Cystoid Macular Edema in a Patient with Chronic Progressive External Ophthalmoplegia with Mitochondrial Myopathy

Purpose: To report the findings of cystoid macular edema in a patient with chronic progressive external ophthalmoplegia and other systemic features of mitochondrial myopathy. Design: Observational case report. Methods: Retrospective review of the ophthalmic examination and genetic studies of a patient with chronic progressive ophthalmoplegia. Results: Fundus photos, retinal optical coherence tomography, and fluorescein angiography were significant for findings consistent with bilateral cystoid macular edema, which were found to have resolved after 18 months without treatment. The medical examination supported the diagnosis of chronic progressive external ophthalmoplegia. Fundus photos, retinal optical coherence tomography, and fluorescein angiography were significant for findings consistent with cystoid macular edema. Conclusions: This case demonstrates the occurrence CME in a patient with CPEO and additional systemic features.     

The evaluation of Chronic Progressive External Ophthalmoplegia with computerized tomography

Introduction: Chronic progressiveexternal ophthalmoplegia is characterisedby limitation of ocular motility in alldirections of gaze and ptosis.Innervational or myogenic factors wereclaimed to be responsible for thismotility disorder. The aim of thisstudy was toinvestigate the extraocular muscles inCPEO with computerized tomography in an attemptto distinguish extraocular musclemorphology caused by this disorderfrom that occurring in normal individuals.Methods: Eighteen orbits from 9patients diagnosed with CPEOwere included in the study. Axialand coronal scans were obtained for CTevaluation of extraocular muscles and thedimensions of extraocular muscles were measured.The control group consisted of40 orbits belonging to 20 individuals and,the results were compared with a student'st test.Results: The thickness (the verticaldimension of vertical recti and thehorizontal dimension of horizontal recti)of all rectus muscles wassignificantly decreased in comparison with the controlgroup, whereas the width (the horizontal dimensionof vertical recti and the verticaldimension of horizontal recti) was similar inboth the diseased and normal orbits.In all the rectus musclesof the diseased orbits,the normal fusiform shape was lost and the muscles appeared asthin bands.Discussion: The differentiation ofCPEO from other myogenic and neurogenicdisorders may present difficulty,and a cluster of criteria are required fora final diagnosis. CT has provento be a valuable tool in assessing extraocularmuscles [1, 2]. In this study, an extremeatrophy of all rectus muscles wasdemonstrated by means of CT. This diagnostic method mayconsequently contribute to a properdiagnosis of CPEO.     

Esthesioneuroblastoma Presenting with Complete External Ophthalmoplegia

An 85-year-old male presented with unilateral third, fourth, and sixth cranial nerve palsies. Neuroimaging revealed a mass involving the medial wall of the left cavernous sinus, without orbital involvement. Biopsy of the mass provided a pathologic diagnosis of esthesioneuroblastoma.     

Maxillary Ameloblastic Carcinoma with Progressive Ophthalmoplegia and Optic Neuropathy

An 80-year-old woman was evaluated for diplopia and blurred vision of the right eye associated with a maxillary ameloblastic carcinoma that had presented as an ameloblastoma 11 years earlier. Neuroimaging revealed ethmoid tumour involving the right orbital apex, cavernous sinus, optic nerve, and middle cranial fossa. After subtotal tumour resection and radiosurgery, ophthalmoplegia, right optic neuropathy, and right trigeminal neuropathy progressed despite initially stable tumour appearance on subsequent neuroimaging. Maxillary ameloblastic carcinoma is a rare tumour that can arise de novo or from a pre-existing ameloblastoma. Little or nothing has been previously reported on this tumour and its associated progressive neuro-ophthalmic deficits.     

The Role of Botulinum Toxin in the Management of Ophthalmoplegia Secondary to Miller Fisher Syndrome

Miller Fisher syndrome is an acute demyelinating polyneuropathy classically presenting with ataxia, areflexia, and ophthalmoplegia. The authors report the case of a 27-year-old female, who presented with limb weakness and double vision following a prodromal pharyngitis. Ophthalmic examination revealed fluctuant ophthalmoplegia eventually consistent with bilateral sixth cranial nerve palsies, prompting investigation for anti-ganglioside antibodies, which returned positive. Due to disabling diplopia, the patient was treated with botulinum toxin, with a resulting favourable reduction in the size of strabismus. Four months following her presentation, the patient was orthophoric and resumed normal activities.     

中国东北某医院2014─2017年间斜视住院患者斜视类型分布变化

目的：根据中国东北地区某医院眼科收集的数据,评估所有年龄阶段斜视住院患者的斜视类型和数量变化趋势。方法：回顾性分析2014年1月至2017年12月在哈尔滨医科大学附属第一医院眼科住院的斜视患者3 661例的资料。收集患者基本信息、斜视类型以及各种斜视的数量等信息,并观察分析斜视类型分布及斜视数量的变化趋势。组间数据比较采用方差分析、χ2 检验或Fisher确切概率法。 结果：最终纳入3 555例患者,年龄为1～79岁（15.5±11.6）岁,其中3 536例患者行斜视手术治疗。患者数量呈逐年递增趋势,且在每年1、2月份及7、8月份大致达到峰值（χ2 =956.67,P<0.001）。外斜视患者数量（71.8%）明显多于内斜视患者数量（16.0%）,差异有统计学意义（χ2 =31.41,P<0.001）, 其中间歇性外斜视是最常见的斜视类型。非调节性内斜视（77.6%）是所有内斜视中最常见的斜视类型。其他特殊类型斜视虽然患者数量较少,但依然有小幅度的上升趋势。在所有年龄阶段患者中, 12岁以下的患者最常见,占总数的56.0%,其中外斜视（71.5%）是最主要的斜视类型。结论：中国东北地区某医院2014─2017年外斜视患者比内斜视患者更常见,且外斜视患者的比例逐年增加,其中间歇性外斜视是最主要的斜视类型。此外12岁以下患者是最常见的患病人群。     

Botulinum Toxin Injection into Extraocular Muscles as an Alternative to Strabismus Surgery

Sixty-seven injections of botulinum A toxin were given to patients for correction of strabismus. No systemic complications of any kind have occurred. The maximum time of paralysis occurs four to five days following the injection, and then gradually diminishes, depending on the dose. The maximum correction of strabismus has been 40 prism diopters. The maximum follow-up following injection is six months. Injection of botulinum A toxin into extraocular muscle to weaken the muscle appears to be a practical adjunct or alternative to surgical correction.     

麻痹性斜视手术治疗25例

目的:分析讨论几种不同类型的麻痹性斜视的临床特点、手术方法和手术效果。方法:回顾总结我院2005-07/2007-02住院手术的25例成人麻痹性斜视的手术方法及手术效果。外直肌麻痹7例,上斜肌麻痹6例,下直肌麻痹5例,双上转肌麻痹4例,双下转肌麻痹2例,上直肌麻痹1例。结果:患者25例中,手术后治愈18例;手术后改善7例,无1例出现眼前节缺血的并发症。结论:麻痹性斜视原因多样,病情复杂,术前充分的检查及合理的手术设计可达良好的治疗效果,对斜视度较大的患者分次手术可达满意的效果。     

Effect of Limited Tenon Capsule and Intermuscular Membranes Dissection on the Outcome of Surgery in Patients with Horizontal Strabismus

Purpose: The aim of the study was to evaluate the effect of limited dissection of Tenon capsule on the outcome of strabismus surgery.

Methods: Patients between the ages of 2 and 50 years with pure horizontal strabismus were enrolled in a prospective study. Patients were divided into two groups: case and control as a non-randomized study. The method of operation was similar in both groups except for the amount of sheath Tenon dissection. In the control group the intermuscular connections and Tenon capsule were cut as much as possible. In the study group, Tenon capsule, 3-4 mm posterior to the location of the sutures over the muscle (recessed or resected), were cut and intermuscular connections remained intact.

Results: The study enrolled 54 patients with 27 patients in each group. In both groups, after operation, regardless of the type of surgery, the angle of strabismus was reduced (P< 0.05). For patients who had undergone bimedial recession, the angle of strabismus was corrected to 2.6 ± 0.4 prism diopters per mm (PD/mm) of muscle recession in the case group, and 2.2 ± 0.9 in the control group (P=0.2). For patients who had undergone monocular recession and resection (R&R) for esotropia, the angle of strabismus was corrected 3.4 ± 0.3 PD/mm of muscle recession or resection in the case group, and 3.2 ± 0.2 in the control group (P=0.05). For patients who had undergone bilateral recession, the angle of strabismus was corrected 2.3 ± 0.2 PD/mm of muscle recession in the case group, and 2.2±0.2 in the control group (P=0.03). For patients who had undergone R&R for exotropia, the angle of strabismus was corrected 3.1 ± 0.5 PD/mm of muscle recession or resection in the case group, and 2.7 ± 0.3 in the control group (P=0.02).

Conclusion: Connective tissue ensheathments, whether disturbed or removed, do not ultimately affect the success of the strabismus surgery.     

斜视手术不同切口对泪膜稳定性的影响

目的探讨显微斜视手术对泪膜稳定性的影响,了解泪膜稳定性的变化与手术方式之间的关系。方法随机抽取2006年5月至2007年10月我院住院的斜视患者120例212眼,分2组。A:常规结膜切口52例(90眼);B:微创结膜切口68例(122眼)。检测术前1d,术后1d、3d、5d、7d、14d的基础泪液分泌试验(Sehirmer I test,SIt)、泪膜破裂时间(break up time,BUT)及角膜荧光素染色积分(nuoreseenee integral,FI),并对其泪膜稳定性的变化进行分析。结果与术前相比,常规结膜切口组术后1d SIt和角膜荧光素染色程度明显增高,BUT明显缩短,差异有显著意义;7d时SIt,14d时BUT、角膜荧光素染色积分恢复至术前水平。微创结膜切口组术后1d仅SIt明显增高,BUT明显缩短,角膜荧光素染色积分无明显变化。术后5d时SIt,7d时BUT恢复至术前水平。结论常规结膜切口行斜视手术,显著降低泪膜的稳定性,微创结膜切口行斜视手术,轻微影响泪膜的稳定性。     

Comparison of Surgical Success for Infantile Esotropia and Strabismus Associated with Neurological Impairment

Purpose: Surgery for strabismus associated with neurological impairment is assumed to have unsatisfactory results in comparison with other strabismus cases. The aim of this study is to compare the surgical success rates of infantile esotropia (IE) and strabismus associated with neurological impairment.

Methods: The records of 103 patients that received operations for IE and strabismus associated with neurological impairment between January 1994 and May 2014 were reviewed retrospectively. The angles of deviation and surgical success rates were evaluated at preoperative, 1-month postoperative, and 24-month postoperative visits.

Results: Forty-five patients received operations for strabismus associated with neurological impairment (25 patients with esotropia and 20 patients with exotropia) and 58 patients for IE. Mean preoperative angles of deviation in cases with neurological impairment were 42 prism diopters (PD) for esotropia, 44.7 PD for exotropia, and 44.4 PD for IE. One patient from each group had consecutive deviation at first visit, and at last visit, 3 patients with neurological impairment and 5 patients with IE had consecutive deviations. Surgical success rates at the end of the second year were 52% for esotropia and 50% for exotropia in patients with neurological impairment and 56.8% for IE cases.

Conclusion: This study was unable to find the differences between surgical success rates in IE and strabismus associated with neurological impairment.     

Decreased Binocular Summation in Strabismic Amblyopes and Effect of Strabismus Surgery

Purpose: Binocular summation (BiS) occurs when binocular visual function surpasses that of the better eye alone. We sought to evaluate whether strabismic amblyopia reduces BiS more than strabismus alone, and determine whether BiS improves in strabismic amblyopes after strabismus surgery. Methods: We prospectively recruited 15 patients with strabismic amblyopia who then underwent strabismus surgery. Thirty age-matched normal subjects and 30 non-amblyopic strabismic patients served as controls. Subjects underwent binocular and monocular visual acuity testing on high-contrast Early Treatment Diabetic Retinopathy Study (ETDRS) as well as 2.5% and 1.25% Sloan low contrast acuity (LCA) charts. BiS was calculated as the difference between better eye and binocular scores. Results: Strabismic amblyopes and strabismic controls did not significantly differ in preoperative BiS, but both had subnormal BiS preoperatively on LCA charts. Among 11 strabismic amblyopes with preoperative and postoperative BiS measurements, average postoperative BiS was not significantly different from preoperative. Improved LCA BiS postoperatively occurred in some patients and was associated with measurable preoperative stereoacuity (P=0.02), older age at strabismus onset (P=0.02), and larger preoperative angle of strabismus (P=0.0043).Conclusions: In this preliminary study, strabismic amblyopes experienced subnormal BiS, but amblyopia generally did not further impair BiS beyond that due to strabismus alone. Some strabismic amblyopes experienced improved low-contrast BiS after strabismus surgery. This suggests that further investigation in larger groups of patients should be undertaken to analyze a previously unrecognized functional benefit of strabismus surgery in strabismic amblyopes.     

A Preliminary Report of 40 Cases of Strabismus Microsurgery

Objective:To improve the qaulity of strabismus surgery and to find out the role of microsurgery in the field of strabismus.Methods:We performed separation and preservation of anterior ciliary vessels(ACV),adjustable sutures,routine rectus recession,and oblique muscle surgeries under microscope in 13 cases of comitant strabismus,19 cases of A-V syndrome and 8 cases of paralytic strabismus.Results:Surgeries were performed in a very clear field under microscope.We successfully did vascular microdissection and ACV preservation.Also with the use of microscope,various kinds of strabismus microsurgery videos were recorded.Conclusions:Microscopic technique can be used to enhance the quality and accuracy of strabismus surgery and to reduce surgical damage,postoperative inflammatory reaction and sear formation.All kinds of strabismus surgery,especially,oblique muscles and complex paralytic operations can be performed under microscope,.     

Delayed Conjunctival Closure in Adjustable Strabismus Surgery

Adjustable suture strabismus surgery has proved to be a significant aid in handling difficult strabismus cases, and various methods of conjunctival closure have been discussed. A new method of conjunctival closure, enabling direct visualization and manipulation of the muscle with minimal tissue drag during adjustment, is described. The conjunctiva can be fully closed over the knot after adjustment, providing increased patient comfort and a better cosmetic result.     

Role of Inferior Rectus Botulinum Toxin Injection in Iatrogenic Vertical Strabismus

Introduction: We describe the uses and effectiveness of botulinum toxin to the inferior rectus muscle in iatrogenic vertical strabismus.

Methods: A retrospective review of our database to identify patients who had undergone inferior rectus botulinum toxin injection between 1982 and 2006 for iatrogenic vertical strabismus.

Results: There were 13 patients, 5 female, with an age range of 14 to 78 years. Eight left eyes were injected. The mean period of follow-up was 3.3 years. Etiologies included post–local anesthetic, post–plaque radiotherapy for malignant melanoma, adherence syndrome after inferior oblique surgery, and post–botulinum toxin to the levator muscle to produce a temporary therapeutic ptosis. Reversal on first injection occurred in 7 patients and occurred in a further 2 patients on second injection. Pre-injection binocularity was not demonstrable in 3 patients; 2 of these patients did have binocular vision demonstrable after botulinum toxin injection. Seven patients had one injection, 3 patients had two, 1 had three, 1 had five, and 1 had six.

Discussion: The data demonstrate the range of indications that can be successfully treated and managed with inferior rectus botulinum toxin injection in iatrogenic vertical strabismus.     

The Early vs Late Infantile Strabismus Surgery Study: do sources for bias exist in this non-randomised trial?

BACKGROUND—The Early vs Late Infantile Strabismus Surgery Study Group investigates whether early or late surgery is preferable in infantile convergent strabismus, in a non-randomised, prospective, multicentre clinical trial. The current state of the study after end of recruitment is reported here, focusing on the question of possible sources for bias in this non-randomised trial.
METHOD—The prognostic factors were analysed at baseline in order to check for imbalances between the two treatment groups. Reasons for possible differences are discussed.
RESULTS—There is no evidence for clinically relevant inhomogeneities between the two groups concerning the distribution of the three prognostic factors spherical equivalent, degree of amblyopia, and limitation of abduction. The fourth prognostic factor, horizontal angle of squint, differs significantly between the two groups.
CONCLUSION—In the analysis of the final results we may have to account for differences in angle of squint at baseline by its inclusion as a covariate or by stratification.

Keywords: convergent squint; strabismus surgery     

重视斜视术后双眼视功能的重建

双眼视是双眼输入的视觉信息进行加工整理最终形成三维立体视觉的过程，属于大脑皮层的高级认知活动。斜视因为眼位的偏斜产生复视和混淆视，进而引起视觉抑制、异常视网膜对应、注视异常、三级视功能受损等一系列双眼视异常，严重影响了双眼视觉形成和发育。手术治疗为斜视的主要的治疗方法，但斜视矫正术后大部分患者无法获得正常的双眼视功能，而斜视的治疗应以重建双眼视功能为目标。斜视治疗不仅要重视眼位的恢复，更要重视双眼视功能的重建。重建双眼视功能在减少斜视的复发率，提高斜视的治疗效果方面具有积极的作用，并大大提高斜视患者术后的生活质量。所以双眼视功能重建应在斜视治疗中占有更重要的地位。斜视的早期手术治疗是建立双眼视觉的先决条件，同时应重视术后正确的屈光矫正和弱视的治疗，正确选用训练手段，个性化制定训练方案，才能促进双眼视功能的重建。     

The Management of Patients with Thyroid Eye Disease After Bilateral Orbital 3 Wall Decompression

Introduction: Thyroid eye disease is the most common cause of unilateral and bilateral proptosis in adults. Orbital decompression surgery may cause and/or worsen a pre-existing ocular motility disorder.

Methods: A retrospective review was carried out of all bilateral 3 wall orbital decompressions for severe thyroid eye disease performed between January 2002 and December 2004 by one surgeon. Subsequent surgeries were recorded.

Results: Seventy-four patients were identified, 59 (80%) females and 15 (20%) males. Mean age at the time of decompression was 46 years. Fifteen (20%) patients complained of diplopia due to strabismus prior to decompression surgery and 20 (27%) developed new diplopia postsurgery. Twenty patients (27%) required no further intervention following decompression surgery; the remainder underwent an average of 2.5 procedures. Strabismus surgery was performed in 32 (43%) patients. The mean time from the decompression to first strabismus surgery was 12 months. Forty-three (58%) patients underwent lid surgery. The mean time from decompression to first lid surgery was 16 months.

Conclusion: This study demonstrates how this group of complex patients required multiple surgical procedures within an extended timescale, therefore requiring several in- and outpatient visits.