Augmented inferior rectus transposition with medial rectus recession in treatment of chronic unilateral sixth nerve palsy.

BACKGROUND: to report the results of augmented inferior rectus muscle transposition (IRT) in management of chronic sixth nerve palsy. METHODS: a retrospective review of medical records of patients with chronic complete sixth nerve palsy who were treated by augmented full thickness IRT to the lateral border of the paralyzed lateral rectus muscle. Patients were selected for IRT if there was more limitation of abduction in inferior gaze associated with V- pattern esotropia. Medial rectus recession (MRRc) was performed in case of positive intraoperative forced duction. Effect on primary position esotropia, face turn, amount of V-pattern and limitation of ocular ductions were reported and analyzed. RESULTS: the review revealed 11 patients (7 males) with chronic unilateral sixth nerve palsy who were treated by simultaneous augmented IRT and MRRc. Causes of sixth nerve palsy were trauma (6 cases), vascular (3 cases), inflammation and congenital (one case each). Mean age of the patients at the time of surgery was 35.6 years (range; 11-63) and mean follow up was 8.6 months (range; 6-13). Postoperatively, average correction of esotropia, V-pattern, face turn and limited abduction were 35.9 PD, 11.4 PD, 25.9° and 2.2 unit, respectively (p < .00). Postoperative complications in the form anterior segment ischemia, symptomatic induced vertical deviations were not found. CONCLUSIONS: In cases of chronic unilateral sixth nerve palsy associated with more limitation of abduction in downgaze and V-pattern esotropia, augmented IRT could be considered as an effective and safe modality.

Surgical Outcomes of Primary Congenital Glaucoma in Children Under One Year from the Nile Delta.

PURPOSE: To present outcomes of surgical management of primary congenital glaucoma (PCG) in children less than one year of age in a population based at the Nile Delta. METHODS: A retrospective review of medical records of patients with PCG less than one year of age at presentation who underwent surgical intervention in a tertiary care facility based at the Nile Delta. All patients underwent measurement of intraocular pressure (IOP), horizontal corneal diameter (HCD), cup-to-disc ratio (CDR) before and after surgery and a minimum of 6 months follow up was required. Surgical success was defined as IOP less than 22mmHg without medications and without progression of main disease parameters. RESULTS: The review revealed 44 eyes of 26 consecutive patients who underwent surgical treatment for PCG. Average age at surgery was 5.2 months and mean follow up was 18.5 months. Preoperative IOP was 28.5±4 mmHg, HCD was 13.7±0.7mm, and CDR (when visible) was 0.65±0.18. A total of 69 surgical procedures were performed with an average of 1.56 procedures per eye. Postoperative IOP was 13.3±4.8 mmHg, HCD was 12.8±0.9mm, and CDR was 0.3±0.2 (P<0.0001). Surgical success was achieved in 32 eyes (72.7%) while sight-threatening postoperative complications were reported in 3 eyes. CONCLUSION: Surgical management of PCG younger than one year of age achieved good success rate in the region of the Nile Delta with low rate of visually significant postoperative complications. However, larger studies with longer follow up are needed to fully reveal the overall characteristics of PCG in the region.

Augmented superior rectus muscle transposition in management of defective ocular abduction.

BACKGROUND: Superior rectus muscle transposition (SRT) is one of the proposed transposition techniques in the management of defective ocular abduction secondary to chronic sixth nerve palsy and esotropic Duane retraction syndrome (Eso-DRS). The aim of the current study is to report the outcomes of augmented SRT in treatment of Eso-DRS and chronic sixth nerve palsy. METHODS: a retrospective review of medical records of patients with Eso-DRS and complete chronic sixth nerve palsy who were treated by augmented full tendon SRT combined with medial rectus recession (MRc) when intraoperative forced duction test yielded a significant contracture. Effect on primary position esotropia (ET), abnormal head posture (AHP), limitation of ocular ductions as well as complications were reported and analyzed. RESULTS: a total of 21 patients were identified: 10 patients with 6th nerve palsy and 11 patients with Eso-DRS. In both groups, SRT was combined with ipsilateral MRc in 18 cases. ET, AHP and limited abduction were improved by means of 33.8PD, 26.5°, and 2.6 units in 6th nerve palsy group and by 31.1PD, 28.6°, and 2 units in Eso-DRS group respectively. Surgical success which was defined as within 10 PD of horizontal orthotropia and within 4 PD of vertical orthotropia was achieved in 15 cases (71.4%). Significant induced hypertropia of more than 4 PD was reported in 3 patients (30%) and in 2 patients (18%) in both groups, respectively. CONCLUSION: augmented SRT with or without MRc is an effective tool for management of ET, AHP and limited abduction secondary to sixth nerve palsy and Eso-DRS. However, this form of augmented superior rectus muscle transposition could result in high rates of induced vertical deviation.

Suture loop myopexy versus silicone band loop myopexy in the management of myopic strabismus fixus.

PURPOSE: To compare two different modalities of superior rectus-lateral rectus loop myopexy; suture (SLM) and silicone band loop (SBM), in the treatment of myopic strabismus fixus. METHODS: The medical records of patients with myopic strabismus fixus who underwent surgical management with either SLM or SBM at a single institution over a period of 4 years were retrospectively reviewed. In cases with positive intraoperative forced duction test, the medial rectus muscle was recessed. The primary outcome measures were improvement of primary position esotropia, hypotropia, and limitations of abduction and elevation. The angle between the displaced superior rectus and lateral rectus muscles (angle of globe dislocation) was also assessed by orbital imaging before and after surgery. RESULTS: A total of 21 patients were identified, of whom 10 underwent SLM and 11 underwent SBM. Mean age at surgery was 65.4 ± 5.7 years in the SLM group and 68.5 ± 6.4 years in the SBM group. Both procedures significantly improved esotropia, hypotropia, angle of globe dislocation, and limitation of abduction and elevation (P < 0.0001), with no significant statistical difference between procedures (P > 0.05). Intraoperative muscle splitting occurred in 2 cases in the SLM group, and transient foreign body sensation was documented in 3 cases in the SBM group. CONCLUSIONS: In this study cohort, both techniques achieved significant correction of ocular deviation, limitation of ocular ductions, and angle of globe dislocation associated with myopic strabismus fixus, with no statistically significant difference between procedures. Operative complications in both groups were mild and innocuous.

Surgical outcomes of three different weakening procedures of inferior oblique muscle in the treatment of unilateral superior oblique palsy.

BACKGROUND: To compare surgical outcomes and complications of three inferior oblique weakening procedures; Inferior Oblique Myectomy (IOM), Inferior Oblique combined Resection-Anterior Transposition (IORAT) and Inferior Oblique Anterior Transposition (IOAT) in the management of unilateral Superior Oblique (SO) palsy. METHODS: Retrospective review of medical records of all patients with unilateral SO palsy who underwent one of the aforementioned IO weakening procedures at Benha University hospital was performed. Patients were excluded if surgery was bilateral or combined with other vertical muscle surgery. Primary outcome parameters were improvement of Hypertropia (HT) in primary gaze, side gazes, on alternate head turn, Inferior Oblique Overaction (IOOA), Superior Oblique Underaction (SOUA), correction of head tilt and postoperative complications. RESULTS: The review reveals a total of 65 patients with unilateral SO palsy; 54 congenital and 11 acquired, who met the study criteria and were classified into 3 groups; IOM group (24cases), IORAT group (19cases) and IOAT group (22cases). Compared with IOM, both IORAT and IOAT induced significant correction of HT in primary position, ipsilateral gaze, contralateral head tilt and IOOA. IORAT was significantly more effective than IOAT in correction of HT in ipsilateral gaze and contralateral head tilt while there was no statistical difference between the three groups in correction of HT in ipsilateral gaze, contralateral head tilt and SOUA. Postoperative Anti-elevation was significantly recorded following IORAT (6 cases, 31%) than IOAT (3 cases, 13%) and IOM (one cases, 4%). CONCLUSIONS: The IORAT and IOAT were more superior to IOM in correction of IOOA and HT in the primary position and some other gaze positions. However, superiority of IORAT over the other two procedures should be weighed against its significant association with postoperative underaction of IO muscle and anti-elevation syndrome.

Management of stretched scar- induced secondary strabismus.

BACKGROUND: To determine characteristics and management of consecutive or recurrent strabismus secondary to stretched scar. METHODS: This is a retrospective review of all patients diagnosed with late secondary consecutive or recurrent strabismus due to stretched scar from 2012 to 2017. The diagnosis of stretched scar was made in any case of late (≥ 1 month) consecutive or recurrent strabismus associated with underaction of the previously operated muscle. The diagnosis was confirmed intraoperatively by negative forced duction test and the characteristic appearance of the scar tissue. Surgical correction involved excision of the scar tissue with muscle re-attachment to the sclera using non-absorbable sutures. Study parameters include improvement in secondary deviations, degree of muscle underaction and diplopia. RESULTS: 21 consecutive and 6 recurrent cases of stretched scar -induced strabismus were identified and all cases were associated with variable degrees of limited ocular duction. After surgical correction of the stretched scar, consecutive deviations in the form of consecutive esotropia and exotropia were corrected by means of 26.1PD and 65.6PD while recurrent deviations in the form recurrent exotropia and recurrent hypertropia were corrected by means of 34.3PD and 11PD respectively with significant improvement of limited ocular ductions. 21 patients had diplopia at presentation and all were improved after surgery. CONCLUSION: management of stretched scar -induced secondary strabismus by excision of the stretched scar and muscle fixation to the sclera using non-absorbable sutures significantly corrects secondary deviations and improves limitation of ocular duction.

Combined surgical strategy for management of unilateral exotropic Duane retraction syndrome associated with limitation of abduction.

PURPOSE: To report the effect of asymmetrical bilateral lateral rectus recession combined with augmented partial vertical rectus transposition (VRT) in the management of exotropia, head turn, limited abduction, and anomalous vertical movements associated with unilateral exotropic Duane retraction syndrome (XT-DRS). METHODS: The medical records of all patients with unilateral XT-DRS associated with limitation of abduction who underwent surgery during a 5-year period from 2013 to 2018 with at least 6 months' follow-up were reviewed retrospectively. Outcome measures were changes in head turn, primary position distance and near exodeviation, degree of limited abduction, and anomalous vertical movements on adduction. RESULTS: A total of 11 patients (6 males) were included. Mean patient age was 16.3 years (range, 6-29). Exodeviation at distance and near fixation were corrected by means of 26.4Δ and 24.8Δ, respectively. Head turn was improved by a mean of 17.3°. Limited abduction and anomalous vertical movements were corrected by means of 1.6 and 1.5 units, respectively. No patients developed symptomatic induced vertical deviation or anterior segment ischemia. CONCLUSIONS: In our study cohort, the combined strategy of asymmetrical bilateral lateral rectus recession with unilateral augmented partial VRT yielded satisfactory results in the management of unilateral XT-DRS associated with limited abduction with no recorded intra- or postoperative complications.

Dual-Augmented Transposition of Vertical Recti in Chronic Abducens Palsy.

PURPOSE: To report the results of dual augmentation of vertical rectus muscle transposition (VRT) in the treatment of chronic sixth nerve palsy. DESIGN: Retrospective case series. METHODS: This is a retrospective review of medical records of patients with chronic sixth nerve palsy who underwent dual augmented VRT with or without medial rectus (MR) recession from 2013 to 2016. Data collection included sex, age, laterality, and duration of postoperative follow-up. Pre- and postoperative limitation of abduction and adduction were recorded using a 6-point scale. Improvement of esotropia in prism diopter (PD), head turn in degrees, and limitation of abduction and adduction were reported and analyzed. RESULTS: Fourteen cases were identified. Mean patients' age at the time of surgery was 22.5 years. Postoperatively, esotropia and head turn were corrected by a mean of 31.3 PD and 18.2 degrees, respectively. Limited abduction was improved from -4.3 to -1.6, while in cases that underwent MR recession, adduction declined from 0.4 to -0.3. Postoperative induced small-amplitude hypertropia was reported in 3 cases. CONCLUSION: Dual augmented VRT was effective in controlling esotropia, head turn, and limited abduction associated with chronic sixth nerve palsy with low rate of induced vertical deviation. Combined MR recession carries a risk of induced limitation of adduction.