Kemal Pamukçu

Recession of the Inferior Rectus Muscle Under Topical Anesthesia in Thyroid Ophthalmopathy

PURPOSE To evaluate the results of inferior rectus muscle recession with adjustable loop suture under topical anesthesia for vertical deviations secondary to thyroid ophthalmopathy. PATIENTS AND METHODS Five patients with a vertical deviation greater than 15 PD and severe limitation of upgaze were enrolled in the study. Before proceeding with corrective strabismus surgery, we waited at least 6 months after stabilization of ocular alignment and normalization of thyroid chemistries. All patients underwent inferior rectus muscle recession with adjustable loop suture under topical anesthesia. The postsurgical follow-up was at least 12 months. RESULTS Preoperatively, the mean vertical deviation was 24 PD. At 1 year postoperatively, it had decreased to 2.4 PD. Two patients were orthotropic and 3 patients had residual hypotropia ranging from 2 to 6 PD. The limitation of upgaze was relieved significantly in the postoperative period. Two patients had minimal limitation of downgaze, but none complained of diplopia in the primary or reading positions. Surgery did not trigger a flare-up of orbital inflammation in the early postoperative period. CONCLUSION We advocate that recession of the inferior rectus muscle with adjustable loop suture under topical anesthesia is safe and effective in patients with thyroid ophthalmopathy.

An approach to the surgical management of total oculomotor nerve palsy

The goal of the procedure was to keep the eyes of patients with total oculomotor palsy in the straight ahead position by means of surgery on the horizontal and inferior rectus muscles in one session, without involving the superior oblique muscles. Six patients underwent surgery for total oculomotor nerve palsy. All of the surgical procedures were carried out on the muscles of the paralytic eye. We performed hemi-hangback recession of the lateral rectus and resection of the medial rectus for exotropia in all patients. Depending on the magnitude of vertical deviation, the insertions of the horizontal rectus muscles were moved upward, alone or in combination with hemi-hangback recession of the inferior rectus. The mean preoperative horizontal deviation was 66.6 PD. Two years after the operation, the horizontal deviation was measured to be 11.6 PD. Similarly, the mean preoperative vertical deviation of 16 PD decreased to 6.6 PD in two years. This procedure did not disturb normally functioning superior oblique and lateral rectus muscles. Subjectively, all of the patients were satisfied with their alignment two years after the operation. We are of the opinion that this technique is a safe, simple and effective procedure and can be regarded as a first-choice operation in total oculomotor palsy. If one fails to maintain the eye position with this procedure, one can still perform a second operation on the superior oblique muscle, which remains untouched in our procedure.

Retroequatorial recession of horizontal recti with loop suture in the treatment of congenital nystagmus

Purpose The authors wished to evaluate the effectiveness and safety of retroequatorial recession of all four horizontal recti using loop sutures for the treatment of congenital nystagmus. Subjects and methods Twelve patients with congenital nystagmus were enrolled in this prospective study. All patients underwent retroequatorial recession of horizontal recti with loop sutures. All recti were recessed 8mm measuring from the insertion, then the amount of loop suture was determined according to the preoperative ocular alignment of the patients. Electronystagmographic recordings were made in every patient preoperatively and postoperatively as well as an ophthalmological examination. The follow-up period ranged from 6 to 26 months. Results All four horizontal recti were recessed 9 to 12mm including the loop suture (range 1-4mm). Compared to preoperative values, postoperative amplitude and intensity of nystagmus decreased statistically significantly in all patients (p = 0.002). The postoperative decrease in the frequency of nystagmus was not statistically significant (p = 0.173). Improvement of both distance and near visual acuity was achieved in 10 patients. Five of seven patients who had ocular misalignment preoperatively were aligned within 10 PD postoperatively. Improvement in head posture was seen in two of three patients. The authors determined that the improvement in the nystagmus characteristics was most prominent in the immediate postoperative period. Conclusion Retroequatorial recession of all four horizontal recti using loop sutures is a safe and effective procedure for the management of congenital nystagmus.

Binocular visual function in congenital esotropia after bilateral medial rectus recession with loop suture.

PURPOSE Our aim was to evaluate the binocular visual function in congenital esotropia after bimedial rectus recession with loop suture and to address the factors that could take part in the attainment of binocular function. SUBJECTS AND METHODS Forty children with congenital esotropia who were operated on between 12 and 48 months of age were included in the study group. Postoperative follow-up ranged from 2 to 10 years. In order to determine the factors affecting the sensory results in congenital esotropia, we classified our patients into two groups according to their fusion status. We compared the preoperative and postoperative characteristics of patients in these two groups. RESULTS Twenty-one of 40 patients (52.5%) fused the Worth four-dot at near (Group 1), 19 patients (47.5%) did not (Group 2) at the final examination. No patient showed evidence of stereopsis. We found significant differences between these two groups in respect to the final angle of vertical deviation, the age at surgery, the presence of postoperative inferior oblique overaction, dissociated vertical deviation and abnormal head position. Correlation analysis revealed that early alignment of the eyes and the absence of postoperative vertical deviation were associated with increased incidence of achieving some degree of binocular vision. CONCLUSION In congenital esotropia, not all infants may have the potential for normal binocular function owing to yet unknown constitutional factors. We determined that achieving some degree of binocular function may be related to early alignment of the eyes. Additionally, close follow-up and precise treatment of the accompanying vertical deviation, especially inferior oblique overaction and dissociated vertical deviation,in a timely manner may enhance the attainment of binocular sensory function.

The Evaluation of Binocular Visual Function in Patients with Congenital Brown's Syndrome

We evaluated the binocular visual function of 14 patients with Browns syndrome and compared this data with that collected from 14 visually normal subjects of similar age and sex. Patients with Browns syndrome underwent a full ophthalmologic examination including a detailed strabismological evaluation. Stereoacuity was measured with the Titmus and TNO stereotests. Visual evoked potentials (VEPs) were recorded. Patients with congenital Browns syndrome had reduced stereoacuity levels compared to the control group. They also had longer binocular VEP latencies and smaller VEP amplitudes. Binocular enhancement of VEP amplitude was present in both groups but more evident in the control group. In conclusion, partial binocular visual functional abnormalities could be found in patients with congenital Browns syndrome in addition to the characteristic ocular motility restrictions.

Effects of intraocular lens malposition on binocular single vision in bilaterally pseudophakic patients

PURPOSE To investigate the relationship between intraocular lens (IOL) malposition and quality of binocular single vision following uncomplicated extracapsular cataract extraction and posterior chamber IOL implantation. METHODS Fifty-two bilaterally pseudophakic patients were included. The main outcome measures were visual acuity, stereoscopic acuity, horizontal and vertical amplitudes of fusion and heterophoria, tilting angle and decentration amount of the pseudophacos and summation of these values in somewhat vectorial manner to define the total decentration and tilt of IOLS. RESULTS The mean total horizontal decentration was 0.19 mm and vertical decentration was 0.90 mm, mean total horizontal tilt being 1.55 degrees and vertical tilt 7.52 degrees. The mean stereoscopic acuity was found to be 1020 seconds of arc. Although the stereoscopic acuity threshold increased as decentration and tilt of IOLS increased, only the horizontal tilt was found to be statistically significantly correlated with stereoscopic acuity (pc0.01). CONCLUSION The quality of binocular single vision may be affected by IOL malposition in pseudophakic patients. Therefore, when an IOL implantation is planned, the most appropriate IOL design and surgical technique causing least decentration and tilt should be preferred.

Qualitative and quantitative evaluation of binocular function in accommodative esotropia using pattern reversal visual evoked responses (VER)

Pattern reversal visual evoked responses (PVER) were recorded in 31 children, in order to evaluate binocular functions in an objective manner. Ten cases had normal binocular functions, 21 cases had various degrees of accommodative esotropia and binocular impairment. Monocular and binocular recordings were performed for all the cases. PVER amplitudes of normal and accommodative esotropic children were compared using the dioptic method. Binocular summation was seen in accommodative esotropic children although less than that of the normal group. Thus, the authors thought it possible to assess objectively the presence of anomalous binocular vision sustained by anomalous retinal correspondence in accommodative esotropia by using PVER.

Effect of bimedial rectus recession with a loop on the deviation in essential infantile esotropia.

Thirty-two patients with essential infantile esotropia were treated by using a 2.5 millimeter loop, added to a 4 millimeter medial recti recession bilaterally. Objective deviation was more than 45 prism diopters (PD) in all of the patients preoperatively. After surgery the deviation ranged between -10 PD and +IO PD in 26 (81.2%) patients, and limitation of abduction disappeared in all of the cases. A slight limitation of adduction was encountered in two (6.2%) patients. The authors concluded that bimedial rectus recession with a loop is an effective method as an early surgical procedure in patients with infantile esotropia with a large deviation.

The results of surgery in a series of partially accommodative esotropic patients

Three different surgical procedures were performed in 32 partially accommodative esotropic patients with a high accommodative convergence/accommodation (AC/A) ratio. The patients were followed-up for an average period of 2.5 years (range: four months to seven years). Recession of the medial rectus and resection of the lateral rectus (group I), bimedial recession (group 2) or bimedial recession with bimedial Faden operation (group 3) were performed, guided by the preoperative AC/A ratio, the difference between the distance and near deviations, and the alternation pattern. At the end of the follow-up period, the average distance and near deviations were found to be less than 10

Negative social bias against children with strabismus

DL in all three groups. The AC/A ratio of all patients was normal or close to normal in the postoperative period.