Recently acquired diplopia in adults with long-standing strabismus.

BACKGROUND: The evaluation and management of recent-onset diplopia in an adult with a history of long-standing strabismus can be perplexing and challenging. No guidelines exist, to my knowledge, for the examination of such patients. DESIGN: A retrospective medical record review. SUBJECTS: Patients seen in my practice with a history of recently acquired diplopia and a history of strabismus dating back to childhood. RESULTS: One hundred fifty-two patients who met the enrollment criteria were identified. Using the treatment approach outlined herein, 132 patients were relieved of their symptoms of diplopia. In most cases, the onset of the diplopia could be correlated with a change in the patient's ocular alignment, refractive needs, or refractive management. Returning patients to their motor status before the onset of symptoms or addressing the change in refractive needs or management usually resulted in relief of symptoms. CONCLUSION: In most cases, adult patients with a history of long-standing strabismus and a recent onset of diplopia can be effectively treated.

Anterior segment ischemia after surgery on 2 vertical rectus muscles augmented with lateral fixation sutures.

Anterior segment ischemia is a rare but potentially serious complication of strabismus surgery. Anterior ischemia typically occurs after surgery on 3 or 4 rectus muscles. Advanced age, dysthyroid ophthalmopathy, and a history of previous strabismus surgery are known risk factors for this complication. This report reviews the case of a healthy 50-year-old patient who developed anterior segment ischemia after surgery on 2 rectus muscles.

Fifteen-year outcome of surgery for the near angle in patients with accommodative esotropia and a high accommodative convergence to accommodation ratio.

OBJECTIVE: To determine the 15-year outcome of patients with partly accommodative esotropia with a high accommodative convergence to accommodation (AC/A) ratio who underwent surgery based on the angle of esotropia at one-third meter while wearing full hyperopic correction. METHODS: A retrospective chart review to determine the 15-year outcome of 25 patients whose 6-month outcome had been previously reported as part of a prospective, randomized, masked clinical trial. All patients had partly accommodative esotropia with a high AC/A ratio and underwent surgery based on their esotropia at one-third meter while wearing full-distance optical correction. RESULTS: Fifteen years after surgery, 19 of the 22 patients for whom follow-up data are available had between 0 and less than 10 prism diopters of esotropia. Only 6 of the 19 needed to continue to wear optical correction to maintain satisfactory alignment; however, 8 more needed spectacles for visual purposes. Only 1 patient needed to use a bifocal add to have satisfactory alignment at one-third meter. All patients showed some degree of sensory fusion, with 4 obtaining 40 seconds of stereopsis and another 8 obtaining between 60 and 200 seconds of stereopsis. CONCLUSION: Surgery for the near angle obtained with patients wearing their full hyperopic distance correction provides excellent motor and sensory results in patients with partly accommodative esotropia with a high AC/A ratio.

Torsion as a contributing cause of the anti-elevation syndrome.

BACKGROUND: The anti-elevation syndrome is an adverse outcome of anterior transposition of the inferior oblique muscle. The presumed cause is an excessive anti-elevating force vector that occurs with attempted elevation in abduction. This causes apparent overaction of the contralateral inferior oblique muscle due to fixation duress. It has been suggested that excessive residual extorsion may help explain this phenomenon. METHODS: Fundus photographs to assess torsion were evaluated by masked observers in 18 patients who had undergone anterior transposition of the inferior oblique muscle. Eight of the patients were found to have the anti-elevation syndrome and 10 were not. RESULTS: Patients with the anti-elevation syndrome had more extorsion (mean, 16.6 degrees +/- 3.4 degrees ) than the patients who did not have the anti-elevation syndrome (mean, 8.8 degrees +/- 2.3 degrees ). This difference was significant (P < .0001). In addition, 2 patients who initially did not show the anti-elevation syndrome were found to have an increase in their fundus extorsion after they subsequently developed the anti-elevation syndrome. Two patients who had the anti-elevation syndrome showed a marked decrease in fundus extorsion after the anti-elevation syndrome was surgically eliminated by converting the anterior transposition to a simple recession. CONCLUSION: The presence of substantial extorsion may contribute to the cause of the anti-elevation syndrome after inferior oblique muscle anterior transposition. Lateral placement of the posterior (lateral) corner of the inferior oblique muscle at the time of surgery may cause substantial extorsion after surgery.

The effect of anterior transposition of the inferior oblique muscle on the palpebral fissure.

BACKGROUND: Anterior transposition of the inferior oblique muscle is a popular treatment for dissociated vertical divergence. It seems that this surgical procedure may alter the palpebral fissure. OBJECTIVES: To investigate the alteration of the palpebral fissure with inferior oblique muscle anterior transposition when it is performed as the sole operative procedure and to report the cases of patients who developed noticeable upper eyelid retraction after inferior oblique muscle anterior transposition preceded by large superior rectus muscle recessions. METHODS: The change in the height of the palpebral fissure surgery was evaluated from photographs by 2 masked observers in 3 groups of patients. The control group underwent inferior oblique muscle recession without transposition. The second group (or the insertion study group) underwent transposition of the inferior oblique muscle that was level with the inferior rectus muscle insertion. The third group (or the 2-mm study group) had the inferior oblique muscle placed 2 mm anterior to the inferior rectus muscle insertion. Also, the insertion study and the control groups were evaluated after surgery for bulging and elevation of the lower eyelid on upgaze. RESULTS: The narrowing of the palpebral fissure after surgery (mean + SD) was -0.14 + 0.6 mm in the 16 patients in the control group, -1.2 + 0.9 mm in the 14 patient in the insertion study group, and -2.1 + 0.5 mm in the 6 patients in the 2-mm study group. The differences were statistically significant between the control and the insertion study groups (P= .001, t test) and between the control and the 2-mm study groups (P< .001, t test). One of the 16 control patients and 10 of the 14 insertion study patients showed bulging of the lower eyelid on upgaze after surgery. This difference was statistically significant (P<.001, Fisher exact test). In addition, 3 patients were seen who developed marked upper eyelid retraction when anterior transposition of the inferior oblique muscles followed previous large superior rectus muscle recessions. CONCLUSIONS: Anterior transposition of the inferior oblique muscle causes significant narrowing of the palpebral fissure as a sole procedure. When preceded by large superior rectus muscle recessions, it can cause upper eyelid retraction. Arch Ophthalmol. 2000;118:1542-1546

The +10 diopter lens occluder.

BACKGROUND: It would be useful to be able to visualize the eye under cover during the cover test. Used as an occluder, a +10 diopter (D) lens will permit such visualization. It is important to know if a +10D lens creates dissociation that is qualitatively similar to an opaque occluder. METHODS: The angle of strabismus was measured in 33 patients with esotropia. Seventeen had intermittent exotropia, and 15 had dissociated vertical divergence with both an opaque occluder and a +10D lens used as an occluder. The findings were then compared. RESULTS: In 64 of the 65 patients participating in this study, the measurements obtained with the 2 occluders agreed within 3 prism diopters on repeated testing. In the remaining patient, the measurements differed by 5 prism diopters. In all patients, the dissociated eye could be clearly visualized through the +10D lens. CONCLUSION: A +10D lens permits excellent visualization of the dissociated eye and provides measurements that are qualitatively similar to those obtained with a standard occluder. Arch Ophthalmol. 2000;118:1071-1073

The usefulness of the cervical range of motion device in the ocular motility examination.

OBJECTIVES: To determine if the cervical range of motion (CROM) device, an instrument designed to assess the range of motion in the cervical spine, may be suited for accurately quantifying the magnitude of a patient's abnormal head posture, limitation of ductions, or range of single binocular vision at distance fixation. METHODS: The CROM device was used to measure abnormal head postures in 10 subjects and limitations of ductions in 12 patients by 2 masked observers. In addition, it was used to test the diplopia field in 17 patients at one third of a meter and 6 m. These findings were compared with a standard diplopia field performed on a Goldmann perimeter. RESULTS: For 10 subjects with abnormal head postures, the findings of the 2 observers had a mean+/-SD difference of 1.0 degrees +/-0.7 degrees (P=.15, paired t test). For the assessment of limitations of ductions, the findings of the 2 observers had a mean+/-SD difference of 1.1 degrees +/-2.6 degrees (P=.17, paired t test). For the 17 patients undergoing diplopia field testing, the results obtained on the Goldmann perimeter and with CROM device at the same test distance were essentially identical (mean+/-SD difference of 1.3 degrees +/-0.95 degrees; P=.88, paired t test); however, there was a significant difference between the results at one third of a meter and 6 m (mean+/-SD difference of 6.0 degrees +/-1.1 degrees for esotropic patients [P=.001]; mean+/-SD difference of 6.0 degrees +/-2.6 degrees for exotropic patients [P=.002]). CONCLUSION: The CROM device seems to be suitable for testing abnormal head postures, limitations of ductions, and the range of single binocular vision. Arch Ophthalmol. 2000;118:946-950