Análisis de fiabilidad y concordancia entre 5 métodos subjetivos de medición de la torsión ocular / Reliability and agreement analysis among 5 subjective methods of ocular torsion measurement

Objetivo Evaluar la fiabilidad en la medición de la torsión ocular y la concordancia de los siguientes métodos subjetivos: test de Maddox bilateral, sinoptóforo, torsionómetro de Gracis, pantalla de Harms y test de ciclodesviaciones de Awaya. Método Se seleccionaron pacientes con estrabismo vertical adquirido en la edad adulta y se realizó la medición de la torsión ocular con los 5 métodos descritos en 3 ocasiones. Al no existir un gold standard en la medición subjetiva de la torsión ocular, se eligió como prueba de referencia aquella que obtuviera mejores datos de repetibilidad. Resultados Veinticinco pacientes fueron incluidos en el estudio. Se estudió la repetibilidad de cada prueba: test de Maddox bilateral (CCI=0,783, CV=29,33%), sinoptóforo (CCI=0,976, CV=6,71%), torsionómetro de Gracis (CCI=0,937, CV=20,10%), pantalla de Harms (CCI=0,962, CV=11,86%) y test de Awaya (CCI=0,987, CV=52,58%). La prueba de referencia para comparar la concordancia fue el sinoptóforo. Se encontraron diferencias estadísticamente significativas al comparar los rangos de torsión ocular entre el sinoptóforo y el torsionómetro de Gracis (p=0,008) y entre el sinoptóforo y el test de Awaya (p=0,02). Conclusiones El test de Maddox bilateral, el sinoptóforo, el torsionómetro de Gracis y la pantalla de Harms son métodos fiables con buenos índices de reproducibilidad. Entre ellos, el sinoptóforo es el método más consistente. El test de Awaya no demostró buena fiabilidad. El test de Maddox bilateral, el torsionómetro de Gracis y la pantalla de Harms fueron métodos con buena concordancia con el sinoptóforo, que se determinó como test de referencia. El test de Awaya no demostró buena concordancia con el sinoptóforo (AU)

Objective To evaluate the reliability in the measurement of ocular torsion and the agreement of the following subjective methods: double Maddox test, synoptophore, Gracis torsionometer, Harms screen and Awaya cyclodeviation test. Method Patients with vertical strabismus acquired in adulthood were recruited and ocular torsion was measured with the 5 methods described on 3 occasions. As a gold standard test does not exist, the one that obtained the best repeatability data was chosen as the reference test. Results Twenty-five patients were included in the study. The repeatability of each test was studied: double Maddox test (ICC=0.783, CV=29.33%), synoptophore (ICC=0.976, CV=6.71%), Gracis torsionometer (ICC=0.937, CV=20.10%), Harms screen (ICC=0.962, CV=11.86%) and Awaya test (ICC=0.987, CV=52.58%). The reference test to compare the agreement was the synoptophore. Statistically significant differences were found when comparing the ocular torsion ranges between the synoptophore and the Gracis torsionometer (P=.008) and between the synoptophore and the Awaya test (P=.02). Conclusion The double Maddox test, the synoptophore, the Gracis torsionometer, and the Harms screen are reliable methods with good reproducibility indices. Among them, the synoptophore is the most consistent method. The Awaya test did not show good reliability. The bilateral Maddox test, the Gracis torsionometer, and the Harms screen were methods with good agreement with the synoptophore, which was determined as the reference test. The Awaya test did not show good agreement with the synoptophore (AU)

Reliability and agreement analysis among 5 subjective methods of ocular torsion measurement.

OBJECTIVE: To evaluate the reliability in the measurement of ocular torsion and the agreement of the following subjective methods: double Maddox test, synoptophore, Gracis torsionometer, Harms screen and Awaya cyclodeviation test. METHOD: Patients with vertical strabismus acquired in adulthood were recruited and ocular torsion was measured with the 5 methods described on three occasions. As a gold standard test does not exist, the one that obtained the best repeatability data was chosen as the reference test. RESULTS: 25 patients were included in the study. The repeatability of each test was studied: double Maddox test (ICC = 0.783, CV = 29.33%), synoptophore (ICC = 0.976, CV = 6.71%), Gracis torsionometer (ICC = 0.937, CV = 20.10%), Harms screen (ICC = 0.962, CV = 11.86%) and Awaya test (ICC = 0.987, CV = 52.58%). The reference test to compare the agreement was the synoptophore. Statistically significant differences were found when comparing the ocular torsion ranges between the synoptophore and the Gracis torsionometer (p = 0.008) and between the synoptophore and the Awaya test (p = 0.02). CONCLUSIONS: The double Maddox test, the synoptophore, the Gracis torsionometer, and the Harms screen are reliable methods with good reproducibility indices. Among them, the synoptophore is the most consistent method. The Awaya test did not show good reliability. The bilateral Maddox test, the Gracis torsionometer, and the Harms screen were methods with good agreement with the synoptophore, which was determined as the reference test. The Awaya test did not show good agreement with the synoptophore.

Eficacia y complicaciones de las transposiciones musculares en el síndrome de Duane con esotropía / Efficacy and complications of transposition surgery in Duane esotropia síndrome

OBJETIVO: Estudiar la eficacia a largo plazo y las complicaciones de varios tipos de transposición en el tratamiento del síndrome de Duane: la transposición muscular de rectos verticales total o parcial, la transposición sin desinserción muscular y la transposición del recto superior. MATERIAL Y MÉTODOS: Estudio retrospectivo de los pacientes diagnosticados de síndrome de Duane con esotropía operados con cualquier tipo de transposición muscular asociada o no al debilitamiento del recto medio con seguimiento mayor de 12 meses. Se consideró un buen resultado una desviación ≤ 10 dioptrías prismáticas (dp) en posición primaria de la mirada, tortícolis < 10° con mejoría de la abducción y sin diplopía. RESULTADOS: Un total de 7 casos fueron incluidos (6 mujeres, 6 unilaterales), con una edad media de 37,71 años. La esotropía inicial en posición primaria de la mirada de 28 ± 11,68dp disminuyó a 6 ± 4,62dp al final del seguimiento (p = 0,009). El tortícolis mejoró en 6, y la abducción mejoró un grado en todos (media: -3,14 a -2,14). En 4 casos apareció una desviación vertical ≤ 8dp. Ningún paciente tuvo diplopía final. El porcentaje de reintervenciones fue del 71,42%; solo un 28,57% obtuvo un buen resultado con una cirugía y ascendió a un 71,42% al final del seguimiento con cirugías adicionales. El tiempo de evolución medio fue de 52 ± 31,65 meses. CONCLUSIONES: Las transposiciones en el síndrome de Duane con signos clínicos moderados o severos han sido solo eficaces en una pequeña proporción de los casos. La mayoría requirió una segunda cirugía para corregir las complicaciones o las hipocorrecciones

OBJECTIVE: To study the long-term efficacy and the complications of several transposition techniques for the treatment of Duane syndrome. These included, full vertical rectus transposition, partial vertical rectus transposition, transposition without muscle disinsertion, and superior rectus transposition. MATERIAL AND METHODS: A retrospective study of the patients diagnosed with Duane syndrome, and who underwent any of the different transposition techniques associated or not to the medial rectus recession with a follow-up longer than 12 months. A good result was considered a final deviation ≤ 10 prism dioptres (pd) in primary position, anomalous head posture < 10°, and an improvement of the abduction without diplopia. RESULTS: Seven cases were included (6 women, 6 unilateral), and a mean age of 37.71 years. Pre-operative central gaze esotropia of 28 ± 11.68 pd decreased to 6 ± 4.62 pd at the final visit (P = .009). The anomalous head posture decreased in 6 patients, and the abduction improved one degree from -3.14 to -2.14 (mean). An induced vertical deviation ≤ 8pd was observed in 4 cases. None experienced diplopia at the final visit. The percentage of reoperations was 71.42%. Only 28.57% had a favourable outcome with a single surgery, which increased to 71.42% with further surgeries at the final follow-up. Mean evolution time was 52 ± 31.65 months. CONCLUSIONS: Vertical rectus transpositions in Duane syndrome with moderate or severe clinical signs have only been effective in a small percentage of the cases. Most of them required further surgeries to resolve the complications or the under-corrections

Efficacy and complications of transposition surgery in Duane esotropia syndrome. / Eficacia y complicaciones de las transposiciones musculares en el síndrome de Duane con esotropía.

OBJECTIVE: To study the long-term efficacy and the complications of several transposition techniques for the treatment of Duane syndrome. These included, full vertical rectus transposition, partial vertical rectus transposition, transposition without muscle disinsertion, and superior rectus transposition. MATERIAL AND METHODS: A retrospective study of the patients diagnosed with Duane syndrome, and who underwent any of the different transposition techniques associated or not to the medial rectus recession with a follow-up longer than 12 months. A good result was considered a final deviation≤10 prism dioptres (pd) in primary position, anomalous head posture<10°, and an improvement of the abduction without diplopia. RESULTS: Seven cases were included (6 women, 6 unilateral), and a mean age of 37.71 years. Pre-operative central gaze esotropia of 28±11.68pd decreased to 6±4.62pd at the final visit (P=.009). The anomalous head posture decreased in 6 patients, and the abduction improved one degree from -3.14 to -2.14 (mean). An induced vertical deviation≤8pd was observed in 4 cases. None experienced diplopia at the final visit. The percentage of reoperations was 71.42%. Only 28.57% had a favourable outcome with a single surgery, which increased to 71.42% with further surgeries at the final follow-up. Mean evolution time was 52±31.65 months. CONCLUSIONS: Vertical rectus transpositions in Duane syndrome with moderate or severe clinical signs have only been effective in a small percentage of the cases. Most of them required further surgeries to resolve the complications or the under-corrections.

Tendencias actuales de la cirugía de estrabismo en un hospital terciario / Current trends of strabismus surgery in a tertiary hospital

OBJETIVO: Analizar las cirugías de estrabismo y los resultados durante un año y medio en un hospital terciario. MATERIAL Y MÉTODOS: Estudio retrospectivo de pacientes operados de estrabismo. Se analizó: edad media, sexo, diagnóstico, diplopía, técnica y anestesia, suturas ajustables, resultados, re-intervenciones y tiempo de seguimiento desde la cirugía. Se consideró buen resultado una desviación horizontal < 10 dioptrías prismáticas (dp) y vertical < 5 dp, sin diplopía. RESULTADOS: Se operaron 153 casos, con una edad media de 43,14 ± 25,58 años (61,4% mujeres). El 74,5% eran ≥ 18 años (33,33% ≥ 60). El 51% tenían diplopía. La desviación más frecuente fue horizontal: 83,6%. El diagnóstico más frecuente fue la parálisis de los nervios craneales: 32% (VI nervio: 12,4%), los estrabismos restrictivos representaron un 7,2% y la esotropía asociada a la edad, un 6,5%. Se emplearon suturas ajustables en el 19,7% y anestesia tópica en el 65,4%. El 79,2% obtuvieron buenos resultados al final del seguimiento. Las re-intervenciones fueron el 25,5%. El tiempo medio de seguimiento fue de 11,87 meses ± 6,5. El sexo femenino (p = 0,012) y la cirugía de oblicuo superior (p = 0,017) se asociaron a un peor resultado. CONCLUSIÓN: La cirugía del estrabismo del adulto fue tres veces más frecuente que la de los niños. La tercera parte de los adultos que se operaron eran ≥ 60 años. Las parálisis fueron la patología más frecuente. Las suturas ajustables se emplearon en escaso número de pacientes. Se obtuvieron buenos resultados en la mayoría de los casos

OBJECTIVE: To analyze the strabismus surgeries and the outcomes during a year and a half in a tertiary hospital. MATERIAL AND METHODS: A retrospective study of patients who underwent strabismus surgery. The mean age, sex, diagnosis, diplopia, surgery, anesthesia, adjustable sutures, results, reoperations and follow up time from surgery were analyzed. A good outcome was considered when the final horizontal deviation was less than 10 prism diopters (pd) and the vertical deviation less than 5 pd without diplopia. RESULTS: A total of 153 cases were operated on, mean age: 43.14 ± 25.58 years (61.4%: women).74.5% of patients were ≥ 18 years (33.33% ≥ 60). Diplopia was present in 51% of patients. The most frequent deviation was horizontal: 83.6%. The most frequent diagnosis was cranial nerve palsies: 32% (VI nerve: 12.4%), restrictive strabismus: 7.2%, and the aged related distance esotropia: 6.5%. Adjustable sutures were used in 19.7% of cases and topical anesthesia in 65.4%. Good outcomes was present in 79.2% of cases at the end of follow-up. Reoperations were needed in 25.5%. Follow-up evolution time was 11.87 months ± 6.5. The sex female (P = .012) and the oblique superior surgery (P = .017) were associated with bad outcome. CONCLUSIÓN: The adult strabismus surgery was three times more frequent than the children strabismus surgery. The third of the adults that were operated on were ≥ 60 years. The cranial nerve palsies were the most frequent diagnosis. Adjustable sutures were rarely used. Good outcomes were obtained in most of the patients at the end of follow-up

Current trends of strabismus surgery in a tertiary hospital. / Tendencias actuales de la cirugía de estrabismo en un hospital terciario.

OBJECTIVE: To analyze the strabismus surgeries and the outcomes during a year and a half in a tertiary hospital. MATERIAL AND METHODS: A retrospective study of patients who underwent strabismus surgery. The mean age, sex, diagnosis, diplopia, surgery, anesthesia, adjustable sutures, results, reoperations and follow up time from surgery were analyzed. A good outcome was considered when the final horizontal deviation was less than 10prism diopters (pd) and the vertical deviation less than 5pd without diplopia. RESULTS: A total of 153 cases were operated on, mean age: 43.14 ±25.58years (61.4%: women). 74.5% of patients were ≥18years (33.33% ≥60). Diplopia was present in 51% of patients. The most frequent deviation was horizontal: 83.6%. The most frequent diagnosis was cranial nerve palsies: 32% (VI nerve: 12.4%), restrictive strabismus: 7.2%, and the aged related distance esotropia: 6.5%. Adjustable sutures were used in 19.7% of cases and topical anesthesia in 65.4%. Good outcomes was present in 79.2% of cases at the end of follow-up. Reoperations were needed in 25.5%. Follow-up evolution time was 11.87 months ±6.5. The sex female (P=.012) and the oblique superior surgery (P=.017) were associated with bad outcome. CONCLUSION: The adult strabismus surgery was three times more frequent than the children strabismus surgery. The third of the adults that were operated on were ≥60 years. The cranial nerve palsies were the most frequent diagnosis. Adjustable sutures were rarely used. Good outcomes were obtained in most of the patients at the end of follow-up.

Espasmo de acomodación unilateral: descripción de un caso y revisión de la literatura / Unilateral accommodation spasm: Case report and literature review

Se describe un caso probable de espasmo de acomodación aislado unilateral en una niña de 10 años sin antecedentes de relevancia. Presentó disminución de agudeza visual en el ojo derecho (OD) que variaba entre 0,2-0,6 y de cerca (Rossano Weiss) 0,125. La refracción sin cicloplejía era de OD -6 dioptrías (D) y OI + 0,25 D y con cicloplejía OD + 0,5 D OI + 0,75 D. Presentó ortotropía, ducciones y versiones normales. Pupilas isocóricas, reactivas a la luz, segmento anterior y posterior, la tomografía de coherencia óptica, estudios neurofisiológicos (potenciales evocados, electrorretinograma y electroculograma) y resonancia magnética craneal normales. Se prescribió atropina 1% en OD durante 15 días mejorando la agudeza visual de lejos 0,8 y cerca 0,25. El espasmo de la acomodación es una situación rara y suele ser bilateral. Puede estar asociado a traumatismos craneales u oculares por lo que las pruebas de imagen son necesarias. El tratamiento consiste en fármacos ciclopléjicos (atropina, ciclopentolato), sin embargo, no existe una pauta definida

This case report describes a probable unilateral accommodation spasm in a 10 year-old girl with no significant medical history. The right eye showed decreased visual acuity, 0.2 to 0.6 for far distance and 0.125 for near distance. Refraction without cycloplegia showed myopization up to -6 and cycloplegic refraction of + 0.50. The patient had normal ocular motility, orthophoria, normal pupil reflex, normal anterior and posterior segments, normal optical coherence tomography. Neurophysiological tests and brain magnetic resonance imaging were all normal. Treatment with atropine 1% drops for 15 days improved distance visual acuity to 0.8. Accommodation spasm is a rare condition and is usually bilateral. Imaging test are necessary because it may be associated with ocular or head trauma. Treatment consists of cycloplegic drugs (atropine, cyclopentolate); however, there is no defined guideline

Unilateral accommodation spasm: Case report and literature review. / Espasmo de acomodación unilateral: descripción de un caso y revisión de la literatura.

This case report describes a probable unilateral accommodation spasm in a 10 year-old girl with no significant medical history. The right eye showed decreased visual acuity, 0.2 to 0.6 for far distance and 0.125 for near distance. Refraction without cycloplegia showed myopization up to -6 and cycloplegic refraction of+0.50. The patient had normal ocular motility, orthophoria, normal pupil reflex, normal anterior and posterior segments, normal optical coherence tomography. Neurophysiological tests and brain magnetic resonance imaging were all normal. Treatment with atropine 1% drops for 15 days improved distance visual acuity to 0.8. Accommodation spasm is a rare condition and is usually bilateral. Imaging test are necessary because it may be associated with ocular or head trauma. Treatment consists of cycloplegic drugs (atropine, cyclopentolate); however, there is no defined guideline.

Causas y tratamiento quirúrgico de la diplopía y estrabismo en la miastenia gravis / Causes and surgical treatment of diplopia and strabismus secondary to myasthenia gravis

Objetivo: Describir las alteraciones de la motilidad ocular, tratamiento y resultados en la miastenia gravis (MG). Material y método: Se analizaron retrospectivamente datos de pacientes con MG. Se evaluaron la edad media, el sexo, el diagnóstico inicial, la desviación ocular, la evolución de los síntomas, el tratamiento realizado y los resultados. Se consideró buen resultado la resolución de la desviación o diplopía al final del seguimiento en posición primaria de mirada y lectura. Resultados: Se incluyeron 14 casos (9: mujeres; bilaterales: 10) de edad media: 55,64 años. En 4 el diagnóstico fue realizado en oftalmología. El diagnóstico inicial fue en 3 casos parálisis del iii par bilateral, en uno parálisis del iii par unilateral, en 3 paresia de recto superior o inferior, en 2 casos parálisis del vi par, en uno paresia del iv par, en 3 de exotropía y en uno de endotropía. La diplopía se presentó en los 14 casos y 9 asociaron ptosis. La desviación ocular fue horizontal en 11 (8: exotropía) y vertical en 4. Se realizó cirugía de estrabismo con buen resultado final en 4 casos que no respondieron al tratamiento farmacológico. Seis pacientes resolvieron la diplopía con el tratamiento farmacológico y un caso con prismas. La ptosis requirió tratamiento quirúrgico en un paciente. Se consiguieron buenos resultados en un 78,57%. Conclusión: La diplopía de comienzo agudo secundaria a un estrabismo de ángulo variable o parálisis oculomotora, con o sin ptosis, puede ser diagnóstico de MG. La cirugía de estrabismo consiguió buenos resultados. El tratamiento farmacológico no consiguió resolver la diplopía en todos los casos

Objective: To present a report of the ocular motility disorders, treatment and outcomes of myasthenia gravis (MG). Material and method: A retrospective study was performed on the data of patients with MG. An evaluation was made using mean age, gender, initial diagnosis, ocular deviation, time of onset of clinical characteristics, treatment and results. Resolution of diplopia and/or ocular deviation in primary and reading gaze was considered a good outcome at the end of follow-up. Results: A total of 14 cases were included. The mean age of the sample was 55.64 years, of which 9 were women, and 10 cases were bilateral. The diagnosis was made by ophthalmologists in 4 cases. The initial diagnoses were diverse: bilateral cranial third nerve palsy in 3, unilateral third nerve palsy in 1, superior or inferior rectus palsy in 3, sixth nerve palsy in 2, fourth nerve palsy in 1, exotropia in 3 and esotropia in 1. Diplopia was presented in 14 cases and 9 associated ptosis. The different types of strabismus were horizontal ocular deviation in 11 cases: 8 with exotropia, and 4 with vertical deviation. Strabismus surgery was performed in 4 cases that did not respond to medical treatment, with a good final outcome. Pharmacological treatment resolved diplopia in 6 cases, and prisms in one. Ptosis surgery was only necessary in one patient. Outcome was favourable in 78.57% at the end of follow-up. Conclusion: Acute onset diplopia caused by strabismus with variable angle or oculomotor palsy, associated or not with a ptosis can indicate MG. There were favourable outcomes with strabismus surgery. Pharmacological treatment did not resolve the diplopia in all cases

Causes and surgical treatment of diplopia and strabismus secondary to myasthenia gravis. / Causas y tratamiento quirúrgico de la diplopía y estrabismo en la miastenia gravis.

OBJECTIVE: To present a report of the ocular motility disorders, treatment and outcomes of myasthenia gravis (MG). MATERIAL AND METHOD: A retrospective study was performed on the data of patients with MG. An evaluation was made using mean age, gender, initial diagnosis, ocular deviation, time of onset of clinical characteristics, treatment and results. Resolution of diplopia and/or ocular deviation in primary and reading gaze was considered a good outcome at the end of follow-up. RESULTS: A total of 14 cases were included. The mean age of the sample was 55.64 years, of which 9 were women, and 10 cases were bilateral. The diagnosis was made by ophthalmologists in 4 cases. The initial diagnoses were diverse: bilateral cranial third nerve palsy in 3, unilateral third nerve palsy in 1, superior or inferior rectus palsy in 3, sixth nerve palsy in 2, fourth nerve palsy in 1, exotropia in 3 and esotropia in 1. Diplopia was presented in 14 cases and 9 associated ptosis. The different types of strabismus were horizontal ocular deviation in 11 cases: 8 with exotropia, and 4 with vertical deviation. Strabismus surgery was performed in 4 cases that did not respond to medical treatment, with a good final outcome. Pharmacological treatment resolved diplopia in 6 cases, and prisms in one. Ptosis surgery was only necessary in one patient. Outcome was favourable in 78.57% at the end of follow-up. CONCLUSION: Acute onset diplopia caused by strabismus with variable angle or oculomotor palsy, associated or not with a ptosis can indicate MG. There were favourable outcomes with strabismus surgery. Pharmacological treatment did not resolve the diplopia in all cases.

Indicaciones y resultados de las recesiones parciales de los rectos verticales / Indications and outcome of vertical rectus partial recessions

OBJETIVO: Valorar indicaciones y resultados conseguidos con las recesiones parciales de los rectos verticales en pacientes con diplopía y estrabismo vertical de pequeño ángulo (≤10 dp). MATERIAL Y MÉTODO: Estudio retrospectivo de 9 pacientes tratados con recesión parcial temporal o nasal de recto superior (RS) o inferior (RI), en 2017. Se consideró buen resultado la eliminación de la diplopía al final del seguimiento en posición primaria de la mirada e infraversión. RESULTADOS: Se incluyeron 9 casos. Edad media: 66,3 años (55,5% mujeres), diagnosticados de paresia del IV nervio (3), paresia incompleta del III (2), sagging eye (2), estrabismo asociado a la edad (1) y estrabismo restrictivo poscirugía de retina (1). La desviación vertical media preoperatoria en posición primaria de la mirada fue 8,2 dp y la postoperatoria 0,8 dp (diferencia significativa entre medias, p = 0,007). En 4 se operó el RS (3 el extremo temporal y uno el nasal). En 5 se operó el RI (4 el extremo temporal y uno el nasal). La dosis media de recesión parcial fue de 3,77mm. En un 55,5% se eliminó la diplopía y un 33,3% quedó con diplopía intermitente bien tolerada. Se obtuvo un buen resultado en el 88,8% con un periodo de seguimiento de 7,1 meses, sin hipercorrecciones. CONCLUSIONES: La recesión parcial de RS o RI consiguió buenos resultados en la mayoría de los casos en los estrabismos verticales de pequeño ángulo con diplopía. Aunque no provocó torsión postoperatoria, ni modificación de la preoperatoria, se debería realizar un estudio previo

OBJECTIVE: To assess the indications and results obtained with partial vertical recti recessions in patients with diplopia and small-angle vertical strabismus ( ≤ 10 dp). MATERIAL AND METHODS: A retrospective study was conducted on 9 patients that were operated on with partial temporal or nasal recession of the superior (SR) or inferior rectus (IR), during 2017. A good outcome was considered when diplopia was resolved in primary position and infraversion, at the end of follow-up. RESULTS: A total of 9 cases were included, with a mean age 66.3 years (55.5 % women), diagnosed with sixth nerve palsy (3), incomplete third nerve palsy (2), sagging eye (2), age related strabismus (1), and restrictive strabismus post-retinal surgery (1). Mean preoperative vertical deviation was 8.2 dp in primary position and the post-operative vertical deviation was 0.8 dp (mean difference was statistically significant, P = .007). In 4 cases, the SR was operated on (temporal pole in 3 and nasal in 1). The IR was operated on in 5 patients (temporal pole in 4 and nasal in 1). Mean recession was 3.77 mm. In 55.5% of case diplopia was eliminated, and in a 33.3% a well-tolerated, intermittent diplopia persisted. A good outcome was obtained in 88.8% of the cases at the end of follow-up (mean: 7. 1 months), with no over-corrections. CONCLUSIONS: Partial SR or IR recessions obtained good results in most of the cases with small angle vertical strabismus and diplopia. Although post-operative torsion or modification of the pre-operative torsion was not observed, a prior study should be made of torsion

Indications and outcome of vertical rectus partial recessions. / Indicaciones y resultados de las recesiones parciales de los rectos verticales.

OBJECTIVE: To assess the indications and results obtained with partial vertical recti recessions in patients with diplopia and small-angle vertical strabismus (≤10 dp). MATERIAL AND METHODS: A retrospective study was conducted on 9 patients that were operated on with partial temporal or nasal recession of the superior (SR) or inferior rectus (IR), during 2017. A good outcome was considered when diplopia was resolved in primary position and infraversion, at the end of follow-up. RESULTS: A total of 9 cases were included, with a mean age 66.3 years (55.5% women), diagnosed with sixth nerve palsy (3), incomplete third nerve palsy (2), sagging eye (2), age related strabismus (1), and restrictive strabismus post-retinal surgery (1). Mean preoperative vertical deviation was 8.2 dp in primary position and the post-operative vertical deviation was 0.8 dp (mean difference was statistically significant, P=.007). In 4 cases, the SR was operated on (temporal pole in 3 and nasal in 1). The IR was operated on in 5 patients (temporal pole in 4 and nasal in 1). Mean recession was 3.77mm. In 55.5% of case diplopia was eliminated, and in a 33.3% a well-tolerated, intermittent diplopia persisted. A good outcome was obtained in 88.8% of the cases at the end of follow-up (mean: 7. 1 months), with no over-corrections. CONCLUSIONS: Partial SR or IR recessions obtained good results in most of the cases with small angle vertical strabismus and diplopia. Although post-operative torsion or modification of the pre-operative torsion was not observed, a prior study should be made of torsion.

Esotropia asociada a la edad: manifestaciones clínicas y resultados terapéuticos / Age-related distance esotropia: clinical features and therapeutic outcomes

OBJETIVO: Analizar las características clínicas de la esotropia asociada a la edad (ETAE), su tratamiento y los resultados terapéuticos obtenidos. MÉTODOS: Se analizaron retrospectivamente expedientes de pacientes diagnosticados de ETAE entre los años 2008 y 2015. Se evaluaron edad media y sexo, desviación en posición primaria de lejos y de cerca medida en dioptrías prismáticas (dp), tratamiento realizado y desviación posquirúrgica. Ducciones y versiones eran normales, sin sospecha de limitación en la abducción. Se excluyó a pacientes con enfermedad neurológica o tiroidea y miopía magna. Se consideró un buen resultado la desaparición de la diplopía en todas las posiciones de la mirada. RESULTADOS: Un total de 16 expedientes fueron analizados (11 mujeres [68,8%]). La edad media al diagnóstico fue de 78,19±6,77 años. La desviación a 33cm variaba desde −4 dp de exotropia hasta 8 dp de esotropia con una desviación media de 2,25±3,08 dp de esotropia. En la mirada lejana, el rango de esotropia era de 2 a 18 dp con una desviación media de 9,75±4,18 dp. En 5 casos no fue necesario tratamiento por ser la sintomatología intermitente y bien tolerada. De 11 pacientes sintomáticos, uno fue corregido con prisma. Se administró toxina botulínica en otro paciente sin resultado satisfactorio. Otros 7 fueron intervenidos mediante plegamiento de recto lateral y uno mediante retroinserción de recto medio, al que se le indicaron prismas antes de la intervención. Un paciente rechazó la cirugía a pesar de la diplopía constante en visión lejana. A los 16,5 meses de media de evolución, todos los pacientes intervenidos quirúrgicamente se encontraban asintomáticos. CONCLUSIONES: No todos los pacientes con ETAE requieren tratamiento, pues la tolerancia a la diplopía es variable de unos sujetos a otros. El debilitamiento del recto medial o el refuerzo del recto lateral proporcionan excelentes resultados

OBJECTIVE: To describe the clinical characteristics and surgical outcomes of a group of patients with age-related distance esotropia (ARDE). METHODS: A retrospective study was conducted on a consecutive case series of 16 adult patients diagnosed with ARDE between 2008 and 2015. The clinical features evaluated included mean age and gender, primary position deviations at distance and near, measured in prism dioptres (pd), treatment offered in each case, and post-surgical deviations. Ductions and versions were full, with no evidence of lateral rectus paresis. None of these patients had any obvious underlying neurological disorder, such as, high myopia or thyroid disease. A good result is considered to be the disappearance of diplopia in all positions of gaze. RESULTS: A total of 16 patients (11 females [68.8%]) were identified. The mean age at diagnosis was 78.19±6.77 years. The mean initial esodeviation was 2.25±3.08 pd at near (−4 to +8 pd) and 9.5±4.18 pd at distance (2 to 18 pd). Treatment was not necessary in 5 cases because the symptoms were intermittent or well-tolerated. Of the 11 patients with symptoms, one was corrected with an external base therapeutic prism. Botulinum toxin was administered in another patient, without satisfactory results. Unilateral medial rectus muscle recession was performed on one patient, and unilateral lateral rectus plication on 7 patients, indicating prisms before surgery. One patient refused surgery despite continuous diplopia in far vision. After a mean follow-up of 16.5 months, all operated patients were asymptomatic. CONCLUSIONS: Not all patients with ARDE require treatment, as the tolerance to diplopia varies from one subject to another. Both medial rectus weakening and lateral rectus strengthening provides excellent results

Age-related distance esotropia: Clinical features and therapeutic outcomes. / Esotropia asociada a la edad: manifestaciones clínicas y resultados terapéuticos.

OBJECTIVE: To describe the clinical characteristics and surgical outcomes of a group of patients with age-related distance esotropia (ARDE). METHODS: A retrospective study was conducted on a consecutive case series of 16 adult patients diagnosed with ARDE between 2008 and 2015. The clinical features evaluated included mean age and gender, primary position deviations at distance and near, measured in prism dioptres (pd), treatment offered in each case, and post-surgical deviations. Ductions and versions were full, with no evidence of lateral rectus paresis. None of these patients had any obvious underlying neurological disorder, such as, high myopia or thyroid disease. A good result is considered to be the disappearance of diplopia in all positions of gaze. RESULTS: A total of 16 patients (11 females [68.8%]) were identified. The mean age at diagnosis was 78.19±6.77 years. The mean initial esodeviation was 2.25±3.08 pd at near (-4 to +8 pd) and 9.5±4.18 pd at distance (2 to 18 pd). Treatment was not necessary in 5 cases because the symptoms were intermittent or well-tolerated. Of the 11 patients with symptoms, one was corrected with an external base therapeutic prism. Botulinum toxin was administered in another patient, without satisfactory results. Unilateral medial rectus muscle recession was performed on one patient, and unilateral lateral rectus plication on 7 patients, indicating prisms before surgery. One patient refused surgery despite continuous diplopia in far vision. After a mean follow-up of 16.5 months, all operated patients were asymptomatic. CONCLUSIONS: Not all patients with ARDE require treatment, as the tolerance to diplopia varies from one subject to another. Both medial rectus weakening and lateral rectus strengthening provides excellent results.

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[Consecutive exotropia surgery]. / Cirugía de la exotropía consecutiva.

PURPOSE: To evaluate the factors involved in the development of consecutive exotropia (XTc), and the surgical procedures used for its treatment. PATIENTS AND METHODS: A retrospective study on 30 patients who underwent surgery for XTc was carried out in our Department. The following characteristics were studied prior to surgery: anamnesis, refraction, deviation angle measurement, detection of amblyopia and diplopia prior to the operation, abnormal head posture rotations and presence of any vertical deviation and anisotropy. The surgical technique used was individually considered for each patient and included bilateral lateral rectus recessions and/or unilateral medial rectus advancement to its/their original insertion site. RESULTS: Before surgery, 53.33% of our patients showed amblyopia, 66.66% of them showed rotation limitation, 46.66% showed dissociated vertical deviation (DVD), 20% had abnormal head posture and 10% diplopia. <> results (residual deviation of 10 prism diopters or less) were obtained in 70% of our patients. More than half of our cases were corrected with one single procedure. CONCLUSIONS: The presence of amblyopia, rotation limitations and vertical deviations (DVD and/or alphabetical syndromes) were found to be the most common factors in the development of a XTc in our study. The results indicate that a residual angle less than 10 prism diopters is obtained in 70% of our patients. The technique of choice is a bilateral lateral rectus muscle recession for deviations up to 35 prism diopters. The association of an advancement of one or both medial rectus muscles is necessary when the initial deviation exceeds 35 prism diopters.

Cirugía de la exotropía consecutiva / Consecutive exotropia surgery

Objetivo: Evaluar los factores que influyen en la aparición de la exotropía consecutiva (XTc), así como sus procedimientos quirúrgicos correctores. Material y métodos: Hemos realizado un estudio restrospectivo en nuestro departamento, incluyendo 30 pacientes operados de XTc. Antes de la cirugía se estudiaron los siguientes aspectos: anamnesis, retracción, ángulo de desviación, detección de ambliopía y diplopía, y exploración de ducciones, tortícolis y anisotropía. La técnica empleada fue individualizada para cada paciente. Se realizó retroinserción de uno o ambos rectos laterales; también se hicieron avanzamientos del recto medio operado previamente. Material y métodos: Hemos realizado un estudio restrospectivo en nuestro departamento, incluyendo 30 pacientes operados de XTc. Antes de la cirugía se estudiaron los siguientes aspectos: anamnesis, retracción, ángulo de desviación, detección de ambliopía y diplopía, y exploración de ducciones, tortícolis y anisotropía. La técnica empleada fue individualizada para cada paciente. Se realizó retroinserción de uno o ambos rectos laterales; también se hicieron avanzamientos del recto medio operado previamente. Resultados: Preoperatoriamente se encontraron un 53,33 por ciento de pacientes con ambliopía, un 66,6 por ciento de limitación de las ducciones, un 46,6 por ciento de DVD, un 20 por ciento de tortícolis y un 10 por ciento de diplopías. En la mayoría de los casos (70 por ciento) el resultado fue 'bueno' (ángulo residual de menos de 10 dioptrías prismáticas). En más de la mitad de los pacientes una cirugía fue suficiente para solventar la XTc. Conclusiones: En nuestro estudio se demuestra que la ambliopía, la limitación de las ducciones, las alteraciones verticales (DVD y síndromes alfabéticos) son las alteraciones más frecuentemente encontrados en la XTc. Los resultados indican que, en un 70 por ciento de los pacientes tratados por nosotros, se consigue un ángulo residual de menos de 10 dioptrías prismáticas (DP). La técnica de elección es la doble recesión de rectos laterales, cuando la desviación es menor a 35 DP; cuando es mayor, es necesario un avanzamiento de uno o ambos rectos mediales (AU)

Diplopía post-cirugía de catarata: causas y tratamiento / Diplopia post-cataract surgery: aetiology and treatment

Objetivo: Conocer las causas y el resultado del tratamiento de la diplopía binocular persistente, observada posteriormente a la cirugía de cataratas. Método: Se realiza un estudio descriptivo retrospectivo de 19 pacientes con diplopía tras cirugía de catarata, a los que se les practica una cuidadosa anamnesis y un examen sensorial y motor antes de proceder al tratamiento médico y/o quirúrgico. Resultados: Se clasificaron según la etiología en: patología o trauma quirúrgico (47,4 por ciento), alteración en la visión binocular (ambliopía, estrabismo previo o larga supresión por la catarata) (47,4 por ciento), alteraciones en la refracción (5,2 por ciento) y enfermedad previa. El tratamiento inicial con prismas fue tolerado en el 47,4 por ciento, requiriendo cirugía el 36,8 por ciento, administración de toxina botulínica en el 5,3 por ciento y penalización para evitar la diplopía en el 10,5 por ciento. Un 36,8 por ciento continúa con diplopía, desapareciendo en el 63,2 por ciento por haber recuperado la visión binocular, por producirse una supresión propia o por penalización. Conclusiones: La diplopía post-cirugía de catarata es una grave complicación que se debe tener en cuenta en la cirugía de polo anterior. A pesar de los distintos tratamientos empleados, su desaparición no es fácil de conseguir (AU)

Afilamiento del oblicuo superior en el síndrome de Brown 'plus'. Resultados / Superior oblique sharpening in Browns syndrome 'plus'. Results

Objetivo: Estudiar los resultados obtenidos en los pacientes con síndrome de Brown congénito intervenidos mediante la técnica del afilamiento del oblicuo superior. Método: De los 19 casos diagnosticados de síndrome de Brown en nuestra sección durante un período de 4 años (enero de 1992 y diciembre de 1995), 9 enfermos fueron seleccionados e intervenidos por presentar hipotropía en posición primaria de la mirada y/o tortícolis. En 3 casos se asoció una retroinsercción del oblicuo superior Resultados: La limitación de la elevación en aducción mejoró en todos los casos excepto en uno (11,1 por ciento). La hipotropía prequirúrgica presente en 7 enfermos (77,8 por ciento) se resolvió posteriormente en 5 (71,42 por ciento). El tortícolis inicial con una incidencia del 77,8 por ciento (7/9) desapareció por completo en 3, y mejoró en otros 3. La visión binocular se recuperó en 2 casos. Un mal resultado se obtuvo en un 22,22 por ciento (2/9) por persistir el tortícolis y la hipotropía. No se observaron complicaciones intraoperatorias ni postoperatorias, salvo una paresia transitoria del oblicuo superior que no requirió cirugía. Conclusiones: El afilamiento del tendón del oblicuo superior es una técnica eficaz en el tratamiento del síndrome de Brown en aquellos pacientes que presentan una alteración vertical en posición primaria de la mirada y/o tortícolis (AU)