Treatment of incomitant hypertropia and diplopia with recession of the inferior rectus and superior rectus muscles of the same eye.

PURPOSE: To evaluate the effectiveness of recession of the inferior rectus (IR) and superior rectus (SR) muscles of the same eye in the treatment of incomitant hypertropia with diplopia. METHODS: Retrospective record review of two groups. (1) Patients with hypertropia and diplopia in downgaze and with fusion in the primary position underwent adjustable recessions of the IR and SR muscles of the eye that was hypotropic in downgaze. (2) Patients with hypertropia and diplopia in the primary position and less hypertropia in downgaze underwent an IR muscle recession of the hypotropic eye in the primary position and adjustable recessions of the contralateral IR and SR muscles. RESULTS: Group 1 included four patients. Mean incomitance between primary position and downgaze was 10(Delta). After mean follow-up of 44 months, all patients were fusing in the primary position and downgaze. Group 2 included six patients. Mean incomitance between primary position and downgaze was 9.3(Delta). After mean follow-up of 40 months, all patients were fusing in the primary position and downgaze. One patient in group 2 required a second procedure. CONCLUSIONS: Recession of both vertical rectus muscles of the same eye appears to be an effective, stable, and predictable procedure for patients with incomitant hypertropia with diplopia in downgaze. A modification of this procedure may also be effective for cases in which postoperative hypertropia in downgaze is anticipated with recession of one IR muscle. The procedure is especially appropriate in the treatment of thyroid eye disease, since it is adjustable, and since it does not require resection or posterior fixation of a vertical rectus muscle.

The management of strabismus in adults--III. The effects on disability.

INTRODUCTION: This is the third article in a series on the various facets of the management of strabismus in adults. Here, we give a broad overview of the types and severity of disability and provide initial validation of an instrument (questionnaire) to assess these disability aspects. METHODS: After undergoing strabismus surgery, 101 patients from 6 centers completed a 6-item questionnaire in which they rated both the before-surgery and after-surgery severity of problems associated with their strabismus, ranging from specific health, daily functioning, social interaction, concerns about the future, and self-image to job-related difficulties. RESULTS: The before-surgery outcomes showed significant variation across the 6 types of problems (P < 0.001), with "specific health" and "daily tasks" yielding the highest problem rating. Patients with diplopia reported more severe problems with "daily tasks" (P = 0.004) and "concerns about the future" (P = 0.026) than patients without diplopia. Overall, all problem ratings declined after surgery (P < 0.001), but patients who were not successfully aligned were left with higher problem ratings on "specific health" (P = 0.005), "daily tasks" (P = 0.003), and "social interaction" (P = 0.024). CONCLUSIONS: The results indicate a wide range of disability aspects in adult patients with strabismus, with moderate differences between patients with or without diplopia. Improvements in disability after surgery, as reflected by these ratings, should be taken into account when assessing the health value of adult strabismus management.

The management of strabismus in adults--II. Patient and provider perspectives on the severity of adult strabismus and on outcome contributors.

PURPOSE: As part of a larger study intended to evaluate the management of strabismus in adults, we documented and compared patient and provider perspectives on the various factors that may contribute to treatment outcome and value of strabismus care. METHODS: By completing a questionnaire, 170 patients with strabismus (ages 19 to 87 years) and 11 strabismus specialists who performed surgery on these patients each indicated the relative weight of several disease- and treatment-related contributors to the outcome and value of care. In addition, each respondent rated the severity of the strabismus before and after surgery. RESULTS: Overall severity ratings improved as a result of surgery. The improvement perceived by the physicians was 5.1 +/- 1.7 on a 10-point scale and was larger than the 2.6 +/- 3.6 points improvement perceived by the patients ( P < 0.001). Patients and physicians expressed different views on the relative contributions to outcome and value (overall P < 0.001). Both groups indicated "the condition," "the physician," and "the procedures" as the largest contributors, but "condition" was perceived as more important by the physicians than by the patients ( P < 0.001), and "physician" was more important to the patients than to the physicians ( P < 0.001). CONCLUSION: Although in approximate agreement on the main contributors to outcome and value, discrepancies exist between perspectives of patients and physicians on the relative weights of those contributors. Public information, education, and counseling may bring these perspectives better in line and ultimately improve both quality and patient satisfaction.

The management of strabismus in adults--I. Clinical characteristics and treatment.

INTRODUCTION: This is the first in a series of articles intended to evaluate the management of strabismus in adults, including clinical outcomes and the quality, cost, and value of treatment from the perspectives of patients and health care providers. Here we present clinical characteristics, complexity of surgery, treatment success, and resolved complaints in a group of adult patients who underwent strabismus surgery. METHODS: This is a multicenter retrospective study analyzing the type and amount of ocular misalignment before and after surgery in adult patients with strabismus onset before (BVM, or age < 9 years) or after (AVM, or age >/= 9 years) visual maturation. Success was evaluated in terms of alignment, motility, and the presence of diplopia; subjective success was measured in terms of resolved complaints. The complexity of surgery was determined using the Intensity/Complexity Index and compared with success rates. RESULTS: Data are reported on 299 patients (90 BVM and 145 AVM) whose eyes were successfully aligned in 63% of the BVM cases and 81% of the AVM cases. Subjective complaints resolved at similar rates in the BVM and AVM subgroups. Successful alignment was not correlated with complexity of surgery, but motility and sensory success rates were correlated with complexity of surgery. CONCLUSION: Within each of the BVM and AVM subgroups, this study of adult strabismus showed similar surgical success rates compared with published data. This qualifies these patient groups as clinically typical of adults undergoing strabismus surgery. Additional studies will expand on health value analyses.

Intensity and complexity index of disease for strabismus surgery.

BACKGROUND: The value of health care must be calculated by weighing quality of care with cost of care, and quality of care must be measured not only by objective clinical outcomes but also by resulting health-related quality of life and patient satisfaction. To date, no validated method allows this determination. In this article, we present results of a survey to determine an intensity and complexity index (ICI) for strabismus surgery and discuss how this information can be used in a larger system of determining treatment outcomes and value. METHODS: We surveyed the membership of the American Association for Pediatric Ophthalmology and Strabismus to determine the ICI for 20 specific surgical procedures on the extraocular muscles and for 17 add-on factors that correct for circumstances altering the difficulty of the surgical procedure. RESULTS: Of the 620 surveys that were sent, 222 (36%) were returned and analyzed. Median ICI ranged from 1.00 for lateral rectus recession and for medial rectus recession to 2.00 for Harada-Ito and for superior oblique lengthening with silicone expander. Median ICI for add-on factors ranged from 0.50 for lateral incomitance, concurrent neurological syndrome, age 70 years or older, and ASA rating III or higher to 2.00 for complicated strabismus operation, eg, lost muscle. CONCLUSIONS: The ICI is a new method of risk-adjusting a patient population undergoing strabismus surgery, thus allowing further evaluation of the outcome and the value of treatment of disease in that patient population.