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OBJECTIVE: To describe the outcomes of a relaxed muscle technique for treatment of dysthyroid strabismus. DESIGN: Retrospective consecutive case series. PARTICIPANTS: Twenty-four patients with thyroid-related orbitopathy (TRO) underwent strabismus surgery using a novel relaxed muscle technique. METHODS: Charts of all patients who underwent rectus muscle recession surgery using a relaxed muscle technique between 1997 and 2004 were reviewed. Twenty-four of 28 patients had more than 2 months of follow-up and were included. The extent of recession was determined by marking where the tendon naturally fell while the relaxed muscle rested freely on the globe with the eye in the primary position. The muscle was sutured to the globe at the mark. Linear regression was used to determine the correlation between the degree of strabismus and the amount of recession required to eliminate diplopia. MAIN OUTCOME MEASURES: Surgical outcomes were analyzed 2 months, 6 months, and 1 year after strabismus repair. Excellent success was defined as no diplopia in primary and reading gazes without prisms. Good outcome was defined as no diplopia in primary and reading positions with the use of <10 prism diopters. Poor outcome was defined as persistent diplopia in primary or reading positions despite prisms, or the inability of the patient to tolerate the necessary prisms. RESULTS: Twenty-four patients underwent 60 muscle recessions. Nine had diplopia without a history of orbital decompression, 8 had diplopia before decompression, and 7 developed diplopia only after orbital decompression. Twenty-one patients (87.5%) had an excellent final outcome. A clinically acceptable (excellent or good) final outcome was achieved in 24 of 24 patients (100%) after an average of 1.08 surgeries. All 7 patients who developed diplopia only after decompression had an excellent outcome. Linear regression did not show good correlation between the degree of strabismus and the amount of recession required to eliminate diplopia (maximum R2 = 0.7292). There were no complications. CONCLUSIONS: The relaxed muscle technique provides excellent ocular alignment and relief from diplopia in a majority of patients with TRO-associated strabismus. Patients who develop diplopia only after orbital decompression may have a higher success rate.
BACKGROUND: An adult strabismus clinic in a regional eye centre provided an opportunity to estimate the risk of postoperative diplopia from regional anesthesia after cataract surgery and to describe the management of these patients. METHODS: Retrospective cohort analysis. All cases were referred over a 22-month period (November 1997 to September 1999) for investigation of postoperative diplopia after cataract surgery. The surgical and anesthetic records were reviewed to determine the number and location of injections, and the volume and type of regional anesthesia. The evolution and management of patients' diplopia was studied prospectively. RESULTS: Twenty-one patients (12 women and 9 men aged 63 to 88 [median 76] years) were ascertained with postoperative diplopia. In 11 cases the right eye was affected, and in 10 cases, the left eye. Vertical diplopia occurred most commonly from inferior rectus restriction (16 cases). Three cases resolved without treatment, which indicated that the diplopia was transient. Four patients declined treatment, five required prism in eyeglasses only, and nine required strabismus surgery. One patient required surgery and prism in eyeglasses. Two patients required more than one strabismus operation to relieve the diplopia. For the period of data collection, we estimate the risk of nontransient postoperative diplopia from regional anesthesia as 2.6 cases per 1000 cataract procedures (95% confidence interval 1.9-4.7). INTERPRETATION: Patients should be forewarned of the risk of diplopia after cataract surgery with regional anesthesia. The treatment of the diplopia may require prism in eyeglasses or strabismus surgery or both.
Severe midfacial trauma presents several challenges to the reconstructive surgeon. Acute rigid fixation of the facial skeleton accompanied by bone grafting to restore the confines and volume of the orbit provide the best opportunity for acceptable aesthetic results. The severity of the trauma causes the late postoperative complication of enophthalmos. Injury to orbital structures with subsequent cicatricial change results in significant alteration in extraocular motility with resultant diplopia. There are no reports in the literature which critically evaluate the effect of late enophthalmos correction on extraocular motility, diplopia, and vision in patients who have suffered Le Fort or NOE fractures. A retrospective study is presented which reviews the results of late surgery for the correction of enophthalmos in 40 patients, all of whom had severe "impure" orbital fractures. This study addresses the following questions: (1) Can the globe effectively be repositioned?, (2) Is there a change in subjective diplopia?, (3) Does a change in extraocular motility occur, and if it does, is it predictable?, (4) Is there a risk to visual acuity? and finally, (5) Do the answers to questions 1 through 4 suggest that late surgical intervention for the correction of enophthalmos should be recommended for this patient population? During a 9-year period, 44 patients with severe diplopia trauma received surgery for enophthalmos correction. A review of 40 patients on whom 56 operations were performed is presented. Thirty-eight patients had enophthalmos and 35 had inferior displacement of the globe. Medial displacement of the globe occurred in 11 patients. Twenty-nine patients had diplopia. Six patients had vision too poor on the injured side to have diplopia. Enophthalmos was improved in 32 patients. Dystopia of the globe was improved in 31 cases. However, neither enophthalmos nor dystopia of the globe could be improved with every operation. Only 35 of the 48 operations for enophthalmos for which measurements were available produced an improvement; in 1 case the enophthalmos was thought to be worse postoperatively. Dystopia operations resulted in improvement in 40 of 48 operations; in 2 instances dystopia was worse postoperatively. Diplopia was unchanged by 33 operations, improved by 11 procedures, and worsened by 6. If patients are considered before and after their total reconstruction course, diplopia was improved in 9 of the 29 patients. In seven of these nine, diplopia was eliminated. There was no change in or production of diplopia in 19 patients, and 5 patients had worsening of their double vision.(ABSTRACT TRUNCATED AT 400 WORDS)
AIM: The optimal treatment of ocular myasthenia gravis (OMG) remains unknown. The authors evaluated the efficacy of prednisone and pyridostigmine in reducing diplopia, ocular motor dysfunction, and ptosis in patients with OMG. METHODS: Review of records from a clinical database from one neuro-ophthalmology service of patients presenting with OMG between 1990 and 2002, excluding those who developed generalised MG within the first month after diagnosis. Institutional review board approval was obtained for this study. PARTICIPANTS/INTERVENTIONS: Non-randomised, unmasked, therapy was given. 55 patients with diplopia in primary or downward gaze and clinically demonstrable extraocular muscle dysfunction received prednisone. 34 patients who had contraindications to steroids or who refused treatment with prednisone received pyridostigmine only. Over 5 days the daily prednisone dose was increased to 50-60 mg and then gradually reduced to 10 mg, followed by further reduction as tolerated. The pyridostigmine dose was begun at 180 mg daily and increased as tolerated. MAIN OUTCOME MEASURES: Follow up evaluations, performed at 1, 3-6, 12, and 24 months, detailed the frequency of ptosis and diplopia and the amount of ocular motor deviation in primary and downward gaze. RESULTS: The prednisone and pyridostigmine groups were similar for age, sex, acetylcholine receptor antibody level, prism cover test results for primary and downward gaze, diplopia in primary and downward gaze, and unilateral ptosis. Bilateral ptosis was present in 32.4% of the pyridostigmine group and 10.9% of the prednisone group (p = 0.02). The prednisone group showed resolution in primary gaze diplopia, downgaze diplopia, unilateral ptosis, and bilateral ptosis in 73.5%, 75.5%, 85.7%, and 98%, respectively at 1 month. The benefit persisted at 3-6, 12, and 24 months except for the bilateral ptosis. The pyridostigmine group showed resolution in primary gaze diplopia, downgaze diplopia, unilateral ptosis, and bilateral ptosis in 6.9%, 17.2%, 50%, and 76.7% of patients after 1 month of treatment. The prism cover results improved (p = 0.003) in the prednisone group only. In the prednisone group, four patients had no response to therapy. Among the 51 prednisone responsive patients, there were 33 recurrences in 26 patients. 12 patients, all prednisone treated, had remissions. Except for three patients who developed diabetes, no patient developed a clinically significant systemic corticosteroid complication. CONCLUSION: These results suggest that 50-60 mg daily prednisone followed by lower doses (10 mg or less) has the benefit of resolving ptosis and diplopia that lasts for at least 2 years in approximately 70% of patients.
PURPOSE: To present complete process of pre-operative strabismus diagnosis, which can be used for prediction of post-operative diplopia in adolescents and adults. MATERIAL AND METHODS: The study involved three patients, who were qualified for the surgical treatment of strabismus. Complete pre-operative diagnosis predicting potential post-operative diplopia was performed in all patients. The prismatic test for diplopia, hyperfunctional muscle botuline toxin injection, and prism correction were performed RESULTS: Regarding the results of tests, two patients were qualified for surgical treatment. None of them suffered from diplopia after this treatment. The third patient in pre-operative tests showed unacceptably high risk of intolerable diplopia. CONCLUSIONS: Post-operative diplopia in adolescents and adults represents a serious problem, especially in susceptible patients. Accurate and complete pre-operative diagnosis allows for risk reduction in post-operative diplopia. The predictive test for post-operative diplopia, botuline toxin injection and prism correction in isolation are not always able, to give a reliable indication, as to the sensory status following strabismus surgery. A combination of the three above mentioned techniques give more reliable diagnosis. For patients, who can possibly suffer from post-operative diplopia, the adjustable suture technique should be applied.
OBJECTIVE: To better understand the pathophysiology and proper management of a subgroup of patients with orbital blowout fracture which manifests by a vertical diplopia and hypertropia on the affected side. PATIENTS AND METHODS: This report is based on a series of ten consecutive patients with orbital floor blowout fractures who had diplopia and hypertropia on the affected side. All patients were followed through at least 13 days of conservative care. Computed tomography demonstrated a characteristic depressed fracture of the posterior orbital floor extending to the posterior wall of the maxillary sinus in all patients. In many patients, the inferior rectus looped inferiorly and then rose to contact the globe at a steep angle. Diplopia did not spontaneously resolve in any patient. At surgery, the orbital contents were elevated to the posterior extent of the fracture, and the floor defects were bridge. Patients were followed for resolution of diplopia. RESULTS: Eight patients had resolution of the hypertropia and diplopia within 2 months of surgery, and two patients had residual diplopia in extreme downgaze but were significantly improved. CONCLUSIONS: When hypertropia and vertical diplopia are noted after orbital trauma, a posterior blowout fracture should be suspected. In these patients, infraduction may be diminished due to changes in the effective origin and insertion of the inferior rectus muscle. The diagnosis of a posterior blowout fracture should be supported by characteristic findings on computed tomography. If the motility abnormality persists for 10 to 14 days, posterior orbital exploration and fracture repair should be undertaken.
BACKGROUND: Monofixation syndrome is characterized by small-angle strabismus with vergence fusional amplitudes and "peripheral fusion." Although it is thought to be a relatively stable condition, some patients with this syndrome deteriorate, resulting in an increasing heterotropia, sometimes associated with diplopia. Deteriorated monofixation syndrome is well known among clinicians; however, there are no studies describing the course and outcomes for these patients. PURPOSE: To assess the clinical characteristics, course, and response to therapy of patients with deteriorated monofixation syndrome. METHODS: We identified all patients from our database that had an ocular deviation of < or =8 Delta on simultaneous prism cover testing, peripheral fusion, and between 3000 and 67 seconds of stereoacuity (monofixators) who subsequently had an increase in their deviation to >8 Delta, loss of fusion, or diplopia. From this group we assessed patient clinical characteristics, course, and response to therapy. RESULTS: We identified 29 patients with deteriorated monofixation syndrome who subsequently underwent treatment. Treatment consisted of surgery in 28 patients and minus lens therapy in one patient. Of the study group, 28 (97%) of the patients had a history of esotropia and 20 patients (69%) had a history of amblyopia. Nine patients noted diplopia at the time of deterioration, which persisted in four patients after treatment. In all, 14 patients (48%) met the criteria for monofixation again after therapy, while 20 patients (69%) had successful motor alignment (< or =8 Delta). There was a trend toward poorer outcomes in the diplopic group when compared with the patients who did not have diplopia, although this was not statistically significant (P = 0.26 for regaining monofixation syndrome). Follow-up ranged from 1 month to 21 years. CONCLUSION: Though monofixation is considered a stable condition, some patients will deteriorate over time as demonstrated by an increase in the ocular deviation and loss of fusion. In this study 31% of our patients noted the onset of diplopia. Following treatment, 48% of the patients regained monofixation. Patients with diplopia following deterioration of their alignment may be less likely to regain good alignment or monofixation after treatment.
OBJECTIVE: This report presents patient-reported optical symptoms after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK). DESIGN: Preoperative and postoperative patient surveys in a prospective, multicenter, randomized clinical trial. PARTICIPANTS: Two hundred twenty eyes of 220 patients entered the study; 105 were randomized to PRK and 115 were randomized to LASIK. INTERVENTION: All patients received a one-pass, multizone excimer laser ablation as part of either a PRK or LASIK procedure. Attempted corrections ranged from 6.00 to 15.00 diopters (D). MAIN OUTCOME MEASURES: Glare, halo, and monocular diplopia symptoms as reported by patients on questionnaires before surgery and at the 6-month follow-up. Comparison was made between symptoms when using optical correction before surgery and symptoms without correction after surgery. RESULTS: For both the PRK and LASIK groups analyzed individually, the difference in average glare index before surgery and after surgery was not statistically significant (P = 0.54 for PRK; P = 0.15 for LASIK; t test). Twenty-four PRK patients (41.4%) reported worsening of glare symptoms from baseline compared with 11 LASIK patients (21.6%); however, the difference between the two groups was not statistically significant (P = 0.086, chi-square test). Within the PRK group, the difference in average halo index before and after surgery was statistically significant (P = 0.0003, t test); in the LASIK group, it was not statistically significant (P = 0.1 1, t test). Thirty-four PRK patients (58.6%) reported worsening of halo symptoms from baseline compared with 26 LASIK patients (50.0%); this difference was not statistically significant (P = 0.086, chi-square test). For both the PRK and LASIK groups, the difference in average diplopia index before and after surgery was statistically significant (P < 0.0001 for PRK; 0.047 for LASIK; t test). Twenty-six PRK patients (44.8%) reported a worsening of monocular diplopia symptoms from baseline compared with 19 LASIK patients (35.8%); this difference was not statistically significant (P = 0.39, chi-square test). When changes in glare and halo from before surgery to after surgery were pooled as a glare-halo index, however, the PRK group did show a significantly greater likelihood of demonstrating an increase in symptoms compared with the LASIK group (P = 0.048, chi-square test). CONCLUSIONS: Optical sequelae of glare, halo, and monocular diplopia may occur in some patients after either both PRK or LASIK for moderate to high myopia; in contradistinction, many other patients' preoperative symptoms improve after surgery. On average, PRK patients show an increase in halo and diplopia symptoms, but not glare, after surgery, and LASIK patients show an increase in diplopia, but not glare and halo symptoms. There is a suggestion of a somewhat lesser tendency toward postoperative optical symptoms in LASIK compared with PRK treated eyes.
PURPOSE: To retrospectively evaluate the incidence of cyclodeviation among patients with diplopia and analyse the causative diseases and clinical manifestations of cyclodeviation. METHODS: The medical records of 266 consecutive patients of 15 years of age or older presenting with diplopia, who had undergone the Lancaster red-green test (LRGT) from January 2001 to December 2002, were retrospectively reviewed. The presence of cyclodeviation on LRGT, predisposing conditions, causative diseases, and clinical manifestations of cyclotropia were analysed. Cyclodeviation on the LRGT were compared with those from the Maddox double-rod test (MDRT) and fundus photography. RESULTS: A total of 63 (24%) out of 266 patients exhibited cyclodeviation on LRGT. Eight out of 63 patients with cyclodeviation on the LRGT complained of torsional diplopia. Superior oblique palsy (SOP) was the most common causative disease (42 patients), followed by skew deviation (six) and thyroid orbitopathy (three). Excyclodeviation was found in 57 patients and incyclodeviation in four patients on the LRGT. The spontaneous recovery rate was 83% in patients of vascular origin and 17% of traumatic origin. Cyclodeviation with the MDRT and fundus photography showed good correlation with those obtained from the LRGT. There was no association of the amount of cyclotropia with the presence of torsional diplopia as well as with its recovery. CONCLUSION: In spite of the rare complaint of torsional diplopia, 24% of the patients with diplopia showed cyclodeviation on the LRGT. SOP was the most common causative disease. Most of the patients with cyclodeviation of a vascular origin showed spontaneous improvement.