Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall.

BACKGROUND/AIMS: Surgical correction of ocular alignment in patients with third cranial nerve paralysis is challenging, as the unopposed lateral rectus muscle often pulls the eye back to exotropia following surgery. The authors present a simple surgical approach to overcome this difficulty. This approach is also applicable to removal of unwanted overactivity of the lateral rectus in Duane syndrome. METHODS: A review was made of the records of four patients with third cranial nerve paralysis and one with Duane syndrome with exotropia in which the lateral rectus muscle was removed from its scleral insertion and reattached to the orbital wall. Additional surgery to bring the eye to the midline included medial rectus resection, medial transposition of the vertical recti, and passive suturing of the eye to the medial orbit wall. RESULTS: All patients achieved satisfactory ocular alignment following surgery. Ocular ductions were limited. These results were stable for 1.5-4 years of follow up. No major complications occurred. CONCLUSION: Lateral rectus muscle disinsertion and reattachment to the orbital wall to absorb its force and thus remove abduction torque was a simple and safe surgical procedure for restoring ocular alignment in four patients with third cranial nerve paralysis and in one patient with Duane syndrome with severe exotropia.

The clinicopathologic basis of Graves' ophthalmopathy: a review.

PURPOSE: Graves' ophthalmopathy (GO) is a controversial disease, with disagreement within the medical community regarding its pathogenesis, diagnosis, and treatment. METHODS: We reviewed recent literature on clinical and pathological aspects of GO from both the endocrinologist's and ophthalmologist's perspective. RESULTS: Investigations into the pathogenesis of GO have included possible antigenic targets, orbital cell types, and development of animal models. Diagnosis has been improved recently with new tools and grading systems, but can be complicated by conditions that may simulate one or more of the findings of GO. The new findings of clinical studies also compel practitioners to reassess commonly used GO treatments such as orbital irradiation. CONCLUSIONS: Improved understanding of the pathogenic mechanisms of GO should hopefully lead to new diagnostic and therapeutic approaches to this problematic condition.

Diplopia following subcutaneous injections of botulinum A toxin for facial spasms.

PURPOSE: To study the incidence, cause, recovery time, and prevention of diplopia following subcutaneous injection of botulinum A toxin for the treatment of facial spasms. METHODS: Patients who experienced diplopia after botulinum A toxin injections had their deviations examined in detail. When the muscle that caused diplopia was identifiable, the injection closest to that muscle was omitted in the next treatment in an attempt to prevent diplopia. RESULTS: Of 250 patients receiving about 1500 sets of injections, 25 (1.7%) incidents of diplopia occurred in 10 patients. Excluding two patients who declined further treatment after having diplopia on their first botulinum A toxin treatment, seven of the remaining eight patients had multiple incidents of diplopia. The most common pattern of diplopia was "uncertain diagnosis." The most common identifiable cause of diplopia was paresis of the inferior oblique muscle. Omission of the injection into the central portion of the lower eyelids in the next treatment prevented recurrence of diplopia in only one of the four patients. No significant correlation between botulinum A toxin doses injected and times to recovery was noted. CONCLUSIONS: Diplopia following botulinum A toxin treatment is uncommon. Seven patients (3% of patients studied) had 22 episodes of diplopia (88% of episodes). When diplopia occurs, it tends to recur on reinjection, sometimes with a prolonged recovery time. This response may not be dose dependent. The extraocular muscles of some patients may be more susceptible to chemodenervation than others, or botulinum A toxin may diffuse to extraocular muscles more easily in some patients than in others.

Facial tics.

This short paper presents an approach to management of facial tics, which are rare in adults. Facial tics are usually progressive. If bilateral, the condition is usually 'benign essential blepharospasm'. If unilateral they are usually due to hemifacial spasm.

Headaches and the ophthalmologist.

Many patients are referred to an ophthalmologist because of headaches. If the headaches are provoked by visual activity, the ophthalmologist can often treat the patient. An approach to assessing the larger number of headache patients without visual problems is presented.

Contraceptive pitfalls.

PIP: I would like to comment on two points raised by Dr. Barbara Simcock in her 'Pitfalls in contraception' (AFP October 1978). IUD-associated fetal anomalies: There have been scattered reports about these, as Dr. Simcock remarks. Further, infants born in the presence of copper-containing IUDs have high serum levels of copper and ceruloplasmin. As copper is intimately involved in the metabolism of mitochondria, collagen and melanin the long term sequelae may be sinister. One case has been documented where high levels were the probable cause of still birth. IUD-associated infections: It is now well established that, apart from gonorrhoea, there is poor correlation between cervical swabs and pathogens higher in the genital tract. Thus the results of these swabs should not be relied on as a guide to treatment.^ieng

Ophthalmic manifestations of head injury.

Head injuries are frequently associated with ophthalmic problems. The commonest problems seen in this series of 161 patients with head injury were problems with poor accommodation (16% of patients; 58% of these persisted), convergence (14% of patients; 35% of these persisted), pseudomyopia (19%; 55% persisted) and optic atrophy (26% of the patients; 78% of these were mild and easily missed on routine testing, and 22% were severe). Motility disorders were common, especially cranial nerve palsies. Other less frequent motility disturbances included apparent inferior oblique palsy, comitant esotropia, and exotropia which was often of the convergence insufficiency type.

Arterial macroaneurysm of the optic disc.

A 64-year-old man presented with an arterial macroaneurysm on the optic disc, an unusual location for retinal arterial macroaneurysm. The macroaneurysm resolved spontaneously without sequelae.

MRI in the heavy eye phenomenon.

The heavy eye phenomenon presents as progressive esotropia and hypotropia in high myopia. It appears to be due to compression of the lateral rectus muscle against the lateral orbital wall by the enlarged myopic globe. We present the first published magnetic resonance imaging (MRI) scans of this condition and a summary of the literature.

The snapped inferior rectus.

PURPOSE: To evaluate the management and possible aetiology of the snapped inferior rectus muscle in strabismus surgery. METHODS: Three patients are described whose inferior rectus muscle broke across its width some 8-10mm behind the insertion while being held on a squint hook without excessive force during strabismus surgery. The proximal part of the muscle was not found. The distal part of the snapped muscle was excised for pathological examination. Transposition of the inferior halves of the adjacent horizontal muscles to the insertion of the inferior rectus (a modified inverse-Knapp procedure) was performed in all cases. RESULTS: After the transposition surgery, one patient was orthotropic in the primary position, one patient required a prism correction to produce a range of single vision and the third patient was orthotropic after a further operation. There was good depression in one case and the other two had a limitation of depression. In all cases, horizontal movements remained intact and there were no signs of anterior segment ischaemia. CONCLUSIONS: The unique relations of the inferior rectus to the surrounding tissues may be a factor in causing the breaking of this muscle. Two of the patients were elderly and this may be a factor also. Transposition surgery is the appropriate management when the proximal part of the snapped muscle cannot be located and has satisfactory but imperfect results.

Diplopia as a complication of laser in situ keratomileusis surgery.

A case is presented of a patient with high myopia who developed vertical binocular diplopia after decentred laser in situ keratomileusis (LASIK) surgery with associated decompensation of pre-existing exophoria into an exotropia. A 40-year-old man underwent LASIK surgery for high myopia in his right eye. Preoperatively, he was approximately -26.00/-2.00 x 35 degrees with visual acuity of 6/12(-2) in that eye. He also had an asymptomatic exophoria. After LASIK surgery, he achieved a refraction of -3.25/-0.50 x 80 degrees with 6/21 best-corrected visual acuity. He also developed binocular diplopia. The ablation zone had been decentred upwards and there was also an exo- and hypo-deviation of his right eye. He was able to superimpose the two images in free space with vertical and horizontal prisms.A hard contact lens also resulted in superimposition of the two images. Vertical decentration of the ablation zone can induce a vertical prism effect after LASIK surgery and result in vertical diplopia. This together with abnormal optics also caused loss of best-corrected vision and decompensation of his pre-existing exophoria into an exotropia.

Abnormal fibrinolysis in retinal vein occlusion.

Some cases of central and branch retinal vein occlusion are associated with and may be caused by abnormal fibrinolytic mechanisms. The abnormality we described is that of plasminogen activator enzyme deficiency, which is a treatable condition. That seven cases were seen by one practitioner in a two year period may indicate that this particular condition is under-recognised.

Facial muscle spasms: an Australian study.

PURPOSE: A group of patients suffering from blepharospasm, hemifacial spasm and Meige's syndrome were surveyed to determine the delay from the onset of their condition until a correct diagnosis was reached, the attitudes of practitioners towards them and their condition, the effect of their condition on their lifestyle and the effects of different types of treatment on their conditions. METHODS: Questionnaires were offered to all patients with blepharospasm, hemifacial spasm and Meige's syndrome presenting to three ophthalmologists licensed to treat patients with botulinum toxin injections over a 12 month period. RESULTS: Patients consulted an average of 4.4 practitioners before a correct diagnosis was made and many waited a number of years before obtaining satisfactory treatment. Approximately two-thirds of all practitioners consulted were unaware of their condition. Ten per cent of patients reported a family history of similar conditions. Most patients received relief from their symptoms with treatment using injections of botulinum toxin. More than 55% of patients considered themselves to have psychological problems (usually relating to stress and trauma) that they associated with the onset of their condition. CONCLUSIONS: Facial muscle dystonias are rare and patient experiences suggest that they are poorly appreciated in the medical community. From the time they first see a practitioner with symptoms of facial dystonia, patients typically wait 2 years and see four practitioners before a correct diagnosis is made. Stress may be a factor in the symptomatic onset of this condition. Many patients describe pain as part of the presenting symptomatology. Botulinum toxin seems to be effective in the management of facial spasm.

Changes as the result of ageing in extraocular muscles: a post-mortem study.

BACKGROUND: Extraocular muscles differ from typical skeletal muscle in many respects such as smaller fibre size, high mitochondrial content, unusual contractile/innervation patterns and highly developed microvascular bed. Changes in typical skeletal muscle with ageing have been well documented yet the reports on ageing changes in extraocular muscles is limited. The aim of this study was to examine these changes. METHODS: The right inferior and medial rectus muscles were removed at post-mortem from patients with no history of prior ocular or neuromuscular disease. These included 25 patients aged between 23 and 88 years (14 male, 11 female). The median age of the patients was 69 years and 72% of patients were aged older than 66 years. The median post-mortem interval was 28 h, RESULTS: In young adults between 20 and 30 years of age, the muscle fibres were regular, of fairly uniform size with minimal endomysial connective tissue and no lipofuscin was detected in fibres. In adults between 40 and 50 years of age, a small amount of subsarcolemmal lipofuscin was detected. Between 50 and 60 years of age, a few fibres with reduced density of myofibrils were noted. All patients over 65 years had definite changes of ageing and those between 70 and 80 years of age showed similar features to those between 60 and 80 years of age. These changes included variation in fibre size, increased endomysial fibrous tissue and increased endomysial adipose tissue, and loss of myofibrils with some fibres devoid of fibrils and comprising 'bags' of mitochondria. There was increased lipofuscin in a number of fibres, increased 'degenerative' changes such as vacuolation of fibres, scattered 'eosinophilic intracytoplasmic bodies' and increased numbers of 'ringbinden'.

CT diagnosis of broncholithiasis.

Computed tomography clearly demonstrated broncholithiasis rather than suspected malignancy as the cause of segmental atelectasis of the right middle lobe. Possible technical limitations as a source of error are presented.