Resultados de la cirugía mínimamente invasiva en pacientes con estrabismos horizontales / Results of the minimally invasive surgery in patient with horizontal strabismus

Objetivo: Determinar los resultados de la cirugía mínimamente invasiva en pacientes con estrabismos horizontales. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo de una serie de 19 pacientes (16 ojos derechos, 17 izquierdos) atendidos en el Servicio de Oftalmología Pediátrica del Instituto Cubano de Oftalmología "Ramón Pando Ferrer", en el periodo comprendido entre junio de 2018 y julio de 2019, a quienes se les realizó cirugía mínimamente invasiva de estrabismo y fueron seguidos por 6 meses. Se evaluaron las variables: tipo de desviación, agudeza visual, signos posoperatorios, ángulo de desviación pre- y posquirúrgico, éxito quirúrgico, fusión, estereopsis y complicaciones. Resultados: El 73,7 por ciento de los pacientes presentaba esotropías; la media de agudeza visual pre- y posoperatoria entre los dos ojos fue muy similar; el signo posoperatorio más frecuente fue la hiperemia conjuntival ligera (75 por ciento ojos derechos y 64,5 por ciento ojos izquierdos) a las 24 horas. Se encontraron diferencias estadísticas (p < 0,001) en el ángulo de desviación horizontal en dioptrías prismáticas, pre- y poscirugía, con el 84,2 por ciento de éxito quirúrgico. El 78,6 y el 80 por ciento de los pacientes con esotropía y exotropías alcanzaron fusión, pero solo lograron estereopsis el 28,5 y el 60 por ciento de ellos respectivamente. La frecuencia de complicaciones ocurrió en el 15,8 por ciento de los pacientes. Conclusiones: Se alcanzaron buenos resultados motores, así como aceptables en los sensoriales en pacientes operados de estrabismos horizontales por cirugía mínimamente invasiva(AU)

Objective: Determine the results of minimally invasive surgery in patients with horizontal strabismus. Methods: A prospective longitudinal descriptive study was conducted of a series of 19 patients (16 right eyes, 17 left eyes) attending the Pediatric Ophthalmology Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology from June 2018 to July 2019. These patients underwent minimally invasive strabismus surgery and were followed up for six months. The variables considered were deviation type, visual acuity, postoperative signs, pre- and postoperative angle of deviation, surgical success, fusion, stereopsis and complications. Results: Of the patients studied, 73.7 percent presented esotropias; mean pre- and postoperative visual acuity was very similar in the two eyes; the most common postoperative sign was slight conjunctival hyperemia (75 percent right eyes and 64.5 percent left eyes) at 24 hours. Statistical differences (p < 0.001) were found in the horizontal angle of deviation in pre- and postoperative prism diopters, with 84.2 percent surgical success. 78.6 percent and 80 percent of the patients with esotropia and exotropia achieved fusion, but only 28.5 and 60 percent of them, respectively, achieved stereopsis. Complications occurred in 15.8 percent of the patients. Conclusions: Good motor results were obtained, as well as acceptable sensory results in patients undergoing minimally invasive horizontal strabismus surgery(AU)

Dissociated Horizontal Deviation after Traumatic Brain Injury

A 4-year-old boy visited the hospital with exotropia after brain hemorrhage caused by trauma. He had undergone decompressive craniectomy and cranioplasty 18 months prior to presentation at our hospital. An alternate prism cover test showed more than 50 prism diopters (PD) of left exotropia when he was fixing with the right eye and 30 PD of right exotropia when he was fixing with the left eye at near and far distance. On the Hirschberg test, 60 PD of left exotropia was noted in the primary position. Brain computerized tomography imaging performed 18 months prior showed hypodense changes in the right middle cerebral artery and anterior cerebral artery territories. Subfalcian herniation was also noted secondary to swelling of the right hemisphere. The patient underwent a left lateral rectus muscle recession of 7.0 mm and a left medial rectus muscle resection of 3.5 mm. Three weeks after the surgery, the Hirschberg test showed orthotropia. On alternate prism cover testing, 8 PD of left exotropia and 8 PD of right esotropia were noted at distance. We report a patient who developed dissociated horizontal deviation after right subfalcian subdural hemorrhage caused by trauma.

Acute Comitant Esotropia in a Child With a Cerebellar Tumor

We report a case of acute comitant esotropia in a child with a cerebellar tumor. A 3-year-old boy was referred for management of a 9 month history of acute acquired comitant esotropia. On first presentation, the patient's angle of esodeviation was 50 prism-diopters (PD) at distance and near fixation without any lateral incomitance. The cycloplegic refraction revealed +0.75 diopters in both eyes. Very mild bilateral papilledema was found on the fundus examination, but the neurological examination did not reveal any other pathological findings. Brain MRI showed a 5 cm mass located in the midline of the cerebellum as well as hydrocephalus. The mass was completely excised and histological examination confirmed the diagnosis of pilocytic astrocytoma. Despite neurosurgery, the patient's strabismus remained unresolved. One year after neurosurgery, both medial rectus muscles were surgically recessed by 6 mm, resulting in esotropia of 8PD at distant and near fixation without restoration of bifoveal fusion at follow-up 2 years after the eye muscle surgery. Therefore, acute onset comitant esotropia in a child can be the first sign of a cerebellar tumor, even without any other neurological signs and symptoms.

Multiple Myeloma Manifesting as a Fluctuating Sixth Nerve Palsy

We report a case of multiple myeloma that presented as a fluctuating sixth cranial nerve palsy in the absence of widespread signs of systemic disease. A 63-year-old woman presented with horizontal diplopia of two weeks duration that subjectively changed over time. Ocular examination showed a fluctuating sixth nerve palsy. A computed tomography (CT) scan of the brain showed multiple, enhancing, soft tissue, mass-like lesions involving the left cavernous sinus and the apex of both petrous bones. Based on bone marrow biopsy and hematologic findings, she was diagnosed with multiple myeloma. Multiple myeloma may be included in the differential diagnosis of a fluctuating sixth nerve palsy, and although ophthalmic signs are rare and generally occur late in the course of multiple myeloma, they can still be its first signs.

Lateral fixation of sclera to the periosteum with medial rectus disinsertion for severe myopic strabismus fixus.

Myopic strabismus fixus is characterized by severe ocular motility restriction with the development of progressive esotropia and hypotropia. Management of severe cases with strongly positive forced duction test can be challenging. We describe a longstanding case of myopic strabismus fixus, which was managed by bilateral medial rectus disinsertion and scleral fixation laterally to the periosteum.

Consecutive Esodeviation After Exotropia Surgery in Patients Older than 15 Years: Comparison with Younger Patients

PURPOSE: The purpose of this study was to investigate the clinical course of esodeviation after exotropia surgery in older patients (older than 15 years) and to compare it with that in younger patients (15 years or younger). METHODS: The medical records of all surgeries for exodeviation from December 2004 to February 2007 were reviewed and 82 patients were found with consecutive esodeviation. The patients were divided into two groups according to their age: Group A (patients older than 15 years) and Group B (patients age 15 or younger). The clinical course of esodeviation in Group A was compared to that in Group B by means of survival analysis. RESULTS: The median survival times of the esodeviation were 2.0+/-0.1 months in Group A and 1.0+/-0.1 months in Group B (p=0.40). The prevalence of consecutive esotropia at six months was 0% in Group A and 6.1% in Group B (p=0.32). The myopic refractive error, worse sensory condition, and a larger preoperative exodeviation in Group A did not affect the clinical course of the two groups differently. CONCLUSIONS: The postoperative esodeviation of patients older than 15 years after exotropia surgery tended to persist longer during the early postoperative period than that of patients 15 years or younger, however, the difference did not persist at postoperative six months.

Correlación entre el grado de desviación y la limitación de abducción en afección del VI nervio / Correlation between the degree of deviation and limitation of abduction in the VI nerve

Se presentan 40 casos con afección del VI nervio por diversas causas etiológicas, siendo parcial (paresial) en 26 casos y total (parálisis) en 14 casos examinados. Fueron evaluados al mes de iniciado el cuadro, enfatizando la correlación entre el grado de endodesviación con el grado de limitación de abducción, encontrando congruencia en 25 casos (62 por ciento), incongruencia por mayor endodesviación que limitación de abducción en 7 casos (18 por ciento) e incongruencia por mayor limitación de abducción que endodesviación en 8 casos (20 por ciento). Se infiere que la afección del recto lateral (grado de limitación de abducción) puede ser congruente o incongruente con el grado de hipertonia del recto medial (endodesviación).

Forty cases with VI nerve alteration caused by different ethiologic factors were studied, being 26 cases with partial alteration (paresis) and 14 with total alteration (paralysis). Clinical evaluation took place one month after the onset of the alteration, emphasizing the correlation between degree of esodeviation with degree of limitation of abduction, founding congruency in 25 cases (62 percent), incongruency by more degree of esodeviation than limitation of abduction in 7 cases (18 percent), and incongruency by more degree of limitation of abduction than esodeviation in 8 cases (20 percent). It is inferred than lateral rectus affection (limitation of abduction) may be congruent or not with the medial rectus hypertonia (esodeviation).

Correção cirúrgica da esotropia progressiva do alto míope pela técnica de Yamada: relato de dois casos / Surgical correction of progressive high myopic esotropia by Yamada's technique: report of two cases

A "esotropia fixa progressiva" se apresenta como um quadro de esotropia progressiva, em adultos altos míopes, que aumenta até que os olhos fiquem fixos numa esotropia de grande ângulo, geralmente associada a hipotropia, e que tem fracos resultados cirúrgicos. O objetivo deste trabalho é descrever a abordagem cirúrgica de 2 pacientes com "esotropia fixa adquirida progressiva" que foram operados segundo a técnica de Yamada (hemitransposição dos retos lateral e superior), e obtiveram bom resultado pós-operatório.

Trombosis de los senos venosos, complicación tardía post mastoiditis en una preescolar / Venous sinus thrombosis: A late complication of mastoiditis in preschoolar girl

Introducción: La trombosis del seno lateral (seno sigmoídeo) secundaria a mastoiditis aguda cada vez es más infrecuente en nuestro medio y aún más si se habla de lesiones más extensas que comprometan a otros senos como el transverso. Sin duda el diagnóstico precoz y el manejo adecuado de la otitis media aguda han influido de manera importante para que esto suceda. Lo habitual es que se trate de pacientes sépticos con una sintomatología otológica manifiesta y repercusión sistémica. Hoy día comenzamos a ver casos en que el cuadro clínico es muy poco llamativo y a veces el diagnóstico se realiza de manera casual en el transcurso de la cirugía matoídea. Caso: Presentamos una niña de 5 años con trombosis de los senos lateral y transverso que tuvo como presentación clínica un signo de focalización neurológica (diplopia) sin otro hallazgo otoscópico ni otorrinolaringológico de interés. Se empleó sólo tratamiento médico, tuvo una evolución favorable y lenta, pero quedó sin secuelas. Discusión: Revisamos la literatura y la comparamos con nuestra decisión terapéutica.

Deterioration of Accommodative Esotropia during Part-time Occlusion Therapy

The authors report two cases of suddenly deteriorated accommodative esotropia with amblyopia during part-time occlusion therapy. A 7-year-old girl with right accommodative esotropia, which was well controlled, showed marked increase in esodeviation after part-time occlusion and regained orthophoria without occlusion. This phenomenon was repeated. Recession of both medial recti was performed and orthophoria was well maintained at both distant and near targets. Accommodative esotropia of a 9-year-old boy with glasses also showed a striking increase in esodeviation after part-time occlusion. The authors recommended wearing only glasses without occlusion or surgery and he recovered fusion. Three months later, orthophoria was maintained at distant target, with 8PD esophoria at near target with glasses. Although this complication should be considered before occlusion therapy, it must be taken continuously if needed, because an increase of the deviation size with occlusion may simply reflect a true deviation and may not be a poor prognostic sign.

Ocular deviation after unilateral laser in situ keratomileusis

Laser keratomileusis and excimer laser photorefractive keratectomy in situ are widely used therapies for treating myopia. The corrections of refractive error by glasses or contact lens result in a relatively equal refractive correction on both eyes. However, refractive surgery on a single eye can cause a focus disparity between both eyes and may result in the impairment of fusion leading to strabismus. This article aims to report a case where diplopia and esotropia occurred 1 month after laser keratomileusis (LASIK) in situ for the correction of myopia.

Comportamiento de los complejos de hiperfunción vertical asociados a endotropia / Behavior overaction complexes associated with vertical esotropia

Se realizó un estudio retrospectivo en 158 casos con diagnóstico de endotropia de etiología diversa asociada a incomitancias verticales. Los pacientes fueron divididos para su estudio en tres grupos: 1.- complejos de hiperfunción de superiores. 2.- complejos de hiperfunción de inferiores y 3.- otros, que incluyó a los complejos monoculares de hiperfunción y otras asociaciones. Los principales resultados que se encontraron fueron: en el 46.2 por ciento de los casos se asoció a complejos de hiperfunción de superiores, con un promedio de edad de 10.3 años. En el 44.3 por ciento se asoció a complejos de hiperfunción de inferiores, con un promedio de edad de 5.1 años. En el tercer grupo quedaron el 9.5 por ciento de los casos. La diferencia en los promedios de edad entre los grupos 1 y 2 fue estadísticamente significativa. (p=.0026507). Se estudiaron también los casos en que las incomitancias verticales eran significativas, encontrando que predominan los casos con hiperfunción de inferiores (57.6 por ciento).

Heterotopia of the macula with paradoxical exotropia

A 34-year-old woman had the rare anomaly of primary nasal displacement of her right macula within less than one disc diameter from the optic disc. Ordinarily, this would cause a pseudoesotropia, but this patient had a paradoxical right exotropia, induced perhaps by the high myopia and amblyopia in the right eye