Combining the Tunnel Orbicularis Oculi Muscle Flap Technique With Skin Grafting for Enhanced Adhesion in Burn-Induced Ectropion Repair.

PURPOSE: Scar contracture of the eyelid following facial burns often has adverse consequences. Total cicatricial contracture often makes adjustment flap translation challenging to implement. Previously used upper and lower eyelid adhesion methods are ineffective for patients with severe cicatricial contracture, and ectropion can easily recur. This study aimed to retrospectively examine upper and lower eyelid adhesions using an orbicularis oculi muscle flap and verify its stability. METHODS: In patients with ectropion caused by severe scar contracture following head and face burns, we employed a tunnel orbicularis oculi muscle flap technique, which involved creating a tunnel between the skin and the tarsal plate of the eyelid, mobilizing the orbicularis oculi muscle, and rotating it into this tunnel to provide stable adhesion of the upper and lower eyelids. Full-thickness skin grafting was then performed. The eyelids were examined postoperatively to determine whether reoperation was necessary and to monitor for any potential complications. RESULTS: This study included 26 patients and 46 eyes. No accidental disconnection occurred after eyelid adhesion, which lasted for an average of 21.87 ± 10.08 months before the eyelid adhesion was cut open. No complications or adverse reactions occurred, and the adhesions did not break unexpectedly. CONCLUSIONS: Repairing eyelid ectropion with the tunnel orbicularis oculi muscle flap is a simple procedure that immediately creates tension against upper and lower eyelid contractures, providing long-term stable adhesion. This method avoids structural disorders, such as eyelid margin scarring, minimally influences surrounding tissues, and has few postoperative complications. It holds great value for repairing eyelid tissue defects and warrants further study.

A Magnetic Actuator Device for Fully Automated Blinking in Total Bidirectional Eyelid Paralysis: First Proof of Concept in a Human Participant.

Purpose: Currently, no solution exists to restore natural eyelid kinematics for patients with complete eyelid paralysis due to loss of function of both the levator palpebrae superioris and orbicularis oculi. These rare cases are prone to complications of chronic exposure keratopathy which may lead to corneal blindness. We hypothesized that magnetic force could be used to fully automate eyelid movement in these cases through the use of eyelid-attached magnets and a spectacle-mounted magnet driven by a programmable motor (motorized magnetic levator prosthesis [MMLP]). Methods: To test this hypothesis and establish proof of concept, we performed a finite element analysis (FEA) for a prototype MMLP to check the eyelid-opening force generated by the device and verified the results with experimental measurements in a volunteer with total bidirectional eyelid paralysis. The subject was then fitted with a prototype to check the performance of the device and its success. Results: With MMLP, eye opening was restored to near normal, and blinking was fully automated in close synchrony with the motor-driven polarity reversal, with full closure on the blink. The device was well tolerated, and the participant was pleased with the comfort and performance. Conclusions: FEA simulation results conformed to the experimentally observed trend, further supporting the proof of concept and design parameters. This is the first viable approach in human patients with proof of concept for complete reanimation of a bidirectionally paretic eyelid. Further study is warranted to refine the prototype and determine the feasibility and safety of prolonged use. Translational Relevance: This is first proof of concept for our device for total bidirectional eyelid paralysis.

Blink Lagophthalmos in Graves Orbitopathy.

PURPOSE: To investigate the relationship between the kinematics of spontaneous blinks and the anterior area of the levator palpebrae superioris muscle in patients with Graves orbitopathy (GO). METHODS: This is a case-control study. The authors measured the margin reflex distance of the upper eyelid (margin reflex distance 1), the kinematics of spontaneous blinks, and the anterior area of levator palpebrae superioris muscle in CT coronal scans of patients with Graves upper eyelid retraction (GO) and a control group. The eye with the greatest margin reflex distance 1 was selected for analysis in each group. RESULTS: A total of 68 participants were included, with 36 in the GO group and 32 in the control group. In the GO group, the mean margin reflex distance 1 measured 6.5 mm, while in the control group, it was 3.9 mm. Almost all parameters related to the closing phase of spontaneous blinking activity, including amplitude, velocity, blinking rate, and interblink time, did not differ between the two groups. However, the effectiveness of the blink's amplitude (ratio of blink amplitude to margin reflex distance 1) and the main sequence (relationship between amplitude and velocity) were significantly reduced in the GO group compared with the control group. The area of the levator palpebrae superioris muscle was significantly larger in GO than in controls, with 71.4% of patients' muscles outside of the maximum range of the controls. CONCLUSIONS: In patients with GO, there is a reduction in blinking effectiveness, also known as blink lagophthalmos, which is a factor in the common occurrence of ocular surface symptoms. The increase in velocity with amplitude is also reduced in GO.

Accuracy of Repetitive Ocular Vestibular-Evoked Myogenic Potentials to Diagnose Myasthenia Gravis in Patients With Ptosis or Diplopia.

BACKGROUND AND OBJECTIVES: We developed repetitive ocular vestibular-evoked myogenic potentials (roVEMP) as an electrophysiologic test that allows us to elicit the characteristic decrement of extraocular muscles in patients with ocular myasthenia gravis (OMG). Case-control studies demonstrated that roVEMP reliably differentiates patients with OMG from healthy controls. We now aimed to evaluate the diagnostic accuracy of roVEMP for OMG diagnosis in patients with ptosis and/or diplopia. METHODS: In this blinded prospective diagnostic accuracy trial, we compared roVEMP in 89 consecutive patients presenting with ptosis and/or diplopia suspicious of OMG with a multimodal diagnostic approach, including clinical examination, antibodies, edrophonium testing, repetitive nerve stimulation of accessory and facial nerves, and single-fiber EMG (SFEMG). We calculated the roVEMP decrement as the ratio between the mean of the first 2 responses compared with the mean of the sixth-ninth responses in the train and used cutoff of >9% (unilateral decrement) in a 30 Hz stimulation paradigm. RESULTS: Following a complete diagnostic work-up, 39 patients (44%) were diagnosed with ocular MG, while 50 patients (56%) had various other neuro-ophthalmologic conditions, but not MG (non-MG). roVEMP yielded 88.2% sensitivity, 30.2% specificity, 50% positive predictive value (PPV), and 76.5% negative predictive value (NPV). For comparison, SFEMG resulted in 75% sensitivity, 56% specificity, 55.1% PPV, and 75.7% NPV. All other diagnostic tests (except for the ice pack test) also yielded significantly higher positive results in patients with MG compared with non-MG. DISCUSSION: The study revealed a high sensitivity of 88.2% for roVEMP in OMG, but specificity and PPV were too low to allow for the OMG diagnosis as a single test. Thus, differentiating ocular MG from other neuro-ophthalmologic conditions remains challenging, and the highest diagnostic accuracy is still obtained by a multimodal approach. In this study, roVEMP can complement the diagnostic armamentarium for the diagnosis of MG. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that in patients with diplopia and ptosis, roVEMP alone does not accurately distinguish MG from non-MG disorders. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov: NCT03049956.

Wearable apparatus for correction of visual alignment under torsional strabismus.

SIGNIFICANCE: A wearable optical apparatus that compensates for eye misalignment (strabismus) to correct for double vision (diplopia) is proposed. In contrast to prism lenses, commonly used to compensate for horizontal and/or vertical misalignment, the proposed approach is able to compensate for any combination of horizontal, vertical, and torsional misalignment. PURPOSE: If the action of the extraocular muscles is compromised (e.g., by nerve damage), a patient may lose their ability to maintain visual alignment, negatively affecting their binocular fusion and stereo depth perception capability. Torsional misalignment cannot be mitigated by standard Fresnel prism lenses. Surgical procedures intended to correct torsional misalignment may be unpredictable. A wearable device able to rectify visual alignment and restore stereo depth perception without surgical intervention could potentially be of great value to people with strabismus. METHODS: We propose a novel lightweight wearable optical device for visual alignment correction. The device comprises two mirrors and a Fresnel prism, arranged in such a way that together they rotationally shift the view seen by the affected eye horizontally, vertically, and torsionally. The extent of the alignment correction on each axis can be arbitrarily adjusted according to the patient's particular misalignment characteristics. RESULTS: The proposed approach was tested by computer simulation, and a prototype device was manufactured. The prototype device was tested by a strabismus patient exhibiting horizontal and torsional misalignment. In these tests, the device was found to function as intended, allowing the patient to enjoy binocular fusion and stereo depth perception while wearing the device for daily activities over a period of several months. CONCLUSIONS: The proposed device is effective in correcting arbitrary horizontal, vertical, and torsional misalignment of the eyes. The results of the initial testing performed are highly encouraging. Future study is warranted to formally assess the effectiveness of the device on multiple test patients.

Asymmetric proptosis in thyroid eye disease.

PURPOSE: Patients with thyroid eye disease (TED) can present with asymmetric disease. The purpose of this study was to evaluate the prevalence of asymmetric TED in an Australian cohort and investigate clinical, biochemical, and radiological associations of asymmetric TED. METHODS: This was a retrospective study of patients with TED who underwent Hertel exophthalmometry and orbital computed tomography (CT) scans. Asymmetry was defined as a difference in the globe protrusion of ≥ 3 mm using Hertel exophthalmometry. Data was collected on patient demographics, clinical disease presentation, thyroid function tests and antibody levels. Muscles volumes were determined by manually segmenting the extraocular muscles on CT scans using a commercially available software. RESULTS: 172 orbits from 86 patients were included in the study. 28 (33%) patients had asymmetric TED. No significant differences were observed in age, gender, thyroid hormone status, anti-thyroid peroxidase levels, thyroid stimulating hormone receptor antibodies, disease activity status, or dysthyroid optic neuropathy between the asymmetric and non-asymmetric groups. The extraocular muscle volumes were significantly higher in the asymmetric orbit compared to its contralateral orbit. CONCLUSION: Asymmetric TED is a reasonably common occurrence in the course of TED. It is associated with higher extraocular muscle volumes, suggesting muscle enlargement as one of the underlying contributors to asymmetric proptosis. Thyroid eye disease should be considered in the differential of asymmetric orbital inflammatory disease.

Combined recession and resection of the same lateral Rectus in the treatment of exotropia.

BACKGROUND: Besides rest position abnormalities, exotropia could also be due to hypertonia of the Lateral Recti (LR) given divergence frequently decreases under general anesthesia (GA). Combined Recession-Resection of the Same Muscle (RRSM) is a promising alternative to the Faden procedure in the surgical treatment of overacting MR in esotropia. We thus examined here the effectiveness of combined RRSM of the LR for the treatment of exotropia that decrease under GA. METHODS: We performed a retrospective, single-center evaluation over a 16-month period of 100 patients operated on for exotropia that decreased under deep GA (91% of 110 consecutive operated cases). We excluded re-operations and pure convergence insufficiencies. We performed a combined RRSM of one or two LR. It included a 10mm-recession and a "fine-tuned" resection of LR based on Quantitative Forced Duction Test scores. MR resection was combined when exotropia exceeded 35PD or for unilateral surgery. We report on patient outcomes 6 months after surgery. RESULTS: Successful results were obtained (-8-+8 PD measured on Alternate Cover Test) among 83% of cases at distance fixation and 91% at near fixation after 6 months. The Newcastle Control Score also improved from 5.8 to 1.7 after 6 months. No surgery-related complications or repeat surgeries were reported. CONCLUSIONS: In our experience a majority of exotropias decrease under GA and our strategy of combined RRSM of the LR is effective for the treatment of such exotropias. Long-term follow-up of the cohort is required to investigate the stability of these outcomes, and confirmation of our results by other works.

Outcome Comparison of Transconjunctival Müller's Muscle Recession With Levator Disinsertion (TMRLD) to Gold Weight Implantation in the Treatment of Paralytic Lagophthalmos.

PURPOSE: To compare clinical outcomes of transconjunctival Müller's muscle recession with levator disinsertion (TMRLD) to the traditional gold weight implantation in patients with paralytic lagophthalmos. METHODS: A retrospective nonrandomized comparative review of patients who had gold weight implantation and TMRLD surgeries for paralytic lagophthalmos from January 2016 to January 2023 was performed. The main outcome comparisons were measurement changes in lagophthalmos, marginal reflex distance 1, visual acuity, and corneal examination. Complication and reoperation rates were also compared. RESULTS: Twenty-six cases of gold weight implantation and 20 cases of TMRLD surgeries were identified. The changes in logMAR visual acuity between gold weight implantation and TMRLD groups were not statistically significant (-0.10 ± 0.48 vs. +0.05 ± 0.14, p > 0.05). The percent improvement in lagophthalmos (62.2% ± 51.8% vs. 58.4% ± 21.1%) and final marginal reflex distance 1 (2.22 ± 1.42 vs. 2.25 ± 1.41 mm) were also comparable between groups ( p > 0.05). Both groups showed similar changes in marginal reflex distance 1 (1.75 ± 1.31 vs. 2.83 ± 1.37 mm) and lagophthalmos (3.77 ± 3.92 vs. 3.36 ± 1.36 mm) ( p > 0.05). The overall complication (15.4% vs. 15.0%) and reoperation rates (15.4% vs. 15.0%) were comparable over the follow-up duration (291.6 ± 437.3 vs. 121.0 ± 177.8 days) ( p > 0.05). CONCLUSION: TMRLD is as safe and effective as the gold weight implantation in addressing paralytic lagophthalmos in patients with facial nerve palsy.

Trocleítis bilateral corticodependiente / Corticodependent bilateral trochleitis

La trocleítis es habitualmente una inflamación transitoria, unilateral y no incapacitante de la tróclea del oblicuo superior. Presentamos el caso de una trocleítis bilateral en mujer de 29 años de evolución tórpida. Tras estudio etiológico exhaustivo con pruebas de neuroimagen, análisis de autoinmunidad e infeccioso no se encontró ninguna causa subyacente. Precisó múltiples infiltraciones en ambos ojos con efecto parcial. Finalmente se decidió intervención quirúrgica para exploración visual de la tróclea, toma de biopsias e infiltración de metilprednisolona que resultaron eficaces en el alivio sintomático. Este caso es excepcional por su bilateralidad y severidad, suponiendo un desafío terapéutico para el equipo clínico (AU)

Trochleitis is usually a transient and non-disabling inflammation of the trochlea of superior oblique. The case is presented of a difficult to manage bilateral trochleitis in a 29-year-old woman. After an exhaustive aetiological study with neuro-imaging tests, as well as an analysis of autoimmunity and infection, no underlying cause was found. Multiple injections of corticosteroids were required in both eyes, with a partial effect. Surgical intervention was finally decided in order to visually examine the trochlea, take biopsies, and inject methylprednisolone. These were effective in relieving the symptoms. This case is exceptional due to it involving both eyes and its severity, and represented a therapeutic challenge for the clinical team (AU)

Adjustable Sutures in the Treatment of Strabismus: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the scientific literature that evaluates the effectiveness of adjustable sutures in the management of strabismus for adult and pediatric patients. METHODS: Literature searches were performed in the PubMed database through April 2021 with no date limitations and were restricted to publications in English. The searches identified 551 relevant citations, of which 55 were reviewed in full text. Of these, 17 articles met the inclusion criteria and were assigned a level of evidence rating by the panel methodologist. The search included all randomized controlled studies regardless of study size and cohort studies of 100 or more patients comparing the adjustable versus nonadjustable suture technique, with a focus on motor alignment outcomes or reoperation rates. RESULTS: The literature search yielded no level I studies. Of the 17 articles that met the inclusion criteria, 11 were rated level II and 6 were rated level III. Among the 12 studies that focused on motor alignment outcomes, 4 small randomized clinical trials (RCTs) did not find a statistically significant difference between groups, although they were powered to detect only very large differences. Seven of 8 nonrandomized studies found a statistically significant difference in motor alignment success in favor of the adjustable suture technique, both overall and in certain subgroups of patients. Successful motor alignment was seen in both exotropia (in 3 studies that were not limited to children) and esotropia (in 1 study of adults and 2 of children). The majority of included studies that reported on reoperation rates found the rates to be lower in patients who underwent strabismus surgery with adjustable sutures, but this finding was not uniformly demonstrated. CONCLUSIONS: Although there are no level I studies evaluating the effectiveness of adjustable sutures for strabismus surgery, the majority of nonrandomized studies that met the inclusion criteria for this assessment reported an advantage of the adjustable suture technique over the nonadjustable technique with respect to motor alignment outcomes. This finding was not uniformly demonstrated among all studies reviewed and warrants further investigation in the development and analysis of adjustable suture techniques.

Morphological change of the posterior pole following the horizontal strabismus surgery with swept source optical coherence tomography.

Extraocular muscle movement during strabismus surgery causes changes in eyeball shape. Because extraocular muscle insertion is in front of the equator, it is thought that changes due to strabismus surgery mainly occur in the anterior segment. However, changes in the posterior segment of eye may also occur, which may also result in changes in refractive error after strabismus surgery. Using a 3-dimensional reconstruction technique (en face imaging) of the swept source optical coherence tomography, we determined and quantitatively measured the posterior polar change. The deepest interface between Bruch's membrane and the choroid could be identified as the deepest point of the eyeball (DPE), and the location of the DPE relative to the optic disc and the fovea was measured. After lateral rectus muscle recession, the DPE moved away from the fovea, but after medial rectus muscle recession, the DPE moved toward the fovea. The amount of DPE movement differed by age and preoperative refractive error. Our findings suggest that the positional shift of the rectus muscle in horizontal strabismus surgery causes a structural change in the posterior segment of the eye, and the postoperative refractive changes may be related to this shift.

Treatment of Severe Ptosis by Conjoint Fascial Sheath Suspension.

OBJECTIVE: To explore the role of conjoint fascial sheath (CFS) suspension in the treatment of severe ptosis. METHODS: A total of 110 patients with severe ptosis who were admitted to our hospital from May 2018 to December 2020 were included. Fifty-seven patients treated with frontalis suspension were assigned into group A, and the remaining 53 patients treated with CFS suspension were assigned into group B. The curative effect, ocular surface alterations, complications, and satisfaction in the two groups were compared. RESULTS: Patients in group B suffered from severe upper eyelid retraction and lid lag than those in group A, as well as more limited range of motion (ROM) (P < 0.05). The curative effect and patient satisfaction in group B were higher than those in group A (P < 0.05). Postsurgical complications in group B were fewer than those in group A (P < 0.05). CONCLUSION: CFS suspension is effective in the treatment of severe ptosis.

Velocity Discrimination in Infantile Nystagmus Syndrome.

Purpose: Research on infantile nystagmus syndrome (INS) and velocity discrimination is limited, and no research has examined velocity discrimination in subjects with INS at their null position and away from it. This study aims to investigate how individuals with INS perform, compared with controls, when carrying out velocity discrimination tasks. Particularly, the study aims to assess how the null position affects their performance. Methods: INS subjects (N = 21, mean age 24 years; age range, 15-34 years) and controls (N = 16, mean age 26 years; age range, 22-39 years) performed horizontal and vertical velocity discrimination tasks at two gaze positions. Eighteen INS subjects were classified as idiopathic INS and three had associated visual disorders (two had oculocutaneous albinism, and one had congenital cataract). For INS subjects, testing was done at the null position and 15° away from it. If there was no null, testing was done at primary gaze position and 15° away from primary. For controls, testing was done at primary gaze position and 20° away from primary. Horizontal and vertical velocity discrimination thresholds were determined and analyzed. Results: INS subjects showed significantly higher horizontal and vertical velocity discrimination thresholds compared with controls at both gaze positions (P < 0.001). Horizontal thresholds for INS subjects were elevated more than vertical thresholds (P < 0.0001) for INS subjects but not for controls. Within the INS group, 12 INS subjects who had an identified null position showed significantly lower horizontal and vertical thresholds at the null than at 15° away from it (P < 0.05). Conclusions: Velocity discrimination was impaired in INS subjects, with better performance at the null. These findings could assist in understanding how INS affects the daily activities of patients in tasks involving moving objects, and aid in developing new clinical visual function assessments for INS.

A novel diagnostic method for myasthenia gravis.

INTRODUCTION/AIMS: Videonystagmography (VNG) which directly records eye movements using infrared video goggles with mini-cameras, is used to measure nystagmus. Our aim is to explore whether VNG can be used to detect a decrement in the extraocular muscle (EOM) activity of patients with myasthenia gravis (MG). METHODS: Thirty-four patients with MG, including 13 with ocular-predominant and 21 with generalized MG, and 23 healthy controls participated. Using VNG we recorded the velocity of the eye movements of the patients as they followed a moving target. We then calculated the gain by dividing the eye movement velocity (degrees/second) by the target velocity (degrees/second). RESULTS: In MG subjects, the mean initial gain (maximum gain) was 1.23 ± 0.31 (range: 0.63-2.15) for the right eye and 1.22 ± 0.37 (range; 0.60-2.28) for the left eye. The mean minimum gain was 0.11 ± 0.12 (0.01-0.58) for the right and 0.14 ± 0.5 (0.02-0.55) for the left. Due to fatigue, the movement gain was reduced by 91.7% in the right eye and 88.2% in the left eye. After reaching minimum velocity, gain remained at a minimum for a mean of 1.08 ± 0.52 (0.3-2.4) s for the right and 1.49 ± 0.85 (0.4-3.6) s for the left, before the velocity increased again. There was no fatigue-induced decrement in healthy subjects. DISCUSSION: Our study documents a decrement in EOM activity recorded by VNG in patients with MG which begins to improve within 1-2 s after reaching minimum velocity, analogous to traditional low-frequency repetitive nerve stimulation testing and its U-shaped pattern. Thus, VNG may be a promising diagnostic test for MG.

Resection of Oculomotor Nerve Lesions Using Continuous Stimulation of the Oculomotor Nerve Proximal to the Lesion: A Technical Report.

BACKGROUND: We describe a continuous monitoring method aimed at preserving nerve function during biopsy of lesions on the oculomotor nerve using stimulation of the oculomotor nerve proximal to the lesion. CASE DESCRIPTION: A 5-year-old girl with a recurrent left oculomotor nerve palsy and contrast-enhancing left oculomotor nerve mass on magnetic resonance imaging underwent a biopsy of the lesion to aid in its diagnosis. At the time of surgery, needle electrodes were inserted into the superior and inferior rectus muscles percutaneously, and cotton-covered electrodes were implanted into the oculomotor nerve proximal to the lesion. Compound muscle action potentials of the oculomotor nerve were measured continuously by monopolar stimulation. The lesion was mapped by direct stimulation, and the unresponsive area was excised. The amplitude of the compound muscle action potentials decreased during the resection but recovered postoperatively. After resection of the lesion, the compound muscle action potentials remained the same as they were preoperatively. No obvious postoperative oculomotor nerve palsy was observed. CONCLUSIONS: This method of continuous monitoring of the function of the oculomotor nerve is simple to use and is suitable for lesions in close proximity to the oculomotor nerve.

Botulinum Toxin Injection for the Treatment of Strabismus: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the available evidence comparing the effectiveness of extraocular muscle botulinum toxin type A (BTXA) injection with eye muscle surgery for restoring ocular alignment in children and adults with nonparalytic, nonrestrictive horizontal strabismus. METHODS: Literature searches in the PubMed Cochrane Library, and clinical trial databases with no date restrictions, but limited to articles published in English, were conducted last on January 10, 2021. The searches yielded 515 citations, 40 of which were reviewed in full text by the first author. Fourteen articles met the criteria for inclusion (randomized or nonrandomized comparative studies, or case series with a minimum 50 patients; evaluating extraocular muscle BTXA injection for initial or repeat treatment of horizontal, nonparalytic, nonrestrictive strabismus; with at least 6 months of follow-up) and were graded by a methodologist. RESULTS: The 14 included studies consisted of 2 randomized clinical trials, 3 nonrandomized comparative studies, and 9 case series. All 5 comparative studies were graded level II evidence, and the 9 case series were graded level III evidence. Successful motor outcomes after BTXA injection were relatively consistent across 4 of the 5 comparative studies at 60%, when adjustment was made for differential selection bias in 1 of the studies. In the 4 studies, successful motor outcomes after surgery ranged from 66% to 77% with a mean follow-up of 23 to 75 months, and the outcomes were not significantly different from those after BTXA injection. In the fifth level II study, success was significantly higher with BTXA injection than with surgery (94% vs. 72%). The level III BTXA case series demonstrated higher motor success rates of 87% to 89% when children were treated in 2 muscles at a time; rates were lower in adults treated with single-muscle BTXA injection. CONCLUSIONS: Extraocular muscle injection of BTXA achieves a high rate of successful motor alignment, comparable with that achieved after eye muscle surgery for nonparalytic, nonrestrictive horizontal strabismus. Good alignment may require multiple BTXA injections, and it is not yet clear whether sensory outcomes are equivalent for BTXA injections versus eye muscle surgery in young children.

Characterization of the position of the extraocular muscles and orbit in acquired esotropia both at distance and near using orbital magnetic resonance imaging.

PURPOSE: Age-related distance esotropia (ARDE) involves acquired esotropia at distance and phoria at near. However, distance-independent esotropia (DIE) exists esotropia both at distance and near. Thus, we examined the orbital magnetic resonance imaging (MRI) findings for DIE to assess differences in its characteristics. METHODS: This study was a retrospective case-control study. We evaluated the efficacy of the standard coronal MRI in patients with acquired esotropia and control patients with optic neuritis. Cases with strabismus in the control group were excluded. DIE was defined as having esotropia both at distance and near, and an angle of more than 10 prism diopters at near. The condition of the lateral rectus-superior rectus band, position of rectus muscles, and the volume ratio of the globe to the whole orbit (G/WO) were examined. RESULTS: The DIE group consisted of 12 eyes of 6 patients (77.3±7.7 years); ARDE group, 38 eyes of 19 patients (73.1±6.8 years); and control group, 34 eyes of 17 patients (70.9±4.3 years). The ratio of abnormality of the lateral rectus-superior rectus bands was higher in the DIE and ARDE groups than in the control group (p<0.01). The vertical angle of the lateral rectus deviated downwards in the control (-7.5±5.1°), ARDE (-12.2±9.1°), and DIE groups (-18.8±5.7°) (p<0.05). The tilting angle of the lateral rectus was tilted temporally in the control (-12.2±9.1°), ARDE (-20.0±8.6°) and DIE groups (-28.6±5.4°) (p<0.01). G/WO was higher in the DIE (0.28±0.01) and ARDE groups (0.27±0.02) compared to the control (0.25±0.03) group (p<0.01). CONCLUSION: In comparison with the ARDE and control groups, the DIE group presented with abnormalities of the lateral rectus-superior rectus band, malposition of the lateral rectus, and differences in the G/WO. The DIE group showed a more severe form of ARDE.

Primary and secondary superior rectus recessions to correct vertical deviations in Graves' orbitopathy patients.

PURPOSE: Patients with vertical strabismus and consecutive diplopia due to Graves' orbitopathy (GO) might need recession of the rectus superior muscle. The aim of this retrospective analysis is to provide dose-effect values and motility analysis for these patients. METHODS: Dose-effect relations (deviation reduction in primary position per amount of recession in mm), monocular excursions and size of the field of binocular single vision (BSV) were evaluated in three different groups of patients. Group 1 (n = 33) patients with primary fibrosis of superior rectus muscle undergoing recession of the ipsilateral rectus superior, Group 2 (n = 14) superior rectus muscle recession after recession of inferior rectus on the contralateral eye and Group 3 (n = 15) simultaneous ipsilateral superior rectus recession and contralateral inferior rectus muscle recession. Surgery was performed using the dose-effect for inferior rectus recession of 4 prism dioptre (PD,Δ ) reduction/per mm recession and the intraoperative traction test. RESULTS: Restoration of BSV in the central 20° of gaze could be reached in 88%, 79% and 67% of patients in the three groups, respectively. Restoration of BSV in downgaze (up to 30°) was a little less successful, 79%, 57% and 53%, respectively. The median dose-effect was 3.2Δ reduction/mm recession in Group 1 (Spearman correlation r = 0.75, p < 0.0001) and 3.3Δ /mm in Group 2 (n.s.) and 4Δ /mm in Group 3 (r = 0.67, p = 0.016). The basis for the improvement was the symmetrization of ductions. CONCLUSION: If superior rectus recession is necessary in GO, higher dosing around 3Δ reduction/per mm recession should be applied. In case of large deviations, combined vertical surgery (inferior rectus and superior rectus contralateral) is required and reasonable (low cyclotorsion). Single-step or two-step procedures lead to similar results.

Preserved eye movements in adults with spinal muscular atrophy.

INTRODUCTION: Spinal muscular atrophy (SMA) most prominently affects proximal limb and bulbar muscles. Despite older case descriptions, ocular motor neuron palsies or other oculomotor abnormalities are not considered part of the phenotype. METHODS: We investigated oculomotor function by testing saccadic eye movements of 15 patients with SMA. Their performance was compared with that of age-matched healthy controls. Horizontal rightward and leftward saccades were recorded by means of video-oculography, whereas subjects looked at light-emitting diode targets placed at ±5°, ±10°, and ±15° eccentricities. RESULTS: No differences in saccade amplitude gains, peak velocities, peak velocity-to-amplitude ratios, or durations were observed between controls and patients. More specifically, for 5° target eccentricities, patients had a mean saccadic peak velocity of 153°/s, whereas for 10° and 15° these values were 268°/s and 298°/s, respectively. The corresponding mean peak velocities of the control group were 151°/s, 264°/s, and 291°/s. DISCUSSION: Our results indicate that patients with SMA perform fast and accurate horizontal saccades without evidence of extraocular muscle weakness. These quantitative oculomotor data corroborate clinical experience that neuro-ophthalmic symptoms in SMA are not common and, if present, should prompt suspicion for an alternative neuromuscular disorder.