Clinical features and surgical outcomes of isolated inferior rectus muscle paralysis

Purpose: To describe clinical features of patients with unilateral isolated inferior rectus (IR) muscle paralysis along with type of surgical treatment and results after surgery.

Methods: Patients diagnosed with unilateral isolated IR muscle palsy between 2009 and 2012 that required surgical treatment were included in the study. Diagnosis of IR muscle palsy was done by hypertropia with the largest angle in depression and abduction and inferior rectus muscle underaction.

Results: Twenty-two patients remained in the study; 17 patients (77.3%) had left eye involvement. IR muscle paresis was traumatic in 12 patients (54.5%), congenital in 9 patients (40.9%), and vascular in 1 patient (4.5%). Limitation of duction in the gaze of IR muscle was ?2 to ?3 in all cases. 3 patients, paradoxically, had contralateral compensatory head tilt (compensatory head tilt to the opposite side of IR muscle palsy). Intraoperatively, we did not detect any gross abnormalities in the IR muscles. The surgical plan at the first operation was IR muscle resection alone in 13 patients (59.1%). At the last follow-up visit, 15 patients (68%) had no deviations in primary position and downgaze. Three cases needed reoperation.

Conclusion: The presence of both ipsilateral and contralateral compensatory head postures in our patients showed that three-step or head-tilt test is not helpful in the diagnosis of IR muscle palsy. In comparison with other studies, more patients in our study were treated with IR muscle resection alone. Also, our reoperation rate was lower than other studies. Absence of gross abnormality in the IR muscles at the operation and partial nature of the paresis may explain these good results. Thus, a considerable number of IR muscle palsy cases with the above characteristics may be treated successfully by one muscle surgery (IR muscle resection).     

DIAGNOSIS AND MANAGEMENT OF LOST MUSCLE FOLLOWING STRABISMUS SURGERY

Of all the complications of strabismus surgery, the lost muscle is one of the most alarming, and yet with patience and careful management it may be one of the most amenable to treatment.
This paper reports seven cases of lost muscle following strabismus surgery, in six of the seven cases referred to the Department of Clinical Ophthalmology there had been delay in diagnosis for periods varying from six weeks to 17 years. All the lost muscles were successfully retrieved.
With good illumination and magnification and a careful search of the sub-Tenon's capsule space it is unusual to need to explore the orbital fat to retrieve the muscle.     

DVD与下斜肌功能过强手术的临床探讨

目的 探讨下斜肌功能过强者采取下斜肌减弱手术的疗效。方法 采取下斜肌减弱手术(截断或切除5～8mm)83例117眼。结果 117眼下斜肌减弱手术，下斜肌功能过强89眼，76眼完全矫正，13眼不同程度改善，其中下斜肌截断15眼，2眼未完全矫正；下斜肌切除5～8mm68眼，11眼未完全矫正。垂直分离性斜视(DVD)28眼，4眼未完全矫正。术前代偿头位32例，28例完全改善，余4例不同程度改善。结论 认真检查或观察斜视度，采取下斜肌减弱手术，均可矫正不同程度的斜视度。     

伴有面转代偿头位的先天性下直肌麻痹临床特征与手术治疗

目的：描述伴有面转代偿头位的先天性单纯下直肌麻痹患者的临床表现,并分析其手术治疗效果。

方法：回顾性分析2014-05/2018-07伴有明显面转代偿头位的先天性下直肌麻痹患者,手术前后患者面转程度的变化借助骨科量角器来检查,垂直、水平斜视度变化通过三棱镜交替遮盖试验来测量,旋转斜视度变化通过眼底对眼球客观旋转状态评估。下直肌缩短术是主要治疗方案。

结果：在15例研究对象中,有13例行下直肌缩短术或者联合上直肌后徙术术后疗效好,下直肌运动不足明显改善,眼球运动协调,以面转为主的代偿头位消失,垂直、水平、旋转斜视得到矫正; 并得出：每缩短1 mm下直肌可矫正1.54±0.93°内旋斜视。而行下斜肌断腱术治疗的垂直斜视度小的患者,面转改善不理想,仍遗留眼球运动不协调。

结论：先天性单纯的下直肌麻痹以面转代偿头位为主,下直肌缩短术治疗效果好,轻度的过矫及欠矫不影响手术疗效。     

Diagnosis and surgical management of isolated inferior oblique palsy

AIM: To describe the etiology, clinical characteristics, surgical options and surgical outcomes of isolated inferior oblique palsy (IOP). METHODS: A retrospective review was performed on patients with isolated IOP who were seen between January 2010 and June 2017. The following clinical data were obtained from the patients’ charts: visual acuity, ocular alignment, ocular motility, cyclotorsion, stereoacuity, Parks three-step test, surgical methods, surgical outcomes and complications. Surgical success was defined as horizontal deviation ≤10 prism diopters (PD) and a vertical deviation ≤5 PD in primary gaze at both near and distant vision as assessed at last follow-up. RESULTS: The records from a total of 18 patients (8 males and 10 females) with an average age of 27.56y were included in this study. The right eye was affected in 11 patients, the left in 6 patients and both eyes in 1 patient. Twelve cases (66.7%) were congenital and 6 (33.3%) were acquired IOP. The 6 acquired cases involved 2 resulting from orbital trauma/surgery, 2 from midbrain microvascular ischemia, 1 from myasthenia gravis and 1 of unknown etiology. Strabismus surgery was performed in 13 cases. Surgical techniques included weakening of superior oblique and vertical rectus recession and resection. After a mean follow-up of 15.11mo, the corrected vertical deviation in primary position was 19.92±8.52 PD (P=0.000) and the corrected horizontal deviation was 14.31±12.68 PD (P=0.002). The surgical success rate was 61.5% and no surgical complications were present. CONCLUSION: Isolated IOP represents a rare condition, with most cases (66.7%) involving a congenital basis. The acquired cases included vascular, orbital trauma/surgery and myasthenia gravis. Weakening of the ipsilateral superior oblique muscle and/or contralateral superior rectus recession often resulted in favorable surgical outcomes with a surgical success rate of 61.5%.     

Muscle belly union associated with simultaneous medial rectus recession for treatment of myopic myopathy: results in 33 eyes

Purpose

To describe the results achieved using muscle belly union associated with the recession of the ipsilateral medial rectus muscle to treat myopic myopathy and restore the normal anatomical relationship of superior and lateral rectus (LR).

Methods

A retrospective, nonrandomized study performed on 33 eyes of 26 patients who underwent muscle belly union between January 2004 and October 2012. We preoperatively and postoperatively recorded: best-corrected visual acuity; refraction; intraocular pressure; complete orthoptic assessment, including the angle of deviation and maximal abduction measured using the Goldmann perimeter. Pictures of the eyes in all gaze directions were taken before and after the surgical treatment. Anatomical relationships between muscle cone and eye globe were preoperatively analyzed using magnetic resonance imaging (MRI). Surgical complications were noted.

Results

The follow-up period was 6 months. Preoperative mean BVCA was 0.97±0.96 logMAR (ranging from 0.1 to 3 logMAR) and no changes were detected during postoperative controls. Preoperative mean hypotropia and esotropia were, respectively, 10.2±3.9 prism diopters (PD) and 46.2±15.5 PD. Postoperative mean hypotropia was 2.48±2.00 PD (P<0.001) and mean esotropia was 7.36±9.09 PD (P<0.001). A statistical incrementation of mean maximal abduction (P<0.001) was also noticed.

Conclusions

Muscle belly union—coupled with the recession of the ipsilateral medial rectus muscle when considered convenient—is the elective surgical technique in myopic myopathy, when a downward displacement of LR muscle is shown on MRI with coronal sections.     

Secondary hyperfunction of unoperated inferior oblique muscle after surgical treatment of strabismus

Secondary hyperfunction of the inferior oblique muscle IO of one of the eyes is a frequent complication after unilateral recession of the overacting IO of the fellow's eye. It is often observed in cases with bilateral asymmetric hyperfunction of the IO's when these are surgically decreased. The pathogenesis of this secondary hyperfunction is not sufficiently explained yet. We evaluated the condition of unoperated IO in 42 children with unilateral hyperfunction of the IO. In all cases the operation we performed was recession combined with a fixed anteroposition. During the two years follow up period we found no secondary hyperfunction of the unoperated oblique muscle in 31 of the children, mild level of elevation in 7 of them, middle — in 2, and severe in 2 of the children. This observation confirmed our conviction of refraining from simultaneous surgical intervention on both IO muscles when there is hyperfunction of one of them.     

土耳其人Duane眼球后退综合征的临床特点及手术疗效分析

目的：分析Duane眼球后退综合征(DRS)患者的临床特点及手术疗效。

方法：评估94例DRS患者临床数据。记录完整的眼科数据,包括年龄、性别、侧位、DRS类型、偏角、异常头部姿势(AHP)、眼球后退、过冲及手术入路类型。

结果：患者年龄为15.4±9.18岁,其中78例男性,16例女性。单侧和双侧受累分别为87% 和13%。在单侧DRS患者中,左眼占65%。94例患者中,59.5%的患者为I型,29.7%的患者为II型,8.5%的患者为III型,2.1%的患者为IV型。大多数患者(36,38%)为嗜热性,43例(96%)患者术前AHP出现10°以上。有40例(43%)患者出现过度调校,通常为II型。对45例(48%)患者进行手术治疗。共32例(78%)行水平直肌手术后获得了较好疗效,24例(53%)患者AHP改善。

结论：侧直肌的Y分裂和后榫固定在有明显过校的情况下都有令人满意的结果。垂直直肌转位增强术在限制外展方面取得了最佳效果。     

Unilateral Recession-Resection Surgery for Infantile Esotropia: Survival of Motor Outcomes and Postoperative Drifts

Purpose: To outline the short- and long-term motor outcomes of unilateral medial rectus muscle recession and lateral rectus muscle resection for the correction of moderate angle infantile esotropia. Methods: A retrospective study of 109 consecutive patients with moderate angle infantile esotropia treated with graded unilateral recession-resection surgery. Criteria for successful motor outcome included alignment ±10Δ from orthophoria. Outcome evaluation was a comparison of successful alignment versus an overcorrection or undercorrection at eight weeks postoperatively as well as on the final follow-up examination. Results: The mean preoperative deviation was 35.5 prism diopters (Δ) and mean follow-up time was 4.9 years. At the eight-week postoperative examination, 99 patients (89.9%) were successfully aligned, as opposed to 75 of 95 patients (78.9%) at the final postoperative visit (P=0.041). There was no statistically significant difference between the rate of early versus late undercorrections (7.3% versus 12.5%, P=0.267) or overcorrections (2.7% versus 8.3%, P=0.125). Ten patients had an esotropic drift over time and 10 patients had an exotropic drift. Recurrent esotropia was associated with high hyperopia and presumed infantile esotropia diagnostic entity. The Kaplan-Meier estimate of survivorship of a successful motor outcome was 75.5% at five years and 71% at 15 years postoperatively. The mean response to surgery was 2.9Δ per mm of muscle recessed and resected and was positively related to the preoperative angle of deviation (R=0.615). Conclusions: The unilateral recession-resection procedure for the correction of infantile esotropia is shown to be associated with a favorable survival of motor outcomes and a relatively balanced rate of undercorrections versus overcorrections tending to be maintained through the follow-up period.     

伊朗亚兹德小儿斜视的流行与手术结果的调查研究

目的: 对伊朗亚兹德不同类型斜视的发病率及术后效果的调查。方法: 在此描述性研究中,对年龄低于 16 岁患斜视人群的医疗记录进行回顾性分析。收集术后效果及并发症的问卷数据,对其进行统计学分析。卡方检验用于定性分析,曼-惠特尼 U 检验用于定量分析。结果: 11a 间有 685 例儿童性斜视确诊。斜视类型如下:307 例 ( 44. 8% ) 外斜视,294 例 ( 42. 9% ) 内斜视,84 例( 12. 2%) 水平斜视合并垂直斜视。术后 280 例( 73. 9%)调整到正常水平( 水平偏差范围< 8Δ) 。结论: 研究中最常见的类型为外斜视。术后效果与已发表文献具有可比性。但仍需较长时间随访以评估手术效果。     

Clinical features, surgical outcomes and genetic analysis of ectodermal dysplasia with ocular diseases

AIM: To report on the clinical features, surgical outcomes and gene mutation analysis of three ectodermal dysplasia probands with ocular diseases.METHODS: A case-note review of three unrelated probands diagnosing with ectodermal dysplasia with ocular diseases was undertaken. Patient clinical features and the outcomes of surgery were analysed. The suspected pathogenic genes were analysed by whole exome sequencing from patients with ectodermal dysplasia and Sanger sequencing from family members.RESULTS: The ocular clinical features of ectodermal dysplasia with ocular diseases mainly include eyelid ectropion, lagophthalmos and absence of lacrimal punctum. All the probands underwent surgeries of full-thickness free skin flap grafting to correct ectropion. They achieved good recovery, and there were no obvious complications during the follow-up. The gene sequencing results did not show any meaningful genetic mutations.CONCLUSION: Lid ectropion is one of the key clinical traits of ectodermal dysplasia with ocular diseases. Ectropion correction with full-thickness free skin flap grafting is an effective procedure to correct ectropion for ectodermal dysplasia patients with ichthyosis-like tissue. The suspected pathogenic genes of ectodermal dysplasia with ectropion should be further verified or confirmed by large samples of the family.     

Extraocular muscles: Basic and clinical aspects of structure and function

Although extraocular muscle is perhaps the least understood component of the oculomotor system, these muscles represent the most common site of surgical intervention in the treatment of strabismus and other ocular motility disorders. This review synthesizes information derived from both basic and clinical studies in order to develop a better understanding of how these muscles may respond to surgical or pharmacological interventions and in disease states. In addition, a detailed knowledge of the structural and functional properties of extraocular muscle, that would allow some degree of prediction of the adaptive responses of these muscles, is vital as a basis to guide the development of new treatments for eye movement disorders.     

先天性眼外肌纤维化一家系临床分析及手术治疗

目的：探讨家族性先天性眼外肌纤维化的临床特点、手术治疗方法及疗效。

方法：对先天性眼外肌纤维化家系成员进行眼部的各项检查,包括：视力、眼压、眼底、眼外肌功能、眼眶CT、双眼B超等检查,并对部分患者行斜视矫正术及额肌悬吊术。

结果：该家系眼外肌纤维化发病率为31%。该家系各患者均双眼受累,自幼表现为眼球运动障碍、上睑下垂,眼球位于下转位,向正前方注视时伴有异常辐辏,向前注视抬下颌。随年龄增长病情加重不明显。其他全身系统器官未见异常。经手术治疗,下颌上抬及外观可获得明显改善,眼球运动改善不明显。

结论：该家系具有常染色体显性遗传特征。通过手术治疗可改善头位及外观。眼球运动无明显改善。     

Infectious endophthalmitis: clinical features, management and visual outcomes

Aim: To identify the clinical features and outcomes of infectious endophthalmitis in New Zealand. Methods: A retrospective review was performed on all patients presenting at Auckland Public Hospital with presumed infectious endophthalmitis between 1996 and 2004. Results: One hundred and six patients were diagnosed with infectious endophthalmitis over the 9‐year study period. More than half the infections occurred in the perioperative setting (58.5%), with the next most common group being patients with a history of ocular trauma (18.9%). Endogenous endophthalmitis accounted for 16.0% of the cases while a small percentage arose from other causes. The mean interval between the onset of symptoms and presentation was 4.2 ± 7.9 days. There was no significant difference in outcomes between clinical settings (P = 0.616) or between gram‐positive, gram‐negative and fungal infections (P = 0.090). Evisceration/enucleation was more likely in Pacific peoples and those with poor presenting visual acuity. Conclusions: The most common clinical scenario for patients presenting with presumed infectious endophthalmitis in this series was in the perioperative setting. We did not find that the prognosis was influenced by the microbiological isolate or clinical setting. However, those patients presenting with poor acuities typically had the worst outcomes. Pacific ethnicity was also associated with increased rate of complications.     

Wall‐eyed bilateral internuclear ophthalmoplegia: review of pathogenesis,diagnosis, prognosis and management

Wall‐eyed bilateral internuclear ophthalmoplegia (WEBINO) is an uncommon disorder of ocular motility that possesses a unique spectrum of clinical findings, consisting of primary gaze exotropia, adduction impairment and nystagmus of the abducting eye. WEBINO is a variant of internuclear ophthalmoplegia (INO) sharing similar pathophysiology and aetiologies. Much of the literature published on internuclear ophthalmoplegia and its variants focuses on aetiology and pathophysiology, whereas there has been less information addressing prognosis and management. This review will provide current perspectives on the pathogenesis, prognosis and management of WEBINO syndrome.     

Toric intraocular lenses: Expanding indications and preoperative and surgical considerations to improve outcomes

Since the introduction of the first toric intraocular lens (IOLs) in the early 1990s, these lenses have become the preferred choice for surgeons across the globe to correct corneal astigmatism during cataract surgery. These lenses allow patients to enjoy distortion-free distance vision with excellent outcomes. They also have their own set of challenges. Inappropriate keratometry measurement, underestimating the posterior corneal astigmatism, intraoperative IOL misalignment, postoperative rotation of these lenses, and IOL decentration after YAG-laser capsulotomy may result in residual cylindrical errors and poor uncorrected visual acuity resulting in patient dissatisfaction. This review provides a broad overview of a few important considerations, which include appropriate patient selection, precise biometry, understanding the design and science behind these lenses, knowledge of intraoperative surgical technique with emphasis on how to achieve proper alignment manually and with image-recognition devices, and successful management of postoperative complications.