Slipped and lost extraocular muscles.

A slipped or lost muscle should be considered in the differential diagnosis of a patient presenting with a marked limitation of duction and inability to rotate the eye beyond the midline. Loss of a rectus muscle can occur after strabismus surgery, trauma, paranasal sinus surgery, orbital surgery, or retinal detachment surgery. The extraocular rectus muscle most frequently slipped or lost is the medial rectus muscle. Forced ductions, active force generation, saccadic velocity studies, differential intraocular pressure measurements, and orbital imaging studies may aid in identifying a slipped or lost muscle. However, no single diagnostic test provides absolute reliability for determining a lost muscle. Slipped muscles develop when the muscular capsule is imbricated without including the muscle or muscle tendon during strabismus surgery. When the capsule is reattached to the sclera, the tendon and muscle are then free to slip posteriorally from the site of attachment. Slipped muscles are retrieved by following the thin avascular muscle capsule posteriorally until the muscle is identified. A lost muscle can be found using a traditional conjunctival approach, by an external orbitotomy, or by an endoscopic transnasal approach. Although many diagnostic maneuvers are useful in identifying a lost rectus muscle, the oculocardiac reflex is the most important. Once the lost muscle is identified, the muscle should be imbricated with a nonabsorbable synthetic suture and securely reattached to the globe.

Clinical and genetic analysis of a family with X-linked congenital nystagmus (NYS1).

PURPOSE: To describe a family with X-linked congenital nystagmus and identify the genetic interval within which the gene is located. METHODS AND DESIGN: Clinical examination with genotyping of 30 individuals from a multi-generational Caucasian family with congenital nystagmus inherited in an X-linked pattern using markers from Xq26-q27, followed by linkage analysis and sequencing of a candidate gene, solute carrier family 25, member 14 (SLC25A14), in four affected individuals from four families linked to this region. RESULTS: The pattern of inheritance in the family was consistent with X-linkage with incomplete penetrance among carrier females. No affected males had affected sons. Based on the extended pedigree, the estimated penetrance among obligate female carriers (daughters of affected males) was 29% (6 of 21). Visual acuity among 15 affected individuals ranged from 20/20 to 20/70 (median 20/30). Clinical examinations, including electroretinography in two individuals, were otherwise normal except for the presence of nystagmus. Significant LOD scores (theta = 0) were found with markers DXS8057, DXS8044, DXS1047, DXS1062, DXS8072, and DXS8078, placing the gene within a approximately 5 cM interval flanked by DXS9909 and DXS1211 on the long arm of the X chromosome. Sequencing the candidate gene SLC25A14 in four affected individuals from four families linked to this region failed to reveal any mutations. CONCLUSIONS: NYS1 appears to be a common gene for familial congenital idiopathic nystagmus. Linkage analysis of this family further reduces the interval in which NYS1 is located.

Retrieval of lost medial rectus muscles with a combined ophthalmologic and otolaryngologic surgical approach.

PURPOSE: To report retrieval of a medial rectus muscle completely detached from the globe and lost in the orbital tissue in four eyes. METHOD: A lost medial rectus muscle was retrieved in four eyes of four patients with either a transcutaneous medial orbitotomy approach or a transnasal endoscopic ethmoid sinus approach. RESULTS: The lost medial rectus muscle was successfully retrieved in all four patients. One patient lost the medial rectus muscle secondary to trauma, and the other three cases resulted from complications of strabismus surgery. The mean preoperative angle of exotropia was 44 prism diopters. The endoscopic approach was attempted in three patients, and the medial rectus muscle was successfully found in two of these patients. In one case in which the endoscopic approach was used, an image guidance system was used to aid in finding the lost medial rectus muscle. The endoscopic approach was abandoned in one case in which the medial rectus muscle could not be identified after extensive searching, but the muscle was subsequently found by means of the transcutaneous medial orbitotomy approach. A transcutaneous medial orbitotomy alone was used to find the lost medial rectus muscle in one of the cases. The postoperative ocular deviation for primary position at distance fixation was a mean of 24 prism diopters of exotropia. With one additional operation in two patients, the mean ocular deviation was less than 12 prism diopters. CONCLUSION: We successfully retrieved a lost medial rectus muscle in four patients with the use of nontraditional strabismus surgical techniques. We effectively combined techniques taken from both ophthalmology and otorhinolaryngology to help solve this difficult problem.

Heterochromia after pediatric cataract surgery.

PURPOSE: Changes in iris color have been noted anecdotally after cataract surgery in infants, but they have not been studied systematically. The mechanism for these iris color changes has not previously been reported in the biomedical literature. METHODS: Photographs were taken of both eyes of 15 children and 11 rhesus monkeys who had undergone unilateral cataract surgery. Masked examiners reviewed the photographs and compared the iris color of the eyes that were operated on with the eyes that were not operated on. Between 4 and 6 weeks postoperatively, the level of prostaglandin F(2alpha) in the aqueous humor (n = 4) and vitreous humor (n = 2) was measured in both the operated and nonoperated eyes of 4 monkeys that had undergone a neonatal lensectomy during the first 5 days of life. RESULTS: Thirteen of 15 children had a darker iris color in the operated eye in relation to the nonoperated (control) eye. Four of 11 monkeys had a uniformly darker iris in the operated eye; the other 7 monkeys had regional darkening or patches of darker iris in the eye that was operated on. The prostaglandin F(2alpha) levels in neonatal monkeys were higher in the aqueous humor and in the vitreous humor of the operated eye in relation to the nonoperated eye. CONCLUSION: In some children, cataract surgery is associated with a darkening of the iris color in the operated eye. We speculate that this darkening results from an exuberant prostaglandin release stimulated by the cataract surgery and may occur through the same or a similar mechanism by which latanoprost causes the darkening of iris color.

Structure and periodicities of cross-bridges in relaxation, in rigor, and during contractions initiated by photolysis of caged Ca2+.

Ultra-rapid freezing and electron microscopy were used to directly observe structural details of frog muscle fibers in rigor, in relaxation, and during force development initiated by laser photolysis of DM-nitrophen (a caged Ca2+). Longitudinal sections from relaxed fibers show helical tracks of the myosin heads on the surface of the thick filaments. Fibers frozen at approximately 13, approximately 34, and approximately 220 ms after activation from the relaxed state by photorelease of Ca2+ all show surprisingly similar cross-bridge dispositions. In sections along the 1,1 lattice plane of activated fibers, individual cross-bridge densities have a wide range of shapes and angles, perpendicular to the fiber axis or pointing toward or away from the Z line. This highly variable distribution is established very early during development of contraction. Cross-bridge density across the interfilament space is more uniform than in rigor, wherein the cross-bridges are more dense near the thin filaments. Optical diffraction (OD) patterns and computed power density spectra of the electron micrographs were used to analyze periodicities of structures within the overlap regions of the sarcomeres. Most aspects of these patterns are consistent with time resolved x-ray diffraction data from the corresponding states of intact muscle, but some features are different, presumably reflecting different origins of contrast between the two methods and possible alterations in the structure of the electron microscopy samples during processing. In relaxed fibers, OD patterns show strong meridional spots and layer lines up to the sixth order of the 43-nm myosin repeat, indicating preservation and resolution of periodic structures smaller than 10 nm. In rigor, layer lines at 18, 24, and 36 nm indicate cross-bridge attachment along the thin filament helix. After activation by photorelease of Ca2+, the 14.3-nm meridional spot is present, but the second-order meridional spot (22 nm) disappears. The myosin 43-nm layer line becomes less intense, and higher orders of 43-nm layer lines disappear. A 36-nm layer line is apparent by 13 ms and becomes progressively stronger while moving laterally away from the meridian of the pattern at later times, indicating cross-bridges labeling the actin helix at decreasing radius.

Flash and smash: rapid freezing of muscle fibers activated by photolysis of caged ATP.

A new approach was used to study transient structural states of cross-bridges during activation of muscle fibers. Rabbit skinned muscle fibers were rapidly and synchronously activated from the rigor state by photolysis of caged ATP in the presence of Ca2+. At several different times during the switch from rigor to fully active tension development, the fibers were rapidly frozen on a liquid helium-cooled metal block, freeze-substituted, and examined in an electron microscope. The limits of structural preservation and resolution with this technique were analyzed. We demonstrate that the resolution of our images is sufficient to draw the following conclusions about cross-bridge structure. Rigor cross-bridges point away from the Z-line and most of them are wider near the thin filaments than near the backbone of the thick filaments. In contrast, cross-bridges in actively contracting fibers stretch between the thick and thin filaments at a variable angle, and are uniformly thin. Diffraction patterns computed from contracting muscle show layer lines both at 38 and 43 nm indicating that active cross-bridges contribute mass to both the actin- and myosin-based helical periodicities. The images obtained from fibers frozen 20 ms after release of ATP show a mixture of rigor and active type cross-bridge configurations. There is little evidence of cross-bridges with the rigor shape by 50 ms, and the difference in configurations between 50 and 300 ms after photolysis is surprisingly subtle.

Mechanics and structure of cross-bridges during contractions initiated by photolysis of caged Ca2+.

Cross-bridge structure and mechanics were studied during development of skinned frog muscle fiber contractions initiated by photolysis of DM-nitrophen (a caged Ca2+). Stiffness rises earlier than tension following photo-release of Ca2+. A similar lead of stiffness in electrically stimulated fibers and the early rise of the I11/I10 ratio of equatorial X-ray reflections are thought to signal attachment of cross-bridges into states with lower force than in steady-state contraction. We investigated the structure of the early attachments by electron microscopy of fibers activated by photolysis of DM-nitrophen and then ultra-rapidly frozen and freeze substituted with tannic acid and OsO4. Sections from relaxed fibers show helical tracks of myosin heads on the thick filaments surface. Optical diffraction patterns show strong meridional intensities and layer lines up to the 6th order of 1/43 nm, indicating preservation and resolution of periodic structures smaller than 10 nm. Following photo-release of Ca2+, the 1/43 nm myosin layer line becomes less intense, and higher orders disappear. A approximately 1/36 nm layer line appears early (12-15 ms) and becomes stronger at later times. The 1/14.3 nm meridional spot weakens initially and recovers at a later time, while it broadens laterally. The 1/43 nm meridional spot is present during contraction, but the 2nd order meridional spot (1/21.5 nm) is weak or absent. These results are consistent with time resolved X-ray diffraction data on the periodic structures within the fiber. In sections along the 1,1 plane of activated fibers, the individual cross-bridges have a wide range of shapes and angles, perpendicular to the fiber axis or pointing toward or away from the Z-line. Fibers frozen at 13 ms, 33 ms, and 220 ms after photolysis all show surprisingly similar cross-bridges. Thus, a highly variable distribution of cross-bridge shapes and angles is established early in contraction.