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PubMed2005

[Stereoacuity before and after surgery in patients with acquired excyclotorsion].

OBJECTIVE: To investigate the stereoacuity before and after superior oblique sagittal transposition in patients with acquired excyclotorsion. METHODS: 14 cases of acquired excyclotorsion who had complaints of forward and downward torsional diplopia were treated with superior oblique sagittal transposition. All patients were examined with Titmus test prior and after surgery. RESULTS: Surgical treatment greatly improved torsional diplopia. The stereoacuity improved gradually from 800 to 60 seconds of arc, peripheral to macular stereoacuity, and even foveal stereoacuity. CONCLUSION: The superior oblique sagittal transposition is an effective method for primary and down gaze acquired excyclotorsion. The operation not only alleviated diplopia in the practical fixation field, but also improved stereoacuity.

Adult↗
PubMedDate not supplied

[Strabismus-associated Parinaud syndrome].

OBJECTIVE: We undertook this study to describe the causes of Parinaud syndrome (PS) with diplopia to determine a topographic diagnosis and prognosis. METHODS: We studied patients with PS from January 1980 to January 2004 and reviewed causes and treatment. We identified all strabismus associated with PS. RESULTS: We included 18 patients with diplopia, 6 females and 12 males. Median age was 28 years old, SD 22 (10; CI 95%). Results are strabismus related: III nerve palsy in 15 patients (79%), optical nerve damage in 8 (44.4%), VII nerve palsy in 3, IV nerve palsy 2, bilateral III nerve palsy 2, nystagmus 2, Foville syndrome 2, one-and-a-half syndrome (1). The following causes were reported: tumors (6), brain stroke (4), cranial trauma (3), neurocysticercosis (2). Orthoposition under botulinum toxin treatment was obtained in 1.72 +/- 1.1 (0.65 CI 95%). Surgery was done in nine patients, and only one patient had spontaneous resolution of diplopia and PS. CONCLUSIONS: It is important to identify the topographic diagnosis and prognosis of brain diseases such as the complete study of strabismus-related PS. In this way we can learn more about the extent of damage and can identify recurrences quickly in order to offer better control.

Adolescent↗
PubMed2005

The utility of strabismus in adults.

PURPOSE: To determine the utility (quality-of-life weight) associated with adult strabismus. METHODS: Time tradeoff utility values were measured in physician-conducted interviews with 140 adult patients with strabismus in a private practice setting. Patients also completed a questionnaire containing six items that rated the following aspects of disability: specific health problems, problems with tasks of daily living, problems with social interaction, self-image problems, concerns about the future, and job-related problems. Patients were characterized as presurgical or nonsurgical, and their diplopia and asthenopia were rated by the physician on a four-level scale. RESULTS: About 60% of all patients indicated willingness to trade part of their life expectancy in return for being rid of strabismus and its associated effects. The median utility was 0.93 (interquartile range, 0.83 to 1.0). A significantly smaller proportion (44%) of the nonsurgical patients (N = 41) appeared willing to trade time compared with surgical patients (68%; P = .009). Median utility in the presurgical patients was 0.90. Strong relationships were found between utility and the level of diplopia (P < .0001), and between utility and the level of asthenopia (P < .0001). Utility was correlated with all six disability ratings (all P < or = .00062). CONCLUSION: A majority of the patients interviewed would trade a portion of their life expectancy in return for being rid of strabismus and its associated effects. These results were validated by significant associations with diplopia, asthenopia, and disability.

Activities of Daily Living↗
PubMed1984

[Blow out fracture of the medial orbital wall--plastic repair with tantalum mesh].

Two cases of blow out fracture of the medial orbital wall were reported. The one was a 14 year-old boy and the other was a 32 year-old man. After hitting the eye against another man or a hard object, the patients felt diplopia, especially on lateral gaze toward the injured side. The blow out fracture was able to be diagnosed by plain roentgenography or tomography. The fractured bone as well as the entrapped soft tissue were clearly detected by CT scan. The fractures occurred at the thinnest part of the Lamina orbitalis ossis ethmoidalis (Lamina papyracea) in both cases. Objects with diameter larger than that of the bony orbit pressed the eye ball and other soft tissue into the orbital cavity, and the blow out fracture occurred in the medial orbital wall in each case. The skin was incised along the supero-medial margin of the orbit and subperiostial dissection was done. The entrapped medial rectus muscle was observed in one case and unverified in the other. Entrapment of the orbital soft tissue other than medial rectus muscle may also have caused diplopia. Tantalum mesh, used for repair is quite thin material. It has much plasticity and little possibility of damaging the orbital tissue and of causing postoperative bleeding. No complication occurred after operation and diplopia disappeared completely or nearly completely in the cases reported.

Adolescent↗
PubMed1998

[Double vision as a symptom of a serious disorder].

Three women, aged 54, 69 and 73 years, respectively, developed diplopia together with ptosis of an upper eyelid during light exercise or fatigue or continuous; in one patient the diplopia was followed by headache and vomiting. The diagnoses made were 'intracranial aneurysm', 'myasthenia gravis' and 'temporal arteritis'. Diplopia may be a symptom of a disorder timely diagnosis and treatment of which may prevent serious consequences.

Aged↗
PubMed1998

Secondary reconstruction of upper midface and orbit after total maxillectomy.

OBJECTIVE: To evaluate the aesthetic and functional results of secondary reconstruction of the upper midface and lower orbit following globe-sparing maxillectomy. DESIGN: Retrospective analysis. SETTING: University medical center. PATIENTS: Six patients, all having previously undergone globe-sparing maxillectomies with or without postoperative radiotherapy, were selected for secondary reconstruction of the upper midface. INTERVENTION: Free calvarial bone grafts (CBGs) alone or in conjunction with alloplastic material were used to reconstruct the upper midface and lower orbit both aesthetically and functionally. Bone grafts were secured using lag screw and nonrigid techniques. Pedicled temporoparietal fascia (TPF) flaps provided coverage of the reconstructions and internal lining of the maxillectomy cavity. OUTCOME MEASURES: Aesthetic and functional results of upper midface and lower orbit as determined by preoperative and postoperative photographs and physical examination. RESULTS: All patients had considerable improvement in upper midfacial contours. All patients had improvement of globe position. Patients with diplopia before reconstruction noted improvement after reconstruction, although 1 patient continued to have moderate diplopia. Complications included persistent globe malposition, persistent diplopia, bone graft resorption, partial loss of 1 TPF flap, need for revision surgery, and subjectively worsened appearance in 1 patient. CONCLUSIONS: Reconstruction with CBGs, alloplastic material, and TPF may reliably, effectively, and efficiently rehabilitate the functional and aesthetic upper midfacial deficits of select patients with secondary reconstruction after globe-sparing maxillectomy. However, patients with evidence of excessive scarring may benefit more from free-tissue transfer reconstruction.

Aged↗
PubMed1999

Endoscopic endonasal repair of orbital floor fracture.

BACKGROUND: High-resolution endoscopes and the advent of endoscopic instruments for sinus surgery provide surgeons with excellent endonasal visualization and access to the orbital walls. OBJECTIVE: To demonstrate repair of orbital floor blowout fractures through an intranasal endoscopic approach that allows repair of the orbital floor fracture and elevation of the orbital content using a balloon catheter without an external incision. DESIGN: This study was a retrospective analysis of 11 patients who underwent surgical repair of orbital floor fractures from September 1994 to June 1997. There were 10 male patients and 1 female patient, aged 12 to 32 years (mean age, 24 years). These patients had undergone primary repair of pure orbital blowout fractures and were followed up at least 6 months after surgery. RESULTS: There were no intraoperative or postoperative complications. Nine patients showed a complete improvement of their diplopia. Two patients with posterior fractures showed persistent diplopia, which was well managed by prisms. CONCLUSION: Endoscopic repair of the orbital floor blowout fracture using an endonasal approach appears to be a safe and effective technique for the treatment of diplopia.

Adolescent↗
PubMed2005

Endoscopic transantral orbital floor repair with antral bone grafts.

OBJECTIVE: To evaluate the endoscopic transantral insertion of antral bone grafts into the orbit for repair of orbital floor defects. DESIGN: A retrospective analysis with a mean follow-up of 5.3 months. PATIENTS: Eleven patients who underwent surgical repair of orbital floor fractures. SETTING: Municipal hospital. MAIN OUTCOME MEASURES: Preoperative and postoperative Hess screen tests and the presence of diplopia, enophthalmos, donor site complications, cosmetic deformity, infection, and graft extrusion. RESULTS: Subjectively, 3 patients with diplopia had complete resolution of their symptoms after surgery, and 8 patients had improvement of their symptoms. Objectively, 11 patients had significant improvement in the postoperative Hess area ratio compared with the preoperative Hess area ratio. In 1 patient with a floor defect measuring 2.5 cm, enophthalmos existed after surgery, but reoperation was not performed in this case because diplopia was improved. There were no donor site complications, cosmetic deformity, infection, or graft extrusion. CONCLUSIONS: The endoscopic transantral insertion of antral bone grafts through the floor defect into the orbit is an effective technique that prevents injury to the lower eyelid, carries minimal donor site morbidity, and provides an optimal support function for the globe. It merits consideration in cases of orbital defects less than 2 cm in diameter.

Adolescent↗
PubMed2005

The differences of blowout fracture of the inferior orbital wall between children and adults.

OBJECTIVES: To review the clinical features and recovery period of patients with blowout fractures of the inferior orbital wall treated surgically and to examine the differences between children and adults. DESIGN: A retrospective study. SETTING: Department of Otorhinolaryngology, Maryknoll General Hospital, Busan, Korea. Patients Medical records of 70 patients were reviewed: 16 patients were children (aged <16 years) and 54 were adults (aged >or=17 years). MAIN OUTCOME MEASURES: Symptoms and fracture patterns were compared between both groups in all subjects, and the recovery period relative to the timing of surgery after the trauma was compared in subjects who complained of diplopia or extraocular limitation. RESULTS: Serious periorbital edema was noted in 43 adults (80%) and 4 children (25%), diplopia in 27 adults (50%) and 16 children (100%), and extraocular muscle limitation in 23 adults (43%) and 13 children (81%). Trapdoor fractures were frequent in the children group (n = 13; 81%), whereas 30 patients (56%) had open-door fractures in the adult group. In the children group, no differences in the recovery period relative to the timing of surgery was noted when all types of orbital fractures were considered. However, among the 13 children with trapdoor fractures, the recovery period was significantly shorter in those who underwent surgery 1 to 5 days after the trauma compared with those who underwent surgery after 6 to 14 days and 15 days or longer. In adults, the recovery period of those who underwent surgery 1 to 5 days and 6 to 14 days after the trauma were significantly shorter compared with those who underwent surgery after 15 days or longer. CONCLUSIONS: Diplopia, extraocular muscle limitation, and trapdoor fractures were more frequent in children than in adult patients. After trauma, surgical intervention might be required within 5 days in children with trapdoor fracture vs within 2 weeks in adults.

Adolescent↗
PubMed1993

Orbital decompression for preservation of vision in Graves' ophthalmopathy.

Graves' ophthalmopathy (thyroid eye disease) can result in progressive visual loss. The University of Washington (Seattle) experience in orbital decompression was reviewed for the years 1983 through 1990 to determine overall safety and outcome. Twenty patients underwent transantral decompression of 36 orbits for either steroid therapy failure, steroid therapy intolerance, or recurrence of optic neuropathy with tapering of the steroid therapy. Decompression successfully improved visual function in 33 of the orbits (92%) and a second decompression procedure was successful in another two (5%) of the orbits (6%). There were no major complications or cases of decreased visual function. Diplopia, present preoperatively in 17 patients (85%), was improved in eight patients (47%) and unchanged in nine patients (53%). However, of the three patients without preoperative diplopia (15%), one had development of new-onset diplopia postoperatively. Transantral decompression of the orbit offers a safe and effective therapeutic modality for vision-threatening Graves' ophthalmopathy.

Adrenal Cortex Hormones↗
PubMed1999

[Automobile driving capacity after retinal detachment surgery].

BACKGROUND: After vitreoretinal surgery the patient is at least temporarily unable to drive. Buckling procedures may cause refractive changes, reduced motility or impaired binocular vision. We examined the ability of these patients to drive a car according to German law after retinal surgery. PATIENTS AND METHODS: The frequency and extent of changes interfering with driving ability were examined in 112 unselected patients 3.5 years (2-5 years) after successful buckling procedures. We used half-round buckling elements of 3-11 mm diameter or encircling bands (2-3 mm). We examined visual acuity, frequency of permanent diplopia and field of normal binocular vision. Driving ability was considered as impaired, when visual acuity was below 0.4 in the better eye or 0.2 in the worse eye, or when diplopia occurred within a gazing field of 20 degrees of diameter. RESULTS: Eighteen of 112 (16%) patients reported diplopia within the first 3 months, so they were temporarily unable to drive. Two to five years later 14 of 112 patients did not have sufficient visual acuity according to the German requirements. Another 2 patients had an impaired binocular vision, resulting in driving disability. CONCLUSION: Driving ability may be temporarily restricted by double vision in 15% of patients after successful buckling for retinal detachment. Permanent driving ability is mainly impaired by macular involvement in retinal detachment. The type of buckling procedure is of minor importance.

Adult↗
PubMed1999

[Evaluation of minimally invasive therapy of zygomatic bone fractures with a classification proposal].

The pre- and postoperative symptoms of zygomatic bone fractures were examined in a follow-up study to prepare a classification proposal. A differential indication for minimally invasive therapy modes was looked for with respect to this proposal. Therapy of isolated zygomatic bone fractures consisted in repositioning with a hook and miniplate fixation across the frontozygomatic suture. The aims of this study were clinical and radiological assessment of the repositioning result in terms of aesthetics and stability and quantification of the postoperative remission of disturbances of sensitivity of the infraorbital nerve. A total of 52 patients were examined. After the operation (on average after 3.5 days following the trauma) they were followed-up postoperatively for 12 months according to a strict schedule. Preoperatively, 49 patients reported disturbances of sensitivity of the infraorbital nerve. Other symptoms, such as periorbital haematoma and flattening of the zygomatic prominence, were observed in 49 patients and 45 patients, respectively. All fractures were repositioned well as assessed clinically and radiologically. The aesthetic result was evaluated as symmetric and durable in all cases. Six months postoperatively 41 patients reported normal sensitivity in the area of the infraorbital nerve. In only five patients (10.2%) was the sensitivity loss persistent throughout the entire follow-up period. Patients with primarily lacking diplopia developed neither eye motility disturbances nor postoperative enophthalmus in the following period. It can be concluded that the treatment of an isolated zygomatic bone fracture which satisfies aesthetic and functional requirements is possible by reposition and fixation with one miniplate at the lateral orbital rim. An additional osteosynthesis at the infraorbital rim or at the zygomaticomaxillary crista is not necessary. A routine revision of the orbital floor is only indicated in cases of preoperative diplopia. A zygomatic bone fracture connected with diplopia should be classified as combined zygomatic-/orbital floor fracture.

Adolescent↗
PubMed1988

Limits of binocular fusion in the short wave sensitive ("blue") cones.

Stereoscopic depth perception is possible when the short wave sensitive (SWS or "Blue") cones are isolated using a yellow adapting field. We have measured the maximum disparity that can be fused (the diplopia threshold) as a function of the separation between pairs of dots or lines. Under all conditions, these diplopia thresholds are the same for the isolated SWS cones as for the entire visual system. In addition, SWS diplopia thresholds vary as a linear function of dot or line separation, so that they exhibit disparity scaling. Further experiments show that disparity scaling is dependent upon the presence of low spatial frequencies in the stimulus and not upon the retinal eccentricity of stimulation. These data indicate that the SWS cones provide information to the disparity processing system through more than one low spatial frequency channel but not through high frequency ones.

Adaptation, Ocular↗
PubMed2004

Combination of transconjunctival and endonasal-transantral approach in the repair of blowout fractures involving the orbital floor.

In the repair of orbital blowout fractures through eyelid or conjunctival incision, it is difficult to see the posterior edge of the fracture and the condition of the herniated tissue before reduction of the orbital contents. Prolapsed orbital tissue or infraorbital nerve and vessels may therefore be damaged in the reduction. The recently advocated combination of traditional transconjunctival approach and endoscopic transantral approach allows reduction and reconstruction under clear endoscopic vision without a facial skin incision. We modified this technique to make it less invasive and applied it to the repair of orbital blowout fractures involving the orbital floor. The use of a 70-degree straight endoscope through an enlarged ostium as for functional sinus surgery allowed clear sight of the roof of the antrum. During the repair of the orbital floor through a transconjunctival approach, reduction and reconstruction was assisted from the antrum. Twelve cases of fresh blowout fractures were treated with this approach. There were seven male and five female patients. Mean age was 23.5 years. Causes of injuries were fights, motor vehicle or bicycle accidents, and sports. Patients with concomitant fractures involving the orbital rim were excluded. Persistent diplopia was present in eight cases and enophthalmos of more than 2 mm was detected in five cases preoperatively. The average intervals from injury to surgery was 22.8 days.Exploration, reduction and reconstruction of the orbital floor fractures were precisely performed with this procedure. Large orbital floor defects were reconstructed with silicone sheets, thin iliac bone grafts or nasal septal cartilage. In all eight cases that showed diplopia, ocular movement recovered and symptomatic diplopia disappeared after surgery. Enophthalmos of more than 2 mm was also improved in all five cases. One early case showed temporary entropion. Transient numbness of the cheek appeared in five cases and temporary maxillary sinusitis recovered in one case. Postoperative infection was not observed.This method provides visualisation of posterior edge of the fracture and the condition of herniated orbital contents before initiation of reduction. Dual manipulation by two surgeons is also possible in reduction and reconstruction of the orbital floor.

Adolescent↗
PubMed2005

Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia.

PURPOSE: We have identified a group of mostly elderly patients characterized by chronic, slowly progressive esotropia with diplopia at distance. This study was undertaken to analyze the outcomes after bilateral medial rectus muscle recessions in this group of patients with a divergence insufficiency pattern of esotropia. MATERIALS AND METHODS: This is a retrospective consecutive case series of eight patients treated for divergence insufficiency pattern esotropia with bilateral medial rectus muscle recessions. RESULTS: Age at presentation was 44 to 77 years (mean age, 60) and symptoms of diplopia at distance had been present between 3 and 30 years (mean, 12.6). Six patients had been managed with progressively larger amounts of base-out (BO) prism in their distance correction over an average of 12.5 years. Each patient had a manifest esotropia at distance and smaller or no deviation at near. The mean preoperative esodeviation was 20.4 prism diopters (range, 12 to 35) at distance and 5.4 PD (range, 0 to 18) at near with a mean distance-near difference of 15.0 PD. Bilateral medial rectus muscle recession of 3.0 to 4.25 mm (mean 3.5) was performed on each patient. The mean postoperative esodeviation at distance was 3.4 PD (range 0 to 10) and the mean near deviation was 1.8 PD exophoria (range, 8 PD exophoria to 10 PD esotropia) with a mean distance-near difference of 5.1 PD. Three patients still required some prism in their spectacles for the relief of diplopia postoperatively (2 BO, 8 BO, 10 BO). The mean follow-up period was 8.5 months (range, 6 weeks to 46 months). CONCLUSIONS: Bilateral medial rectus muscle recession is an effective treatment for slowly progressive divergence insufficiency pattern esotropia in elderly patients. The reduction in the difference between the distance and near magnitudes of esodeviation afforded by this treatment suggests that a subtle loss of medial rectus muscle elasticity is the etiology.

Adult↗
PubMed2005

The management of strabismus in adults--III. The effects on disability.

INTRODUCTION: This is the third article in a series on the various facets of the management of strabismus in adults. Here, we give a broad overview of the types and severity of disability and provide initial validation of an instrument (questionnaire) to assess these disability aspects. METHODS: After undergoing strabismus surgery, 101 patients from 6 centers completed a 6-item questionnaire in which they rated both the before-surgery and after-surgery severity of problems associated with their strabismus, ranging from specific health, daily functioning, social interaction, concerns about the future, and self-image to job-related difficulties. RESULTS: The before-surgery outcomes showed significant variation across the 6 types of problems (P < 0.001), with "specific health" and "daily tasks" yielding the highest problem rating. Patients with diplopia reported more severe problems with "daily tasks" (P = 0.004) and "concerns about the future" (P = 0.026) than patients without diplopia. Overall, all problem ratings declined after surgery (P < 0.001), but patients who were not successfully aligned were left with higher problem ratings on "specific health" (P = 0.005), "daily tasks" (P = 0.003), and "social interaction" (P = 0.024). CONCLUSIONS: The results indicate a wide range of disability aspects in adult patients with strabismus, with moderate differences between patients with or without diplopia. Improvements in disability after surgery, as reflected by these ratings, should be taken into account when assessing the health value of adult strabismus management.

Adult↗
PubMed2004

Strabismus surgery for adults: a report by the American Academy of Ophthalmology.

OBJECTIVE: To describe the effectiveness and safety of surgical treatment of adult patients with strabismus, and to review the reported functional benefits and complications of strabismus surgery for adults. METHODS: A literature search was conducted in September 2001. It was repeated and updated in April 2003, with retrieval of relevant citations. Panel members reviewed the articles and rated them according to their relevance to the topic and methodology. RESULTS: The literature search identified 49 reports that describe the surgical treatment of strabismus in adult patients and meet predetermined review criteria. Of these reports, 2 were of randomized controlled trials, and 1 addressed the primary objective of this review. In this randomized study of adults with strabismus, direct comparison of surgical correction with botulinum toxin A chemodenervation indicated that surgical treatment was superior to botulinum toxin A in realigning the eyes (76.9% vs. 29.4%, P = 0.027). Several large case series of adults with strabismus (level III evidence) with successful surgical realignment rates of 68% to 85% have been reported. Functional benefits of surgical treatment are reported in many patients. These include elimination of diplopia, development of binocular fusion, expansion of binocular visual fields, and improvement of head position. Surgical complications, including new, postoperative diplopia (1%-14%) or scleral perforation (0.8%-1.8%), occur in a minority of patients. Unplanned reoperations (subsequent strabismus procedures that were not anticipated as part of a staged treatment) were needed in up to 21% of patients in large case series of comitant strabismus, and in up to 50% of patients with thyroid ophthalmopathy. CONCLUSIONS: Despite the paucity of level I evidence from randomized controlled trials, the existing literature suggests that surgical treatment of adults with strabismus is safe and effective in improving ocular alignment. In many cases it improves visual function, based largely on level III evidence. Risks include unplanned reoperation, postoperative diplopia, and scleral perforation. Additional level I studies of surgical treatment of adult patients would help to document the effectiveness and substantiate the safety of this treatment.

Adult↗