Comparison between Hummelsheim and Jensen procedures in the management of chronic sixth nerve palsy.

PURPOSE: To compare the postoperative alignment, degree of improvement of abduction, and complications of the Hummelsheim procedure to the Jensen procedure in chronic sixth nerve palsy, and to calculate the dose-response of both procedures. METHODS: A retrospective study was done on patients who either had Hummelsheim or Jensen procedure for chronic sixth nerve palsy. Demographic characteristics, details of surgical procedure, ductions, versions, and angles of misalignment before and after surgery were analyzed. RESULTS: A total of 79 patients were identified: 38 Jensen and 41 Hummelsheim. There were no statistically significant differences in baseline characteristics of both groups. Medial rectus recession was performed in 35 patients in the Jensen group and in 30 patients in the Hummelsheim group. Success defined as orthotropia within 8 PD was achieved in 25 (66%) patients in the Jensen group and in 24 (59%) patients in the Hummelsheim group (P = 0.51). The mean improvement in the angle of deviation in the primary position was 42 ± 12 PD in the Jensen group and 42 ± 16 PD in the Hummelsheim group (P = 0.89). The mean improvement in abduction was slightly better in the Hummelsheim group (1.8 vs 1.5, P = 0.32). A new vertical deviation occurred in three patients in the Jensen group and in 4 patients in the Hummelsheim group. Anterior segment ischemia occurred in one patient in the Jensen group. CONCLUSIONS: There was no difference in the success rate between the Hummelsheim and Jensen procedures in cases of chronic sixth nerve palsy. Strabismus surgeons can choose between the two procedures according to their preference.

Overcorrection after vertical muscle transposition with augmentation sutures in sixth nerve palsy.

PURPOSE: To report a series of cases, who developed consecutive exodeviation after vertical muscle transposition (VRT) performed for sixth nerve palsy, describe their management and analyse their outcome. DESIGN: Retrospective case series. METHODS: This is an institutional study on patients who developed consecutive exotropia following VRT for sixth nerve palsy in two different centres. The age, gender, cause, and time to surgery were reviewed. Ductions, versions and angles of misalignment were analysed. In those who developed an exotropia >10 PD after surgery, a second surgery was performed. The time to the second surgery, intra-operative findings, surgical procedure and outcome were studied. RESULTS: A total of 164 cases of VRT for sixth nerve palsy were identified. Nine patients developed consecutive exotropia >10 PD (5.5%). There were no significant differences in the characteristics of those who developed overcorrection compared to those who did not. Five patients had full-tendon muscle transposition, three patients had Hummelsheim procedure and one patient had Jensen procedure. The average angle of consecutive exotropia was 26 ± 9 Δ (range 10-40 Δ). After the second surgery, angle of exotropia decreased to 21 ± 15 PD. Seven patients still had residual exotropia ≥10Δ and the exotropia was corrected in the remaining two patients. The time to second surgery in those two patients was much shorter than the other seven patients. CONCLUSIONS: Patients who undergo VRT should be followed up in the early post-operative period and revisiting the transposition should be done immediately in case of consecutive exotropia to avoid permanent overcorrection.

Extraocular muscle ductions following nasal transposition of the split lateral rectus muscle.

OBJECTIVE: To quantify changes in ductions following nasal transposition of the split lateral rectus muscle (NTSLR) for treating third nerve palsy. DESIGN: Retrospective cohort study. PARTICIPANTS: A single eye from each patient with third nerve palsy treated with NTSLR with ocular motility measurements. METHODS: Observation of changes in pre- and postoperative ductions. Outcome measures including patient demographic and surgical factors associated with the ability to adduct beyond the midline after NTSLR were evaluated using multivariable logistic regression. RESULTS: A total of 116 patients met the inclusion criteria for this study. The NTSLR significantly decreased abduction (median of 0 limitation [interquartile range (IQR), 0-0] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p < 0.001), with a corresponding improvement in adduction (median, -5 [IQR, -5 to -4] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p < 0.001). There was no change in median supraduction or infraduction after NTSLR (p > 0.05). The ability to adduct beyond the midline after NTSLR was demonstrated in 42% of patients. Although not statistically significant, a trend toward a postoperative ability to adduct beyond the midline was seen in patients who had concurrent superior oblique muscle tenotomy (odds ratio [OR] = 5.08; 95% CI, 0.91-40.9) or who were designated with partial rather than complete third nerve palsy (OR = 2.29; 95% CI, 0.82-6.70). CONCLUSIONS: NTSLR improves the horizontal midline positioning of eyes with third nerve palsy. Most eyes lose the ability to abduct, but some regain a modest ability to adduct while vertical ductions remain unchanged.

Treatment of partially accommodative esotropia in children using a medial rectus muscle fenestration technique.

PURPOSE: To report the results of bilateral fenestration of the medial rectus muscle in cases of partially accommodative esotropia in pediatric patients. METHODS: In this fenestration technique, two splitting incisions are made by blunt dissection parallel to the muscle fibers on the superior and inferior borders of the medial rectus muscle, leaving a thin strip of muscle fibers on each edge. The wide, central part of the muscle is excised from its insertion to a point 5-8 mm from the insertion, depending on the angle of the esotropia. Sutures are not used in this procedure. Children with partially accommodative esotropia and no high ratio of accommodative convergence to accommodation who underwent surgery from February 2018 to August 2019 were prospectively enrolled. The success rate was defined as alignment within 8 prism diopters of orthotropia at the last follow up. RESULTS: A total of 61 children were included. The procedure was well tolerated by patients and reduced the angle of esotropia for distance from 22.20Δ ± 4.22Δ to 2.72Δ ± 4.71Δ (P < 0.001) and caused no incomitance or distance-near disparity. Satisfactory horizontal alignment defined as alignment within 8Δ of orthotropia at distance was achieved in 88% of the cases at 3-6 months' follow-up. There were no overcorrections. CONCLUSIONS: In our study cohort, the fenestration technique reduced the angle of deviation in cases of partially accommodative esotropia.

Nasal Transposition of the Split Lateral Rectus Muscle for Strabismus Associated With Bilateral 3rd-Nerve Palsy.

PURPOSE: To determine the success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating bilateral 3rd-nerve palsy. DESIGN: Retrospective, interventional case series. METHODS: An international, multicenter registry was used for the study. The study population was all patients with bilateral 3rd-nerve palsy treated with NTSLR. Sensorimotor evaluations were conducted before and 6 months after unilateral or bilateral NTSLR. Outcome measures were postoperative horizontal alignment ≤15 prism diopters (PD), intraoperative technical difficulties, and vision-threatening complications. The association of patient demographics and surgical technique with each outcome was analyzed using multivariable logistic regression. RESULTS: A total of 34 patients were included, with a median age of 46 years (interquartile range [IQR] = 25-54 years) at surgery. The most common etiologies were ischemic (29%), neoplastic (15%), and congenital (12%). NTSLR performed unilaterally with alternative surgery on the opposite eye (65%) resulted in a median postoperative exotropia of 18 PD (IQR = 7-35 PD), and when performed bilaterally (35%) resulted in postoperative exotropia of 14 PD (IQR = 5-35 PD). Success was achieved in 50% of cases, intraoperative technical difficulties were reported in 18%, and vision-threatening complications occurred in 21%. Attachment of the lateral rectus muscle ≥10 mm posterior to the medial rectus insertion was associated with increased vision-threatening complications (odds ratio = 9.0; 95% CI = 1.3-99). CONCLUSIONS: NTSLR can address the large-angle exotropia associated with bilateral 3rd-nerve palsy. Surgeons should be aware that posterior placement of the lateral rectus muscle may increase the risk of vision-threatening complications, particularly serous choroidal effusion.

Stepped Strabismus Surgery.

PURPOSE: To present stepped strabismus surgery as a novel technique in cases of small to moderate angle strabismus. METHODS: Retrospective chart review of cases of stepped strabismus surgery from 2010 untill 2018. In stepped surgery, the first muscle is operated on under rapid induction-recovery IV propofol infusion. Patient is assessed in the OR. If deemed necessary, other muscles are operated on under general anesthesia. No adjustable sutures are used. RESULTS: The technique was used in 22 cases of superior oblique palsy (SOP) (primary position hypertropia in the range of 12-25 prism diopters) and 29 horizontal strabismus cases (angles in the range 12-20 prism diopters). The first step was an inferior oblique myectomy in the SOP cases and a single rectus recession in the horizontal cases. After intraoperative assessment, 31% (16/51) needed additional muscle surgery. After 6 months of follow up, the overall reoperation rate was 9%. The technique was well tolerated by all patients. CONCLUSION: Stepped strabismus surgery is a useful technique for small to moderate angle strabismus cases with the potential for reducing the number of extraocular muscles operated on without compromising the surgical outcome.

Pattern strabismus in consecutive esodeviation after bilateral lateral rectus muscle recession for intermittent exotropia.

PURPOSE: After bilateral lateral rectus recession for intermittent exotropia, children can develop V- or A-pattern esodeviation and adopt a chin-down or chin-up position to facilitate fusion. The aim of this study was to discuss possible causes and management of this pattern. METHODS: The medical records of children who developed consecutive esodeviation with V- or A-pattern strabismus after surgery for intermittent exotropia but with no pre- or postoperative oblique muscle dysfunction were reviewed retrospectively. Ductions, versions, angles of deviation, and fundus torsion were evaluated before and after surgery. Patient management and outcomes were analyzed. RESULTS: A total of 37 patients were identified (mean age, 5.7 ± 1.5 years), with a mean preoperative deviation of 30.6Δ ± 5.2Δ; no patient had a preoperative pattern strabismus. Mean bilateral lateral rectus recession was 6.2 ± 0.9 mm. Of the 37, 34 (89%) returned postoperatively with V pattern, 2 with an A pattern, and 1 with an hourglass-like pattern. No patient showed oblique muscle dysfunction or fundus torsion. Reoperation for the consecutive deviation was performed in 19 patients, in all of whom the lateral rectus muscles were not vertically displaced. The pattern disappeared completely after reoperation and reestablishment of adequate alignment in the primary position. CONCLUSIONS: In our patient cohort, pattern strabismus after bilateral lateral rectus recession was successfully reversed by correction of the consecutive esodeviation.

Outcomes of bilateral lateral rectus recession in treatment of recurrent exotropia after bilateral medial rectus resection.

PURPOSE: To report the results of bilateral lateral rectus muscle recession for recurrent exotropia in cases where the primary surgery was a bilateral medial rectus resection. METHODS: Retrospective chart review of 15 subjects who completed 6 months of follow-up. Data collected included patients' demographics and pre- and post-operative measurements of ocular alignment and motility. Surgical nomogram used was the same nomogram we use for primary cases of exotropia. RESULTS: At 6-month follow-up, 73.3% of cases had a successful surgical outcome (defined as 8 PD of esotropia to 10 PD of exotropia). In addition, recession of lateral rectus muscles against the previously resected medial recti did not result in a significant increase in the limitation of abduction. CONCLUSION: Bilateral lateral rectus recession using standard surgical tables is a safe and effective method for treating recurrent exotropia following bilateral medial rectus resection. Even large primary resections up to 12 mm do not seem to affect the results of bilateral lateral rectus recession.

Single-piece femtosecond-assisted mushroom keratoplasty in children.

PURPOSE: To report outcomes of femtosecond-assisted single-piece mushroom keratoplasty for the treatment of full-thickness corneal disease in pediatric patients with healthy endothelium. METHODS: Femtosecond-assisted mushroom keratoplasty was performed in 8 eyes of 8 patients (age range, 8-17 years) with central full-thickness corneal opacity. The single-piece mushroom-shaped graft consisted of a large anterior portion (9 mm in diameter; 250 µm in thickness) and a small posterior portion (6-6.5 mm). Donor and recipient corneas were prepared using the WaveLight FS200 laser (Alcon Laboratories, Fort Worth, TX). The donor cornea was oversized by 0.2 mm. Outcome measures were best spectacle-corrected visual acuity, spectacle refraction, topographic astigmatism, endothelial cell density, graft rejection, and graft failure at 1, 3, 6, and 12 months. RESULTS: Mean best spectacle-corrected visual acuity at 1, 3, 6, and 12 months was 0.28, 0.16, 0.13, and 0.10 logMAR; all patients achieved logMAR of at least 0.4 at 1, 3, 6, and 12 months. The mean refractive cylinder was 2.6 D, and mean endothelial cell loss was 13.3% at 12 months postoperatively. Two eyes had immunologic rejection episodes that were reversed with topical steroids. All corneas remained clear at final follow-up. CONCLUSIONS: Femtosecond-assisted mushroom keratoplasty is a viable surgical option for eyes of older pediatric patients with full-thickness corneal stromal disease and healthy endothelium. Mushroom keratoplasty combines the refractive advantage of a large keratoplasty with the immunologic advantage of a small keratoplasty. Single-piece femtosecond-assisted mushroom keratoplasty may have a mechanical advantage over regular penetrating keratoplasty.

A randomized controlled trial comparing the efficacy of topical antibiotic steroid combination versus no treatment after fornix-incision strabismus surgery.

PURPOSE: To compare comfort and inflammation in patients treated with postoperative topical antibiotic steroids in one eye versus no treatment in the other eye. METHODS: This prospective, randomized single-masked study included all patients with planned symmetrical strabismus surgery via fornix incision. One eye was randomly assigned to topical postoperative tobramycin-dexamethasone and the other eye was not treated. Patient and parent questionnaires were administered, and two masked observers assessed conjunctival injection over the muscle and wound site. RESULTS: A total of 70 patients completed at least 1 postoperative visit and were included. There was no statistically significant difference between the treatment eye and the no treatment eye in any of the studied parameters. CONCLUSIONS: Postoperative topical antibiotic steroid did not prove to be superior to no treatment in uncomplicated fornix surgery with regard to patient comfort and inflammation. In those cases, consideration may be given to sparing the patient the inconvenience, cost, and potential complications of the topical medication.

Developing and validating a simple and cost-effective strabismus surgery simulator.

PURPOSE: To demonstrate that a nonbiologic strabismus surgery simulator is not inferior to a biologic wet lab for teaching the key steps of strabismus surgery. METHODS: A total of 41 medical students were randomly assigned to one of two groups: biologic wet lab or nonbiologic simulator. The students trained according to the group's protocol then participated in a recorded final assessment using a realistic strabismus surgery model. Two independent reviewers, masked to training method, graded the video recordings using three scoring systems: the International Council of Ophthalmology Approved-Ophthalmology Surgical Competency Assessment Rubric for Strabismus Surgery (ICO-OSCAR), the Global Rating Scale of Objective Structured Assessment of Technical Skills (OSATS), and the Alphabetic Summary Scale (ASS). RESULTS: The primary endpoint, total ICO-OSCAR score, was 36.7 ± 2.2 for the wet lab group and 36.0 ± 2.7 for the nonbiologic group (difference in means, -0.7; one-sided 95% CI, -2.0, ∞). The lower bound of the one-sided 95% confidence interval for the difference in mean scores was -2.0, which was greater than the a priori noninferiority margin of -5.0 points. The secondary outcome measure, mean total OSATS score and ASS score, revealed no statistical significant differences between training methods (P = 0.73 and P = 0.44, resp.). CONCLUSIONS: The simple, nonbiologic strabismus surgery simulator is not inferior to the biologic wet lab with respect to total ICO-OSCAR score. It is a portable, inexpensive, and effective training tool for novice surgeons.

Bilateral medial rectus resection for primary large-angle exotropia.

BACKGROUND: Surgical treatments for large-angle exotropia include bilateral lateral rectus recession, recession-resection procedures, and three- and four-muscle surgery. Undercorrection and limitation of abduction are common complications of these procedures. This study reports the results of bilateral medial rectus resection as a first procedure for primary large-angle exotropia. METHODS: The medical records of patients who underwent bilateral medial rectus resection for angles ≥60Δ in the period from 2006 till 2016 with a minimum follow-up period of 6 months were reviewed retrospectively. The amount of resection ranged from 8 mm to 12 mm according to the preoperative angle. Success was defined as a final outcome within the range of 8Δ of esotropia to 10Δ of exotropia. RESULTS: A total of 64 patients were included, in whom angles ranged from 60Δ to 140Δ. The overall success rate was 77%, and there was no significant difference in success rate between classes of smaller and larger angles. Limitation of abduction was seen in first postoperative week. At 6 months' follow-up 64% of eyes had no limitation of abduction. CONCLUSIONS: In our patient cohort bilateral medial rectus resection successfully corrected large-angle exotropia of up to 140Δ, with results comparable to three- and four-muscle procedures. It has the advantage of not causing significant abduction deficits, even with resections up to 12 mm.

ACCIDENTAL DUPLICATION: Bilateral medial rectus resection for primary large angle exotropia.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.jaapos.2017.03.003. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Improved visual acuity and recognition time in nystagmus patients following four-muscle recession or Kestenbaum-Anderson procedures.

PURPOSE: Many patients describe more rapid recognition of objects after surgical procedures for nystagmus; however, this "recognition time" is not reflected in the parameters typically studied in these patients. The purpose of this study is to assess the effect of nystagmus surgery on visual acuity and recognition time. METHODS: In this prospective, interventional, comparative case series, patients with nystagmus were divided into two groups. group A (n = 13) underwent four-muscle retroequatorial recession; group B (n = 8) underwent the Kestenbaum-Anderson procedure. Visual acuity, binocularity, and recognition time were assessed before and after surgery. Recognition time was measured in a routine examination setting using specially designed software that controlled the time of appearance of optotypes in 0.1 second increments. RESULTS: A total of 21 patients were enrolled. The entire group experienced significant postoperative improvement in visual acuity (P = 0.002) and recognition time (P = 0.005). The mean improvement in recognition time was 0.3 seconds at maximum preoperative visual acuity level. A trend toward more improvement in group A than in group B was not statistically significant. CONCLUSIONS: Both the four-muscle recession and the Kestenbaum-Anderson procedures resulted in a 1- to 2-line improvement in visual acuity and a 0.3 second improvement in optotype recognition time.

Recession of three muscles to reduce ocular oscillations in patients with Heimann-Bielschowsky phenomenon.

Heimann-Bielschowsky phenomenon (HBP) refers to unilateral vertical nystagmoid eye movements associated with long-standing monocular poor vision. The monocular vertical oscillations of HBP occasionally have large amplitudes and may be cosmetically objectionable and/or functionally disturbing. We report 2 cases of HBP in which recession of the superior rectus, inferior rectus, and inferior oblique muscles were successful in ameliorating the amplitude of oscillations.