Ali Sefik Sanac

Magnetic resonance imaging in evaluation of congenital and acquired superior oblique palsy

BACKGROUND According to the recently popularized classification of superior oblique (SO) palsy based on congenital variations of the tendon, the primary pathology is the abnormality of the SO tendon rather than an innervational problem in congenital cases. If this hypothesis is true, denervation atrophy of SO muscle should not occur in patients with congenital SO palsy. METHODS Eight patients with traumatic and nine patients with definite congenital SO palsy underwent magnetic resonance imaging (MRI) of the orbit. SO muscle width and cross-sectional area measurements were taken from coronal images and compared with the clinically uninvolved superior oblique muscles. RESULTS Atrophy of varying degrees was observed in the SO muscle both in congenital and acquired cases. No significant difference was found in the appearance of the SO muscle between acquired and congenital SO palsy groups. CONCLUSION We have been unable to demonstrate abnormalities of the SO tendon in both groups. The MRI appearance of the SO muscle suggested that in congenital SO palsy, the pathology is not limited to the tendon; there also is an abnormality of the muscle itself.

Factors influencing the successful outcome and response in strabismus surgery

In this retrospective study based on 140 esotropic and 51 exotropic patients, the factors influencing successful outcome and response to strabismus surgery were investigated. Thirteen independent variables were chosen. The pre-operative deviation was found to be the only discriminant factor for early and late successful surgical outcomes in esotropic patients. For exotropic patients the visual acuity of the left eye was the discriminant factor for early successful surgical outcome. In esotropic patients the response to surgery increased with increasing amounts of pre-operative deviation. It was lower for patients with older age of onset and larger amounts of medial rectus recession. For exotropic patients the response to surgery was higher for larger pre-operative deviations. Eliminating possible sources of error when determining the pre-operative deviation will improve the predictability of the response to surgery and surgical outcome.

Evaluation of congenital Brown's syndrome with magnetic resonance imaging

The magnetic resonance (MR) findings in congenital Browns syndrome were investigated. Sixteen involved eyes of 12 patients were compared with 20 eyes of 10 controls. An enlargement of the tendon-trochlea complex was observed in congenital Browns syndrome. In addition, the appearance of the tendon-trochlea complex was irregular in shape and of intermediate signal intensity. The MR appearances in patients with a satisfactory or poor response to surgery did not show any significant differences from each other or from those in patients who had not undergone surgery. This was also the case for the patient with spontaneous improvement. The MR examination in congenital Browns syndrome suggested that the abnormality was located at the tendon-trochlea complex but clinically it does not give a clue about the outcome of the disease.

Factors influencing success and dose-effect relation of botulinum A treatment.

Botulinum toxin type A (BTA) treatment is an alternative to strabismus surgery. In this retrospective study the data on 45 esotropic and 49 exotropic patients with concomitant strabismus who were treated with BTA were analysed for dose-effect relationship, the effect of repeat doses and amblyopia on success of botulinum treatment. The esotropic patients were treated with a total of 80 and exotropic patients with 91 injections. The deviations were corrected within 5 degrees of straight in 33% of esotropic and 18% of exotropic patients. In esotropic patients the effect was dose dependent. This relation was not shown in exotropic patients. The repeat doses of BTA corrected the deviation to the same extent as the primary ones for both esotropic and exotropic patients.

Ocular surface alterations in blepharospasm patients treated with botulinum toxin A injection.

Purpose To evaluate ocular surface changes secondary to periocular botulinum toxin A injection in patients with essential blepharospasm. Methods Thirteen eyes of 13 patients with essential blepharospasm who underwent periocular botulinum toxin A injection were included in this prospective study. Patients were evaluated prior to and at 2-week and 1-, 3-, and 6-month time points following injections. Ocular surface tests were carried out in the order of tear break-up time (TBUT), lissamine green (LG) staining, Schirmer I test with anesthesia, and ocular surface disease index (OSDI) questionnaire for all patients. The Friedman test with Conover post hoc method was used for statistical comparisons of values at different time points. Results The TBUT was found to be increased at 1 month after the injection (8.5 ± 2.1; p = 0.018) and decreased below baseline levels (6.4 ± 2.1) at the 6-month visit (5.7 ± 2.0; p = 0.018). None of the Schirmer test values at follow-up visits were significantly different as compared to baseline levels (11.3 ± 5.5), although the 2-week measurement (14.3 ± 5.6) was significantly higher as compared to that at the 6-month follow-up visit (9.6 ± 4.9; p = 0.034). There was also a significant decrease in LG staining scores at 2-week (0.6 ± 0.4; p = 0.012) and 1-month (0.6 ± 0.4; p = 0.012) time points compared to the baseline levels (1.1 ± 0.6). The OSDI scores improved at 2-week (5.4 ± 6.8; p<0.001), 1-month (3.2 ± 5.1; p<0.001), 3-month (2.5 ± 4.4; p<0.001), and 6-month (5.5 ± 5.4; p<0.001) time points as compared to baseline levels (11.6 ± 8.5). Conclusions Botulinum toxin A injection appears to have a positive but temporary effect on ocular surface parameters in patients with blepharospasm.

Congenital Brown's syndrome: clinical and surgical approach

Browns syndrome is a well-recognized clinical disorder of ocular motility consisting mainly of a restriction of active and passive elevation in adduction. We report a series of 17 patients with true Browns syndrome and discuss the clinical features and results of surgical intervention. Surgery should be considered carefully for the treatment of this syndrome as reoperation may be necessary and spontaneous resolution is seen during long-term follow-up of some patients.

An assessment of ocular morbidities of children born prematurely in early childhood.

PURPOSE To assess the ocular morbidities of premature children in early childhood. METHODS One hundred seventeen children with a history of gestational age of less than 37 weeks at birth underwent ophthalmic examination including visual acuity testing with Lea symbols, anterior and posterior segment examination, refraction, orthoptic examination for strabismus, and ocular biometry. They were subdivided into three groups according to gestational age (28 or less, 29 to 32, and 33 to 36 weeks). The prevalence of ocular morbidities and mean value of refractive errors were studied. RESULTS The mean age of the subjects at examination was 37.6 ± 1.1 months (range: 20 to 65 months). Only 62.4% of the eyes had visual acuity better than 20/32. The prevalence of high myopia (above -5.0 diopters [D]), myopia (below -5.0 D), and strabismus was 12.5%, 22.5% and 33.3% in the 28 weeks or less group and 3.6%, 18.9%, and 24.1% in the 29 to 32 weeks group, respectively, whereas 7.9% of the 33 to 36 weeks group had myopia and 13.2% had strabismus. Spherical equivalent in eyes that received cryotherapy and with macular heterotopia was -2.7 ± 3.9 and - 4.4 ± 3.4 D, respectively. Biometric measurements showed that high myopic eyes had statistically significantly thicker lenses compared to myopic and hyperopic eyes (P = .01). CONCLUSION This study confirms that children born prematurely are at increased risk of ocular morbidities such as defective visual acuity, myopia, and strabismus. High myopic eyes have thicker lenses compared to myopic and hyperopic eyes, and eyes with macular heterotropia and treated with cryotherapy are more prone to development of high myopia.

Inferior Oblique Muscle Weakening: Is It Possible to Quantify Its Effects on Horizontal Deviations?

Objective. To evaluate and quantify the effect of inferior oblique muscle weakening on horizontal deviations. Methods. The medical files of patients who had undergone an inferior oblique weakening as a single procedure were all reviewed. The main measures were the type of inferior oblique overaction (IOOA), pre- and postoperative amount of IOOA, and horizontal deviations in primary position. Results. The study was conducted with 66 patients (30 males, 36 females). The median age was 11 years (1–49). Of the 66 patients, 30 (45.5%) had primary and 36 (54.5%) had secondary IOOA. The most common procedure was inferior oblique anteriorization in 32 patients (48.5%). The mean postoperative horizontal and vertical deviations and the amount of IOOA were decreased postoperatively (p = 0.001 for all). The median amount of correction of horizontal near and distance deviations was 4Δ (0–20). The preoperative amount of IOOA, the presence of fourth nerve palsy, and the type of the weakening procedure had no significant effect on the amount of correction of horizontal deviations. Conclusion. The inferior oblique weakening procedures have secondary effects and warrant reduction of horizontal deviations in varying degrees. This should be borne in mind in planning a simultaneous horizontal muscle surgery and setting the surgical amount.

Strabismus Surgery in Congenital Fibrosis of the Extraocular Muscles: A Paradigm

Abstract Background: Congenital fibrosis of extraocular muscles (CFEOM) is a rare group of disorders with variable phenotypes that result from aberrant innervation to the EOMs leading to synergistic vertical and/or horizontal deviations. We report our experience with the surgical management of patients with CFEOM. Materials and Methods: We reviewed the clinical findings, the surgical management, and outcomes of 52 consecutive CFEOM patients operated by one surgeon at a university hospital setting between 1993 and 2014. Patients were divided into CFEOM1, 2, or 3 based on clinical and/or molecular genetic findings. Results: Thirty-seven (71.2%) cases were bilateral and 15 (28.8%) were unilateral. Six of the bilateral cases had CFEOM2, and the rest of the patients had either CFEOM1 or CFEOM3. The median age at the first surgery was 10 (1–43) years. Twenty-five were females and 27 were males. Nineteen patients had previous strabismus and/or ptosis surgeries elsewhere. The mean number of operations at our center was 1.6 ± 0.7 (1–4). A temporary stay suture was used in eight patients and permanently in seven. Of the 40 patients with abnormal head position, 18 achieved excellent, 15 good, and seven poor outcomes and ocular alignment in primary position following the latest surgery was excellent in 19, good in 18, and poor in 14 of the patients, as defined in the “Methods” section of the paper. Conclusions: Although patients with CFEOM present significant strabismus surgical challenges because of EOM dysinnervation, fibrosis, and/or heterotopia, satisfactory alignment and improvement of the head posture can be attained in a significant proportion of patients using an individually tailored surgical approach.

Horizontal muscle transposition or oblique muscle weakening for the correction of V pattern

PurposeTo report and to analyze the efficacy of horizontal rectus muscle transposition and inferior oblique muscle weakening in terms of pattern correction for patients with V pattern.MethodsThe review of the medical files identified 55 patients who had esotropia (ET) or exotropia (XT) with V pattern. The primary outcome measure was the amount of V pattern collapse (Δ).ResultsOf the 55 patients (mean age 22.1±9.5 years), 27 (49.1%) were males and 28 (50.9%) were females. The type of deviations was XT in 30 patients (54.5%) and ET in 25 patients (45.5%). Inferior oblique muscle weakening was performed in 43 (78.2%) patients, whereas horizontal muscle transposition was carried out in 12 (21.8%) patients in addition to recession-resection procedures. The amount of pattern was significantly reduced in both groups (P=0.01 for the horizontal offset group and P<0.01 for the oblique muscle weakening group).ConclusionOblique muscle weakening surgery and horizontal muscle offset are effective in the correction of V pattern when the amount of pattern is under 30Δ.