Varied presentations of congenital ocular synkinesis: do they all fit congenital cranial dysinnervation disorder spectrum? / Apresentações variadas de sincinesias oculares congênitas: todas elas se enquadram ao espectro das desordens congênitas da desnervação craniana?

ABSTRACT Purpose: Synkinesis results from nerve miswirings and causes aberrant movements of the affected muscles. We present a series of cases of rare congenital ocular synkinesis involving the extraocular muscles and the levator palpebrae superioris and speculate the possibility of classifying these entities in the spectrum of congenital cranial dysinnervation disorder. Methods: Records of patients with the diagnosis of congenital ocular synkinesis were analyzed retrospectively. We analyzed the sex, laterality, and complete features of the ocular motility of each patient. Results: Nine patients with congenital ocular synkinesis were included. A slight predominance of women was noted. In terms of laterality, four patients had only the right eye involved, four had only the left eye, and one had both eyes involved. Notably, 55.5% were orthotropic in the primary position. The third, fourth, and sixth cranial nerves were involved in the miswiring in 100%, 44.4%, and 11.1% of the cases, respectively. Conclusions: Congenital synkinesis might present in a very eclectic and uncommon fashion. The aberrant innervation in these cases classifies them into the group of congenital cranial dysinnervation disorders.

RESUMO Objetivo: Sincinesias são resultado de inervações anômalas e ocasionam movimentos aberrantes dos músculos envolvidos. Apresentamos uma série com casos raros de sincinesias oculares congênitas dos músculos extraoculares e do levantador da pálpebra superior e especulamos a possibilidade de classificá-las dentro do espectro das desordens congênitas da desnervação cranianana. Métodos: Prontuários de pacientes com diagnóstico de sincinesia ocular congênita foram estudados retrospectivamente. Analisamos sexo, lateralidade e as características completas do exame de motilidade de cada paciente. Resultados: Nove pacientes com sincinesias oculares congênitas foram incluídos. Houve discreta predominância no sexo feminino. Em termos de lateralidade, o olho direito foi o único envolvido em 4 casos, o olho esquerdo também em 4 casos e 1 caso apresentou acometimento bilateral. 55,5% dos pacientes eram ortotrópicos na posição primária. Os III, VI e IV nervos participaram da sincinesia em 100%, 44,4% e 11,1% dos casos, respectivamente. Conclusões: Sincinesias oculares congênitas podem se apresentar de modo bastante eclético e incomum. A inervação aberrante presente em cada um desses casos os coloca na lista de candidatos a integrar o grupo das desordens congênitas da desenervação craniana.

Varied presentations of congenital ocular synkinesis: do they all fit congenital cranial dysinnervation disorder spectrum?

PURPOSE: Synkinesis results from nerve miswirings and causes aberrant movements of the affected muscles. We present a series of cases of rare congenital ocular synkinesis involving the extraocular muscles and the levator palpebrae superioris and speculate the possibility of classifying these entities in the spectrum of congenital cranial dysinnervation disorder. METHODS: Records of patients with the diagnosis of congenital ocular synkinesis were analyzed retrospectively. We analyzed the sex, laterality, and complete features of the ocular motility of each patient. RESULTS: Nine patients with congenital ocular synkinesis were included. A slight predominance of women was noted. In terms of laterality, four patients had only the right eye involved, four had only the left eye, and one had both eyes involved. Notably, 55.5% were orthotropic in the primary position. The third, fourth, and sixth cranial nerves were involved in the miswiring in 100%, 44.4%, and 11.1% of the cases, respectively. CONCLUSIONS: Congenital synkinesis might present in a very eclectic and uncommon fashion. The aberrant innervation in these cases classifies them into the group of congenital cranial dysinnervation disorders.

Long-Term Follow-Up of Cyclic Esotropia.

BACKGROUND AND PURPOSE: To describe the development and treatment of patients with cyclic esotropia. PATIENTS AND METHODS: The clinical course of seven patients with cyclic esotropia were retrospectively reviewed and described. All patients underwent bilateral medial rectus recession based on the deviation manifested on the day they were esotropic. Additionally, one patient had previously undergone surgery for intermittent exotropia. RESULTS: All patients developed excellent postoperative alignment. After strabismus surgery, normal eye alignment with some degree of binocularity was reached in five patients. Moreover, there was no recurrence of the cyclic deviation in any patient, and no patient experienced an overcorrection. CONCLUSIONS: Strabismus surgery aimed to correct the horizontal esotropic angle present on the day the esotropia is manifested provides a good outcome that is stable long-term, with minimal risk of overcorrection. Possible explanations for the origin of cyclic esotropia are discussed.

Measurement of ocular torsion variation following superior oblique tenectomy / Medida da variação da torção ocular após a tenectomia do oblíquo superior

Purposes: To objectively evaluate the torsional effect of the superior oblique muscle-weakening surgery using the tenectomy technique proposed by Souza-Dias. Methods: The present prospective study included 10 patients (20 eyes) with horizontal strabismus, bilateral superior oblique overaction and A-pattern of 15 to 30 prism diopters who underwent superior oblique tenectomy. Objective assessment of ocular torsion was performed by retinography immediately before and one month after surgery. The amount of ocular torsion was determined by measuring the angle formed by a horizontal line drawn across the geometric center of the optic disc and a second line connecting this point to the fovea. Results: The median preoperative angle was 5.56° in the right eyes and -3.43° in the left eyes. The median postoperative angle was 1.84° in the right eyes and -3.12° in the left eyes. The angle variation was statistically significant in both eyes (p=0.012 and p=0.01, respectively). Conclusion: The present study suggests that superior oblique tenectomy has an extorter effect, decreasing the intorsion detected on overaction of this muscle. .

Objetivo: Avaliar, de forma objetiva, a torção ocular após a tenectomia do oblíquo superior, proposta por Souza-Dias. Métodos: Estudo prospectivo de dez pacientes (20 olhos) com estrabismo horizontal, hiperfunção bilateral dos oblíquos anisotropia em A de 15 a 30 dioptrias prismáticas, submetidos à tenectomia bilateral dos oblíquos superiores. A avaliação objetiva da torção foi realizada com a retinografia antes e após a cirurgia, determinando-se o ângulo de torção formado entre a linha horizontal que passa pelo centro do disco óptico e a linha que passa pelo centro da fóvea. Resultados: A mediana dos ângulos de torção pré-operatória foi de 5,56° nos olhos direitos e de 3,43° nos esquerdos. Após a cirurgia, o ângulo mediano foi de 1,84° nos olhos direitos e de -3,12° nos esquerdos. Em ambos os olhos, a variação absoluta foi estatisticamente significativa (p=0,012/p=0,01). Conclusões: O presente estudo demonstrou que a tenectomia do oblíquo superior tem ação extorsora, reduzindo de forma significante a intorção encontrada nos casos de hiperfunção deste músculo. .

The influence of body position on Bielschowsky's test.

PURPOSE: To investigate the veracity of Jampolsky's statement that Bielschowsky's head tilt test is inverted if performed with the patient in the upside-down position and to interpret its neuromuscular mechanism. METHODS: We present a series of 10 patients selected from a referred sample who were diagnosed with superior oblique paresis. Hypertropia was measured in the primary position, with the head erect and tilted toward both shoulders with the patient in the erect, supine, and upside-down positions. The last position was achieved by hanging the patient upside-down. RESULTS: As expected, our results showed the veracity of Jampolsky's statement. The forced head tilt difference was inverted or significantly decreased when the test was performed in the upside-down position. Moreover, in all patients, Bielschowsky's phenomenon was neutralized in the supine body position, in which hypertropia with the head erect tended to vanish. In 3 patients, it disappeared completely. CONCLUSIONS: This study showed that, in patients with superior oblique paresis, differences in the extent of hypertropia in Bielschowsky's test tended to vanish when the test was performed with the patient in the supine position and invert when it was performed with the patient in the upside-down position.

The influence of body position on Bielschowsky's test / A influência da posição corporal sobre o teste de Bielschowsky

Purpose: To investigate the veracity of Jampolsky's statement that Bielschowsky's head tilt test is inverted if performed with the patient in the upside-down position and to interpret its neuromuscular mechanism. Methods: We present a series of 10 patients selected from a referred sample who were diagnosed with superior oblique paresis. Hypertropia was measured in the primary position, with the head erect and tilted toward both shoulders with the patient in the erect, supine, and upside-down positions. The last position was achieved by hanging the patient upside-down. Results: As expected, our results showed the veracity of Jampolsky's statement. The forced head tilt difference was inverted or significantly decreased when the test was performed in the upside-down position. Moreover, in all patients, Bielschowsky's phenomenon was neutralized in the supine body position, in which hypertropia with the head erect tended to vanish. In 3 patients, it disappeared completely. Conclusions: This study showed that, in patients with superior oblique paresis, differences in the extent of hypertropia in Bielschowsky's test tended to vanish when the test was performed with the patient in the supine position and invert when it was performed with the patient in the upside-down position. .

Objetivo: Investigar a veracidade da suposição de Jampolsky de que o teste de inclinação da cabeça de Bielschowsky invertese caso seja realizado com o paciente de cabeça para baixo, e tentar interpretar o mecanismo neuromuscular envolvido. Métodos: Apresentamos uma série de 10 pacientes portadores de paresia do oblíquo superior. Foi medida a hipertropia dos pacientes na posição primária do olhar e com a cabeça inclinada para cada um dos lados nas posições ereta, supina e de cabeça para baixo. Resultados: Como esperado, nossos resultados confirmaram a suposição de Jampolsky; além disso, e em todos os pacientes, o fenômeno de Bielschowsky foi neutralizado em posição supina. As diferenças da magnitude da hipertropia ao teste de Bielschowsky diminuiram significativamente ou inverteramse quando o paciente foi testado de cabeça para baixo. Conclusões: Este estudo demonstrou que, nos pacientes com paresia do oblíquo superior, a hipertropia evidenciada pelo teste de Bielschowsky tende a desaparecer com o paciente na posição supina e a se inverter quando o teste é realizado com o paciente de cabeça para baixo. .

Measurement of ocular torsion variation following superior oblique tenectomy.

PURPOSES: To objectively evaluate the torsional effect of the superior oblique muscle-weakening surgery using the tenectomy technique proposed by Souza-Dias. METHODS: The present prospective study included 10 patients (20 eyes) with horizontal strabismus, bilateral superior oblique overaction and A-pattern of 15 to 30 prism diopters who underwent superior oblique tenectomy. Objective assessment of ocular torsion was performed by retinography immediately before and one month after surgery. The amount of ocular torsion was determined by measuring the angle formed by a horizontal line drawn across the geometric center of the optic disc and a second line connecting this point to the fovea. RESULTS: The median preoperative angle was 5.56° in the right eyes and -3.43° in the left eyes. The median postoperative angle was 1.84° in the right eyes and -3.12° in the left eyes. The angle variation was statistically significant in both eyes (p=0.012 and p=0.01, respectively). CONCLUSION: The present study suggests that superior oblique tenectomy has an extorter effect, decreasing the intorsion detected on overaction of this muscle.

Prevalence of refractive errors in Möbius sequence.

PURPOSE: To assess the prevalence of refractive errors in Möbius sequence. METHODS: This study was carried out during the Annual Meeting of the Brazilian Möbius Society in November 2008. Forty-four patients diagnosed with the Möbius sequence were submitted to a comprehensive assessment, on the following specialties: ophthalmology, neurology, genetics, psychiatry, psychology and dentistry. Forty-three patients were cooperative and able to undertake the ophthalmological examination. Twenty-two (51.2 %) were male and 21 (48.8%) were female. The average age was 8.3 years (from 2 to 17 years). The visual acuity was evaluated using a retro-illuminated logMAR chart in cooperative patients. All children were submitted to exams on ocular motility, cyclopegic refraction, and fundus examination. RESULTS: From the total of 85 eyes, using the spherical equivalent, the major of the eyes (57.6%) were emmetropics (>-0.50 D and <+2.00 D). The prevalence of astigmatism greater than or equal to 0.75 D was 40%. CONCLUSION: The prevalence of refractive errors, by the spherical equivalent, was 42.4% in this studied group.

Prevalence of refractive errors in Möbius sequence / Prevalência de erros refrativos na sequência de Möbius

PURPOSE: To assess the prevalence of refractive errors in Möbius sequence. METHODS: This study was carried out during the Annual Meeting of the Brazilian Möbius Society in November 2008. Forty-four patients diagnosed with the Möbius sequence were submitted to a comprehensive assessment, on the following specialties: ophthalmology, neurology, genetics, psychiatry, psychology and dentistry. Forty-three patients were cooperative and able to undertake the ophthalmological examination. Twenty-two (51.2 %) were male and 21 (48.8%) were female. The average age was 8.3 years (from 2 to 17 years). The visual acuity was evaluated using a retro-illuminated logMAR chart in cooperative patients. All children were submitted to exams on ocular motility, cyclopegic refraction, and fundus examination. RESULTS: From the total of 85 eyes, using the spherical equivalent, the major of the eyes (57.6%) were emmetropics (>-0.50 D and <+2.00 D). The prevalence of astigmatism greater than or equal to 0.75 D was 40%. CONCLUSION: The prevalence of refractive errors, by the spherical equivalent, was 42.4% in this studied group.

OBJETIVO: Avaliar a prevalência de erros refrativos em crianças portadoras da sequência de Möbius. MÉTODOS: Trabalho realizado durante o encontro anual da Associação Möbius do Brasil (AMoB) em novembro de 2008. Quarenta e quatro pacientes com diagnóstico de sequência de Möbius foram submetidos a avaliação multidisciplinar: oftalmológica, neurológica, genética, psiquiátrica, psicológica e odontológica. Quarenta e três pacientes colaboraram com exame oftalmológico. Vinte e dois (51,2 %) eram do sexo masculino e 21 (48,8 %) do sexo feminino. A idade média foi de 8,3 anos (2 a 17 anos). A medida da acuidade visual foi realizada com tabela logMAR retro-iluminada, nos pacientes que colaboravam. Todas as crianças foram submetidas a exame da motilidade ocular, refração sob cicloplegia e fundo de olho. RESULTADOS: Do total de 85 olhos estudados, usando o equivalente esférico, a maioria dos olhos (57,6%) são emétropes (>-0,50 D e <+2,00 D). A prevalência de astigmatismo maior que 0,75D foi 40%. CONCLUSÃO: A prevalência de erros refrativos, pelo equivalente esférico, no grupo estudado foi de 42,4%.

[Surgical correction of permanent exotropia outcomes in amblyopic and non-amblyopic patients]. / Resultados da correção cirúrgica da exotropia permanente em pacientes amblíopes e não-amblíopes.

UNLABELLED: Permanent exotropia (XT) occurs in 1 to 2% of the pediatric population. Its management involves careful assessment of patient, treatment of amblyopia, refractive errors and surgery. The aim of the surgery is to straighten the eyes in the primary gaze position, giving a better cosmetic outcome. The factors reported to affect surgical outcome after exotropia surgery vary widely in reports and success rates for strabismus surgery have been reported to range from 60% to 80%. There are few reports to determine the relation between amblyopia and surgical outcome in exotropic patients. PURPOSE: To compare the surgical outcome of permanent exotropia surgery in amblyopic and non-amblyopic patients. METHODS: This is a retrospective study of 37 clinical records from amblyopic patients (Group A) and non-amblyopic patients (Group B) who underwent recess-resect in one eye for XT. Postoperative deviation was analyzed in one month (immediate) and in six months (final) in both groups and in between. Age: group A 24.7 ± 14.2 years, group B 22.6 ± 18.6 years; Preoperative deviation: group A 29.1 ± 7.2(Δ), group B 28.4 ± 6.8(Δ). RESULTS: The success rate in the immediate postoperative period was 60% (Group A) and 100% (Group B) (p<0.05); 50% (Group A) and 82.3% (Group B) (p=0.082) in the final postoperative period. There was a statistical difference in the immediate postoperative deviation, but the final deviation and the variation of the deviation were similar in both groups. CONCLUSION: There is a better outcome in patients of group B and no diference in the surgical outcome between these amblyopic and non-amblyopic patients in the final postoperative period.

[Reoperation in congenital and essential acquired non acomodative esotropia]. / Reoperação nas esotropias congênita e essencial adquirida não acomodativa.

PURPOSE: To analyze the results in patients reoperated from congenital and essential esotropia. METHODS: A retrospective chart review of 393 patients who underwent surgery from 2000-2004 was performed. Subjects were divided into two groups: Congenital esotropia (91 patients) and essential esotropia (302 cases). RESULTS: Among congenital cases we had 9 reoperations (9.9%). There were undercorrections (3.3%), overcorrections (2.2%), anisotropia (V) (1.1%), hypotropia (1.1%) and dissociatd vertical divergences (2.2%). Among the essential cases, there were 31 (10.3%) reoperations due to undercorrections (n=6.6%), overcorrections (n=2%) and hypotropias (1.7%). CONCLUSIONS: Outcomes reoperations rates were 9.9% and 10.2% between congenital and essential esotropias with a higher rate of undercorrections. Amblyopia in both groups and deviations higher than 50∆ in essential esotropias seems to be the most important factors for poor results.

Horizontal effect of the surgical weakening of the oblique muscles.

PURPOSE: To evaluate the influence of the oblique muscles surgical weakening on the horizontal alignment in the primary position (PP) and its efficacy on the correction of the "A" and "V" anisotropies. METHODS: In order to study the influence of bilateral superior oblique muscles (SO) weakening on the horizontal alignment in PP, we analyzed the files of 12 patients who underwent only that operation; no other muscle was operated on. We took the opportunity of those 12 patients to analyze the effect of their operation on the correction of "A" incomitance. For evaluating the effect of the inferior oblique muscles (IO) weakening on the correction of the "V" pattern, we analyzed retrospectively the files of 67 anisotropic patients who underwent a bilateral SO weakening. In 10 of them, the only operation was the oblique muscles weakening and, in 57 patients, the horizontal recti were also operated on for the horizontal deviations in primary position. These patients were divided into two groups: 50 were esotropic and 17 exotropic. There was not any mixed anisotropy. RESULTS: The mean value of the preoperative "V" incomitance of the 50 esotropic patients was 24.25∆ ± 10.15∆; the mean postoperative correction was 15.56 ∆ ± 8.74∆. The mean correction between the PP and upgaze was 7.52∆ ± 7.47∆ and from the PP to downgaze was 8.56∆ ± 9.21∆. The same values of the 17 exotropic patients was: preoperative 31.88∆ ± 9.4∆; primary position to upgaze was 13.11∆ ± 4.9∆ and primary position to downgaze 14.11∆ ± 12.48∆. The mean preoperative value of the "A" incomitance among the 12 patients who underwent isolated SO weakening was 30.50∆ ± 19.25∆ and the postoperative was of 9,92∆, therefore a mean correction of 22.58∆ ± 17.54∆. Among these ones, in 5 there was no alteration of the deviation in primary position, in 4 there was an exo-effect and in 3 there was an eso-effect. The mean alteration of the deviation in PP was an exo-shift of 2.25∆. CONCLUSIONS: 1) There was no difference in the relative correction of "V" pattern between the esotropic and exotropic patients, although the absolute numbers were greater in the exotropic ones. 2) The correction of the "V" pattern was between 65 and 75 % from the initial values. 3) The IO weakening corrected similarly the anisotropia between the superior and inferior components among the esotropic patients, but among the exotropic ones the correction was greater in the inferior component. 4) The SO weakening did not cause an eso-effect in the deviation in primary position.

Acquired oculomotor muscle fibrosis in infant: case report.

The authors report the case of a 5 year-old boy who up to 2 years old presented normal eyes, when his right eye started to deviate upward and laterally, until be hidden under the superior lid. At the surgery, a strong passive limitation to infraduction of this eye was felt. He had already been operated on in another clinic, but the surgeon could not succeed in hooking his superior rectus. With great difficulty, the only thing that we could do was a free tenotomy of the superior rectus. As the eye was equilibrated in a moderate abduction, we performed an 8 mm recession of the lateral rectus. As there was still a small hypertropia and exotropia postoperatively, we performed in a second operation an eight millimeters resection of the medial rectus, a recession with anterior transposition of the inferior oblique and an advancement of the inferior rectus according to the Romero-Apis technique, in order to avert circulatory problems to the anterior segment of the eye. As he presented a small blepharoptosis, we did, in a third surgery, a tarsectomy according to the Fasanella-Servat technique, with good result. He ended with good eye position, almost no limitation of the horizontal movements and - 3 limitation of up and down ductions. The magnetic resonance imaging showed an altered image of the superior rectus, suggesting fibrosis post myositis.

Resultados da correção cirúrgica da exotropia permanente em pacientes amblíopes e não-amblíopes / Surgical correction of permanent exotropia outcomes in amblyopic and non-amblyopic patients

A exotropia permanente (XT) acomete cerca de 1 a 2 por cento da população. Seu tratamento é clínico: antiambliogênico e correção dos erros refrativos, e cirúrgico. O objetivo do tratamento cirúrgico é alinhar os olhos na posição primária do olhar, proporcionando melhor resultado estético. Há muito tempo diversos autores estudam os fatores pré, per e pós-operatórios relacionados ao resultado cirúrgico, uma vez que a taxa de sucesso varia de 60 a 80 por cento. Ainda são poucos os estudos que comparam a presença de ambliopia como fator de influência no resultado final. OBJETIVO: Comparar o resultado cirúrgico dos pacientes amblíopes e não-amblíopes submetidos à cirurgia de correção de XT. MÉTODOS: Análise retrospectiva de 37 prontuários de pacientes amblíopes (Grupo A) e não-amblíopes (Grupo B) submetidos à correção cirúrgica de XT por retrocessoressecção monocular, sendo avaliados os registros pós-operatórios imediatos e tardios. Idade: grupo A 24,7 ± 14,2 anos, grupo B 22,6 ±18,6 anos; Desvio pré-operatório: grupo A 29,1± 7,2Δ, grupo B 28,4 ± 6,8Δ. RESULTADOS: A taxa de sucesso foi de 60 por cento e 100 por cento (p<0,05), no pós-operatório imediato e 50 por cento e 82,3 por cento (p=0,082), no pós-operatório final, nos grupos A e B, respectivamente. Não houve diferença significante quanto aos desvios pós-operatórios imediatos, tardios e variação do desvio. CONCLUSÃO: Pode-se concluir que o grupo B mostrou melhor resultado no pós-operatório imediato; porém não houve diferença no resultado cirúrgico de correção de exotropia permanente entre pacientes amblíopes e não-amblíopes no período pós-operatório de seis meses.

Permanent exotropia (XT) occurs in 1 to 2 percent of the pediatric population. Its management involves careful assessment of patient, treatment of amblyopia, refractive errors and surgery. The aim of the surgery is to straighten the eyes in the primary gaze position, giving a better cosmetic outcome. The factors reported to affect surgical outcome after exotropia surgery vary widely in reports and success rates for strabismus surgery have been reported to range from 60 percent to 80 percent. There are few reports to determine the relation between amblyopia and surgical outcome in exotropic patients. PURPOSE: To compare the surgical outcome of permanent exotropia surgery in amblyopic and non-amblyopic patients. METHODS: This is a retrospective study of 37 clinical records from amblyopic patients (Group A) and non-amblyopic patients (Group B) who underwent recess-resect in one eye for XT. Postoperative deviation was analyzed in one month (immediate) and insixmonths (final) in both groups and in between. Age: group A 24.7 ± 14.2 years, group B 22.6 ± 18.6 years; Preoperative deviation: group A 29.1 ± 7.2Δ, group B 28.4 ± 6.8Δ. RESULTS: The success rate in the imediate postoperative period was 60 percent (Group A) and 100 percent (Group B) (p<0.05); 50 percent (Group A) and 82.3 percent (Group B) (p=0.082) in the final postoperative period. There was a statistical difference in the imediate postoperative deviation, but the final deviation and the variation of the deviation were similar in both groups. CONCLUSION: There is a better outcome in patients of group B and no diference in the surgical outcome between these amblyopic and non-amblyopic patients in the final postoperative period.

Reoperação nas esotropias congênita e essencial adquirida não acomodativa / Reoperation in congenital and essential acquired non acomodative esotropia

OBJETIVO: Analisar os resultados das reoperações nas esotropias congênita e essencial adquirida não acomodativa. MÉTODOS: Foram avaliados retrospectivamente 393 prontuários de pacientes com diagnóstico de esotropia (91 esotropias congênitas e 302 adquiridas) no Departamento de Oftalmologia da Santa Casa de São Paulo, operados entre os anos de 2000 e 2004. RESULTADOS: No grupo dos portadores de esotropia congênita, 9 pacientes foram reoperados (9,9 por cento). As indicações para a nova intervenção foram: subcorreções (3,3 por cento), supercorreções (2,2 por cento), anisotropia (V) (1,1 por cento), hipotropia (1,1 por cento) e divergências visuais dissociadas (2,2 por cento). No grupo dos portadores de esotropia essencial adquirida não acomodativa 31 pacientes foram reoperados (10,3 por cento). As indicações para a nova intervenção foram: subcorreções (n=6,6 por cento), supercorreções (n=2 por cento) e hipertropias (n=1,7 por cento). CONCLUSÕES: A porcentagem de reoperação nos casos de esotropia congênita e essencial adquirida não acomodativa foram 9,9 por cento e 10,2 por cento respectivamente, com predominância de subcorreções nas indicações para a realização de nova cirurgia. A presença de ambliopia e desvios maiores que 50∆ na esotropia essencial adquirida não acomodativa (EEANA) foram os mais importantes fatores para maus resultados.

PURPOSE: To analyze the results in patients reoperated from congenital and essential esotropia. METHODS: A retrospective chart review of 393 patients who underwent surgery from 2000-2004 was performed. Subjects were divided into two groups: Congenital esotropia (91patients) and essential esotropia (302 cases). RESULTS: Among congenital cases we had 9 reoperations (9.9 percent). There were undercorrections (3.3 percent), overcorrections (2.2 percent), anisotropia (V) (1.1 percent), hypotropia (1.1 percent) and dissociatd vertical divergences (2.2 percent). Among the essential cases, there were 31 (10.3 percent) reoperations due to undercorrections (n=6.6 percent), overcorrections (n=2 percent) and hypotropias (1.7 percent). CONCLUSIONS: Outcomes reoperations rates were 9.9 percent and 10.2 percent between congenital and essential esotropias with a higher rate of undercorrections. Amblyopia in both groups and deviations higher than 50∆ in essential esotropias seems to be the most important factors for poor results.

Horizontal effect of the surgical weakening of the oblique muscles / Efeito horizontal do debilitamento cirúrgico dos músculos oblíquos

PURPOSE: To evaluate the influence of the oblique muscles surgical weakening on the horizontal alignment in the primary position (PP) and its efficacy on the correction of the "A" and "V" anisotropies. METHODS: In order to study the influence of bilateral superior oblique muscles (SO) weakening on the horizontal alignment in PP, we analyzed the files of 12 patients who underwent only that operation; no other muscle was operated on. We took the opportunity of those 12 patients to analyze the effect of their operation on the correction of "A" incomitance. For evaluating the effect of the inferior oblique muscles (IO) weakening on the correction of the "V" pattern, we analyzed retrospectively the files of 67 anisotropic patients who underwent a bilateral SO weakening. In 10 of them, the only operation was the oblique muscles weakening and, in 57 patients, the horizontal recti were also operated on for the horizontal deviations in primary position. These patients were divided into two groups: 50 were esotropic and 17 exotropic. There was not any mixed anisotropy. RESULTS: The mean value of the preoperative "V" incomitance of the 50 esotropic patients was 24.25∆ ± 10.15∆; the mean postoperative correction was 15.56 ∆ ± 8.74∆. The mean correction between the PP and upgaze was 7.52∆ ± 7.47∆ and from the PP to downgaze was 8.56∆ ± 9.21∆. The same values of the 17 exotropic patients was: preoperative 31.88∆ ± 9.4∆; primary position to upgaze was 13.11∆ ± 4.9∆ and primary position to downgaze 14.11∆ ± 12.48∆. The mean preoperative value of the "A" incomitance among the 12 patients who underwent isolated SO weakening was 30.50∆ ± 19.25∆ and the postoperative was of 9,92∆, therefore a mean correction of 22.58∆ ± 17.54∆. Among these ones, in 5 there was no alteration of the deviation in primary position, in 4 there was an exo-effect and in 3 there was an eso-effect. The mean alteration of the deviation in PP was an exo-shift of 2.25∆. CONCLUSIONS: 1) There was no difference in the relative correction of "V" pattern between the esotropic and exotropic patients, although the absolute numbers were greater in the exotropic ones. 2) The correction of the "V" pattern was between 65 and 75 percent from the initial values. 3) The IO weakening corrected similarly the anisotropia between the superior and inferior components among the esotropic patients, but among the exotropic ones the correction was greater in the inferior component. 4) The SO weakening did not cause an eso-effect in the deviation in primary position.

OBJETIVOS: Avaliar a influência do debilitamento cirúrgico dos músculos oblíquos sobre o alinhamento horizontal na posição primária do olhar (PPO) e na correção das anisotropias em "A" e "V". MÉTODOS: Para estudar a influência do debilitamento bilateral dos músculos oblíquos superiores (OS) no alinhamento horizontal na posição primária do olhar, analisamos prontuários de 12 pacientes com debilitamento isolado desses músculos. Aproveitamos para verificar o seu efeito na correção da anisotropia em "A". Para avaliar eficácia do debilitamento dos oblíquos inferiores (OI) na correção da incomitância em "V", analisamos retrospectivamente os prontuários de 67 pacientes com debilitamento bilateral desses músculos. Em 10 pacientes, a única operação foi o debilitamento dos OI e em 57 operaram-se também os retos horizontais, para o desvio na PPO. Destes, 50 tinham esotropia e 17 exotropia. Nenhum tinha anisotropia mista. RESULTADOS: O valor médio da incomitância em "V" pré-operatória dos pacientes esotrópicos era 24.25∆ ± 10,15∆ e a correção média pós-operatória foi 15.56∆ ± 8,74∆ (68,0 por cento). O componente superior era de 10,98∆ e a correção foi de 7,52∆ ± 7,47∆ (68,5 por cento) e, entre a PPO e a infraversão, o valor era de 13,28∆ e a correção foi de de 8,56∆ ± 9,21∆ (64,5 por cento). Esses valores nos 17 exotrópicos foram: pré-operatório 31.88∆ ± 9.4∆ e correção de 20,93∆; no componente superior a incomitância era de 13.11∆ ± 4.9 ∆ e a correção foi de 6,82∆ (52,0 por cento); da PPO à infraversão, o incomitância era de 18,76∆ e a correção foi de 14.11∆ ± 12.48∆ (75,2 por cento). A incomitância em "A" dos 12 pacientes com debilitamento isolado dos OS era 32,17∆ ± 19,25∆ e a pós-operatória era de 9,92∆, correção, portanto, de 22,25∆ ± 17,54∆. Entre estes, em 5 não houve alteração do desvio na PPO, em 4 houve exo-efeito e em 3 houve eso-efeito nessa posição; a alteração média foi um exo-efeito de 2,25∆. CONCLUSÕES: 1) Não houve diferença na correção relativa da incomitância em "V" entre esotrópicos e exotrópicos; embora os números absolutos tenham sido maiores entre estes. 2) A correção da forma em "V" foi entre 65 e 75 por cento dos valores iniciais. 3) O debilitamento dos OIs corrigiu similarmente a anisotropia entre os componentes superior (da PPO à supraversão) e inferior (da PPO à infraversão) entre esotrópicos, mas entre exotrópicos, a correção foi maior no componente inferior. 4) O debilitamento dos OS não provocou eso-efeito do desvio na PPO.

Acquired oculomotor muscle fibrosis in infant: case report / Fibrose adquirida de músculo oculomotor em criança: relato de caso

The authors report the case of a 5 year-old boy who up to 2 years old presented normal eyes, when his right eye started to deviate upward and laterally, until be hidden under the superior lid. At the surgery, a strong passive limitation to infraduction of this eye was felt. He had already been operated on in another clinic, but the surgeon could not succeed in hooking his superior rectus. With great difficulty, the only thing that we could do was a free tenotomy of the superior rectus. As the eye was equilibrated in a moderate abduction, we performed an 8 mm recession of the lateral rectus. As there was still a small hypertropia and exotropia postoperatively, we performed in a second operation an eight millimeters resection of the medial rectus, a recession with anterior transposition of the inferior oblique and an advancement of the inferior rectus according to the Romero-Apis technique, in order to avert circulatory problems to the anterior segment of the eye. As he presented a small blepharoptosis, we did, in a third surgery, a tarsectomy according to the Fasanella-Servat technique, with good result. He ended with good eye position, almost no limitation of the horizontal movements and - 3 limitation of up and down ductions. The magnetic resonance imaging showed an altered image of the superior rectus, suggesting fibrosis post myositis.

Os autores relatam o caso de um menino de 5 anos que, até os 2 anos, possuía olhos normais, quando seu olho direito começou a desviar para cima e lateralmente, até chegar a esconder-se sob a pálpebra superior. À cirurgia, notou-se forte limitação passiva de abaixamento desse olho. Ele já havia sido operado em outra clínica, mas o colega não conseguiu enganchar o reto superior. Numa segunda operação, o único que conseguimos foi uma tenotomia livre do reto superior; como o olho ficou equilibrado em abdução, fizemos um retrocesso de 8 mm do reto lateral. Como restou moderada exotropia e pequena hipertropia, numa terceira operação fizemos uma ressecção de 8 mm do reto medial, um retrocesso com transposição anterior do oblíquo inferior e um avançamento do reto inferior segundo a técnica de Romero-Apis, para evitar transtornos circulatórios ao segmento anterior do olho. Como restou pequena blefaroptose, realizamos, numa quarta operação uma tarsectomia segundo Fasanella-Servat. O paciente terminou com o olho direito bem posicionado, sem limitações aos movimentos horizontais e limitação de -3 dos verticais. A imagem de ressonância magnética demonstrou alterações do reto superior, sugerindo fibrose após miosite.