Full-tendon nasal transposition of the vertical rectus muscles: a retrospective review.

The authors report the results of a retrospective review of patients who underwent nasal transposition of the vertical rectus muscles between 1997 and 2004. Eight patients were identified, 4 males and 4 females. There was an average age at surgery of 37 years, with a range from 8 to 79 years. The aetiologies included 6 patients with trauma to their medial rectus (4 following endoscopic sinus surgery) and 2 patients with paralytic medial rectus muscles secondary to 3rd nerve palsy. All patients underwent whole tendon transposition of the superior and inferior rectus muscles, with resection of both muscles in 7 cases, before reattachment adjacent to the upper and lower borders of the medial rectus, respectively. One patient had a reduced amount of resection and this was combined with inferior oblique disinsertion and traction sutures. All patients had a reduction in deviation in the primary position and in 5 patients there was some improvement in adduction. A consequence of surgery was a degree of limitation of abduction, elevation and depression in some patients. Overall, patients were satisfied with the improvement in their appearance.

Benefits of retroequatorial four horizontal muscle recession surgery in congenital idiopathic nystagmus in adults.

INTRODUCTION: Four muscle surgery for congenital nystagmus was originally described in 1956 and popularized by two articles in the 1990s. A review of the literature revealed only three studies of seven, nine, and six patients published since then. We therefore reviewed our patients to determine the objective and subjective benefits of this procedure. METHODS: A retrospective review was carried out on patients who underwent bilateral maximal horizontal muscle recessions for congenital nystagmus between 1997 and 2002. Improvement in visual acuity was documented. An external assessor administered an anonymized questionnaire to discover any perceived benefit. Eighteen patients were identified, 12 men and 6 women, with an average age at surgery of 32 years. RESULTS: Preoperative visual acuity ranged from 6/9 binocularly to 6/60. All underwent bilateral medial rectus muscle recessions of 8 mm to 10 mm and bilateral lateral rectus muscle recessions of 8 mm to 12 mm. Nine patients (50%) gained one line of Snellen visual acuity. There were four complications: one scleral perforation; two developed exotropia; and one complained of asthenopic symptoms. This latter patient was the only one who experienced some deterioration of vision acuity. Fourteen of 18 (78%) questionnaires were returned. Eight patients said they were pleased; four were indifferent and two were displeased. CONCLUSIONS: We conclude that this operation delivers limited objective benefit. None of our patients were able to obtain a driving license. Fifty-seven percent of patients expressed the view that they were glad to have had the surgery, although the visual improvement was only slight.

Does botulinum toxin have a role in the treatment of secondary strabismus?*.

METHODS: We reviewed the Toxin Clinic database over a 20-year period, identifying patients with strabismus secondary to permanent or temporary impairment of vision. RESULTS: Five hundred-and-three patients who fulfilled our criteria were treated with Botulinum toxin. There were 301 males and 202 females, with a mean age at treatment of 35 years (range 6-86). Three hundred-and-eighty-three patients (76%) had exotropia, 114 (22.5%) had esotropia and 6 (1.5%) had vertical strabismus. Reduced vision secondary to trauma accounted for 45% (227) of patients. Other causes were congenital anomalies 121 (24%), refractive error 30 (6%), retinal detachment 20 (4%), senile cataract 24 (5%), corneal problems 19 (4%), glaucoma 10 (2%) and other 52 (10%). One hundred-and-ninety-three (38%) were aphakic. One thousand-four-hundred-and-fifty-seven injections were given, with a range of 1-50 per patient. Ninety-nine (20%) patients were managed with continued toxin treatment. Two hundred-and-eighteen patients (43%) proceeded to surgery. Forty patients (8%) required no further treatment as they regained binocularity by injection alone. CONCLUSIONS: Botulinum toxin appears to have a role in the treatment of secondary strabismus, since only 3% (14) failed to obtain any reduction in their angle. It was well tolerated, with no permanent side effects. Only 22 (4%) patients developed ptosis.

Beneficial effect of treatment for strabismus in patients with bilaterally poor vision, who cannot see their strabismus.

METHODS: Retrospective case note review of management of patients with bilaterally severely reduced vision presenting with symptomatic strabismus. RESULTS: There were 10 females and 7 males, mean age at treatment was 36 years, range 19 to 74 years. Thirteen patients had an exotropia ranging from 20 to 90(Δ) (mean 52(Δ)). Four had an esotropia ranging from 30 to 70(Δ) (mean 53(Δ)). Vision in each eye ranged from 6/24 Snellen to light perception, except for one patient with Usher's syndrome who had grossly restricted visual fields and vision of 6/12 and 6/36. The etiology was retinitis pigmentosa in 5 patients; 3 had cone dystrophy, 2 were high myopes. Other etiologies included CMV retinitis in both eyes secondary to HIV, bilateral optic atrophy post craniopharyngioma, and cortical visual impairment. All patients were unable to see well enough to assess their strabismus but were aware of its presence from family members and friends and wished improvement. Eleven patients underwent botulinum toxin injections; 2 of these then proceeded to surgery. A total of 8 patients had surgery. Post-operative angles ranged from 6(Δ) to 25(Δ) of esotropia. Five patients continue with maintenance toxin. Follow-up ranged from 3 months to 15 years. DISCUSSION/CONCLUSIONS: This is the first report of patients with bilaterally severely reduced vision requesting treatment for strabismus that they were unable to see for themselves. All patients were pleased they had undergone treatment for their strabismus despite being unable to see the outcome.

Role of inferior rectus botulinum toxin injection in vertical strabismus resulting from orbital pathology.

INTRODUCTION: We describe the uses and efficacy of botulinum toxin injection to the inferior rectus muscle in vertical strabismus resulting from orbital pathology. METHODS: A retrospective review of patients undergoing inferior rectus botulinum toxin injection between 1982 and 2006 for vertical strabismus due to orbital pathology. RESULTS: There were 13 patients identified; 6 with idiopathic orbital inflammatory syndrome (IOIS) including myositis, 3 with previous orbital wall fractures, 1 post-optic nerve sheath Schwannoma resection, 1 with lymphoma, 1 with metastasis, and 1 post-superior ophthalmic vein hemorrhage. A beneficial effect with inferior rectus botulinum toxin was obtained in 9/13 (69%) patients (mean follow-up 14 months). Resolution or improvement occurred in 4/6 (67%) patients with IOIS. Resolution was also obtained in the patient with previous optic nerve sheath Schwannoma resection, and the patient who sustained the superior ophthalmic vein hemorrhage. Improvement was noted in both the patient with lymphoma and in the patient with a metastasis. However, in patients with orbital wall fractures, only 1 of 3 patients obtained improvement. Benefit appeared independent of the size of vertical deviation, with 4/6 (67%) showing improvement with a pre-toxin angle 4-12 PD, and 5/7 (71%) improving with a pre-toxin angle 16-25 PD. Eleven patients received only 1 injection, one patient received 2, and another had an ongoing course of 8 injections. DISCUSSION: Vertical strabismus secondary to a range of orbital conditions, particularly inflammatory, often can be successfully managed by inferior rectus botulinum toxin injections.

Role of inferior rectus botulinum toxin injection in iatrogenic vertical strabismus.

INTRODUCTION: We describe the uses and effectiveness of botulinum toxin to the inferior rectus muscle in iatrogenic vertical strabismus. METHODS: A retrospective review of our database to identify patients who had undergone inferior rectus botulinum toxin injection between 1982 and 2006 for iatrogenic vertical strabismus. RESULTS: There were 13 patients, 5 female, with an age range of 14 to 78 years. Eight left eyes were injected. The mean period of follow-up was 3.3 years. Etiologies included post-local anesthetic, post-plaque radiotherapy for malignant melanoma, adherence syndrome after inferior oblique surgery, and post-botulinum toxin to the levator muscle to produce a temporary therapeutic ptosis. Reversal on first injection occurred in 7 patients and occurred in a further 2 patients on second injection. Pre-injection binocularity was not demonstrable in 3 patients; 2 of these patients did have binocular vision demonstrable after botulinum toxin injection. Seven patients had one injection, 3 patients had two, 1 had three, 1 had five, and 1 had six. DISCUSSION: The data demonstrate the range of indications that can be successfully treated and managed with inferior rectus botulinum toxin injection in iatrogenic vertical strabismus.

Diagnostic use of botulinum toxin in patients with Duane syndrome.

INTRODUCTION: Duane syndrome is a difficult condition to treat. Patients and parents need to be informed that it will not resolve and it is not possible to create normal eye movements surgically. Botulinum toxin may be used to assess the likelihood of reducing the abnormal head posture and reducing the diplopia by increasing the field of binocular single vision. If results are favorable then surgery may be offered. This article is a retrospective review of patients with Duane syndrome treated with botulinum toxin using the toxin clinic database between 1980 and 2007. METHODS: Eighty-eight patients were identified, 48 females and 40 males. The average age at presentation was 29 years, range 5 to 68 years. The left eye was affected in 50 (57%) patients and 21 (24%) patients were affected bilaterally. The average angle was 28.6 +/- 18.4 Delta for the esotropic patients and 32.5 +/- 14.5 Delta for the exotropic patients. In 58 patients the medial rectus was injected, in 30 the lateral rectus. RESULTS: As a result of the outcome of botulinum toxin, 41 (46.5%) patients proceeded to surgery; 12 (14%) continued with maintenance toxin. Forty-seven (53%) demonstrated a long-term reduction in deviation. Transient complications were ptosis in 11 patients and induced vertical deviation in 10. CONCLUSION: This is the first study to explore the diagnostic role of botulinum toxin in Duane syndrome. It is a safe treatment that may also offer long-term benefits.