Long-term follow-up of surgical treatment of thyroid-associated orbitopathy restrictive strabismus.

Objective: Thyroid-associated orbitopathy (TAO) is the most frequent cause of extraocular muscle enlargement, with consecutive restrictive strabismus. The main muscles involved are inferior and medial rectus, resulting in horizontal esotropia and/or vertical strabismus. Surgery may either establish or improve binocular single vision. The aim of the present study is to describe long-term follow-up of patients who underwent horizontal or vertical TAO strabismus surgery. Methods: This observational retrospective study included 29 patients suffering from either vertical or horizontal TAO strabismus and diplopia, of whom 11 underwent bilateral medial recti muscle recession (Group A) and 18 underwent unilateral inferior rectus muscle recession (Group B). The endpoint of the study was the assessment of changes in deviation angle and diplopia across four time points (baseline, 7 days, 6 months, and 24 months) in each group. Results: In Group A, the horizontal deviation angle significantly decreased 7 days after intervention (p < 0.001), without modifications overtime. In Group B, both deviation angles in primary and down-gaze position significantly decreased from baseline, both 7 days after surgery (p < 0.001) and at 6 months (p = 0.040). An overcorrection, with an inversion of vertical deviation angle, was observed across the different time points. Conclusions: Horizontal TAO strabismus correction leads to significant improvements of deviation angle and diplopia, with a stable undercorrection overtime. Inferior rectus recession leads to more unstable results, with a trend towards overcorrection limited to the first 6 months after surgery.

Strabismus in retinoblastoma survivors with long-term follow-up.

PURPOSE: To report the long-term strabismus rate in salvaged retinoblastoma (Rb) patients and investigate possible risk factors leading to strabismus. METHODS: The medical records of patients with Rb presenting at a single institution over a 9-year period were reviewed retrospectively with regard to ocular alignment outcomes after long-term follow-up. RESULTS: A total of 64 eyes of 42 patients (22 bilateral cases [52%]) were included, presenting with International Intraocular Retinoblastoma Classification (IIRC) in the worse eye as follows: group A (n = 1), B (n = 16), C (n = 12), D (n = 11), no Rb (n = 2). Fifteen patients (36%) were initially referred because of family history of Rb. Mean age at presentation was 8.2 months (range, 0.3-58.3 months). Overall treatments included intravenous chemotherapy (62 eyes), intraophthalmic artery chemotherapy (10 eyes), brachytherapy (11 eyes), transpupillary thermotherapy (22 eyes), cryotherapy (47 eyes), and external beam radiotherapy (4 eyes). At final follow-up (mean, 93.7 months), 69% of patients had strabismus, with exotropia being the most common type (n = 18), followed by esotropia (n = 8), and alternate exotropia/esotropia (n = 3). On univariate analysis, the worse eye group IIRC and cTNMH, sporadic cases, strabismus, and foveal tumor at presentation were found to be significantly associated with strabismus at final follow-up (P ≤ 0.043). On multivariate analysis, only foveal involvement was found to be significant (P < 0.001). CONCLUSIONS: Strabismus, exotropia in particular, is a common adverse sequela following successful conservative treatment for Rb, with 69% of the present cohort having some type of deviation after long-term follow-up, for which foveal tumor at presentation was found to be a significant risk factor.

Long-term Visual Acuity, Strabismus, and Nystagmus Outcomes Following Multimodality Treatment in Group D Retinoblastoma Eyes.

PURPOSE: To analyze the long-term visual acuity, strabismus, and nystagmus outcomes in Group D retinoblastoma following multimodality treatments in a national retinoblastoma referral center. DESIGN: Retrospective interventional case series. METHODS: A 13-year retrospective chart review of Group D eyes treated initially with intravenous chemotherapy (IVC) and followed up for at least 1 year from last treatment. Risk factors for final visual acuity (VA) were analyzed, and rate of strabismus and nystagmus at last follow-up visit were calculated. RESULTS: One hundred and four Group D eyes (92 patients) presented to our center during the study period, of which 32 (27 patients) met the inclusion criteria. Following IVC (vincristine, etoposide, and carboplatin), adjuvant treatments included intraophthalmic artery chemotherapy in 5 (16%) eyes, plaque brachytherapy in 5 (16%), transpupillary thermotherapy (TTT) in 18 (56%), and cryotherapy in 24 (75%) eyes. On last examination, 64.41 ± 6.76 months from presentation, mean final VA was 20/283 (logMAR equivalent of 1.15 ± 0.15). On univariate analysis, presentation age, foveal retinoblastoma (at initial examination), use of TTT, and tumor-foveola distance (at last visit) were found to be significant risk factors for worse VA (P < .026). On multivariate analysis, however, only TTT was found to be significant (P = .010). At last visit, 6 of 27 (22%) patients had nystagmus and 12 of 20 (60%) bilaterally salvaged patients had strabismus (n = 10 exotropia and n = 2 esotropia). CONCLUSIONS: After multimodality treatments initiated with IVC, 50% of salvaged Group D retinoblastoma eyes had <20/200 vision, with TTT being a risk factor for worse vision; 60% had strabismus; and 22% had nystagmus.

In-utero exposure to smoking, alcohol, coffee, and tea and risk of strabismus.

In a prospective, population-based cohort study, the authors investigated the effect of in-utero exposure to maternal smoking and consumption of alcohol, coffee, and tea on the risk of strabismus. They reviewed medical records for children in the Danish National Birth Cohort identified through national registers as possibly having strabismus. Relative risk estimates were adjusted for year of birth, social class, maternal smoking, maternal age at birth, and maternal coffee and tea consumption. The authors identified 1,321 cases of strabismus in a cohort of 96,842 Danish children born between 1996 and 2003. Maternal smoking was associated with a significantly elevated risk of strabismus in the child, increasing with number of cigarettes smoked per day (<5 cigarettes/day: relative risk (RR) = 0.95, 95% confidence interval (CI): 0.80, 1.14; 5-<10 cigarettes/day: RR = 1.38, 95% CI: 1.12, 1.70; > or =10 cigarettes/day: RR = 1.90, 95% CI: 1.57, 2.30). Nicotine replacement therapy was not associated with strabismus risk (RR = 1.22, 95% CI: 0.92, 1.61). Light maternal alcohol consumption was inversely associated with strabismus risk, whereas maternal coffee and tea drinking were not associated with strabismus risk. In conclusion, smoking during pregnancy is associated with an increased risk of strabismus in the offspring. Conversely, light alcohol consumption is associated with decreased risk.

Inferior rectus paresis and medial rectus overaction following retrobulbar anesthesia for cataract surgery.

Strabismus is a well recognized complication of retrobulbar anesthesia for cataract surgery. This may manifest as either paresis or sometimes contracture (overaction) in the late stage. Management of the patient is tailored to the individual case. Herein, we report a patient with inferior rectus paresis and medial rectus overaction after retrobulbar anesthesia. The presenting symptom was diplopia increasing on downgaze, which improved with medial rectus recession and plication of the inferior rectus.

Change in ocular alignment after topical anesthetic cataract surgery.

BACKGROUND: To report the incidence of, and change in ocular misalignment following topical anesthetic cataract surgery. METHODS: Prospectively, 160 consecutive patients who were scheduled for cataract surgery under topical anesthesia were evaluated. All patients had a complete ophthalmic examination, including ocular alignment evaluation, just before and 1 day, 1 week, 3 weeks, and 2 months after cataract surgery. RESULTS: Preoperatively, 26 patients had ocular misalignment. Mean deviation in these preexisting misalignment was 7.2 +/- 6.8 prism diopters (PD). Postoperatively, the angle of deviation improved to 5.4 +/- 7.4 PD. Acquired ocular misalignment after cataract surgery occurred in 12 of 160 patients (8%) at 1 day, and seven of 131 (5%) at 2 months. None of these seven patients sought medical attention for the diplopia. CONCLUSIONS: The overall incidence of topical anesthesia-related change in ocular alignment after uneventful cataract surgery was 5%. However, no patients had symptomatic diplopia. Topical anesthetic cataract surgery could abolish the risk of postoperative diplopia and improve the heterophoric status of preexisting misalignment.

[Intraoperative adjustable strabismus surgery under drop anesthesia in patients with Graves' orbitopathy]. / Cirurgia de estrabismo ajustável no peroperatório com anestesia tópica em pacientes com orbitopatia de Graves.

PURPOSE: To report the clinical features of strabismus associated with Graves' orbitopathy, and the results of surgery with adjustable suture under drop anesthesia. METHODS: The charts of 13 patients who had surgical treatment for strabismus related to Graves' orbitopathy at Hospital das Clínicas of University of São Paulo were retrospectively reviewed. Ocular motility, sensorial examination and the follow-up after strabismus correction were studied. RESULTS: Preoperatively, the most common type of deviation was esotropia with hypotropia. Adjustable recession was done in nine patients and a second surgery occurred in 3 patients. After follow-up of at least six months, 8 of 13 patients were orthotropic or had a small phoria with some degree of binocular vision. CONCLUSION: In this study, 62% (8/13) of patients showed hypotropia with esotropia, probably because fibrotic and restrictive muscles (medial and inferior rectus). In nine of 13 patients adjustable recession with a good postoperative alignment of the eyes was performed. Adjustment of strabismus surgery under drop anesthesia in patients with Graves' orbitopathy was successful in restoring binocular vision with minimum complications.

Cirurgia de estrabismo ajustável no peroperatório com anestesia tópica em pacientes com orbitopatia de Graves / Intraoperative adjustable strabismus surgery under drop anesthesia in patients with Graves' orbitopathy

OBJETIVO: Descrever as características clínicas pré-operatórias dos pacientes com estrabismo secundário à orbitopatia de Graves e os resultados da cirurgia com anestesia tópica e sutura ajustável. MÉTODOS: Estudo retrospectivo realizado no Hospital das Clínicas da Universidade de São Paulo. Foram pesquisados os prontuários de todos os pacientes atendidos no ambulatório de estrabismo no período de março de 1994 a maio de 2004. Destes, foram separados aqueles com estrabismo associado à orbitopatia de Graves submetidos à cirurgia ajustável com anestesia tópica. As características clínicas pré-operatórias e os resultados cirúrgicos foram levantados a partir desta análise. RESULTADOS: Foram incluídos 13 pacientes. O tipo de desvio mais freqüentemente encontrado foi esotropia com hipotropia. Em 9 pacientes modificou-se o retrocesso programado no pré-operatório. Três casos necessitaram de uma segunda cirurgia. Após 6 meses de seguimento, 8 dos 13 pacientes estavam ortotrópicos ou com foria pequena e com algum grau de estereopsia. CONCLUSÃO: Neste estudo observou-se que 62 por cento (8/13) dos pacientes apresentavam hipotropia com esotropia, provavelmente por causa do comprometimento associado do reto inferior e reto medial. Nove dos 13 pacientes necessitaram de ajuste no peroperatório e apenas 3 foram reoperados, indicando a importância da técnica ajustável para melhor alinhamento ocular no pós-operatório, possibilitando obter resultados mais satisfatórios.

PURPOSE: To report the clinical features of strabismus associated with Graves' orbitopathy, and the results of surgery with adjustable suture under drop anesthesia. METHODS: The charts of 13 patients who had surgical treatment for strabismus related to Graves' orbitopathy at Hospital das Clínicas of University of São Paulo were retrospectively reviewed. Ocular motility, sensorial examination and the follow-up after strabismus correction were studied. RESULTS: Preoperatively, the most common type of deviation was esotropia with hypotropia. Adjustable recession was done in nine patients and a second surgery occurred in 3 patients. After follow-up of at least six months, 8 of 13 patients were orthotropic or had a small phoria with some degree of binocular vision. CONCLUSION: In this study, 62 percent (8/13) of patients showed hypotropia with esotropia, probably because fibrotic and restrictive muscles (medial and inferior rectus). In nine of 13 patients adjustable recession with a good postoperative alignment of the eyes was performed. Adjustment of strabismus surgery under drop anesthesia in patients with Graves' orbitopathy was successful in restoring binocular vision with minimum complications.

[Diplopia through toxic myopathy after cataract surgery]. / Diplopie prin miopatie toxica dupa operatia de cataracta.

UNLABELLED: Cataract surgery is one of the most successful procedures in the last decades. In this paper we present the evolution and the treatment results in four cases of post cataract surgery diplopia, analyzing the causes influencing the outcome of strabismus. MATERIAL AND METHOD: In the last three years, four cases of post cataract surgery diplopia have been diagnosed in the Ophthalmological Clinic of Cluj. The surgical procedure used in all four patients was phacoemulsification and artificial lens implantation. The patients received para- or retrobulbar xylocaine 2- % anesthesia. Hypertropia was present in all patients, with a variable time of onset. The evolution of diplopia decided the therapeutic attitude. One patient was treated with extraocular muscle surgery. The second one received prismatic optical correction. In one patient diplopia disappeared spontaneously after one month of evolution. The fourth patient refused surgical correction. RESULTS AND CONCLUSIONS: The two treated patients (surgery and prismatic optical correction) had a favorable outcome. The following conclusions could be drawn. 1. Toxic myopathy is the main cause of ocular deviations and diplopia after cataract surgery. 2. The inferior rectus muscle is the most frequently affected. 3. Hypertropia is the most frequent ocular deviation. 4. Post cataract surgery diplopia may disappear spontaneously or can be treated surgically (extraocular muscle surgery) or optically (prismatic optical correction).

Intraoperative eye position after sub-Tenon's anesthesia for cataract surgery.

BACKGROUND: To evaluate the incidence and extent of ocular deviation associated with sub-Tenon's anesthesia. METHODS: Seventy-five consecutive patients undergoing routine phacoemulsification with sub-Tenon's anesthesia at the Eye Unit, Royal Gwent Hospital, were prospectively enrolled in this observational case series. The exclusion criteria were patients taking warfarin, or patients with preexisting ocular motility disorders, allergy to local anesthetics, or previous surgery for squint or retinal detachment. Eleven patients were subsequently excluded from the study group as they required additional anesthesia blocks before measurements were taken for ocular deviation. We injected 5 mL of a local anesthetic mixture of 2% lignocaine and 7.5 mg/mL levobupivacaine in the sub-Tenon's space in the inferonasal quadrant. Ocular deviation was assessed objectively by means of the Krimsky test. Forced duction tests were performed before and after anesthesia. RESULTS: Hyperdeviation was documented in 49 (77%) eyes, exodeviation in 62 (97%), and hypodeviation in 6 (9.4%). No esodeviations were documented. Only 2 patients were orthophoric after anesthesia. Mean vertical deviation was 4.4 prism dioptres (PD) (SD 4.7 PD, 95% CI 3.2-5.5 PD, range 0-14 PD). Mean horizontal deviation was 19.5 (SD 9.6, 95% CI 17-22, range 0-50) PD. Forced duction test revealed no mechanical restriction before or after anesthesia. INTERPRETATION: This study suggests that there is an appreciable ocular deviation with sub-Tenon's anesthesia. Intraoperative ocular deviation may make certain procedures more difficult; therefore, we recommend a low threshold for an additional corrective block administered before surgery to rectify the deviation.

Persistent diplopia and strabismus after cataract surgery under local anesthesia.

BACKGROUND AND PURPOSE: Diplopia is an infrequent complication described for retrobulbar local anesthesia. The objective of this study is to report the clinical characteristics and treatments for this surgical complication. METHODS: Retrospective study of medical records. PERIOD: 5.3 years ending February 2005. During this period, 20453 cataract surgeries were performed. The anesthesia used was retrobulbar block with ropivacaine diluted with hyaluronidase. Nineteen patients reported diplopia due to strabismus after the cataract surgical procedure and were referred for evaluation at the Extrinsic Ocular Motility Department. RESULTS: Persistent diplopia after cataract surgery occurred in 19 (0.093%) of the 20453 cases. The types of deviations found were: exotropia (n=3), esotropia (n=5), hypertropia (n=1), exotropia + hypertropia (n=5) and esotropia + hypertropia (n=5). Small deviations and dysfunction of the lateral rectus muscles were most commonly seen. Prism was applied to 4 patients, eye muscle surgery was the option in 8 patients, orthoptic treatment was performed in 3 patients and for 2 patients the decision was to only observe progress. Overall, binocular vision was restored in eleven of the nineteen patients. CONCLUSIONS: Persistent diplopia due to strabismus is an infrequent complication after cataract surgery with retrobulbar block. Etiology of this disorder of extrinsic ocular motility is variable, including mixed components. We stress the importance of adequate preoperative history of strabismus and evaluation of extrinsic ocular motility. Considering the reported incidence of this problem is as high as one in 25 cataract surgeries, one should advise the patient of the possibility of persistent postoperative diplopia and the possible need for surgical intervention and/or prism to treat the symptoms.

[Diplopia after sub-Tenon's anesthesia for cataract surgery]. / Diplopía postcirugía de catarata con anestesia subtenoniana.

PURPOSE: To study the clinical signs, treatment and prognosis of strabismus after sub-Tenon's anesthesia for cataract surgery. METHODS: Eight patients without previous strabismus developed incomitant diplopia immediately after cataract surgery; the left eye was affected in five patients and the right eye in three. Restrictive strabismus was diagnosed with the cover test, prisms, and active and passive ductions in all cases. In seven cases the deviation was vertical and in one patient it was horizontal. The average deviation was 17.5 S.D. 9.84 (range 5-35) prismatic dioptres in primary position. The deviation increased looking upward in seven cases, and looking sideways to the left in the other. It was considered to be a good result if the diplopia disappeared after treatment. RESULTS: Botulinum toxin was the first treatment applied in four patients, but only one showed a good response and required no further therapy. Strabismus surgery was required in four cases, and prisms were adapted in three. Three patients required two strabismus operations. A good result was achieved in all cases, with the average time interval being 10.12 (SD 5.5) months. CONCLUSIONS: Sub-Tenon's anesthesia may result in restrictive strabismus and incomitant diplopia which does not resolve spontaneously. The inferior rectus is the most commonly affected muscle. Strabismus surgery is required to resolve the diplopia in half of the cases. Good results have been achieved in all patients.

Acquired simulated brown syndrome following surgical repair of medial orbital wall fracture.

Simulated Brown syndrome is a term applied to a myriad of disorders that cause a Brown syndrome-like motility. We encountered a case of acquired simulated Brown syndrome in a 41-year-old man following surgical repair of fractures of both medial orbital walls. He suffered from diplopia in primary gaze, associated with hypotropia of the affected eye. We performed an ipsilateral recession of the left inferior rectus muscle as a single-stage intraoperative adjustment procedure under topical anesthesia, rather than the direct approach to the superior oblique tendon. Postoperatively, the patient was asymptomatic in all diagnostic gaze positions.

Acquired Simulated Brown Syndrome following Surgical Repair of Medial Orbital Wall Fracture

Simulated Brown syndrome is a term applied to a myriad of disorders that cause a Brown syndrome-like motility. We encountered a case of acquired simulated Brown syndrome in a 41-year-old man following surgical repair of fractures of both medial orbital walls. He suffered from diplopia in primary gaze, associated with hypotropia of the affected eye. We performed an ipsilateral recession of the left inferior rectus muscle as a single-stage intraoperative adjustment procedure under topical anesthesia, rather than the direct approach to the superior oblique tendon. Postoperatively, the patient was asymptomatic in all diagnostic gaze positions.

Rectus muscle trauma complicating sub-Tenon's local anaesthesia.

PURPOSE: To describe three cases of rectus muscle trauma in patients undergoing phacoemulsification cataract extraction and intraocular lens implantation under sub-Tenon's local anaesthesia via the inferonasal quadrant. METHODS: Retrospective review was carried out of 3 cases from 1080 patients who underwent phacoemulsification cataract extraction and intraocular lens implantation under sub-Tenon's local anaesthesia in our unit over a 3 year period up to April 2000. RESULTS: Two patients complained postoperatively of vertical diplopia and were shown to have restriction of elevation of the eye, which was found at surgical exploration to be due to inferior rectus muscle restriction. One patient had post-operative horizontal diplopia due restriction of abduction and exploration of the medial rectus muscle was planned. CONCLUSION: Rectus muscle trauma is proposed as a complication of sub-Tenon's local anaesthesia and caution is advised to operators to clearly identify the sub-Tenon's space for injection of local anaesthetic.

Superior oblique muscle paresis after sub-Tenon's anesthesia for cataract surgery.

A 68-year-old man developed strabismus after having sub-Tenon's anesthesia for cataract extraction and intraocular lens implantation. An ipsilateral hypertropia with superior oblique muscle paresis developed in the operated eye. The hypertropia appeared 1 day after surgery and resolved 1 month later. Although sub-Tenon's anesthesia is considered safer than other methods of local anesthesia, strabismus may occur.