Characteristics and type of strabismus associated to macular diplopia. Treatment outcomes.

OBJECTIVE: To study the clinical characteristics of macular diplopia, treatment, and outcome. METHODS: Retrospective descriptive study of cases referred to the ocular motility section of a tertiary hospital with diplopia, diagnosed with macular diplopia between 2022-23. The etiology of the macular pathology and the type of associated strabismus were recorded. The result was considered good if the diplopia improved or was eliminated with the medical or surgical treatment. Follow-up time from the onset of diplopia until data collection was recorded. RESULTS: a total of 19 cases comprised the sample (63.2% women), mean age: 67.16 years. Amblyopia (21.1%), high myopia (47.4%), epirretinal membrane (ERM) (36.8%), neovascular membrane (26.3%), macular hole (10.5%), and lamellar (15.8%), and age macular degeneration (5.3%) were registered. The 47.4% had vertical diplopia, horizontal: 5.3 and 47.4% mixed. The mean horizontal deviation was: 7.3 PD (prism diopters) and vertical: 6.22 PD. Ocular extorsion was observed in 26.3%, and intorsion: 5.3%. Torticollis was present in 15.8%. The treatment consisted of strabismus surgery + Botox (15.8%), strabismus surgery (47.4%), medical treatment with Fresnel prims or Scotch cellophane (36.8%). A 68.4% presented a good result at the end of the study. The mean follow-up was 55.58 months. CONCLUSIONS: Misregistration of macular photoreceptors is the most common cause of binocular diplopia in patients with ERM or other macular pathologies. Most complains of vertical or mixed diplopia. Sensorimotor evaluation of these patients should be thorough. Early diagnosis prevents unnecessary prescription of prism glasses. Surgical and/or medical treatment achieves good results in most cases.

Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye.

PURPOSE: To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy. METHODS: A retrospective study of 9 cases between 2017-2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD). RESULTS: The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology). CONCLUSION: Supra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

Convergence insufficiency with diplopia: Surgical treatment in adults.

OBJECTIVE: To study the outcomes of treatment with central mini-plication of the medial rectus (MR) muscles in adult convergence insufficiency with diplopia. METHODS: The study sample comprised 9 cases (7 women). The length of MR plication was collected. Other variables reported were postsurgical deviation, overcorrections in the early postoperative period and at the end of follow-up, final horizontal deviation at near and at distance vision, diplopia, and mean follow-up from surgery. Surgical outcome was considered to be favorable when diplopia and symptoms were resolved and final exotropia at near was ≤8 pd at the end of follow-up. RESULTS: A central mini-plication of the MR was performed in 9 patients (8 unilateral). Mean (±SD) age was 58.66 (21.39) years. Mean near preoperative deviation: 16.22 (±2.9) pd and distance preoperative deviation: 6.88 (±4) pd Overcorrection at distance vision was recorded in 5 cases; this resolved by 3 months postoperatively. There was not overcorrection at near vision except one case. None of the cases operated on had overcorrection at the end of follow-up. The final horizontal deviation was ≤8 pd at near vision, except for 3 cases (mean: 6.22). Symptoms and diplopia resolved in 8 cases. The mean follow-up was 10.33 months. CONCLUSION: Central mini-plication of 1 or 2 medial rectus muscles can improve the symptoms and signs of exotropia associated with convergence insufficiency when exercises and the prisms are rejected by the patients and when these approaches have not solved the problem.

Transposition of the inferior oblique muscle belly without disinsertion for overshoot in adduction treatment.

PURPOSE: To evaluate the efficacy and safety of inferior oblique muscle transposition and myopexy in patients with mild/moderate inferior oblique muscle overaction, with or without diplopia. METHOD: We retrospectively analysed data for the 12 patients who underwent the technique. Data were collected from October 2018 to September 2021. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal end of the inferior rectus. All 12 patients had mild hypertropia (≤6 prism diopters [pd]) in primary position and mild/moderate inferior oblique overaction. Mean preoperative hypertropia was 4.42 pd ±â€¯1.62. Diplopia was recorded in 10 cases. The diagnoses were fourth nerve paresis (9), unilateral primary inferior oblique overaction (2) and dissociated vertical deviation (1). Torticollis was observed in 7 cases, 2 had subjective torsion and 2 objective torsion. RESULTS: Mean age was 46.86 ±â€¯25.1 years (50%: men). Diplopia resolved in 9 of the 10 cases. The mean final vertical deviation was 1.5 ±â€¯2.93 (p = 0.001) pd in straight gaze. Of 7 mild overshoot in adduction, it disappeared in 3 and 4 remained the same. Of 5 moderate overshoot in adduction, 2 improved to mild and 3 disappeared. Torticollis was eliminated in 5 patients and improved in another 2. Mean time from surgery was 14.08 ±â€¯8.05 months. There were no overcorrections. CONCLUSIONS: Inferior oblique muscle transposition with myopexy is a safe and effective procedure in patients with mild-to-moderate inferior oblique muscle overaction and small-angle hypertropia, with or without diplopia.

Surgical outcomes of acquired acute comitant esotropia. Causes and classification.

PURPOSE: To study the results of surgical treatment of acquired concomitant esotropia and its posible causes. METHODS: Retrospective study of the patients with acute acquired esotropia that were operated on since 2017. Distance and near horizontal deviation, spherical equivalent and the excessive use of the tablets and smartphones were analyzed. A good sensorial outcome was considered when stereopsis was recovered and good motor outcome if horizontal deviation was ≤10 prism diopters at the end of the follow-up. RESULTS: A total of 15 cases were included (60% women), mean age: 29.07 years (86.66% ≥16 years). Mean time since the beginning of the symptoms to the surgery was 23.3 months. Mean horizontal preoperative deviation was 19.73 ± 7.2 pd at near and 22.93 ± 7.3 dp at distance decreasing to 3.33 ± 3.8 pd at near and 3.86 ± 3.9 pd at distance (P < .001). The 66.6% had diplopía. The 46.66% had decompensated esophoria or microesotropia, 86,66 % myopia and the 33.33% referred excesive use of the tablets and smartphones. The medial rectus recession were done in 10 cases. A good motor outcome was obtained in the 93.33% of the cases and sensorial outcome in the 53.3% without diplopía. CONCLUSION: Surgery was an excellent treatment to resolve the deviation and diplopia. The esophorias and microesotropias represented near the half of the cases and the excesive use of the tablets and smartphones were the third part of the sample. Most of the patients had myopia.