Postoperative outcomes for unilateral congenital trochlear nerve palsy: A retrospective cohort study.

PURPOSE: Congenital trochlear nerve palsy is the most common cause of vertical strabismus. The goal of this study was to investigate surgical outcomes after superior oblique tendon plication with or without inferior oblique recession in children and adults with unilateral congenital trochlear nerve palsy. METHODS: Data and outcomes were collected in patients with a diagnosis of unilateral congenital superior oblique palsy during a retrospective single-center study conducted at the University Hospital of Tours. A reproducible, standard ophthalmological and oculomotor examination was performed pre- and postoperatively at 1 year, including presence or absence of diplopia, vertical and horizontal deviations, and compensatory head posture. Surgical success, defined as an endpoint including absence of diplopia in primary position, absence of head tilt, and vertical deviation at distance fixation<5 prism diopters (PD), was analyzed. RESULTS: A total of fifty-seven patients (median [IQR] age of 11 years [5-42]) were analyzed. Patients experienced a significant reduction in vertical distance and near deviations (p<0.001), compensatory head tilt (p < 0.001), and diplopia after surgery (p < 0.001). Surgical success was higher in adults (17/24, 70.8%) than in children (15/33, 45.5%), although this did not reach statistical significance (p=0.0657). CONCLUSION: This study suggests that plication of the superior oblique muscle tendon, with or without recession of the inferior oblique muscle, can be effective in treating unilateral congenital trochlear nerve palsy. Further studies are necessary to compare surgical procedures and investigate their efficacy in adults compared to children in the short and long term.

[Outcomes of partial vertical rectus transposition in acquired sixth nerve palsy]. / Efficacité de la transposition partielle des muscles droits verticaux dans les paralysies acquises du sixième nerf crânien.

PURPOSE: This study aimed to assess the outcomes of partial vertical rectus transposition (PVRT) in acquired sixth nerve palsy (SNP) on distance ocular deviation in primary position (PP), binocular diplopia in PP, head turn, and limitation of abduction. METHODS: This retrospective, single center study was conducted at the Regional University Medical Center of Tours between 2004 and 2019. All patients underwent comprehensive orthoptic and ophthalmic examination before and after surgery. Total success was defined as horizontal distance deviation in PP≤10 prism diopters (PD), absence of permanent diplopia in PP, head turn≤5 degrees and absence of any induced vertical deviation at last examination. RESULTS: Ten patients underwent PVRT with a median delay of 3.3 years (2.3 to 7.3) following the diagnosis of SNP. The median duration of postoperative follow-up was 13 months (3.25 to 25). Seven patients (70%) were considered a total success. The mean distance horizontal deviation in PP was reduced from 25.4±11.7 PD preoperatively to 9.2±11 PD postoperatively. Preoperatively, 10 patients did not cross midline in abduction, compared to 8 patients at the last follow-up examination. Postoperatively, 3 patients had permanent binocular diplopia in PP, and 2 patients had an anomalous head turn. CONCLUSION: Although further prospective investigations are needed, PVRT can be considered a safe and effective procedure for acquired SNP.

Surgical outcomes after unilateral horizontal rectus surgery in children with infantile esotropia for the correction of A or V pattern.

PURPOSE: The management of A or V pattern deviation associated with esotropia can be challenging since the horizontal deviation changes with position of gaze. This study aimed to assess the effect of unilateral horizontal rectus surgery for the correction of horizontal deviation associated with A or V pattern in children with non-comitant infantile esotropia. METHODS: Twenty-seven children with infantile esotropia and A-V pattern, more than 10 and 15 prism diopters respectively, were included in this retrospective observational single-center study. Horizontal rectus surgery was performed on the most deviated eye under general anesthesia. The patients were divided into two groups: A pattern and V pattern. The outcome measures were change in the amount of pattern and rate of regression after surgery. The amount of pattern was characterized by the difference in esodeviation between upgaze and downgaze. RESULTS: Horizontal deviation at distance and near fixation decreased significantly (P<0.0001). Vertical gaze esotropia disparity decreased significantly (P=0.01 and P=0.0002 for A and V patterns respectively). A pattern esotropia was reported in only 2 (7%) cases after surgery compared to 9 (33%) before surgery. The number of subjects with V pattern esotropia decreased from 18 (67%) to 3 (11%) after surgery. CONCLUSIONS: The mechanisms involved in the pathophysiology of A and V patterns may not always be related to oblique muscle dysfunction. These findings suggest that unilateral horizontal rectus surgery may be an effective procedure to correct both horizontal deviation and A-V pattern in non-comitant infantile esotropia.

Reliability of objective ocular torsion assessment using fundus photography in infantile esotropia.

PURPOSE: To evaluate the interobserver reproducibility of objective ocular torsion measurements in infantile esotropia using fundus photography analysis. MATERIALS AND METHODS: This retrospective observational study was conducted in our ophthalmology department at the University Hospital in Tours from 2009 to 2015. OBJECTIVE: Ocular torsion was assessed using fundus photography and analysed on Adobe Photoshop software within a population of children with infantile esotropia. Two observers, an orthoptist and an ophthalmologist, carried out the evaluation separately. The interobserver agreement was calculated for quantitative measurement by the interclass correlation coefficient (ICC) and by Cohen's Kappa coefficient for qualitative assessment. RESULTS: A total of 200 eyes (100 subjects, mean age: 6.88 years) were assessed. Statistical analyses for quantitative measurements resulted in an ICC of 0.98 (95% CI, 0.97-0.99) for right eyes, 0.96 (95% CI, 0.95-0.97) for left eyes, 0.98 (CI 95%, 0.97-0.98) for pre- operative eyes and 0.96 (95% CI, 0.95-0.97) for postoperative eyes. The ICC calculated on all four hundred fundus photographs was 0.97 (95% CI, 0.97-0.98). The interobserver agreement for qualitative measurements resulted in a Kappa coefficient of 0.91 for right eyes, 0.85 for left eyes, 0.90 for preoperative eyes and 0.86 for postoperative eyes. The analysis of all four hundred eyes returned a Kappa coefficient of 0.88. CONCLUSIONS: Objective ocular torsion assessment using our procedure, whether by an orthoptist or ophthalmologist, is a reliable and reproducible method for the management of infantile esotropia.

[Surgical management of strabismus in dysthyroid orbitopathy: A retrospective single-center study of 32 cases]. / Prise en charge chirurgicale des strabismes compliquant une orbitopathie dysthyroïdienne : étude rétrospective monocentrique d'une série de 32 cas.

INTRODUCTION: Thyroid-related immune orbitopathy often results in a restrictive strabismus. We report our experience of surgical management in these cases. PATIENTS AND METHODS: We present a retrospective case series conducted on 32 patients, operated between 2008 and 2017. Strabismus surgery was proposed in the postinflammatory stage with stable clinical findings for at least 6 months. It was performed under general anesthesia by recessions of restrictive muscles using a fixed suture technique. Outcomes were graded as excellent, good or poor, according to the presence or absence of diplopia in primary or reading positions, and according to whether prism prescription was necessary. RESULTS: The study included 32 patients (21 women, 11 men) with a mean age of 53 years. Average follow-up was 9.6 months. Eight patients developed diplopia after orbital decompression. Fifteen patients had vertical surgery, 8 horizontal surgery, 9 mixed surgery. A mean of 1.31 surgeries (range 1-3) were performed. After all surgeries, 28 patients (87.5 %) had an excellent outcome, 4 (12.5 %) had a good outcome, and none had a poor outcome. There was a significant improvement in stereoscopic acuity (P<0.01), but not motility. Among the 8 patients who developed diplopia after orbital decompression, a clinically acceptable final outcome was achieved after only one surgery. CONCLUSION: Strabismus surgery using conventional non-adjustable sutures provides excellent ocular alignment and relief from diplopia in the majority of patients with dysthyroid strabismus. The reoperation rate is similar to other techniques, such adjustable suture and intraoperative relaxed muscle technique.

[Influence of the instillation of two versus three eyedrops of cyclopentolate 0.5% on refraction of Caucasian nonstrabismic children]. / Influence de l'instillation de 2 ou 3 gouttes de cyclopentolate à 0,5% sur la réfraction de l'enfant caucasien non strabique.

INTRODUCTION: Children's refraction can usually be measured using cyclopentolate 0.5%. Instilling three drops is time-consuming and inconvenient to both the clinical staff and the child. To remedy this situation, we investigated the refractive results of instilling two drops of cyclopentolate 0.5% at a 10-min interval compared with three drops at a 5-min interval in a group of a Caucasian nonstrabismic children. The kinetics of refraction in this population was also assessed. PATIENTS AND METHODS: We conducted a randomized cross-over study on 36 children aged between 4 and 13 years from March 1st to August 1st, 2003 at the University of Tours School of Ophthalmology. In protocol I, two cyclopentolate eyedrops were instilled in both eyes at a 10-min interval. In protocol II, three eyedrops were instilled at a 5-min interval. The refractive results were evaluated in terms of sphere and cylinder strength and axis. We used an auto-kerato-refractometer every 15 min from the first instillation for both protocols until the 90th min. RESULTS: Before the first drop instillation, there was no significant influence on skiascopy results for both eyes (-0.30+/-0.20 D for the right eye; -0.37+/-0.24 D for the left eye). The strength and the axis of the cylinder were comparable and stable (-0.5+/-0.18 D for strength; 5 degrees +/-22 for the axis) for all protocols and subjects tested. Sphere variation reached +1+/-0.6 D between t0 and t30 min for both protocols and remained stable between t30 and t90 min (+0.01+/-0.2 D). CONCLUSION: Instilling two eyedrops of cyclopentolate 0.5% at a 10-min interval in Caucasian nonstrabismic children aged 4-13 years is as effective as instilling three eyedrops at a 5-min interval in terms of kinetics and depth of cycloplegia. In addition, skiascopy can be performed as early as 30 min after the first instillation and until the 90th minute with the same effectiveness. The stability of astigmatism should be underlined in this population. Since these refractive results cannot be extrapolated for strabismic and ametropic children, we recommend, especially for the latter, instilling three drops for the first exam and only two thereafter, depending on the results.

[Post-traumatic disinsertion of the superior oblique muscle trochlea]. / Desinsertion post-traumatique de la poulie du muscle oblique supérieur.

INTRODUCTION: Ophthalmologic examination may rule out an ocular wound in the event of orbital traumatism. Some lesions are obvious but others may not be detected. We report a case of superior oblique muscle trochlea trauma. This infrequent pathology is illustrated with a scanned imagery and magnetic resonance imaging (MRI). OBSERVATION: The initial penetrating trauma was caused by a hook in the medial canthus. The wound was sutured in the emergency unit. Three days later, oblique diplopia developed. Three weeks later, abnormal ocular movements appeared when contracting the frontal muscle. The patient then decided to consult. One month after the traumatism, the orthoptic assessment confirmed the presence of an acquired Brown syndrome suggesting a lesion of the superior oblique muscle. Orbital MRI could not find the trochlea and revealed a thickening by retraction of the posterior portion of the muscle and a hypotrophic aspect of the anterior portion. A fracture of the right orbital edge was revealed by the scanner. Surgical exploration was performed. DISCUSSION: The trochlea is located very anteriorly and likely to be affected in the event of an internal palpebral wound. A direct traumatism of the pulley and/or the superior oblique muscle leads to an acquired Brown syndrome. This observation stresses the importance of surgical wound exploration for the supero-medial palpebral area as well as using MRI which allows proving the diagnosis.