Squint operations for impaired motility due to endocrine ophthalmopathy

In every case of an uncertain vertical diplopia one should think of an endocrine ophthalmopathy. A squint operation done in time will improve the motility of the eye. 8 of our 9 patients had no longer a diplopia after surgery and got binocular vision. 6 months after stabilization of the endocrine situation we resected and recessed the rectus muscles, especially the vertical rectus muscles, in 1 case we advanced the inferior oblique muscle. The amount of the surgical correction depended on the motility disturbance and the angle of squint which we compensated a few days before the operation by means of prisms. Postoperatively the patients got steroids parenterally.     

Restrictive factors in strabismus

Either muscle weakness (paresis) or mechanical restrictions can account for diminished ocular rotation. In practice, restrictions are more commonly seen. The forced duction test, differential intraocular pressure measurement and saccadic velocity studies can all assist in documenting the presence of restriction. Restrictions frequently occur with orbital floor fracture, endocrine ophthalmopathy and Brown's syndrome, and following multiple stabismus procedures, orbital or retinal detachment surgery, or muscle transposition surgery. They also occur as a result of antagonist muscle contracture after rectus muscle palsy or they may be due to orbital tumor or inflammation.     

Botulinum toxin as a tool for testing the risk of postoperative diplopia

If preoperative examinations indicate postoperative diplopia, we generally would dissuade a patient from a squint operation. In this situation, a reliable test for diplopia can be done by injection of Botulinum toxin into an eye-muscle. Thus a predominantly transient paresis is produced during which there is parallelism for a sufficient period of time, so that the patient has time enough to experience disturbing double vision or its absence. In all 31 patients of this study a clear decision for or against an operation was possible, only in three cases was an operation contraindicated.     

Orbital decompression and motility disturbances in endocrine ophthalmopathy

The changes in ocular motility in 15 patients with endocrine ophthalmopathy before and after orbital decompression according to Ogura-Walsh are discussed. The conclusion is that decompression of the orbita gives rise to a considerable risk of development or increase of limitations of ocular movements, with diplopia as a result.     

Distance ESO Deviation—A Basic Deviation or Paralysis of Divergence

A Group of one hundred patients is described with the condition of distance eso deviation or convergent squint which is present for distance viewing together with an exo deviation for near viewing and in-between distance and near there is a neutral point or crossing distance where there is no deviation. The crossing distance determines the distance at which an exo deviation will be present. Accommodation increases the degree of eso deviation and shortens the crossing distance, especially in younger patients, but does not have much effect in presbyopic patients. Distance eso deviation occurs at all ages and varies in degree from a small phoria to an obvious tropia. It is a cause of diplopia in elderly patients, and may be the underlying cause of convergent squint in young patients. It is distinct from the rare condition of divergence paresis.     

Thyroid and the eye

Any thyroid cancer can metastasize to the uveal tract, even after decades; medullary thyroid cancer can be part of multiple endocrine neoplasia syndrome. Superior limbic keratoconjunctivitis and lagophthalmos are prognostic markers for more severe thyroid-associated ophthalmopathy (TAO). The restrictive ophthalmopathy of TAO may be associated with more sustained ocular hypertension and require topical therapy. Several new studies address the therapy of TAO, ranging from retrobulbar to oral to intravenous glucocorticoids, alone or combined with radiotherapy. Endonasal decompression of the posterior orbit can be done well for severe optic nerve compression; however, leaving the anterior orbital septum intact can minimize postoperative diplopia. Smoking increases the risk and relapse rate for ophthalmopathy. Thyrotropin receptor antigen on fibroblasts diffusely in the body is causative in TAO and pretibial myxedema with even increased urinary secretion of glycosaminoglycans. Corticosteroid-responsive patients show a sustained up-regulation of the Th1/Th2 profile.     

眶壁骨折修复术后斜视和复视的手术治疗

目的 观察眶壁修复术后斜视和复视眼外肌手术矫正效果.方法 对14例眼眶爆裂性骨折修复手术6月后仍有斜视和复视的患者,采取二期眼外肌手术治疗.结果 4例为限制性斜视,二期手术探查,松解肌肉、解除限制因素,后徙受累肌或/和缩短拮抗肌后,前方及前下方视野内复视消除;10例为非限制性眼肌功能不足所致斜视,二期手术缩短受累肌/和后徙拮抗肌后,9例复视明显好转,前方及前下方视野内垂直及水平斜视度分别小于10△和15△.1例仍有眼位偏斜,需佩戴三棱镜矫正复视.结论 正确分析爆裂性眼眶骨折修复术后斜视和复视的原因,采取相应的术式,可获得较好的治疗效果.     

Ocular motility problems after orbital decompression for dysthyroid ophthalmopathy

Ocular motility problems of 50 consecutive patients following orbital decompression for dysthyroid (Graves') ophthalmopathy were analyzed retrospectively. No significant relationship to the development of postoperative diplopia was seen in the amount of retrodisplacement of the globe, the anatomical approach for orbital decompression, or the indication for decompression. Several clinical observations were made. Patients whose indication for orbital decompression was a vision-threatening ophthalmopathy were more likely (although not statistically significantly) to develop postoperative strabismus. Patients who developed changes in preoperative strabismus were more likely to develop increased esotropia and/or restrictive hypertropia. Of 32 patients who were orthotropic in the primary position before operation, 11 developed postoperative strabismus in the primary position. Only five patients had normal versions and ductions before operation. All five of these patients had normal versions and ductions after operation.     

改良结膜入路眼眶内下壁减压术治疗轻中度甲状腺相关眼病的临床效果

目的　评价改良结膜入路眼眶内下壁减压术治疗轻中度甲状腺相关眼病的疗效。方法　回顾性分析2017年1月至2018年8月在云南省第二人民医院行改良结膜入路眼眶内下壁减压术治疗的10例（11眼）轻中度甲状腺相关眼病患者。所有患者在术前均给予眼眶水平位、冠状位和矢状位CT检查，测量视力、眼球突出度、复视情况，检查眼外观进行眼前段照相等。将手术前、后眼球突出度，视力以及复视的改善情况作为效果评价指标，对相关数据进行统计和分析。结果　本组11眼术前眼球突出度为（18.94±1.40）mm，术后（15.22±1.46）mm；术后与术前比较，眼球突出度降低（3.72±0.64）mm，差异有统计学意义（t=18.379，P＜0.001）。术前视力为 0.53±0.29，术后为0.62±0.32；术后与术前比较，视力提高0.08±0.10，差异有统计学意义（t=-2.733，P=0.021）。术前复视2例；术后新发生复视2例，均为轻度复视。术前已存在复视的患者，术后复视程度无加重。结论　改良结膜入路眼眶内下壁减压术能有效改善甲状腺相关眼病患者的眼球突出度与视力，术后复视发生概率低，手术切口隐蔽美观，是一种可靠且有效的眶减压术式。     

Results of transantral orbital decompression in patients with thyroid-associated ophthalmopathy

PURPOSE: To present the results of orbital decompression in patients with thyroid-associated ophthalmopathy (TAO). METHODS: Transantral orbital decompression was performed in 63 patients with TAO. In 40 patients (63%) the operation was made because of progressive ophthalmopathy not responding to medical therapy, and in 23 patients (37%) the operation was made for rehabilitative reasons. The long-term hypesthesia engaging the infraorbital nerve was assessed with a questionnaire using a Visual Analogue Scale (VAS). RESULTS: The mean proptosis reduction was 3.2 mm (range 0-8 mm). Twenty-one patients had impaired visual acuity preoperatively, and 20 improved. Altogether 30 patients (40%) had worsened ocular motility postoperatively. Forty-three patients did not have diplopia in the primary position preoperatively, and new diplopia developed in 22 of these (51%). Hypesthesia in the infraorbital nerve area was reported for half of the operated sides, but was a major cause of distress (VAS-scoring >5) to eleven patients. CONCLUSIONS: Transantral orbital decompression is indicated in patients with progressive TAO or in patients with prominent exophthalmos, and results in a good proptosis reduction, but the risk of postoperative diplopia is significant. Postoperative hypesthesia is common but often not a major problem.     

Diplopia after retinal detachment surgery

In the Amsterdam Academic Medical Centre with an annual rate of 200 retinal detachment procedures, about the same incidence (4.5%) of diplopia after detachment surgery was found as by Fison and Chignell (1987). In 13 out of 18 patients with diplopia (sent for orthoptic evaluation between 01.01.1986 and 31.12.1987) double vision could be eliminated by various ways: orthophorization with or without temporary prismatic therapy was seen in 3 patients; a compensatory head posture eliminated diplopia in two cases, and prisms were effective in 4 cases (one of them had additional squint surgery). In 4 patients strabismus surgery alone restored binocular single vision. Binocular single vision was not restored in 5 cases.     

眼眶骨折修复手术后残余复视的手术矫正

目的 探讨眼眶骨折修复手术后主要功能视野内消除复视的手术时机、方法和效果。方法 筛选眼眶骨折修复手术后,对残余复视进行手术矫正的40全（40眼）进行回顾性研究。分析不同患者复视的成因,手术时机及手术方法的选择。术后随访6个月对手术疗效进行评价。结果 40例术前存在Ⅲ级复视,行眼外肌手术。根据被动牵拉试验结果,选择直肌后徒悬吊、截除以及Jensen联结、眶骨膜固定等术式。术中25例角膜映光基本正位,主要功能视野内无复视,10例略过矫,5例欠矫。术后6月观察,27例主要功能视野无复视;7例正前方无复视,但下方视野残留复视;6例第一眼位残留复视,给予配戴压贴三棱镜后复视改善。结论 眼眶骨折修复术后消除主要功能视野复视的手术方法应根据术前和术中牵拉试验结果以及眼球运动检查来选择,合理的手术方式可有效地消除复视、改善眼球运动功能。     

The clinical characteristics and treatment tactics of vertical strabismus

Examination of 328 patients with vertical squint has revealed peculiarities of its clinical forms. Their characteristics are: I. Concomitant vertical squint; II. A mixed form--concomitant convergent or divergent squint with a vertical component; III. Paretic or paralytic vertical squint; IV. Atypical kinds of vertical squint. Special attention is drawn to the presence of torticollis, difference in lid slit width, pseudoptosis, diplopia. Basic principles of treatment of vertical squint corresponding the clinical form are suggested. Results of treatment in patients with different forms of vertical squint are analysed.     

Transconjunctival orbital decompression in Graves' ophthalmopathy: lateral wall approach ab interno

AIMS: A modified surgical technique is described to perform a one, two, or three wall orbital decompression in patients with Graves' ophthalmopathy. METHODS: The lateral wall was approached ab interno through a "swinging eyelid" approach (lateral canthotomy and lower fornix incision) and an extended periosteum incision along the inferior and lateral orbital margin. In addition, the orbital floor and medial wall were removed when indicated. To minimise the incidence of iatrogenic diplopia, the lateral and medial walls were used as the first surfaces of decompression, leaving the "medial orbital strut" intact. During 1998, this technique was used in a consecutive series of 19 patients (35 orbits) with compressive optic neuropathy (six patients), severe exposure keratopathy (one patient), or disfiguring/congestive Graves' ophthalmopathy (12 patients). RESULTS: The preoperative Hertel value (35 eyes) was on average 25 mm (range 19-31 mm). The mean proptosis reduction at 2 months after surgery was 5.5 mm (range 3-7 mm). Of the total group of 19 patients, iatrogenic diplopia occurred in two (12.5%) of 16 patients who had no preoperative diplopia or only when tired. The three other patients with continuous preoperative diplopia showed no improvement of double vision after orbital decompression, even when the ocular motility (ductions) had improved. In the total group, there was no significant change of ductions in any direction at 2 months after surgery. All six patients with recent onset compressive optic neuropathy showed improvement of visual acuity after surgery. No visual deterioration related to surgery was observed in this study. A high satisfaction score (mean 8.2 on a scale of 1 to 10) was noted following the operation. CONCLUSION: This versatile procedure is safe and efficacious, patient and cost friendly. Advantages are the low incidence of induced diplopia and periorbital hypaesthesia, the hidden and small incision, the minimal surgical trauma to the temporalis muscle, and fast patient recovery. The main disadvantage is the limited exposure of the posterior medial and lateral wall.     

眼眶减压术治疗Graves眼病的临床效果

目的:探讨眼眶减压术治疗Graves眼病的效果及安全性.方法:选取2011-02/2016-02在我院治疗的Graves眼病患者55例77眼,均行眼眶减压术治疗,观察患者术后6 mo视力、眼球突出度及并发症.结果:患者术后6 mo最佳矫正视力(0.23±0.09)明显较术前(0.46±0.07)有所提高,差异有统计学意义(P<0.05);患者术后6 mo眼球突出度(16.20±1.99 mm)明显较术前(20.13±1.87mm)有所减少,差异有统计学意义(P<0.05);术后CAS评分≤3分眼数为56眼(73%),明显较术前15眼(19%)有所增加,差异有统计学意义(P<0.05);术前共有50眼(65%)存在色觉障碍,术后有42眼(55%)视觉障碍明显改善,8眼(10%)无变化;77眼术后6 mo眼球突出度平均下降3.87±1.03 mm;术后出现新复视患者5例8眼,新发复视率10%,随访3 mo后,复视消失.结论:眼眶减压术治疗Graves眼病是一种有效方法,但应注意术后复视等并发症发生.     

Extraocular muscle surgery for Graves' ophthalmopathy: does prior treatment influence surgical outcome?

We analysed the results of extraocular muscle surgery in 38 patients with stable Graves' ophthalmopathy. Fixed sutures were used in all patients. A useful field of binocular single vision was achieved in 27 patients (71%) after one operation and in seven patients (18%) after more than one, whereas double vision was persistent in four (11%). No recurrence of diplopia was seen during one year of follow-up. No differences were found in duration of eye disease, angle of deviation, or in prior forms of treatment between patients who responded well to a single operation and those who needed more surgical procedures or those who responded less well. We conclude that, although the individual outcome cannot be predicted, every patient with diplopia and stable Graves' ophthalmopathy has an 89% chance of binocular single vision after extraocular muscle surgery. Prior treatment does not appear to influence this outcome.     

Recurrence of cyclic esotropia after surgical correction

Cyclic esotropia is a rare form of strabismus in which a convergent squint appears and disappears typically, but not always, in a regular 48-hour cycle. Characteristically, the convergent squint, when present, has a large angle with associated suppression and no binocular function. On normal or "nonsquinting" days, no manifest deviation is detectable (although in some cases there may be an esophoria). Physiologic diplopia is appreciated, whereas fusion and stereopsis are all normal. Amblyopia may occur in up to 20% of cases.     

One stage vertical rectus muscle recession using adjustable sutures under local anaesthesia.

AIMS: To assess the results of visual axis alignment following one stage adjustable suture surgery to correct vertical diplopia. METHOD: Eight patients with a mean age of 44.9 years (range 16-80 years) complaining of vertical diplopia underwent rectus muscle recession under local anaesthesia with intraoperative adjustment of sutures. Diplopia was secondary to superior oblique paresis in four patients, dysthyroid eye disease in two patients, superior rectus paresis in one patient, and one developed a consecutive deviation after previous squint surgery. The surgery consisted of seven single muscle recessions (six inferior recti and one superior rectus) and one two muscle recession (inferior and lateral recti). The surgery was performed under topical anaesthesia supplemented with a subconjunctival injection of local anaesthetic over the muscle insertions. RESULTS: The patients remained comfortable throughout their surgery. All had a reduction in their vertical deviation. Six were asymptomatic and were eventually discharged. One had residual diplopia which was well tolerated without further intervention. One had persistent troublesome diplopia which was corrected by temporary Fresnel prisms. He became asymptomatic after further surgery of a 1 mm inferior rectus advancement. CONCLUSION: One stage adjustable suture surgery is recommended in all cases of strabismus surgery when postoperative results would otherwise be unpredictable.     

视网膜脱离手术后斜视的手术特点和疗效

目的 探讨视网膜脱离手术后斜视的手术特点和效果。方法 ２３例２６眼视网膜脱离手术后斜视，手术前后三棱镜加交替遮盖或三棱镜映光法（Ｋｒｉｍｓｋｙ法）测定客观斜视角等，术后追踪２～２８月。结果 （１）术中特点：眼外肌粘连、纤维化的程度不同；各直肌附着点距离角膜缘比正常的平均远２～３ｍｍ。（２）斜视矫正量：以单纯直肌减弱术矫正量最小，直肌减弱联合缩短再复信术矫正量最大。（３）术后眼位：第１正位率５６．５     

Diplopia in fractures of the orbital floor

Based on their own experience with surgical treatment of 43 patients with fractures of the orbital floor, the authors discuss the problem of early operation in relation to the development of residual diplopia. They evaluate the functional result by the size of the visual field where diplopia occurred. In confirmed fractures of the orbit they recommend operation as early as possible after the injury. All patients were operated by the method of transantral reposition of the orbital floor. Satisfactory functional results were achieved in all operated patients. None of them had diplopia in the primary position of the eyes. The best results were achieved in patients operated early (residual diplopia in 10%), where none of the patients had diplopia in the visual field beneath 30 degrees.