Results of anterior tucking of the superior oblique muscle tendon in bilateral fourth nerve palsy.

BACKGROUND: Bilateral fourth nerve palsy is characterised by excyclotorsion, which can be corrected by reinforcement of the anterior tendon fibres of the superior oblique muscle. PATIENTS AND METHODS: A retrospective study of 40 consecutive patients with bilateral acquired fourth nerve palsy operated by a selective tuck of the anterior portion of the superior oblique tendon between 1994 and 2012 was undertaken. Horizontal, vertical and torsional deviations were measured in 9 diagnostic positions of gaze and the field of binocular single vision was evaluated with the Harms tangent screen. Postoperative follow-ups took place at 1 week, 6 months, and ≥3 years. RESULTS: Preoperative mean excyclotorsion was 9° in the primary position and 15° in downgaze. These values decreased to 2° and 5° 6 months after surgery, and 2.5° and 6° at ≥3 years. Immediate post-operative incyclotorsion in upgaze (28 patients) and Brown syndrome (15 patients) regressed spontaneously. The median score of field of binocular single vision improved from 4% preoperatively to 76% postoperatively. CONCLUSIONS: The selective tuck of the anterior tendon fibers of the superior oblique tendon enables an efficient and long-lasting correction of the ocular torsion induced by bilateral trochlear palsy.

Torsional strabismus and vertical rectus muscle surgery in thyroid eye disease.

PURPOSE: To assess the torsional component in patients with vertical strabismus due to thyroid eye disease (TED) and its course after vertical rectus muscle surgery. PATIENTS AND METHODS: Retrospective chart review of patients undergoing vertical strabismus surgery for TED between 1998 and 2017, having undergone pre- and postoperative Harms tangent screen examination. RESULTS: Forty patients (27 women) were identified. A torsional component was present in all patients. Thirty-three patients had a mean excyclotorsion of 4.5° in primary position, increasing to 8.2° in upgaze, associated with restricted elevation. Inferior rectus muscle recession (n=29) reduced the excyclotorsion in all cases. A 4.4° mean incyclotorsion was present in primary position in 7 cases, increasing to 7.1° in downgaze. Superior rectus muscle recession reduced the incyclotorsion in 5/6 cases. The torsional surgical dose-effect relationship was correlated with the amount of preoperative torsion. The field of binocular single vision improved from 6.5% preoperatively to 71.1% after surgery. CONCLUSIONS: Ocular torsion is common in vertical strabismus secondary to TED and is significantly improved by vertical rectus muscle surgery alone. Surgery should be planned according to vertical deviation and motility limitation, and vertical rectus muscles surgery should be considered the first line of treatment, with selective oblique muscle surgery as a second-line option, which was unnecessary in our series.

Anterior segment angiography in strabismus surgery.

BACKGROUND: Anterior ciliary arteries travelling along recti muscles provide anterior segment vascularization, which can be compromised by surgery involving more than 2 muscles. PATIENTS AND METHODS: We studied retrospectively the files of 10 patients in whom a fluorescein angiography of the iris had been performed as a pre-operative assessment prior to a second or third oculomotor surgery. RESULTS: The median age of the patients was 47.5 years (range 15 to 73 years). Relative iris ischemia was present in 4 patients following multiple surgeries, none of them presenting any general cardiovascular risk. The initial surgical protocol was modified according to angiographic results in these 4 patients. CONCLUSION: When further surgery has to be performed on previously multi-operated patients, anterior segment angiography can be useful in the planning of surgery in order to minimize the risks of anterior segment ischemia.

[Ophthalmology. Stereopsis: back in the spotlight]. / Ophtaltmologie. La stéréoscopie sur le devant de la scène.

Stereopsis was brought to the fore by its stunning development in a virtual element, in movies or game devices. The mechanisms used to produce 3D artificially are very similar to those involved in natural depth perception. They include binocular stereopsis, generated by the simultaneous perception of two images with a slight horizontal shift, together with the interpretation of monocular clues (perspective, distribution of light and shadow,...). Because virtual 3D uses the same mechanisms as natural perception, there is no reason to believe that 3D movies might be dangerous for the eyes.

[Management of motility disorders secondary to iatrogenic orbital fracture during endoscopic sinus surgery]. / Prise en charge des troubles oculomoteurs après effraction iatrogène de l'orbite au cours d'interventions sinusiennes endoscopiques.

PURPOSE: Orbital wall fracture may occur during endoscopic sinus surgery, resulting in oculomotor disorders. We report the management of four cases presenting with this surgical complication. METHODS: A non-comparative observational retrospective study was carried out on four patients presenting with diplopia after endoscopic ethmoidal sinus surgery. All patients underwent full ophthalmologic and orthoptic examination as well as orbital imaging. RESULTS: All four patients presented with diplopia secondary to a medial rectus lesion confirmed by orbital imaging. A large horizontal deviation as well as limitation of adduction was present in all cases. Surgical management consisted of conventional recession-resection procedures in three cases and muscle transposition in one patient. A useful field of binocular single vision was restored in two of the four patients. CONCLUSION: Orbital injury may occur during endoscopic sinus surgery and cause diplopia, usually secondary to medial rectus involvement due to the proximity of this muscle to the lamina papyracea of the ethmoid bone. Surgical management is based on orbital imaging, duration of the lesion, evaluation of anterior segment vasculature, results of forced duction testing and intraoperative findings. In most cases, treatment is aimed at the symptoms rather than the cause, and the functional prognosis remains guarded.

Management of diplopia secondary to neurosurgical injury of the orbital roof.

BACKGROUND: Diplopia related to neurosurgical procedures is often consecutive to oculomotor nerve lesions. We hereby report an oculomotor dysfunction secondary to an orbital roof effraction and its treatment. HISTORY AND SIGNS: Following surgery for a left anterior communicating artery aneurysm, a 45-year-old woman reported vertical diplopia associated with a left orbital hematoma. The diagnosis of third cranial nerve palsy was excluded by orbital imaging which revealed an orbital roof defect with incarceration of the levator palpebrae and superior rectus. THERAPY AND OUTCOME: As neurosurgeons advised against muscle adhesiolysis, diplopia was corrected by a two-step procedure on the oculomotor muscles. We first corrected horizontal and torsional deviations by operating on the healthy eye, before correcting the vertical deviation on the fellow eye. This two-step extraocular muscle surgery allowed restoration of binocular single vision in a useful field of gaze. CONCLUSIONS: Diplopia can occur as a rare orbital complication during neurosurgical procedures. Surgery of extraocular muscles can provide good functional results.

Perioperative visual loss: a rare complication of general surgery.

BACKGROUND: Perioperative visual loss (PVL) refers to the loss of vision following surgery performed at distance from the visual pathways. An ischemic optic neuropathy (ION) is the most frequent clinical presentation of PVL, and can be bilateral. PATIENTS AND METHODS: A retrospective chart review of 11 consecutive patients with PVL examined between 2002 and 2007 was undertaken. RESULTS: An ION was found in all 11 cases: 8 were anterior (AION) and 3 were posterior (PION). Visual loss was bilateral in 9 patients. Mean visual acuity (VA) was 0.2 on the Snellen chart (0.74 LogMAR). Most frequently an arcuate/altitudinal visual field defect was present. PVL followed orthopedic (6), spinal (1), cardiac (2) and vascular (2) procedures. The average delay between surgery and visual loss was 32 hours (range: 0-96 hours). Average lowest perioperative hemoglobin level was 75 g/L. Average follow-up time was 14.7 months. VA improved by at least 2 Snellen lines in 5/20 eyes (25 %). CONCLUSIONS: PVL is a rare but dreadful complication of surgery, and is usually associated with severe anemia. Like other causes of ION, there is no specific therapy. Prompt correction of the anemia might decrease the rate of this complication.

Acquired unilateral pseudoptosis: a presentation of silent sinus syndrome.

BACKGROUND: Acquired unilateral ptosis usually results from either levator palpebrae disinsertion, eyelid disorder, myasthenia gravis, mitochondrial myopathy, Horner's syndrome, or third nerve palsy. In rare cases, an orbital process is responsible for ptosis or pseudoptosis. HISTORY AND SIGNS: A healthy 31-year-old patient complained for 6 months of right eyelid ptosis. On examination, there was 1 mm right upper eyelid ptosis and 1 mm of right enophthalmos. Upon downgaze, an apparent right eyelid retraction was present. Magnetic resonance imaging showed filling and retraction of the right maxillary sinus with inferior displacement of the right orbital floor. THERAPY AND OUTCOME: Surgical management was performed with a favourable outcome. CONCLUSIONS: Silent sinus syndrome is an asymptomatic chronic maxillary sinus atelectasis, resulting in ipsilateral enophthalmos, hypoglobus, and occasionally eyelid pseudoptosis. Silent sinus syndrome should be incorporated in the differential diagnosis of acquired unilateral ptosis.