Michael C. Struck

Augmented vertical rectus transposition surgery with single posterior fixation suture: Modification of Foster technique

PURPOSE To describe a modification of the lateral posterior fixation augmentation suture of the vertical rectus muscles that is proposed to enhance the abducting vector while balancing the vertical vectors, therefore limiting stress on the sclera and preventing vertical deviations. METHODS Full tendon temporal transposition of the vertical rectus muscles was performed on 5 patients with Duane retraction syndrome and 5 with sixth (abducens) nerve palsy. Augmentation was created by the use of a single lateral fixation suture of 5-0 polyester that incorporated the muscle bellies of both vertical muscles. The lateral rectus muscle was disinserted and attached to the lateral orbital wall in 4 of the patients with Duane syndrome. RESULTS Four of 5 patients with Duane syndrome and 4 of 5 patients with abducens nerve palsy had successful horizontal alignment, defined as reduction or elimination of head turn, a deviation < or =10(Delta), and resolution of diplopia. Patients with Duane syndrome had improved adduction, elimination of co-contraction, and decreased torticollis. Patients with abducens nerve palsy were noted to have a reduction of esotropia with improved abduction. CONCLUSIONS The modified technique limits stress on the scleral portion of the lateral fixation suture; the opposing vertical vectors are transmitted to the opposite vertical rectus muscle. Patients exhibited improved abduction, adduction, torticollis, and range of single binocular vision with a low risk of vertical deviations induced by surgery. Complications included repeat strabismus surgery (2 cases) and scleral perforation (1 case). A vertical deviation of 3(Delta) developed in 1 patient.

Long-term Results of Pediatric Cataract Surgery and Primary Intraocular Lens Implantation From 7 to 22 Months of Life

IMPORTANCE Pediatric primary posterior intraocular lens (IOL) implantation in children older than 24 months has become the standard of care. Results of the Infantile Aphakia Treatment Study have concluded that primary IOL implantation before age 7 months has no advantages over aphakia. The current evidence does not address our understanding of the risks and benefits of primary IOL implantation for children aged 7 to 24 months. OBSERVATIONS Final optotype acuity, adverse events, refractive growth, strabismus, binocular function, and need for additional surgery were retrospectively reviewed for 14 eyes of 10 patients from November 2001 to June 2012. The records were reviewed for children aged 6 to 24 months; included patients were aged 7 to 22 months. The mean (SD) visual acuity was 0.29 (0.30) logMAR (Snellen equivalent 20/40). The mean follow-up was 5 years. The rate of adverse events was 3 in 14 eyes (21%). Adverse events included lens reproliferation (2 eyes) and lens dislocation (1 eye). The rate of strabismus correction was 4 in 10 patients (40%). The mean (SD) rate of refractive growth at 3 times the age at surgery was -5.80 (3.09) diopters. CONCLUSIONS AND RELEVANCE The data suggest that primary IOL implantation in this age group has a lower rate of adverse events than reported in the Infantile Aphakia Treatment Study. Additionally, favorable visual outcome was found, similar to that in children undergoing primary IOL implantation when older than 2 years. Primary IOL implantation should be considered in children who require cataract surgery after age 7 months.

Outcomes of Harada-Ito surgery for acquired torsional diplopia

PURPOSE To evaluate the outcomes of Harada-Ito surgery in correcting various types of torsional diplopia. METHODS The medical records of patients who underwent Harada-Ito surgery at two academic institutions were retrospectively reviewed. Data collected included etiology of torsional diplopia, strabismus and torsion measurements, reoperation rate, patient symptoms, and use of prism. Postoperative success was defined as a lack of diplopia in the primary position at distance and downgaze at near with or without prism. Failure was defined as persistent torsional diplopia; partial success was defined as surgical success but with restrictive strabismus in the secondary gaze positions. RESULTS A total of 26 patients (mean age, 46 years; range, 13-89 years) were included. Of these, 17 had superior oblique palsy. The mean follow-up duration was 2 years (range, 2-60 months). The surgical outcome was success in 73% of patients, partial success in 7%, and failure in 19%. All patients with ≤10° of torsion preoperatively obtained surgical success. Patients in the failure group had higher amounts of preoperative torsion compared to the success group (P = 0.009). The reoperation rate was 23%, including four patients with additional surgery for downgaze esotropia or torsion. One-third of the patients wore a prism immediately after surgery. CONCLUSIONS Harada-Ito surgery successfully treated torsional diplopia. Patients with ≤10° of preoperative torsion had a better outcome. Downgaze diplopia was a common reason for additional surgery.

Surgical management of clinically significant hypertropia associated with exotropia

PURPOSE To report the surgical treatment of hypertropia coexisting with exotropia, with either vertical offset surgery or additional vertical muscle surgery simultaneous to correction of the exotropia. METHODS A total of 35 patients with exotropia and hypertropia who underwent a horizontal muscle surgery for exotropia were included. To determine efficacy in resolving a vertical deviation in patients with exotropia, 28 patients were compared in 2 groups: those who underwent horizontal muscle surgery with vertical offset and those who underwent horizontal muscle surgery with additional vertical muscle surgery. An additional 7 patients who had exotropia and hypertropia but did not undergo vertically corrective surgery were included for comparison. RESULTS Vertical offset of horizontal rectus muscles (4 mm) resulted in 8(Delta) correction of the distance hypertropia. Vertical rectus muscle recession used in the treatment of larger hypertropic deviations with exotropia had a 3(Delta) correction per 1 mm of recession. Success rates for hypertropia correction were similar between groups, 63% vertical offset and 71% vertical muscle groups; overcorrections occurred in 29% of the vertical muscle group. The vertical correction in both groups was stable in 88% over 6 months postoperatively. CONCLUSIONS Vertical offset of the horizontal muscles simultaneous with exotropia correction has a beneficial effect in small-angle hypertropia (<14(Delta)). Vertical rectus muscle surgery in patients with hypertropia greater than 10(Delta) had equivalent success; however, in intermittent exotropia the hypertropia was prone to overcorrection.

Resolution of hypertropia with correction of intermittent exotropia

Purpose We describe the spontaneous resolution of hypertropia in a subset of patients with preoperative exotropia and hypertropia, who underwent surgery for intermittent exotropia alone. Design This was a retrospective case series. Methods The charts were reviewed of 17 patients who underwent surgical correction for an intermittent exotropia, who additionally were noted on preoperative exam to have greater than 5 prism dioptres of vertical deviation in primary position. Patients were excluded if they had prior strabismus surgery, dissociated vertical deviation, and paretic or restrictive deviations. Results All patients were documented to have complete resolution of any vertical deviation in any field of gaze. This effect was noted to persist. Conclusions We propose that the measured distance hypertropia, which is coincident with intermittent exotropia, even with the appearance of superior oblique dysfunction or inferior oblique overaction, is not created by a true vertical or cyclovertical muscle imbalance. Further, that the reduction of the hypertropia at near fixation predicts its resolution with horizontal muscle surgery. Therefore, vertical surgery should not be performed to address the coincident vertical deviation in these patients.

Surgery for Supranuclear Monocular Elevation Deficiency.

Abstract Purpose: We report a novel approach to surgery for monocular elevation deficiency (MED). Methods: A retrospective review of 5 patients undergoing surgery for supranuclear MED between 2003 and 2014. All patients had intact Bell’s phenomenon, hypotropia, limited elevation above the primary position, and negative forced duction testing of the paretic eye. Preoperatively all patients preferred chin-up head posture and three had pseudoptosis or ptosis. One of the 5 had prior vertical muscle surgery. Surgery correction for the MED consisted of near maximal superior rectus recession on the contralateral sound eye. Results: Compensatory chin-up head position and alignment in primary position was improved in all patients. Average age at surgery was 5.3 years. Average superior rectus recession was 9.7 mm. Mean follow-up was 4.8 years (range 12 months to 11.5 years). The vertical deviation of the paretic eye in primary position postoperatively was orthotropic for 2, hypotropic for 2, and overcorrected for 1. Conclusions: In cases of supranuclear MED (double elevator palsy) contralateral superior rectus recession based on the innervational principle is a simple and reliable alternative surgical approach compared to published results of the Knapp transposition procedure. Additionally, it holds the possibility for decreased complications and less complicated future surgical treatment options.

Use of Topical Insulin to Treat Refractory Neurotrophic Corneal Ulcers

Purpose: To report the clinical course of 6 patients with refractory neurotrophic corneal ulcers that were treated with topical insulin drops. Methods: Retrospective chart review of patients who had neurotrophic corneal ulcers or epithelial defects refractory to standard medical and surgical treatment. Insulin drops, prepared by mixing regular insulin in artificial tears with a polyethylene glycol and propylene glycol base at a concentration of 1 unit per milliliter, were prescribed 2 to 3 times daily. Results: Six patients, aged 2 to 73 years, developed neurotrophic corneal ulcers refractory to a range of medical and surgical treatments, including bandage contact lens, amniotic membrane grafting, and permanent tarsorrhaphy. Each patient was administered topical insulin drops with complete corneal reepithelialization within 7 to 25 days. Conclusions: Topical insulin may be a simple and effective treatment for refractory neurotrophic corneal ulcers. Further study is required to determine the clinical efficacy and side effect profile of insulin drops.

Albinism: Update on Ocular Features

Oculocutaneous albinism (OCA) and ocular albinism (OA) are disorders of abnormal melanogenesis. The ocular features of these hypopigmentation disorders and how they affect the visual function and ocular structure are becoming more defined. A hallmark of OCA and OA is the variability in phenotypic expression. Recent advances in genetic analysis and theories on the interaction of genes that alter expression in albinism have helped our understanding of this variable expression. Molecular genetics has also advanced the understanding of the interactions at the biochemical and cellular level that alter normal function and development. Additionally, major strides have been made in defining the anatomic structural deficits in the macula, retina, optic nerve, and optic pathway. Although our understanding of albinism has greatly advanced, the treatment of the functional visual deficit remains primarily supportive in nature. The promise for effective treatment paradigms is on the horizon.

Surgical management of strabismus following vitreo-retinal surgery.

Motility disorders and strabismus after vitreo-retinal surgical intervention have multiple etiologic factors. The main focus here is strabismus following scleral buckling surgery. The preoperative evaluation of these patients must be inclusive for restrictions, redirected muscle forces, adherence syndromes, muscle weakness, and visual sensory disturbance. Restoration of binocular function is generally the goal of surgical intervention, but paramount to surgery is assessing the potential for binocular function. Surgical techniques for overcoming the barriers to fusion are discussed with clinical vignettes to illustrate the principal. Surgery, which is appropriately planned, based on these principals can be highly successful in restoring visual functioning.

Successful treatment of anisometropic amblyopia with spectacles alone

BACKGROUND The efficacy of treating anisometropic amblyopia with occlusion therapy is well known. However, this form of treatment can be associated with risks. Spectacle correction alone may be a successful and underutilized form of treatment. METHODS The records of 28 patients treated successfully for anisometropic amblyopia with glasses alone were reviewed. Age, initial visual acuity and stereoacuity, and nature of anisometropia were analyzed to assess associations with time required for resolution, final visual acuity, and stereoacuity. Incidence of amblyopia recurrence and results of subsequent treatment, including patching, were also studied. RESULTS Mean time to amblyopia resolution (interocular acuity difference <or=1 line) was 5.8 months (range 2 to 15 months). Worse best corrected initial visual acuity was associated with longer time to resolution (Spearmans rho = 0.37, P = 0.05), while age, initial stereoacuity, amount, and type of anisometropia were not (P = 0.43, 0.68, 0.26, 0.47, respectively). None of the astigmatic or myopic patients achieved visual acuity of 20/20 in the amblyopic eye, while seven (39%) of the hyperopic patients did. This difference was significant (P = 0.03). Better initial stereoacuity predicted good final stereoacuity (P = 0.01). Only four (14%) patients developed amblyopia recurrence over an average follow-up period of 1.7 years. All were successfully treated with updated spectacles or patching. CONCLUSIONS Treatment of anisometropic amblyopia with spectacles alone can be a successful option. Patients treated with spectacles alone may experience a lower amblyopia recurrence rate than those treated with occlusion therapy.