Carlos Souza-Dias

Intermittent exotropia: comparative surgical results of lateral recti-recession and monocular recess-resect

PURPOSE To compare the results between recession of the lateral recti and monocular recess-resect procedure for the correction of the basic type of intermittent exotropia. METHODS 115 patients with intermittent exotropia were submitted to surgery. The patients were divided into 4 groups, according to the magnitude of preoperative deviation and the surgical procedure was subsequently performed. Well compensated orthophoria or exo-or esophoria were considered surgical success, with minimum of 1 year follow-up after the operation. RESULTS Success was obtained in 69% of the patients submitted to recession of the lateral recti, and in 77% submitted to monocular recess-resect. In the groups with deviations between 12 PD and 25 PD, surgical success was observed in 74% of the patients submitted to recession of the lateral recti and in 78% of the patients submitted to monocular recess-resect. (p=0.564). In the group with deviations between 26 PD and 35 PD, surgical success was observed in 65% out of the patients submitted to recession of the lateral recti and in 75% of the patients submitted to monocular recess-resect. (p=0.266). CONCLUSION Recession of lateral recti and monocular recess-resect were equally effective in correcting basic type intermittent exotropia according to its preoperative deviation in primary position.

Unilateral Anterior Transposition of the Inferior Oblique Muscle for Correction of Hypertropia in Primary Position

PURPOSE To evaluate the correction of hypertropia in primary position with unilateral inferior oblique (IO) anterior transposition (IOAT). METHODS Ten patients with idiopathic (nonparalytic, restrictive, or dissociated vertical deviation) hypertropia with marked IO overaction, who underwent unilateral IOAT, were prospectively evaluated to observe the correction of the hypertropia in primary position. No previous ocular muscle surgery had been performed. Four patients had esotropia and two had exotropia. In addition to the proposed surgery, horizontal procedures were performed to correct horizontal deviation, but no vertical transposition of horizontal muscles was done. Four patients had hypertropia and IO overaction, without horizontal strabismus, and IOAT was the only procedure performed. The IO muscle was reinserted 1 mm laterally to the lateral extremity of the inferior rectus muscle insertion using only one suture. The statistical analysis was performed by Wilcoxon rank sum test. RESULTS The mean absolute correction in primary position was 18.1 prism diopters (PD) (range, 4 to 33), directly proportional to the size of the hypertropia before surgery. Nine of the 10 patients had a residual vertical deviation of </=6 PD. After surgery, 4 patients (40%) presented limited elevation in adduction (-2) in the field of the operated IO, presumably caused by the antielevator effect of the transposed muscle, which did not improve during the follow-up period (range, 2 to 79 months). CONCLUSION Unilateral IOAT is an effective technique for correction of large hypertropia associated with marked unilateral IO overaction. Some lower lid curvature deformity and some limitation of elevation were observed in forced upgaze in some patients, but this was of no cosmetic importance.

Resultados da correção cirúrgica da exotropia permanente em pacientes amblíopes e não-amblíopes

UNLABELLED Permanent exotropia (XT) occurs in 1 to 2% of the pediatric population. Its management involves careful assessment of patient, treatment of amblyopia, refractive errors and surgery. The aim of the surgery is to straighten the eyes in the primary gaze position, giving a better cosmetic outcome. The factors reported to affect surgical outcome after exotropia surgery vary widely in reports and success rates for strabismus surgery have been reported to range from 60% to 80%. There are few reports to determine the relation between amblyopia and surgical outcome in exotropic patients. PURPOSE To compare the surgical outcome of permanent exotropia surgery in amblyopic and non-amblyopic patients. METHODS This is a retrospective study of 37 clinical records from amblyopic patients (Group A) and non-amblyopic patients (Group B) who underwent recess-resect in one eye for XT. Postoperative deviation was analyzed in one month (immediate) and in six months (final) in both groups and in between. Age: group A 24.7 ± 14.2 years, group B 22.6 ± 18.6 years; Preoperative deviation: group A 29.1 ± 7.2(Δ), group B 28.4 ± 6.8(Δ). RESULTS The success rate in the immediate postoperative period was 60% (Group A) and 100% (Group B) (p<0.05); 50% (Group A) and 82.3% (Group B) (p=0.082) in the final postoperative period. There was a statistical difference in the immediate postoperative deviation, but the final deviation and the variation of the deviation were similar in both groups. CONCLUSION There is a better outcome in patients of group B and no diference in the surgical outcome between these amblyopic and non-amblyopic patients in the final postoperative period.

Projeto piloto de informatização dos prontuários do setor de motilidade ocular extrínseca da Santa Casa de São Paulo

PURPOSE To develop a system of support to the research in the field of the computer science, based on the automatic search of information, on the percentage of patients with certain characteristics and the crossing of this information among themselves. METHODS A computer with Pentium III 650 MHz processor, 128 MB RAM, 32 MB video plate, free 20 MB in the hard disk and fitted with Windows 98/2000/XP. The data base used to store the information is Interbase version 6.1 and the program was developed in Delphi 5.0 language. Three hundred and four charts of esotropia-operated patients were registered in the Extrinsic Ocular Motility Sector of the Departament of Ophthalmology of the College of Medical Sciences of the Santa Casa of Misericórdia of São Paulo, in the period from 07/02/1976 to 03/09/1992. To include the patients in the program, a questionnaire was elaborated, with the relevant clinical variations of this type of misalignment. Examples of totalizations and crossings of information were presented. RESULTS This new program will be able to contribute to scientific research, accelerating data collection. After registering the patients any type of survey, election of a specific group of patients or crossing of data may be obtained in seconds. CONCLUSION This can be made for all ophthalmologic specialties, varying the questionnaire in accordance with each specialty.

Reoperação nas esotropias congênita e essencial adquirida não acomodativa

PURPOSE: To analyze the results in patients reoperated from congenital and essential esotropia. METHODS: A retrospective chart review of 393 patients who underwent surgery from 2000-2004 was performed. Subjects were divided into two groups: Congenital esotropia (91patients) and essential esotropia (302 cases). RESULTS: Among congenital cases we had 9 reoperations (9.9%). There were undercorrections (3.3%), overcorrections (2.2%), anisotropia (V) (1.1%), hypotropia (1.1%) and dissociatd vertical divergences (2.2%). Among the essential cases, there were 31 (10.3%) reoperations due to undercorrections (n=6.6%), overcorrections (n=2%) and hypotropias (1.7%). CONCLUSIONS: Outcomes reoperations rates were 9.9% and 10.2% between congenital and essential esotropias with a higher rate of undercorrections. Amblyopia in both groups and deviations higher than 50∆ in essential esotropias seems to be the most important factors for poor results.

Measurement of ocular torsion variation following superior oblique tenectomy

PURPOSES To objectively evaluate the torsional effect of the superior oblique muscle-weakening surgery using the tenectomy technique proposed by Souza-Dias. METHODS The present prospective study included 10 patients (20 eyes) with horizontal strabismus, bilateral superior oblique overaction and A-pattern of 15 to 30 prism diopters who underwent superior oblique tenectomy. Objective assessment of ocular torsion was performed by retinography immediately before and one month after surgery. The amount of ocular torsion was determined by measuring the angle formed by a horizontal line drawn across the geometric center of the optic disc and a second line connecting this point to the fovea. RESULTS The median preoperative angle was 5.56° in the right eyes and -3.43° in the left eyes. The median postoperative angle was 1.84° in the right eyes and -3.12° in the left eyes. The angle variation was statistically significant in both eyes (p=0.012 and p=0.01, respectively). CONCLUSION The present study suggests that superior oblique tenectomy has an extorter effect, decreasing the intorsion detected on overaction of this muscle.

The intimate nature of oculomotor muscles contracture

The author makes comments about the shortening and loss of elasticity of the oculomotor muscle that remains slack for some time (contracture), by means of a reasoning based on the Hooke s law and on the papers carried out to demonstrate that a muscle that remains relaxed for some time suffers a shortening due to loss of sarcomeres on the longitudinal direction and the increase of the cross-sectional area due to the increase of collagen tissue in the perimysium and the endomysium.

Correção cirúrgica do estrabismo horizontal em portadores de alta miopia

Purpose: To analyze results of correction of horizontal strabismus surgical in high myopia patients. Methods: A retrospective chart review of 24 patients with esotropia and high myopia (greater than -6.00 spherical diopters) and 17 patients with exotropia and high myopia compared with their control groups. Deviation between 10D of esotropia and 10D of exotropia was considered a surgical success. Results: We noticed a high incidence of bad results among the esotropic patients with high myopia. Conclusion: There is a tendency of bad results among the esotropic patients with myopia greater than -6.00 when compared with patients with spherical refractive error between -0.75 and +3.50.

The influence of body position on Bielschowsky's test.

PURPOSE To investigate the veracity of Jampolskys statement that Bielschowskys head tilt test is inverted if performed with the patient in the upside-down position and to interpret its neuromuscular mechanism. METHODS We present a series of 10 patients selected from a referred sample who were diagnosed with superior oblique paresis. Hypertropia was measured in the primary position, with the head erect and tilted toward both shoulders with the patient in the erect, supine, and upside-down positions. The last position was achieved by hanging the patient upside-down. RESULTS As expected, our results showed the veracity of Jampolskys statement. The forced head tilt difference was inverted or significantly decreased when the test was performed in the upside-down position. Moreover, in all patients, Bielschowskys phenomenon was neutralized in the supine body position, in which hypertropia with the head erect tended to vanish. In 3 patients, it disappeared completely. CONCLUSIONS This study showed that, in patients with superior oblique paresis, differences in the extent of hypertropia in Bielschowskys test tended to vanish when the test was performed with the patient in the supine position and invert when it was performed with the patient in the upside-down position.

Prevalence of refractive errors in Möbius sequence

PURPOSE To assess the prevalence of refractive errors in Möbius sequence. METHODS This study was carried out during the Annual Meeting of the Brazilian Möbius Society in November 2008. Forty-four patients diagnosed with the Möbius sequence were submitted to a comprehensive assessment, on the following specialties: ophthalmology, neurology, genetics, psychiatry, psychology and dentistry. Forty-three patients were cooperative and able to undertake the ophthalmological examination. Twenty-two (51.2 %) were male and 21 (48.8%) were female. The average age was 8.3 years (from 2 to 17 years). The visual acuity was evaluated using a retro-illuminated logMAR chart in cooperative patients. All children were submitted to exams on ocular motility, cyclopegic refraction, and fundus examination. RESULTS From the total of 85 eyes, using the spherical equivalent, the major of the eyes (57.6%) were emmetropics (>-0.50 D and <+2.00 D). The prevalence of astigmatism greater than or equal to 0.75 D was 40%. CONCLUSION The prevalence of refractive errors, by the spherical equivalent, was 42.4% in this studied group.