Full-tendon nasal transposition of the vertical rectus muscles: a retrospective review.

The authors report the results of a retrospective review of patients who underwent nasal transposition of the vertical rectus muscles between 1997 and 2004. Eight patients were identified, 4 males and 4 females. There was an average age at surgery of 37 years, with a range from 8 to 79 years. The aetiologies included 6 patients with trauma to their medial rectus (4 following endoscopic sinus surgery) and 2 patients with paralytic medial rectus muscles secondary to 3rd nerve palsy. All patients underwent whole tendon transposition of the superior and inferior rectus muscles, with resection of both muscles in 7 cases, before reattachment adjacent to the upper and lower borders of the medial rectus, respectively. One patient had a reduced amount of resection and this was combined with inferior oblique disinsertion and traction sutures. All patients had a reduction in deviation in the primary position and in 5 patients there was some improvement in adduction. A consequence of surgery was a degree of limitation of abduction, elevation and depression in some patients. Overall, patients were satisfied with the improvement in their appearance.

Benefits of retroequatorial four horizontal muscle recession surgery in congenital idiopathic nystagmus in adults.

INTRODUCTION: Four muscle surgery for congenital nystagmus was originally described in 1956 and popularized by two articles in the 1990s. A review of the literature revealed only three studies of seven, nine, and six patients published since then. We therefore reviewed our patients to determine the objective and subjective benefits of this procedure. METHODS: A retrospective review was carried out on patients who underwent bilateral maximal horizontal muscle recessions for congenital nystagmus between 1997 and 2002. Improvement in visual acuity was documented. An external assessor administered an anonymized questionnaire to discover any perceived benefit. Eighteen patients were identified, 12 men and 6 women, with an average age at surgery of 32 years. RESULTS: Preoperative visual acuity ranged from 6/9 binocularly to 6/60. All underwent bilateral medial rectus muscle recessions of 8 mm to 10 mm and bilateral lateral rectus muscle recessions of 8 mm to 12 mm. Nine patients (50%) gained one line of Snellen visual acuity. There were four complications: one scleral perforation; two developed exotropia; and one complained of asthenopic symptoms. This latter patient was the only one who experienced some deterioration of vision acuity. Fourteen of 18 (78%) questionnaires were returned. Eight patients said they were pleased; four were indifferent and two were displeased. CONCLUSIONS: We conclude that this operation delivers limited objective benefit. None of our patients were able to obtain a driving license. Fifty-seven percent of patients expressed the view that they were glad to have had the surgery, although the visual improvement was only slight.

Does botulinum toxin have a role in the treatment of secondary strabismus?*.

METHODS: We reviewed the Toxin Clinic database over a 20-year period, identifying patients with strabismus secondary to permanent or temporary impairment of vision. RESULTS: Five hundred-and-three patients who fulfilled our criteria were treated with Botulinum toxin. There were 301 males and 202 females, with a mean age at treatment of 35 years (range 6-86). Three hundred-and-eighty-three patients (76%) had exotropia, 114 (22.5%) had esotropia and 6 (1.5%) had vertical strabismus. Reduced vision secondary to trauma accounted for 45% (227) of patients. Other causes were congenital anomalies 121 (24%), refractive error 30 (6%), retinal detachment 20 (4%), senile cataract 24 (5%), corneal problems 19 (4%), glaucoma 10 (2%) and other 52 (10%). One hundred-and-ninety-three (38%) were aphakic. One thousand-four-hundred-and-fifty-seven injections were given, with a range of 1-50 per patient. Ninety-nine (20%) patients were managed with continued toxin treatment. Two hundred-and-eighteen patients (43%) proceeded to surgery. Forty patients (8%) required no further treatment as they regained binocularity by injection alone. CONCLUSIONS: Botulinum toxin appears to have a role in the treatment of secondary strabismus, since only 3% (14) failed to obtain any reduction in their angle. It was well tolerated, with no permanent side effects. Only 22 (4%) patients developed ptosis.

Radiotherapy in thyroid eye disease: the effect on the field of binocular single vision.

PURPOSE: Thyroid eye disease (TED) can be a functionally disabling condition if ocular muscle involvement causes diplopia. The extraocular muscle restriction creates a reduced or eccentric field of binocular single vision (BSV). Orbital radiotherapy is now widely used in the treatment of TED, and although it has been reported as improving ocular motility, there have been few quantitative studies of the effect of treatment on ocular motor function. METHODS: Retrospective case note review of patients undergoing orbital radiotherapy for TED between 1992-1998 identified 79 case records. A total of 27 patients had diplopia in primary position or a significantly reduced binocular field before undergoing radiotherapy. The fields of BSV were analyzed pretreatment and at 3, 12, and 24 months after therapy to assess any improvement in function. We used the field of BSV as an outcome measure because it can be quantified and is a good indicator of functional ability. RESULTS: None of the 12 patients with double vision in primary position pretreatment regained a central binocular field with radiotherapy alone. Of the 15 patients with a central but reduced binocular field, 8 (53%) remained unchanged with treatment. In 4 patients (26.6%), there was an improvement in the field, while in 3 (20%) the field deteriorated. In all, 12 patients (44%) went on to require strabismus surgery. CONCLUSIONS: Orbital radiotherapy alone is ineffective in treating restrictive thyroid myopathy and improving binocular function.

The use of botulinum toxin to treat strabismus following retinal detachment surgery.

METHODS: Persistent symptomatic strabismus may be seen in up to 25% of patients post retinal detachment surgery. Surgical correction of ocular misalignment in this situation can be technically difficult to perform and the results are less predictable than in other forms of strabismus surgery. We report on our experience of the use of botulinum toxin injections as an alternative. RESULTS: A retrospective review was made of all patients who had received botulinum toxin injections in the management of their strabismus following retinal detachment surgery at our institution between November 1982 and January 2006. One hundred and forty patients fulfilled our criteria with a mean length of follow-up of 27 months. Thirty-three patients (23.6%) were symptom free following botulinum toxin injection alone and were discharged from the clinic, 50.5% of these after only 2 injections. Fusion was regained in 37.9%. The only factor associated with lack of restoration of fusion in the multivariate analysis was visual acuity in the injected eye. Complications were seen in 2.9% of patients. CONCLUSION: Botulinum toxin injections may represent a safe and acceptable alternative to surgery and may be particularly useful for those in whom surgery is contraindicated or not desired.

Beneficial effect of treatment for strabismus in patients with bilaterally poor vision, who cannot see their strabismus.

METHODS: Retrospective case note review of management of patients with bilaterally severely reduced vision presenting with symptomatic strabismus. RESULTS: There were 10 females and 7 males, mean age at treatment was 36 years, range 19 to 74 years. Thirteen patients had an exotropia ranging from 20 to 90(Δ) (mean 52(Δ)). Four had an esotropia ranging from 30 to 70(Δ) (mean 53(Δ)). Vision in each eye ranged from 6/24 Snellen to light perception, except for one patient with Usher's syndrome who had grossly restricted visual fields and vision of 6/12 and 6/36. The etiology was retinitis pigmentosa in 5 patients; 3 had cone dystrophy, 2 were high myopes. Other etiologies included CMV retinitis in both eyes secondary to HIV, bilateral optic atrophy post craniopharyngioma, and cortical visual impairment. All patients were unable to see well enough to assess their strabismus but were aware of its presence from family members and friends and wished improvement. Eleven patients underwent botulinum toxin injections; 2 of these then proceeded to surgery. A total of 8 patients had surgery. Post-operative angles ranged from 6(Δ) to 25(Δ) of esotropia. Five patients continue with maintenance toxin. Follow-up ranged from 3 months to 15 years. DISCUSSION/CONCLUSIONS: This is the first report of patients with bilaterally severely reduced vision requesting treatment for strabismus that they were unable to see for themselves. All patients were pleased they had undergone treatment for their strabismus despite being unable to see the outcome.

Role of inferior rectus botulinum toxin injection in vertical strabismus resulting from orbital pathology.

INTRODUCTION: We describe the uses and efficacy of botulinum toxin injection to the inferior rectus muscle in vertical strabismus resulting from orbital pathology. METHODS: A retrospective review of patients undergoing inferior rectus botulinum toxin injection between 1982 and 2006 for vertical strabismus due to orbital pathology. RESULTS: There were 13 patients identified; 6 with idiopathic orbital inflammatory syndrome (IOIS) including myositis, 3 with previous orbital wall fractures, 1 post-optic nerve sheath Schwannoma resection, 1 with lymphoma, 1 with metastasis, and 1 post-superior ophthalmic vein hemorrhage. A beneficial effect with inferior rectus botulinum toxin was obtained in 9/13 (69%) patients (mean follow-up 14 months). Resolution or improvement occurred in 4/6 (67%) patients with IOIS. Resolution was also obtained in the patient with previous optic nerve sheath Schwannoma resection, and the patient who sustained the superior ophthalmic vein hemorrhage. Improvement was noted in both the patient with lymphoma and in the patient with a metastasis. However, in patients with orbital wall fractures, only 1 of 3 patients obtained improvement. Benefit appeared independent of the size of vertical deviation, with 4/6 (67%) showing improvement with a pre-toxin angle 4-12 PD, and 5/7 (71%) improving with a pre-toxin angle 16-25 PD. Eleven patients received only 1 injection, one patient received 2, and another had an ongoing course of 8 injections. DISCUSSION: Vertical strabismus secondary to a range of orbital conditions, particularly inflammatory, often can be successfully managed by inferior rectus botulinum toxin injections.

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.

Diagnostic use of botulinum toxin in patients with Duane syndrome.

INTRODUCTION: Duane syndrome is a difficult condition to treat. Patients and parents need to be informed that it will not resolve and it is not possible to create normal eye movements surgically. Botulinum toxin may be used to assess the likelihood of reducing the abnormal head posture and reducing the diplopia by increasing the field of binocular single vision. If results are favorable then surgery may be offered. This article is a retrospective review of patients with Duane syndrome treated with botulinum toxin using the toxin clinic database between 1980 and 2007. METHODS: Eighty-eight patients were identified, 48 females and 40 males. The average age at presentation was 29 years, range 5 to 68 years. The left eye was affected in 50 (57%) patients and 21 (24%) patients were affected bilaterally. The average angle was 28.6 +/- 18.4 Delta for the esotropic patients and 32.5 +/- 14.5 Delta for the exotropic patients. In 58 patients the medial rectus was injected, in 30 the lateral rectus. RESULTS: As a result of the outcome of botulinum toxin, 41 (46.5%) patients proceeded to surgery; 12 (14%) continued with maintenance toxin. Forty-seven (53%) demonstrated a long-term reduction in deviation. Transient complications were ptosis in 11 patients and induced vertical deviation in 10. CONCLUSION: This is the first study to explore the diagnostic role of botulinum toxin in Duane syndrome. It is a safe treatment that may also offer long-term benefits.

Long-term management of strabismus with multiple repeated injections of botulinum toxin.

BACKGROUND: In the healthcare system in the United Kingdom, a number of patients may be offered botulinum toxin as an alternative to surgery in the treatment of their strabismus. We report on our experience of treating those who have received 25 or more injections. METHODS: A retrospective review of the botulinum toxin clinic database was used to identify patients who underwent 25 or more injections between November 1982 and January 2006. All patients with strabismus who met this criterion were included. A statistical analysis was performed in which we compared aspects of this group with those who had received 24 or fewer injections. RESULTS: Fifty-seven patients (0.90%) fulfilled our criteria. There were 37 women and 20 men, with a mean age at first injection of 39 years (range, 15 to 80 years). The number of injections per patient ranged from 25 to 68 (mean, 34). The duration of treatment was between 3 and 22 years. The time interval between injections tended to increase in most patients and the angle tended to reduce. There was no statistical difference between the age at first injection, sex, site injected, diagnosis, and complication rate between the long-term group and the group that received 24 or fewer injections. The long-term group, however, had undergone more previous operations (p < or = 0.001) and had a lower degree of binocularity (p

Imaging and spatial distribution of beta-amyloid peptide and metal ions in Alzheimer's plaques by laser ablation-inductively coupled plasma-mass spectrometry.

Laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) has been developed as a new strategy for detection and imaging of beta-amyloid protein in immunohistochemical sections from the brains of a transgenic mouse model of Alzheimer's disease. The distribution of beta-amyloid deposits in tissue was based on measurement of Eu- and Ni-coupled antibodies. The laser-based methodologies (spot ablation, single line raster, and two-dimensional imaging) were also used to detect and map trace element distributions and thus provide a novel probe for both elemental and protein data. We also report the combination of laser capture microdissection with LA-ICP-MS as an alternative strategy for microanalysis of immunohistochemical sections.