RESULTS: The orbital computed tomographic muscle-diameter index enlargement ratio did not change in either group (radiotherapy group, 1.54 to 1.51, not significant; nonradiotherapy group, 1.37 to 1.36, not significant). The mean (+/- SEM) number of muscles with low-density areas increased in both groups (radiotherapy group, 1.1 [+/- 1.9] muscles per orbit; P < .001). Soft-tissue signs improved significantly with lesser improvements in extraocular muscle function in both groups. Proptosis, visual acuity, and intraocular pressure rise on upgaze did not improve significantly in either group. CONCLUSIONS: No changes in muscle size measured with computed tomography were found in either patients undergoing radiotherapy or patients not undergoing radiotherapy after long-term follow-up. Clinical indexes of thyroid orbitopathy, especially soft-tissue signs, improved on follow-up, but this was not influenced by the method of treatment.     

Reconstruction of the lower orbital wall in the remote posttraumatic period]

The authors share their experience gained in the treatment of 11 patients with different fractures of the lower orbital wall in remote periods after the injury (1 month to 4 years). A specific feature of late injury in all the patients we observed were disorders of binocular vision presenting as diplopia due to cicatricial changes in the orbit. X-Ray examinations showed deep fractures of the lower orbital wall involving the posterior half of the orbital space in all cases. An operation had to be performed in all the patients: inferior orbitotomy via a transcutaneous access combined with anterior highmorotomy and submucosal refracture of the upper wall of the maxillary sinus within the framework of improperly consolidated fracture along the borders of the orbital hernia. The choice of this operation was dictated by specific localization of the fractures (zones difficult to access), solidity of scar growth at the site of the fracture (because of long period elapsed after the injury), and by limited possibility of intervention via an isolated transorbital access. An accessory element: refracture of the lower deformed wall and its reposition in the proper state helped repair the defect in the wall with a homocartilage on the side of strips and the orbit. Binocular vision and mobility of the eyeball in the orbit were repaired in all the patients, the degree of posttraumatic enophtalmos was appreciably decreased.     

Service-mix in general dental practice in Japan: a survey in a suburban area

The authors describe a supernumerary muscle in each orbit of an elderly male subject. There appear to be no previous reports of this muscle; most reports of anomalies of extraocular muscles describe hypoplasia or aplasia. Thirty-five formalin-fixed cadavers assigned to medical students for dissection were studied. The orbits were dissected by a superior approach which involved removal of the orbital plate of the frontal bone and the superior orbital margin. A supernumerary extraocular muscle was seen in each orbit of one cadaver, located between the superior oblique and levator palpebrae superioris muscles. It originated on the inferior surface of the lesser wing of sphenoid bone and was inserted into the skin of the medial one-third of the upper eyelid. It was innervated by a branch from the superior division of the oculomotor nerve. The insertion of the muscle into the upper eyelid produced a crease running obliquely upwards and medially, from the junction of the medial one-third and lateral two-thirds of the lid margin, towards the medial part of the superior orbital fold. The authors suggest the name levator palpebrae superioris accessorius for this muscle in view of its topography and action as tested in the cadaver. The significance of the findings is discussed and the literature on the development of the muscles supplied by the oculomotor nerve is reviewed.     

Changes in dorsal neck muscle activity related to imposed eye movement in the decerebrate pigeon

Movements of the head and eyes are known to be intimately related. Eye position has also been shown to be closely related to the electromyographic activity of dorsal neck muscles; however, extraocular muscle proprioception has not generally been considered to play a part in the control of such movements. We have previously shown that, in the pigeon, imposed movements of one eye modify the vestibular responses of several dorsal neck muscles in ways that are dependent on stimulus parameters such as the amplitude and velocity of imposed eye movement. The present study examines more closely the interactions between imposed eye movements and different muscle pairs. The three neck muscle pairs studied each responded to afferent signals from the extraocular muscles in discrete and specific ways which appeared to be correlated with their different actions. Complementary effects of imposed eye movements in the horizontal plane were seen for both the complexus and splenius muscle pairs, with imposed eye movements in one direction producing the largest inhibition of the ipsilateral muscle's vestibular response and imposed eye movements in the opposite direction the largest inhibition of the contralateral muscle's vestibular response. During roll tilt oscillation (ear-up/ear-down) in the frontal plane, similar complementary effects of imposed eye movement were seen in the complexus muscle pair, but the splenius muscle pair showed little tuning, with similar inhibition for imposed eye movement directed either upwards or downwards. In contrast to these complementary effects, the biventer cervicis muscle pair showed no vestibular modulation during vestibular stimulation in the horizontal plane and their spontaneous activity was not altered by imposed eye movement. During roll-tilt oscillation (ear-up/ear-down) in the frontal plane imposed eye movement directed vertically upwards increased both muscles' vestibular responses and imposed eye movement directed vertically downwards inhibited both muscles' vestibular responses. Section of the ophthalmic branch of the trigeminal nerve (deafferenting the eye muscles) abolished the effects of imposed eye movement on the neck muscle pairs. In conjunction with further control experiments these results provide compelling evidence that proprioceptive signals from the extraocular muscles reach the neck muscles and provide them with a functionally significant signal. We have previously shown that signals from the extraocular muscles appear to be involved in the control of the vestibulo-ocular reflex. It follows from the experiments reported here that proprioceptive signals from the extraocular muscles are also likely to be involved in the control of gaze.     

Frequency of cervical intraepithelial neoplasia following large loop excision of the transformation zone

Acute ophthalmoparesis (AO) is a monophasic disease characterized by acute onset of paresis of the extraocular muscles without ataxia or areflexia. Here we report a case of AO with gadolinium enhancement in the cisternal portion of the abducens nerves using contrast-enhanced three-dimensional magnetic resonance imaging.