Piggy back en el tratamiento de la sorpresa refractiva hipermetrópica / Piggy Back in the treatment of the hypermetropic refractive surprise

La técnica de piggy back o el implante de dos lentes intraoculares se plantea principalmente cuando se precisa la corrección de más de 30 dioptrías en la cirugía del cristalino. Lentes por encima de 34 dioptrías no están disponibles comercialmente, a la vez que lentes de más de 30 dioptrías no se recomiendan por la aberración esférica que produce una superficie óptica con un radio de curvatura demasiado pequeño. Se presenta un paciente de 47 años de edad con antecedentes de cirugía refractiva corneal previa en ambos ojos, pero portador de una hipermetropía elevada en su ojo derecho y, por tanto, una anisometropía hipermetrópica para lo cual se decide, como opción terapéutica, realizar la extracción del cristalino del ojo derecho y el implante de dos lentes: uno en saco capsular y otro en sulcus ciliar. Se obtuvo corrección del defecto refractivo del paciente sin complicaciones

The Piggy Back technique or the implant of two lens is proposed mainly when it is necessary the correction of more than 30 diopters in crystalline lens surgery. The lens above 34 diopters are not available in the market at the same time that the lens of more than 30 diopters are not recommendable due to the spherical aberration producing an optical surface with a very small curvature.radius. This is the case of a patient aged 47 with backgrounds of previous corneal refractive surgery in both eyes, but carrier of a high hypermetropia in his right eye and thus, a hypermetropic anisometropia leading to as therapeutical option, to carried out the crystalline extraction of right eye and the implant of both lens: one in capsular sac and other in ciliary sulcus. The correction of the refractive defect of this patient was achieved without complications

[Möbius sequence: long-term strabismus surgical outcome]. / Seqüência de Möbius: resultados a longo prazo, da correção cirúrgica do estrabismo.

PURPOSE: To analyze the long-term results in a consecutive series of Möbius sequence patients, who underwent surgical correction of strabismus. METHODS: Ten patients with Möbius sequence fulfilled the inclusion criteria of this study. All patients presented esotropia at the preoperative examination, above or equal to 15 prismatic diopters (DP) varying from 15 to 85. All patients presented lateral rectus muscles severe underaction, six presented hipertropia above or equal 10 DP associated with esodeviation, and five presented anisotropia in A or in V. The patients were operated upon protocol, in a consecutive way, in July 2002. Patients were reexamined periodically, and at 2nd postoperative year as for: the visual acuity; deviation measurements; ocular rotations; cosmetic aspect and socialization. RESULTS: The patients presented satisfactory surgical results in eight cases, considering an eso or exodeviation up to 15 DP and a hipertropia lower than 10 DP. Four (40%) patients presented correction of the preoperative anisotropia. Variation of ocular deviation in the primary position (from the 90th day to the 2nd postoperative year was observed) in 9 patients (90%), demonstrating that strabismus surgical stabilization needs time. CONCLUSIONS: The surgical results were considered satisfactory, improving patient self-esteem and the parent satisfaction, making the social inclusion easier.

Seqüência de Möbius: resultados a longo prazo, da correção cirúrgica do estrabismo / Mõbius sequence: long-term strabismus surgical outcome

OBJETIVOS: Analisar os resultados cirúrgicos, a longo prazo, em uma série consecutiva de pacientes com a seqüência de Mõbius, submetidos à correção cirúrgica do estrabismo. MÉTODOS: Dez portadores da seqüência de Mõbius atenderam aos critérios de inclusão. Todos apresentaram esotropia no exame pré-operatório maior ou igual a 15 dioptrias prismáticas (DP), variando de 15 a 85. Todos os pacientes demonstraram hipofunção dos músculos retos laterais, seis, apresentaram hipertropia associada maior ou igual que 10 DP e, cinco, anisotropia em A ou em V. Os pacientes foram submetidos de forma consecutiva à cirurgia para a correção do estrabismo em julho de 2002, de acordo com protocolo previamente elaborado. Todos os casos foram reavaliados periodicamente, analisando-se o resultado visual final no segundo ano pós-operatório, quanto a: acuidade visual, desvio ocular, rotações oculares, estética e socialização. RESULTADOS: Os pacientes apresentaram resultado cirúrgico satisfatório final em oito casos, considerando-se um eso ou exo desvio de até 15 DP e uma hipertropia menor que 10 DP. Quatro (40 por cento) pacientes apresentaram correção da anisotropia pré-operatória. Observou-se variação do desvio ocular em posição primária do olhar (entre o 90° dia e o 2° ano pós-operatório) em 9 pacientes (90 por cento), demonstrando que a estabilização da correção cirúrgica do estrabismo requer tempo. CONCLUSÕES: O resultado cirúrgico final mostrou-se bastante satisfatório, elevando a auto-estima dos pacientes e a de seus genitores, facilitando a sua inclusão social.

PURPOSE: To analyze the long-term results in a consecutive series of Mõbius sequence patients, who underwent surgical correction of strabismus. METHODS: Ten patients with Mõbius sequence fulfilled the inclusion criteria of this study. All patients presented esotropia at the preoperative examination, above or equal to 15 prismatic diopters (DP) varying from 15 to 85. All patients presented lateral rectus muscles severe underaction, six presented hipertropia above or equal 10 DP associated with esodeviation, and five presented anisotropia in A or in V. The patients were operated upon protocol, in a consecutive way, in July 2002. Patients were reexamined periodically, and at 2nd postoperative year as for: the visual acuity; deviation measurements; ocular rotations; cosmetic aspect and socialization. RESULTS: The patients presented satisfactory surgical results in eight cases, considering an eso or exodeviation up to 15 DP and a hipertropia lower than 10 DP. Four (40 percent) patients presented correction of the preoperative anisotropia. Variation of ocular deviation in the primary position (from the 90th day to the 2nd postoperative year was observed) in 9 patients (90 percent), demonstrating that strabismus surgical stabilization needs time. CONCLUSIONS: The surgical results were considered satisfactory, improving patient self-esteem and the parent satisfaction, making the social inclusion easier.

[LASIK for high anisometropia in adults: case report]. / LASIK em pacientes adultos com alta anisometropia: relato de casos.

PURPOSE: To evaluate the efficacy of the laser in situ keratomileusis (LASIK) technique in the reduction of anisometropy in adults, for whom conventional treatment was not successful. METHODS: A sequence of cases of three eyes of three adult patients, two females and one male, age ranging from 28 and 49 years (average 38.3 years), who underwent LASIK. Two patients were followed up for eighteen months and one for six months. RESULTS: Comparing the corrected visual acuity before surgery with the non-corrected visual acuity after surgery, one eye gained two lines of vision, one eye remained the same and one eye lost one line of vision. All eyes remained without spheric refraction, and astigmatism did not exceed -0.75 D after surgery. There has been an improvement in the symptoms of asthenopia in the three patients. CONCLUSION: The LASIK technique proved to be efficient in the correction of anisometropy in adults, improving visual accuity and asthenopia complaints, and leading to a similar refraction in both eyes.

LASIK em pacientes adultos com alta anisometropia: relato de casos / LASIK for high anisometropia in adults: case report

OBJETIVO: Avaliar a eficácia da técnica laser in situ keratomileusis (LASIK) na redução de anisometropia em adultos, para os quais os tratamentos convencionais não tiveram sucesso. MÉTODOS: Série de casos de três olhos de três pacientes adultos, dois do sexo feminino e um do sexo masculino, com idade entre 28 e 49 anos (média de 38,3 anos), os quais foram submetidos à técnica de LASIK. Dois pacientes foram acompanhados por dezoito meses e um por seis meses após a cirurgia. RESULTADOS: Comparando a acuidade visual corrigida do pré-operatório com a acuidade visual não corrigida do pós-operatório, um olho ganhou duas linhas de visão, um olho manteve-se igual e um olho perdeu uma linha de visão. Todos os olhos se mantiveram sem ametropia esférica, e o astigmatismo não excedeu -0,75 D no pós-operatório. CONCLUSÃO: A técnica LASIK mostrou-se eficaz na correção de alta anisometropia em adultos, melhorando a acuidade visual e as queixas astenopéicas, e diminuindo a anisometropia.

Vertical transposition of medial rectus muscles for correction of A-pattern anisotropia.

BACKGROUND AND PURPOSE: A-pattern esotropias without superior oblique muscle overaction form a small but distinct group among A and V pattern anisotropias. The purpose of this study was to determine the results of ungraded 5 mm bilateral medial rectus muscle transpositions as a treatment of A anisotropia in esotropic patients, and to study these results with relation to the magnitude of preoperative A anisotropia and to the magnitude of preoperative esotropia in primary position. METHODS: Patient data on all 37 esotropic patients who had 5 mm elevation of the medial rectus muscle insertion for correction of A anisotropia at our institution during the previous 25 years were studied. We considered the surgical result to be "satisfactory" when a total correction, and A pattern less than 10 Prism Diopters (PD) or a V pattern less than 15 PD were obtained. The patients were divided into different groups, according to the magnitude of the preoperative A pattern and according to the magnitude of the preoperative esotropia in primary position. For statistical analysis, the Chi Square and the Fisher Tests were employed. RESULTS: "Satisfactory" results were found in 70.3% of the cases. The mean correction of A anisotropia was 11.4 PD (76.1%), which corresponded to 2.3 PD per millimeter of transposition. "Unsatisfactory" results were more prevalent in patients with esotropia in primary position larger than 40 PD (p=0.0418). CONCLUSIONS: A five millimeter vertical transposition (elevation) of both medial rectus muscles is an effective treatment for correction of A anisotropia in most esotropic patients, but is associated with unsatisfactory results when the preoperative esotropia in primary position is larger than 40 PD.

Laser in situ keratomileusis in children 8 to 15 years old.

PURPOSE: To determine the safety, efficacy, predictability, and stability of laser in situ keratomileusis (LASIK) to correct high myopia or high myopic astigmatism in patients with high anisometropia in whom conventional treatments have failed. METHODS: Nine eyes of nine patients, three boys and six girls with high anisometropia (>3.50 D), were included in this study. Patient age was 8 to 15 years. Minimum follow-up was 12 months. All patients were treated with the Chiron Technolas 217 excimer laser. RESULTS: Three months after LASIK, uncorrected visual acuity improved by at least five Snellen lines in all eyes. Three eyes (33.3%) were 20/40 or better without correction. Due to dense amblyopia, no eye had uncorrected visual acuity of 20/20 or better. The mean spherical equivalent refraction decreased from -7.66 to -0.22 D, and mean preoperative astigmatism decreased from -3.11 to -0.69 D. Eight eyes (88.8%) were within +/-1.00 D of emmetropia. Two eyes (22.2%) were within +/-0.50 D of the desired outcome. All patients were able to function binocularly. CONCLUSION: In this study of selected older children, LASIK was a safe and effective option for the correction of high anisometropia and for improved binocularity, when conventional therapies had failed. Further study is necessary to determine the long-term refractive stability in these young patients.

Efeito do debilitamento do músculo oblíquo superior hiperfuncionanteassociado à anteriorizaçäo do músculo oblíquo inferior na divergência vertical dissociada / Debility effect of overacting superior oblique muscle associated with anteriority of the inferior oblique muscle in dissociated vertical deviation

Objetivo: Analisar o efeito do debilitamento do oblíquo superior associado à transposiçäo anterior do oblíquo inferior em casos de pacientes com DVD (divergência vertical dissociada) e hiperfunçäo do músculo oblíquo superior (HOS). Métodos: Em 14 pacientes foram analisadas a correçäo média da divergência vertical dissociada da hiperfunçäo do músculo oblíquo superior e da anisotropia em A. A cirurgia de tenectomia do oblíquo superior e a transposiçäo anterior do músculo oblíquo inferior foram realizadas nos 28 olhos. Resulta-dos: A reduçäo da divergência vertical dissociada foi de 65,5 por cento no olho direito (OD) e de 61,3 por cento no olho esquerdo (OE). A correçäo da hiperfunçäo do músculo oblíquo superior foi de 85,8 por cento no olho direito e de 85,0 por cento no olho esquerdo. Houve reduçäo de 92,2 por cento da anisotropia em A. Estas correçöes foram estatisticamente significantes (p<0,01). Conclusöes: A cirurgia proposta se mostrou eficaz na correçäo da divergência vertical dissociada e da hiperfunçäo do músculo oblíquo superior.

Piggyback posterior chamber multifocal intraocular lenses in anisometropia.

A 63-year-old white man with anisometropic hyperopia presented with cataract in both eyes. He had uneventful temporal limbal phacoemulsification with intracapsular placement of a multifocal 3-piece silicone intraocular lens (IOL) in his right eye (model SA-40N, Allergan, Inc.). One week later, 2 intracapsular 3-piece silicone IOLs (1 monofocal backward, Allergan model SI-40NB; 1 multifocal in front, Allergan model SA-40N) were implanted in his left eye. At 8 days postoperatively, uncorrected visual acuity was 20/20 for distance and J1 for near vision in the right eye and 20/30 and J2, respectively, in the left. These values remained constant until the patient was seen 7 months postoperatively. Power calculation and insertion order of the piggyback IOLs were considered.

Técnica cirúrgica para correçäo de miopia. Anel corneano intra-estromal / Myopia correction with intrastromal corneal ring

Os implantes intracorneanos para correçäo de ametropias vêm sendo pesquisados desde a década de 50. Os anéis corneanos intra estromais, por serem bem tolerados, vêm se destacando como um técnica alternativa segura para tratamento daas ametropias. Após prolongados estudos em animais, utilizando anéis com 5,00 mm de diâmetro e espessuras variáveis, reslizamos um implante em paciente míope e amblíope, no terço anterios do estroma corneano, utilizando a técnica de ceratectomia parcial. Após 3 anos de observaçäo clínica ficaram evidenciados e perfeita tolerância da córnea à prótese e a estabilidade do resultado refracional. Desenvolvemos a partir daí, uma técnica para implante do anel através de tunelizaçäo do estroma. Selecionamos um paciente míope, anisométrope e amblíope e realizamos a cirurgia. O resultado, após o primeiro mês de observaçäo, mostrou boa tolerância além de um aplanamento central da córnea de 3,00 dioptrias confirmado tanto pela ceratometria quanto pelo topografia corneana computadorizada. Embora o período de observaçäo seja muito pequeno, podemos afirmar, embasados em nossos estudos preliminares, que esta técnica representa uma alternativa promissora para o tratamento dos erros refracionais

Refracción y paquimetría postoperatoria con lente de Baikoff ZB5M en altas anisometrías miópicas / Postsurgical refraction and pachimetry with Baikoff ZB5M lens in myopic high anysometries

Se presenta el resultado de 7 casos de lentes de cámara anterior de Baikoff para miopía alta. La edad promedio fue 34.7 años. El equivalente esférico preoperativo fue -12.5 D y postoperativo fue -0.7 D. La paquimetría y el recuento de células endoteliales se estabilizó durante los primeros 3 meses y no hubo cambios después de 6 meses, la refracción es buena y latécnica es fácil de obtener con buenos resultados en la agudeza visual

Efeito da anteriorizacâo dos obliquos inferiores sobre a anisotropia em V / Effect of anteriorization of low obliques over anisotropia in V

A prospective analysis of 19 patients with dissociated deviation and/or inferior oblique overaction who had an anterior transposition of the inferior oblique was undertaken. The mean postoperative follow-up was 8,3 months. Clinical aspects of dissociated vertical deviation and inferior oblique overaction were studied. Thirty two anterior transpositions were performed on eyes with inferior oblique overaction and the mean correction was 77,6. The mean V patterns horizontal deviation at last followup was 8,4 for bilateral cases and 14,5 for unilateral cases. Conclusion, anterior transposition on the inferior oblique is an effective treatment for dissociated vertical deviation and inferior oblique overaction with beneficial effect on the V patterns

Tratamiento de la desviación vertical disociada / Treatment of dissociated vertical deviation

Se presentan los resultados de los tratamientos de la DVD bilateral asimétrica, monocular y la DVD asociada a hiperfunción de los oblicuos inferiores. En 35 pacientes se hicieron retroinserciones bilaterales asimétricas de los rectos superiores, obteniéndose buenos resultados en 25 pacientes. En 17 pacientes con DVD monocular se hizo retroinserción solamente de un recto superior, obteniéndose buenos resultados en 12 pacientes. En 19 pacientes se hizo una transposición anterior de los oblicuos inferiores para pacientes con DVD disociada a una hiperfunción de oblicuos inferiores, obteniéndose buenos resultados en 14 pacientes

Efectos del desplazamiento vertical de músculos horizontales y el debilitamiento de oblicuos superiores sobre la anisotropia en A / Effects of vertical displacement of the horizontal muscles and superior obliques weakening over A pattern

Revisadas 36 historias clínicas de pacientes operados de anisotropias en A, 19 casos sometidos a desplazamiento de R.Hs. y 17 a debilitamiento de O.Ss., se observó tendencia a mayor corrección de la A con este último procedimiento. En los casos sometidos a debilitamiento exclusivo de O.Ss., se produjo modificación del ángulo en PPM e infraversión que debe tenerse en cuenta para el plan quirúrgico

Anisotropias alfabéticas en V: cirugía de oblicuos inferiores versus cirugía de oblicuos superiores / Alphabetic anisotropies in V: inferiores obliques surgery versus superiores obliques surgery

De 17.071 historias clínicas privadas de uno de los autores, el 17 porciento (2.900 casos) fueron heterotropias de las cuales el 12.48 porciento (362 casos) fueron anisotropias alfabéticas y de ellas, el 61.60 porciento (223 casos) eran anisotropias en V. De éstas, 134 (el 60.09 porciento) se llevaron a cirugía. De acuerdo con una clasificación clínico quirúrgica basada en el diagnóstico correcto de los músculos directamente implicados en el síndrome, se intervinieron adecuadamente 120 casos (89.56 porciento); con diagnóstico dudoso o causa desconocida, 7 (5.22 porciento) y la cirugía no fue adecuada en 7 casos (5.22 porciento). Los resultados fueron buenos o excelentes en 123 casos (91,79 porciento); quedó un defecto residual importante en 5 pacientes (3.73 porciento) y se produjo un defecto consecutivo en 6 casos (4.48 porciento). Se precisan las indicaciones del debilitamiento de los oblicuos inferiores versus el fortalecimiento de los oblicuos superiores