Miopexia supra-ecuatorial del recto lateral en el tratamiento del síndrome «sagging/heavy eye» miópico / Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye

Objetivo Describir los resultados de sujetos con síndrome «sagging/heavy eye miópico» operados mediante la miopexia supraecuatorial del recto lateral. Método Estudio retrospectivo de 9 casos entre 2017-2023. Se analizaron desviación horizontal, vertical, ambliopía, diplopía, ducciones, torsión, pruebas sensoriales antes y después de la cirugía, patología macular y resonancia magnética orbitaria. El tratamiento se consideró exitoso cuando desaparecía o mejoraba la diplopía y una desviación vertical≤5 dioptrías prismáticas (Dp) al final del seguimiento. Resultados La edad media (DE) fue: 62,11 (4,6) años (100% mujeres). El 88,88% presentaba diplopía. La hipotropía media preoperatoria fue: 11,33Dp (DE 3,16), y la desviación vertical final 3,44Dp (DE 3,05). Tras la cirugía, la hipotropía se invirtió en un caso, quedó subcorregida en 5 y se alcanzó ortoforia en otros 3. La técnica se asoció a la cirugía de otro músculo recto en 4 sujetos. El tiempo medio de seguimiento posquirúrgico fue de 34 meses (DE 34,62). Seis de las 9 pacientes quedaron con una desviación vertical≤5Dp. En 3 pacientes se consiguió eliminar totalmente la diplopía, mientras que en 5 quedó intermitente (3 con patología macular) Conclusión En el tratamiento del «sagging/heavy eye miópico», el supradesplazamiento ecuatorial con miopexia del recto lateral constituye una opción terapéutica si la hipotropía es menor de 12Dp o la técnica de Yokoyama no está indicada. Se obtuvo un buen resultado en más de la mitad de los casos, suprimiéndose totalmente la diplopía en 3 y quedando en otros 5 de forma intermitente (AU)

Purpose To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with lateral rectus myopexy. Methods A retrospective study of 9 cases between 2017 and 2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered successful if the diplopia was improved or eliminated and a final vertical deviation≤5prism diopters (PD). Results The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33PD (SD 3.16), and the mean final VD 3.44PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another 3. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation≤5PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (3 with macular pathology). Conclusion Supra-equatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye is a therapeutic option if hypotropia is less than 12PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent (AU)

Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye.

PURPOSE: To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy. METHODS: A retrospective study of 9 cases between 2017-2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD). RESULTS: The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology). CONCLUSION: Supra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

Insuficiencia de convergencia con diplopía: tratamiento quirúrgico en adultos / Convergence insufficiency with diplopia: Surgical treatment in adults

Propósito Estudiar los resultados del mini plegamiento central del recto medial (RM) en las insuficiencias de convergencia de adultos con diplopía. Método Análisis retrospectivo de una muestra de 9 casos (7 mujeres). Se recogieron los datos de la dosis de plegamiento del RM, la hipercorrección inmediata posquirúrgica y al final del seguimiento, la desviación final de cerca y de lejos, la diplopía y el tiempo de seguimiento desde la cirugía. Se consideró buen resultado la desaparición de la diplopía, mejoría de los síntomas y una exotropía final de cerca ≤8dioptrías prismáticas (dp). Resultados Se realizó un mini-plegamiento central del RM en 9 pacientes (8 unilaterales). Edad media: 58,66 años (SD: 21,39). La media de la desviación preoperatoria de cerca fue de 16,22 (±2,99) dp y de lejos 6,88 (±4) dp. Se registró hipercorrección en visión lejana en 5 casos que se resolvió a los 3 meses después de la operación. No hubo hipercorrección en visión de cerca excepto en un caso. Ninguno de los casos operados presentó hipercorrección al final del seguimiento. La desviación horizontal final fue ≤8dp en visión cercana, excepto en 3 casos (media: 6,22). Los síntomas y la diplopía se resolvieron en 8 casos. El seguimiento medio fue de 10,33 meses. Conclusión El mini-plegamiento central de 1 o 2 músculos rectos mediales puede mejorar los síntomas y signos de exotropía asociados a la insuficiencia de convergencia cuando los ejercicios y los prismas son rechazados por los pacientes o cuando estos abordajes no han resuelto el problema (AU)

Objective To study the outcomes of treatment with central mini-plication of the medial rectus (MR) muscles in adult convergence insufficiency with diplopia. Methods The study sample comprised 9 cases (7 women). The length of MR plication was collected. Other variables reported were postsurgical deviation, overcorrections in the early postoperative period and at the end of follow-up, final horizontal deviation at near and at distance vision, diplopia, and mean follow-up from surgery. Surgical outcome was considered to be favorable when diplopia and symptoms were resolved and final exotropia at near was ≤8 pd at the end of follow-up. Results A central mini-plication of the MR was performed in 9 patients (8 unilateral). Mean (± SD) age was 58.66 (21.39) years. Mean near preoperative deviation: 16.22 (± 2.9) pd and distance preoperative deviation: 6.88 (± 4) pd Overcorrection at distance vision was recorded in 5 cases; this resolved by 3 months postoperatively. There was not overcorrection at near vision except one case. None of the cases operated on had overcorrection at the end of follow-up The final horizontal deviation was ≤8 pd at near vision, except for 3 cases (mean: 6.22). Symptoms and diplopia resolved in 8 cases. The mean follow-up was 10.33 months. Conclusion Central mini-plication of 1 or 2 medial rectus muscles can improve the symptoms and signs of exotropia associated with convergence insufficiency when exercises and the prisms are rejected by the patients and when these approaches have not solved the problem (AU)

Convergence insufficiency with diplopia: Surgical treatment in adults.

OBJECTIVE: To study the outcomes of treatment with central mini-plication of the medial rectus (MR) muscles in adult convergence insufficiency with diplopia. METHODS: The study sample comprised 9 cases (7 women). The length of MR plication was collected. Other variables reported were postsurgical deviation, overcorrections in the early postoperative period and at the end of follow-up, final horizontal deviation at near and at distance vision, diplopia, and mean follow-up from surgery. Surgical outcome was considered to be favorable when diplopia and symptoms were resolved and final exotropia at near was ≤8 pd at the end of follow-up. RESULTS: A central mini-plication of the MR was performed in 9 patients (8 unilateral). Mean (±SD) age was 58.66 (21.39) years. Mean near preoperative deviation: 16.22 (±2.9) pd and distance preoperative deviation: 6.88 (±4) pd Overcorrection at distance vision was recorded in 5 cases; this resolved by 3 months postoperatively. There was not overcorrection at near vision except one case. None of the cases operated on had overcorrection at the end of follow-up. The final horizontal deviation was ≤8 pd at near vision, except for 3 cases (mean: 6.22). Symptoms and diplopia resolved in 8 cases. The mean follow-up was 10.33 months. CONCLUSION: Central mini-plication of 1 or 2 medial rectus muscles can improve the symptoms and signs of exotropia associated with convergence insufficiency when exercises and the prisms are rejected by the patients and when these approaches have not solved the problem.

Resultados quirúrgicos de la esotropía adquirida comitante aguda. Causas y clasificación / Surgical outcomes of acquired acute comitant esotropia. Causes and classification

Objetivo Estudiar los resultados del tratamiento quirúrgico de las esotropías comitantes adquiridas y analizar sus posibles causas. Métodos Estudio retrospectivo de pacientes operados de esotropía aguda comitante desde 2017-2021. Se analizó la desviación horizontal de lejos y cerca, el equivalente esférico, y uso excesivo de tablets y smartphones. Se consideró buen resultado sensorial la presencia de estereopsis y motor si la deviación era≤10 dioptrías prismáticas (dp), y sin diplopía al final del seguimiento. Resultados Se incluyeron 15 casos (60% mujeres), edad media: 29,07 años (el 86,66%≥16 años). El tiempo medio desde el inicio de los síntomas hasta la cirugía: 23,3 meses. La media de la desviación horizontal preoperatoria fue de 19,73±7,2dp de cerca y 22,93±7,3 dp de lejos, disminuyendo al final del seguimiento a 3,33±3,8dp de cerca y 3,86±3,9dp de lejos (p<0,001). Un 66,6% refería diplopía. Un 46,66% tenían esoforias o microestrabismos descompensados, un 86,66% miopía y el 33,33% refería uso excesivo de tablets y smartphones. En 10 casos se realizó retroceso de rectos medios. El resultado motor fue bueno en un 93,33% de los casos y sensorial en 46,66%, con desaparición de la diplopía. Conclusiones La cirugía fue un excelente tratamiento para resolver la desviación y la diplopía. Las esoforias y los microestrabismos representaron casi la mitad de los casos y el excesivo uso de tablets y smartphones la tercera parte de la muestra. La mayoría de los sujetos eran miopes (AU)

Purpose To study the results of surgical treatment of acquired concomitant esotropia and its posible causes. Methods Retrospective study of the patients with acute acquired esotropia that were operated on since 2017 to 2021. Distance and near horizontal deviation, spherical equivalent and the excessive use of the tablets and smartphones were analyzed. A good sensorial outcome was considered when stereopsis was recovered and good motor outcome if horizontal deviation was≤10 prism diopters (pd) at the end of the follow-up. Results A total of 15 cases were included (60% women), mean age: 29.07 years (86.66%≥16 years). Mean time since the beginning of the symptoms to the surgery was 23.3 months. Mean horizontal preoperative deviation was 19.73±7.2pd at near and 22.93±7.3dp at distance decreasing to 3.33±3.8pd at near and 3.86±3.9pd at distance (P<.001). The 66.6% had diplopia. The 46.66% had decompensated esophoria or microesotropia, 86,66% myopia and the 33.33% referred excesive use of the tablets and smartphones. The medial rectus recession were done in 10 cases. A good motor outcome was obtained in the 93.33% of the cases and sensorial outcome in the 46.66% without diplopía. Conclusion Surgery was an excellent treatment to resolve the deviation and diplopia. The esophorias and microesotropias represented near the half of the cases and the excesive use of the tablets and smartphones were the third part of the sample. Most of the patients had myopia (AU)

Transposición del vientre del oblicuo inferior sin desinserción en el tratamiento de la hipertropia en aducción / Transposition of the inferior oblique muscle belly without disinsertion for overshoot in adduction treatment

Propósito Analizar la eficacia y la seguridad de la transposición del oblicuo inferior con miopexia en pacientes con hiperfunción primaria o secundaria del oblicuo inferior leve-moderada, con o sin diplopía. Método Estudio observacional retrospectivo de 12 pacientes tratados con dicha técnica entre octubre de 2018 y septiembre de 2021. Se suturó el oblicuo inferior a esclera a 5mm posterior a la inserción temporal del recto inferior. Todos tenían desviación vertical de pequeño ángulo (media ±DE: 4,42±1,62) en posición primaria (≤6 dioptrías prismáticas [dp]), hipertropia en aducción leve-moderada y 10 tenían diplopía. Los diagnósticos fueron: paresia del IVnervio (9), DVD (1) e hipertropia en aducción unilateral (2). De los 12 casos, 7 presentaban tortícolis, 2 torsión subjetiva y 2 torsión objetiva. Resultados La edad media de la muestra fue 46,86±25,1 años (50% hombres). De los 10 casos con diplopía, en 9 se resolvió. La desviación vertical media final en mirada al frente fue: 1,5dp ±2,93 (p=0,001). De 7 casos con hipertropia en aducción leve, en 3 desapareció y 4 quedaron igual. De 5 casos con hipertropia en aducción moderada, 2 mejoraron a leves y en 3 desapareció. El tortícolis se resolvió en 5 casos, y en otros 2 mejoró. El tiempo de seguimiento medio fue de 14,08±8,05 meses. No se registraron hipercorrecciones. Conclusiones La transposición del oblicuo inferior con miopexia es una nueva técnica eficaz y segura en pacientes con leve-moderada hipertropia en aducción e hipertropia de pequeño ángulo, con o sin diplopía (AU)

Purpose To evaluate the efficacy and safety of inferior oblique muscle transposition and myopexy in patients with mild/moderate inferior oblique muscle overaction, with or without diplopia. Method We retrospectively analysed data for the 12 patients who underwent the technique. Data were collected from October 2018 to September 2021. Surgery was performed by suturing the inferior oblique belly to the sclera at 5mm posterior to the temporal end of the inferior rectus. All 12 patients had mild hypertropia (≤6 prism diopters [pd]) in primary position and mild/moderate inferior oblique overaction. Mean preoperative hypertropia was 4.42pd ±1.62. Diplopia was recorded in 10 cases. The diagnoses were fourth nerve paresis (9), unilateral primary inferior oblique overaction (2) and dissociated vertical deviation (1). Torticollis was observed in 7 cases, 2 had subjective torsion and 2 objective torsion. Results Mean age was 46.86±25.1 years (50%: men). Diplopia resolved in 9 of the 10 cases. The mean final vertical deviation was 1.5±2.93 (P=.001) pd in straight gaze. Of 7 mild overshoot in adduction, it disappeared in 3 and 4 remained the same. Of 5 moderate overshoot in adduction, 2 improved to mild and 3 disappeared. Torticollis was eliminated in 5 patients and improved in another 2. Mean time from surgery was 14.08±8.05 months. There were no overcorrections Conclusions Inferior oblique muscle transposition with myopexy is a safe and effective procedure in patients with mild-to-moderate inferior oblique muscle overaction and small-angle hypertropia, with or without diplopia (AU)

Surgical outcomes of acquired acute comitant esotropia. Causes and classification.

PURPOSE: To study the results of surgical treatment of acquired concomitant esotropia and its posible causes. METHODS: Retrospective study of the patients with acute acquired esotropia that were operated on since 2017. Distance and near horizontal deviation, spherical equivalent and the excessive use of the tablets and smartphones were analyzed. A good sensorial outcome was considered when stereopsis was recovered and good motor outcome if horizontal deviation was ≤10 prism diopters at the end of the follow-up. RESULTS: A total of 15 cases were included (60% women), mean age: 29.07 years (86.66% ≥16 years). Mean time since the beginning of the symptoms to the surgery was 23.3 months. Mean horizontal preoperative deviation was 19.73 ± 7.2 pd at near and 22.93 ± 7.3 dp at distance decreasing to 3.33 ± 3.8 pd at near and 3.86 ± 3.9 pd at distance (P < .001). The 66.6% had diplopía. The 46.66% had decompensated esophoria or microesotropia, 86,66 % myopia and the 33.33% referred excesive use of the tablets and smartphones. The medial rectus recession were done in 10 cases. A good motor outcome was obtained in the 93.33% of the cases and sensorial outcome in the 53.3% without diplopía. CONCLUSION: Surgery was an excellent treatment to resolve the deviation and diplopia. The esophorias and microesotropias represented near the half of the cases and the excesive use of the tablets and smartphones were the third part of the sample. Most of the patients had myopia.

Transposition of the inferior oblique muscle belly without disinsertion for overshoot in adduction treatment.

PURPOSE: To evaluate the efficacy and safety of inferior oblique muscle transposition and myopexy in patients with mild/moderate inferior oblique muscle overaction, with or without diplopia. METHOD: We retrospectively analysed data for the 12 patients who underwent the technique. Data were collected from October 2018 to September 2021. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal end of the inferior rectus. All 12 patients had mild hypertropia (≤6 prism diopters [pd]) in primary position and mild/moderate inferior oblique overaction. Mean preoperative hypertropia was 4.42 pd ±â€¯1.62. Diplopia was recorded in 10 cases. The diagnoses were fourth nerve paresis (9), unilateral primary inferior oblique overaction (2) and dissociated vertical deviation (1). Torticollis was observed in 7 cases, 2 had subjective torsion and 2 objective torsion. RESULTS: Mean age was 46.86 ±â€¯25.1 years (50%: men). Diplopia resolved in 9 of the 10 cases. The mean final vertical deviation was 1.5 ±â€¯2.93 (p = 0.001) pd in straight gaze. Of 7 mild overshoot in adduction, it disappeared in 3 and 4 remained the same. Of 5 moderate overshoot in adduction, 2 improved to mild and 3 disappeared. Torticollis was eliminated in 5 patients and improved in another 2. Mean time from surgery was 14.08 ±â€¯8.05 months. There were no overcorrections. CONCLUSIONS: Inferior oblique muscle transposition with myopexy is a safe and effective procedure in patients with mild-to-moderate inferior oblique muscle overaction and small-angle hypertropia, with or without diplopia.

Alteraciones de la motilidad ocular en el síndrome de Kabuki / Changes in ocular motility in Kabuki síndrome

El síndrome de Kabuki es una enfermedad genética rara debida a una mutación genética en los genes KMT2D y KDM6A, que afecta a múltiples órganos, entre ellos los ojos, en la mayoría de los pacientes. Las características clínicas más típicas son: facies peculiar, baja estatura, anormalidades esqueléticas y bajo coeficiente intelectual. Las manifestaciones oculares más frecuentes son el estrabismo, la ptosis y los defectos refractivos. Presentamos una serie de casos de 5 pacientes (3 mujeres), 4 de ellos con estrabismo en forma de esotropía, hiperacción de oblicuos inferiores e hipofunción de oblicuos superiores asociado a un síndrome V. Son pocos los casos publicados de síndrome de Kabuki que describan las afectaciones oftalmológicas y las estrabológicas. Podría ser conveniente la realización de resonancias magnéticas orbitarias para detectar cambios en los trayectos musculares que estén relacionados con la patología de los movimientos oculares encontrados

Kabuki syndrome is a rare genetic disorder, caused by mutation in the KMT2D or KDM6A genes, which affects several organs in the majority of patients, among which are the eyes. The most typical clinical characteristics are mental retardation, postnatal growth retardation, skeletal anomalies, and characteristic facial features. As the eyes are affected in most of the cases, ophthalmological examination is recommended for the early detection of ocular anomalies, in order to prevent visual impairment. The most frequent ocular signs are strabismus, ptosis, and refractive anomalies. A series of cases of Kabuki syndrome is described in five children, four of whom exhibited strabismus with esotropia, over action of inferior oblique muscles, and under action of superior oblique muscles associated with a V pattern. Most published papers do not report or might underestimate the ocular problems. It may be appropriate to perform orbital magnetic resonances in order to detect changes in the muscle paths that are related to the pathology of the eye movements found

Changes in ocular motility in Kabuki syndrome. / Alteraciones de la motilidad ocular en el síndrome de Kabuki.

Kabuki syndrome is a rare genetic disorder, caused by mutation in the KMT2D or KDM6A genes, which affects several organs in the majority of patients, among which are the eyes. The most typical clinical characteristics are mental retardation, postnatal growth retardation, skeletal anomalies, and characteristic facial features. As the eyes are affected in most of the cases, ophthalmological examination is recommended for the early detection of ocular anomalies, in order to prevent visual impairment. The most frequent ocular signs are strabismus, ptosis, and refractive anomalies. A series of cases of Kabuki syndrome is described in five children, four of whom exhibited strabismus with esotropia, over action of inferior oblique muscles, and under action of superior oblique muscles associated with a V pattern. Most published papers do not report or might underestimate the ocular problems. It may be appropriate to perform orbital magnetic resonances in order to detect changes in the muscle paths that are related to the pathology of the eye movements found.

Diplopía binocular en un hospital terciario: etiología, diagnóstico y tratamiento / Binocular diplopia in a tertiary hospital: Aetiology, diagnosis and treatment

Objetivo: Estudiar las causas, el diagnóstico, el tratamiento y los resultados de una serie de casos con diplopía binocular. Material y método: Estudio retrospectivo de pacientes referidos a consulta de diplopía del servicio de oftalmología durante un año. La diplopía se clasificó en aguda ≤1mes desde su inicio, subaguda (1-6 meses) y crónica (>6). La resolución de la diplopía se consideró espontánea si desaparecía sin necesidad de tratamiento, parcial cuando quedaba intermitente y no resolución espontánea cuando se necesitó tratamiento. Se consideró buen resultado cuando desaparecía por completo la diplopía con/sin tratamiento o era intermitente sin afectar a la calidad de vida del paciente. Resultados: Un total de 60 casos fueron incluidos. La edad media fue 58,65 años (60% mujeres). El 60% fueron agudas o subagudas. La evolución media de la diplopía fue 82,97 semanas. La etiología más frecuente fue isquémica en el 45%. La parálisis del sexto nervio fue el diagnóstico más frecuente: 38,3%, después estrabismos descompensados: 30%. Se encontraron lesiones en las pruebas de neuroimagen en un 17,7%. La resolución espontánea se produjo en un 28,3%. El 53,3% presentó un buen resultado con desaparición de la diplopía al final del estudio. Conclusiones: Las causas más frecuentes de diplopía binocular fueron las parálisis de los nervios craneales, especialmente del vi, seguidas de estrabismos descompensados. Se encontraron lesiones estructurales en las pruebas de imagen en un porcentaje importante. Solo en un tercio de los pacientes la diplopía se resolvió espontáneamente y la mitad tuvo un mal resultado a pesar del tratamiento (AU)

Objective: To study the causes, diagnosis and treatment in a case series of binocular diplopia. Material and method: A retrospective chart review was performed on patients seen in the Diplopia Unit of a tertiary centre during a one-year period. Diplopia was classified as: acute ≤ 1 month since onset; subacute (1-6 months); and chronic (>6 months). Resolution of diplopia was classified as: spontaneous if it disappeared without treatment, partial if the course was intermittent, and non-spontaneous if treatment was required. It was considered a good outcome when diplopia disappeared completely (with or without treatment), or when diplopia was intermittent without significantly affecting the quality of life. Results: A total of 60 cases were included. The mean age was 58.65 years (60% female). An acute or subacute presentation was observed in 60% of the patients. The mean onset of diplopia was 82.97 weeks. The most frequent aetiology was ischaemic (45%). The most frequent diagnosis was sixth nerve palsy (38.3%), followed by decompensated strabismus (30%). Neuroimaging showed structural lesions in 17.7% of the patients. There was a spontaneous resolution in 28.3% of the cases, and there was a good outcome with disappearance of the diplopia in 53.3% at the end of the study. Conclusions: The most frequent causes of binocular diplopia were cranial nerve palsies, especially the sixth cranial nerve, followed by decompensated strabismus. Structural lesions in imaging tests were more than expected. Only one third of patients had a spontaneous resolution, and half of them did not have a good outcome despite of treatment (AU)

Binocular diplopia in a tertiary hospital: Aetiology, diagnosis and treatment. / Diplopía binocular en un hospital terciario: etiología, diagnóstico y tratamiento.

OBJECTIVE: To study the causes, diagnosis and treatment in a case series of binocular diplopia. MATERIAL AND METHOD: A retrospective chart review was performed on patients seen in the Diplopia Unit of a tertiary centre during a one-year period. Diplopia was classified as: acute≤1 month since onset; subacute (1-6 months); and chronic (>6 months). Resolution of diplopia was classified as: spontaneous if it disappeared without treatment, partial if the course was intermittent, and non-spontaneous if treatment was required. It was considered a good outcome when diplopia disappeared completely (with or without treatment), or when diplopia was intermittent without significantly affecting the quality of life. RESULTS: A total of 60 cases were included. The mean age was 58.65 years (60% female). An acute or subacute presentation was observed in 60% of the patients. The mean onset of diplopia was 82.97 weeks. The most frequent aetiology was ischaemic (45%). The most frequent diagnosis was sixth nerve palsy (38.3%), followed by decompensated strabismus (30%). Neuroimaging showed structural lesions in 17.7% of the patients. There was a spontaneous resolution in 28.3% of the cases, and there was a good outcome with disappearance of the diplopia in 53.3% at the end of the study. CONCLUSIONS: The most frequent causes of binocular diplopia were cranial nerve palsies, especially the sixth cranial nerve, followed by decompensated strabismus. Structural lesions in imaging tests were more than expected. Only one third of patients had a spontaneous resolution, and half of them did not have a good outcome despite of treatment.

Complicaciones de la transposición aumentada de recto superior en el síndrome de Duane / Complications of augmented superior rectus transposition in Duane syndrome

CASO CLÍNICO: Paciente con síndrome de Duane, operado con transposición aumentada de recto superior (TRS) al recto lateral (RL), y recesión del recto medio (RM). En el postoperatorio se observó desviación vertical, torsional y diplopía. La retirada de la fijación escleral y la recesión del RS lo resolvieron. DISCUSIÓN: La TRS al RL está descrita en el tratamiento del síndrome de Duane con resultados controvertidos. Puede ser una alternativa a la transposición de los rectos verticales cuando asocia la recesión del RM en el mismo procedimiento, o en el postoperatorio inmediato para disminuir el riesgo de isquemia del segmento anterior

CLINICAL CASE: A patient diagnosed with Duane syndrome underwent an augmented superior rectus transposition (SRT) to lateral rectus (LR) and medial rectus (MR) recession. Vertical, torsional deviation and diplopia were observed post-operatively. Removal of the Foster suture and superior rectus recession resolved the symptoms. DISCUSSION: SRT to LR is proposed in Duane syndrome with a favorable outcome. The benefit of SRT is open to debate. It could be an alternative for the vertical rectus transposition when MR recession has to be operated on in the same procedure, or in the immediate post-operative period, in order to decrease the risk of anterior segment ischaemia

Complications of augmented superior rectus transposition in Duane syndrome. / Complicaciones de la transposición aumentada de recto superior en el síndrome de Duane.

CLINICAL CASE: A patient diagnosed with Duane syndrome underwent an augmented superior rectus transposition (SRT) to lateral rectus (LR) and medial rectus (MR) recession. Vertical, torsional deviation and diplopia were observed post-operatively. Removal of the Foster suture and superior rectus recession resolved the symptoms. DISCUSSION: SRT to LR is proposed in Duane syndrome with a favorable outcome. The benefit of SRT is open to debate. It could be an alternative for the vertical rectus transposition when MR recession has to be operated on in the same procedure, or in the immediate post-operative period, in order to decrease the risk of anterior segment ischaemia.

Resultados de la cirugía de estrabismo mínimamente invasiva en las desviaciones horizontales / Outcomes of minimally invasive strabismus surgery for horizontal deviation

OBJETIVO: Estudiar los resultados de la cirugía de estrabismo mínimamente invasiva (MISS) en desviaciones horizontales (DH). MÉTODO: Serie de los primeros 26 casos consecutivos operados de estrabismo horizontal en nuestro hospital mediante MISS desde febrero de 2010 a marzo de 2014. RESULTADOS: Se incluyeron 40 ojos: 26 pacientes (edad media: 7,7 años [DS: 4,9]; 34,61%: hombres). Se operaron 43 músculos: 20 rectos medios y 23 rectos laterales; 28 recesiones (rango: 3-7,5 mm), 6 resecciones (rango: 6-7 mm) y 9 plegamientos (rango: 6,5-7,5 mm). Se encontraron diferencias estadísticamente significativas (p < 0,001) en la desviación horizontal en dioptrías prismáticas pre y poscirugía, con un 88,46% de buenos resultados (desviaciones finales ≤ 10 dioptrías prismáticas). No se hallaron diferencias estadísticamente significativas (p > 0,05) en la AV al día siguiente de la cirugía y a los 6 meses. Un 29,27% de los ojos presentó hiperemia leve, 48,78% moderada y 21,95% severa al primer día postoperatorio, pasando al cuarto día al 63,41%, 31,70% y 4,87% respectivamente. Las complicaciones fueron 4 casos de sangrado conjuntival intraoperatorio, una perforación escleral y 2 prolapsos de Tenon. En un caso hubo que reconvertir a incisión fornix por mala visualización. El rango del tiempo quirúrgico disminuyó desde 30 a 15 min por músculo. CONCLUSIONES: La MISS ha obtenido buenos resultados en la cirugía del estrabismo horizontal. La inflamación conjuntival es leve en la mayoría de los casos a los 4 días de la cirugía. La AV se mantiene estable y el tiempo quirúrgico va disminuyendo una vez superada la curva de aprendizaje de 4 años

OBJECTIVE: To study the outcomes of minimally invasive strabismus surgery (MISS) for treating horizontal deviation. METHOD: Case Series of the first 26 consecutive patients operated on using the MISS technique in our hospital from February 2010 to March 2014. RESULTS: A total of 40 eyes were included: 26 patients (mean age: 7.7 years old ± 4.9); 34.61%: male. A total of 43 muscles were operated on: 20 medial, and 23 lateral recti; 28 recessions (range: 3-7.5 mm), 6 resections (6-7 mm), and 9 plications (6.5-7.5 mm) were performed. No significant difference was found (P > 0 .05) for visual acuity at postoperative day 1, and 6 months after surgery. A mild hyperaemia was observed in 29.27%, moderate in 48.78%, and severe in 21.95% at postoperative day 1 and in 63.41%, 31.70% and 4.87%, respectively, at 4 days after surgery. The complications observed were 4 intraoperative conjunctival haemorrhages, 1 scleral perforation, and 2 Tenon's prolapses. A conversion from MISS to a fornix approach was necessary in 1 patient because of bad visualization. The operating time range decreased from 30 to 15 minutes. CONCLUSIONS: The MISS technique has obtained good results in horizontal strabismus surgery. The conjunctival inflammation was mild in most of the cases at postoperative day 4. The visual acuity was stable during follow-up, and operating time decreased after a 4-year learning curve

Outcomes of minimally invasive strabismus surgery for horizontal deviation.

OBJECTIVE: To study the outcomes of minimally invasive strabismus surgery (MISS) for treating horizontal deviation METHOD: Case Series of the first 26 consecutive patients operated on using the MISS technique in our hospital from February 2010 to March 2014. RESULTS: A total of 40 eyes were included: 26 patients (mean age: 7.7 years old ± 4.9); 34.61%: male. A total of 43 muscles were operated on: 20 medial, and 23 lateral recti; 28 recessions (range: 3-7.5mm), 6 resections (6-7 mm), and 9 plications (6.5-7.5 mm) were performed. No significant difference was found (P>0.05) for visual acuity at postoperative day 1, and 6 months after surgery. A mild hyperaemia was observed in 29.27%, moderate in 48.78%, and severe in 21.95% at postoperative day 1 and in 63.41%, 31.70% and 4.87%, respectively, at 4 days after surgery. The complications observed were 4 intraoperative conjunctival haemorrhages, 1 scleral perforation, and 2 Tenon's prolapses. A conversion from MISS to a fornix approach was necessary in 1 patient because of bad visualization. The operating time range decreased from 30 to 15 minutes. CONCLUSIONS: The MISS technique has obtained good results in horizontal strabismus surgery. The conjunctival inflammation was mild in most of the cases at postoperative day 4. The visual acuity was stable during follow-up, and operating time decreased after a 4-year learning curve.

Espasmo del reflejo de cerca. Tratamiento con toxina botulínica / Spasm of the near reflex. Treatment with botulinum toxin

CASO CLÍNICO: Mujer de 38 años con diplopía y endotropía. Limitación total de la abducción en AO al explorar las versiones, que se normalizan al explorar el reflejo de los ojos de muñeca. Es diagnosticada de espasmo del reflejo de cerca (ERC) y tratada con inyecciones repetidas de Botox en rectos medios, resolviéndose temporalmente el espasmo. DISCUSIÓN: El ERC se caracteriza por miosis, seudomiopía y convergencia que producen diplopía, visión borrosa, cefalea y endotropía variable, progresiva e intermitente. Se puede confundir con una paresia bilateral del vi nervio. El tratamiento con inyecciones repetidas de bótox puede ser efectivo en algunos casos

CLINICAL CASE: A 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DISCUSSION: Near reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases

[Spasm of the near reflex. Treatment with botulinum toxin]. / Espasmo del reflejo de cerca. Tratamiento con toxina botulínica.

CLINICAL CASE: A 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DISCUSSION: Near reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases.

Tratamiento del síndrome de Duane vertical / Duane vertical surgical treatment

Caso clínico: Se describen tres casos con una incomitancia vertical en Y, disminución de la hendidura palpebral y pseudohiperfunción de oblicuos inferiores. La cirugía consistió en una suprainserción de ambos rectos laterales con debilitamiento asimétrico. El resultado fue satisfactorio en 2 casos, obteniendo en el tercero una inversión de la desviación vertical. Discusión: En el síndrome de Duane vertical, el debilitamiento de los rectos laterales y la transposición superior de los mismos permitió mejorar la desviación en dos de los tres pacientes tratados. Sin embargo, la corrección total de la desviación suele ser infrecuente, pudiendo quedar alteraciones residuales (AU)

Case report: We report 3 cases with a vertical incomitance in upgaze, narrowing of palpebral fissure, and pseudo-overaction of both inferior oblique muscles. Surgery consisted of an elevation of both lateral rectus muscles with an asymmetrical weakening. A satisfactory result was achieved in 2 cases, whereas a Lambda syndrome appeared in the other case. Discussion: The surgical technique of upper-insertion with a recession of both lateral rectus muscles improved vertical incomitance in 2 of the 3patients; however, a residual deviation remains in the majority of cases (AU)

[Duane vertical surgical treatment]. / Tratamiento del síndrome de Duane vertical.

CASE REPORT: We report 3 cases with a vertical incomitance in upgaze, narrowing of palpebral fissure, and pseudo-overaction of both inferior oblique muscles. Surgery consisted of an elevation of both lateral rectus muscles with an asymmetrical weakening. A satisfactory result was achieved in 2 cases, whereas a Lambda syndrome appeared in the other case. DISCUSSION: The surgical technique of upper-insertion with a recession of both lateral rectus muscles improved vertical incomitance in 2 of the 3 patients; however, a residual deviation remains in the majority of cases.