Inferior oblique muscle belly transposition and myopexy for diplopia.

To evaluate the outcomes of and review the indications for Inferior oblique muscle belly transposition in adults with diplopia and small-angle hypertropia associated with mild or moderate upshoot in adduction. We retrospectively analyzed data for the six patients who underwent the technique. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal pole of the inferior rectus. Data were collected from October 2018 to April 2020. All six patients had diplopia and mild hypertropia (≤6 prism diopters [pd]) in primary position. Mean preoperative hypertropia was 4.17 pd (range, 2-6 pd). Mean age was 51 ± 28.71 years. The diagnoses were fourth nerve paresis (5) and dissociated vertical deviation (1). All patients had mild/moderate upshoot in adduction. Torticollis was observed in four cases. Diplopia resolved in 5 of the 6 cases. The mean final vertical deviation was 2 pd in straight gaze. Torticollis was eliminated in 2 patients and improved in another 2. The upshoot in adduction was totally eliminated in the six patients. Transitory mild limitation of elevation in adduction was observed in two patients during the first week after surgery. No ocular torsion was diagnosed after surgery. Mean time from surgery was 11.5 months. No overcorrections were recorded. Inferior oblique muscle belly transposition with myopexy is a good alternative procedure in patients with diplopia associated with mild-to-moderate upshoot in adduction and small-angle hypertropia.

Orbital magnetic resonance imaging is useful in age-related distance esotropia / Utilidad de la resonancia magnética orbitaria en la esotropía asociada a la edad

Purpose: To describe findings for orbital magnetic resonance imaging (MRI) in patients with age-related distance esotropia (ARDE). Methods: We compared 31 orbital MRI from patients with ARDE (77 ± 7 SD years) with 2 control groups: 32 orbits from individuals aged 18-50 years (33 ± 8 SD years) and 16 orbits from individuals aged >60 years (77 ± 7 SD years). MRI scans were acquired using 3D fast field echo in T1 sequence without fat saturation. Exclusion criteria for all groups were neurological or thyroid disease and a relevant ophthalmological history (e.g., high myopia, diplopia from another etiology, complicated cataract surgery, etc.). Muscle displacement and characteristics of the lateral rectus-superior rectus (LR-SR) intermuscular band were analyzed. Results: The analysis of the muscles and angles revealed a series of statistically significant differences (p < 0.07) between the groups. Subjects with ARDE had LR pulley positions 1.32 ± 0.19 mm lower than in younger controls, and the medial rectus (MR) pulley positions were 0.68 ± 0.19 mm lower than in younger. Older controls had LR and MR pulley positions 0.85 ± 0.20 mm and 0.49 ± 0.23 mm lower than in younger. ARDE subjects had LR pulley positions 0.46 ± 0.26 mm lower than in older control group. The LR-SR band was absent in 35.5% of ARDE patients and in 12.5% of older control group (p = 0.168). Conclusions: MRI showed that displacements of LR and LR-SR band degeneration could facilitate the diagnosis of patients with ARDE

Objetivo: Describir los hallazgos encontrados en la resonancia magnética orbitaria (RMN) en pacientes con esotropía asociada a la edad (ETAE). Métodos: Comparamos 31 RMN orbitarias de pacientes con ETAE (77 ± 7 DE años) con 2 grupos control: 32 órbitas de individuos con edades comprendidas entre 18 y 50 años (33 ± 8 DE años) y 16 órbitas de individuos con edades >60 años (77 ± 7 DE años). Las RMN se adquirieron utilizando eco de campo rápido 3D en secuencia T1 sin saturación de grasa. Los criterios de exclusión para todos los grupos fueron enfermedad neurológica o tiroidea y antecedentes oftalmológicos relevantes (ej.: alta miopía, diplopía de otra etiología, cirugía complicada de cataratas...). Se analizaron el desplazamiento muscular y las características de la banda intermuscular recto lateral-recto superior (RL-RS). Resultados: El análisis de los músculos y ángulos reveló una serie de diferencias estadísticamente significativas (p < 0,07) entre los grupos. Los sujetos con ETAE presentaban la polea del RL 1,32 ± 0,19 mm inferior a los controles jóvenes y la polea del recto medial (RM) 0,68 ± 0,19 mm inferior a los sujetos jóvenes. Los controles de mayor edad tenían las poleas del RL y del RM posicionadas 0,85 ± 0,2 mm y 0,49 ± 0,23 mm inferiores a los jóvenes. Los sujetos con ETAE tenían la polea del RL 0,46 ± 0,26 mm inferior a la del grupo control de mayor edad. La banda RL-RS estaba ausente en el 35,5% de los pacientes con ETAE y en el 12,5% del grupo control de mayor edad (p = 0,168). Conclusiones: La RMN reflejó que los desplazamientos del RL y la degeneración de la banda RL-RS podrían facilitar el diagnóstico de los pacientes con ETAE

Adjustable Strabismus Surgery under Topical Anesthesia: Alignment in Supine vs Seated Position.

PURPOSE: To compare ocular deviation in the operating room depending on whether the patient is in supine decubitus or seated after single-stage adjustable strabismus surgery under topical anesthesia. MATERIAL AND METHOD: We performed a prospective observational study of 30 patients with horizontal and/or vertical strabismus who underwent single stage adjustable strabismus surgery under topical anesthesia. Both distance and near deviation were evaluated before surgery, during surgery in both positions (seated and supine), and at 1 day, 1 month, and 3 months after surgery. A final horizontal deviation <10 pd and a vertical deviation <5 pd without diplopia was considered to be a good outcome (3 months after surgery). RESULTS: The mean age of the sample was 55 years and 76.7% were women. Most had esotropia (70%). The most frequently used surgical combination was the medial rectus and lateral rectus (36.7%). Surgical adjustment was necessary in 40% of cases. Mean preoperative deviation was 21.9 ± 12.63 pd (distance) and 20.66 ± 4.76 (near). Deviation with the patient supine was 8 ± 8.25 pd (distance) and 7.26 ± 5.81 (near). Deviation with the patient seated was 8.13 pd±8.38 (distance) and 8.5 ± 7.41 (near). There was no significant difference between the positions. Outcome was favorable in 70% of patients; this percentage increased to 83.33% at 1 day, 1 month, and 3 months after surgery. CONCLUSIONS: No statistically significant differences were found between ocular deviations in the seated or supine position in the operating room. Outcome was favorable in most cases 3 months after surgery. Intraoperative ocular deviation was not a predictor of outcome.

Orbital magnetic resonance imaging is useful in age-related distance esotropia.

PURPOSE: To describe findings for orbital magnetic resonance imaging (MRI) in patients with age-related distance esotropia (ARDE). METHODS: We compared 31 orbital MRI from patients with ARDE (77±7 SD years) with 2 control groups: 32 orbits from individuals aged 18-50 years (33±8 SD years) and 16 orbits from individuals aged >60 years (77±7 SD years). MRI scans were acquired using 3D fast field echo in T1 sequence without fat saturation. Exclusion criteria for all groups were neurological or thyroid disease and a relevant ophthalmological history (e.g., high myopia, diplopia from another etiology, complicated cataract surgery, etc.). Muscle displacement and characteristics of the lateral rectus-superior rectus (LR-SR) intermuscular band were analyzed. RESULTS: The analysis of the muscles and angles revealed a series of statistically significant differences (p<0.07) between the groups. Subjects with ARDE had LR pulley positions 1.32±0.19mm lower than in younger controls, and the medial rectus (MR) pulley positions were 0.68±0.19mm lower than in younger. Older controls had LR and MR pulley positions 0.85±0.20mm and 0.49±0.23mm lower than in younger. ARDE subjects had LR pulley positions 0.46±0.26mm lower than in older control group. The LR-SR band was absent in 35.5% of ARDE patients and in 12.5% of older control group (p=0.168). CONCLUSIONS: MRI showed that displacements of LR and LR-SR band degeneration could facilitate the diagnosis of patients with ARDE.

Minimally Invasive Strabismus Surgery (MISS) Compared with the Fornix Approach in Pediatric Horizontal Strabismus Surgery.

OBJECTIVE: To compare minimally invasive strabismus surgery (MISS) with the fornix approach in horizontal strabismus operations. PATIENTS AND METHODS: We performed a retrospective study of all patients aged ≤ 12 years who underwent symmetrical surgery of the medial or lateral recti over a 1-year period. MISS was performed in one eye, and fornix opening was performed in the contralateral. We compared pre- and postoperative visual acuity (VA), conjunctival hyperemia, swelling after surgery, and operating time. The techniques were performed by 2 surgeons after a 4-year training period. RESULTS: The sample comprised 16 patients, with a mean age of 6.75 ± 3.02 years. The medial rectus was operated on in 9, the lateral rectus in 7 cases. Recession was performed in 14 muscles (mean dose, 5 mm) and plication in 2 (5.5 mm and 7 mm, respectively). MISS was performed in 12 right eyes and 4 left eyes. Preoperative VA was 0.77 in MISS and 0.80 in the control group. VA was 0.83 in MISS and 0.76 in the control group 1 day after surgery. No significant differences were found for conjunctival hyperemia between the MISS and fornix groups 1 day or 1 week after surgery. Nevertheless, moderate/severe conjunctival hyperemia was less frequent in the MISS group (31.3% versus 62.5%). No significant differences were found for operating time (14.43 minutes [MISS] vs 12.37 minutes [control]). CONCLUSION: The MISS technique was similar to the fornix approach in the early postoperative period with respect to VA, conjunctival inflammation, and operating time in pediatric horizontal strabismus surgery.

Anestesia tópica en la cirugía de estrabismo / Topical anesthesia in strabismus surgery

Definimos la anestesia tópica asistida en la cirugía de estrabismo como la asociación de sedación o analgesia por vía sistémica y la administración de anestésicos por vía tópica. La anestesia tópica ha permitido modificar el procedimiento quirúrgico de las suturas ajustables en el tratamiento del estrabismo. Los criterios de selección de pacientes, músculos, y técnicas quirúrgicas han ido aumentado con el tiempo, pero se debe descartar a los enfermos que tengan menos de 14 años, aquellos con enfermedades mentales graves, y operados previamente de retina. Las ventajas del ajuste intraoperatorio son: mayor comodidad del paciente, control anestésico, menor riesgo potencial de infecciones, disminución del número de músculos que deben ser operados, conocer la posición exacta de los músculos después del ajuste, y una menor estadía hospitalaria. En diferentes estudios realizados con anestesia tópica en nuestro departamento hemos tenido buenos resultados, tanto en el posoperatorio inmediato (90%), como a los seis meses de la cirugía (85%), con una baja tasa de reintervenciones (15%), la mayoría por hipocorrección quirúrgica, y una elevada satisfacción y tolerancia a la realización de la cirugía con anestesia tópica. Podemos concluir que este procedimiento ha permitido modificar la cirugía de los músculos extraoculares en la actualidad, evitando los inconvenientes de la anestesia general, y disminuyendo el costo de las operaciones de estrabismo al convertir la cirugía en un procedimiento ambulatorio.

Topical anesthesia in strabismus surgery is defined as a procedure that includes the use of systemic analgesics and/or sedatives in combination with local anesthetics. Topical anesthesia has favored the modification of adjustable sutures in strabismus surgery. The selection criteria of patients, muscles, and surgical techniques have become stricter over time; however this approach is not appropriate for patients younger than 14 years of age, those with severe mental disease and those with prior retinal surgery. Topical anesthesia strabismus surgery using adjustable sutures has many advantages, such as greater patient comfort, anesthetic control, lower risk of infections, reduced number of intervened muscles, better control of muscle alignment and shorter hospital and recovery time. The results of different studies performed on topical anesthesia in our department produced a favorable outcome for strabismus surgery in the early postoperative period (90%) as well as 6 months after surgery (85%), lower rate of reoperations (15%), mostly for surgical hypocorrection, and higher patient satisfaction and tolerance. In conclusion, topical anesthesia has improved the treatment of extraocular muscle pathology, avoiding the drawbacks related to general anesthesia and reducing the cost of strabismus surgery.