- •Table of Contents
- •Preface
- •ESA meeting organization 2004
- •ESA lectures
- •Foreword by the President
- •Special lecture: History of Strabismology
- •Macular translocation surgery
- •Effects of early and late onset strabismic amblyopia on magnocellular and parvocellular visual function
- •MRI measurements of horizontal rectus muscles in esotropia: the role of amblyopia
- •Combined optical and atropine penalization in the treatment of amblyopia
- •Telescopic spectacle therapy in amblyopia and its efficacy in cases over 9 years of age
- •Treatment of anisometropic amblyopia with no or minimal patching
- •Session 3: Sensorial aspects
- •Binocular functions in pseudophakic patients in early postoperative period
- •The age-related decline in stereopsis as measured by different stereotests
- •Visual recognition time in strabismus: small-angle versus large-angle deviation
- •Session 4: Botulinum toxin
- •Botulinum toxin in strabismus treatment of brain injury patients
- •Botulinum toxin-A injection in acute complete sixth nerve palsy
- •The role of Botulinum toxin A in augmentation of the effect of recess resect surgery
- •Does Botulinum Toxin have a role in the treatment of secondary strabismus?
- •Session 5: Various aspects
- •Evaluation of the effect of strabismus surgery on retrobulbar blood flow with Doppler US
- •Computer assisted parent’s vision screening in children
- •Acquired neurological nystagmus: clinical and surgical approach
- •Session 6: Adjustable surgery
- •Strabismus surgery under topical lidocaine gel
- •When should the amount of surgery be adjusted during conventional muscle surgery?
- •Non-absorbable suture should be used for adjustable inferior rectus muscle recessions
- •Session 7: Physiology and refractive surgery
- •Metabolic changes in brain related to strabismus registered by brain SPECT
- •Histological analysis of the efferent innervation of human extraocular muscle fibres
- •Effect of refractive surgery on ocular alignment and binocular vision in patients with manifest or intermittent strabismus
- •Diplopia and strabismus after refractive surgery
- •Session 8: Various surgical methods
- •Does the bilateral inferior obliques anterior transposition influences the amount of surgery on the horizontal muscles?
- •Efficacy of the anterior transposition of the inferior oblique as a secondary procedure in cases of recurrent DVD
- •Outcomes of surgery for vertical strabismus in thyroid-associated ophthalmopathy
- •Session 9: Brown’s syndrome and congenital fibrosis syndrome
- •Surgical findings in Brown’s syndrome
- •A new surgery technique in Brown’s syndrome
- •Long term outcome of silicone expander for Brown’s syndrome
- •Outcome of strabismus surgery in Congenital Fibrosis of Extraocular Muscles (CFEOM)
- •Surgical management in a newly identified CFEOM/postaxial oligo-syndactyly syndrome
- •Session 10: Superior oblique paresis
- •Superior oblique palsy: a ten year survey
- •Results of different surgical procedures in superior oblique palsy
- •How predictable is muscles surgery in superior oblique palsy?
- •Anterior transposition of inferior oblique muscle for treatment of unilateral superior oblique palsy with 16 to 25 prism diopters hyperdeviation in primary position
- •Familial congenital superior oblique palsy
- •Session 11: Surgery in exotropia and special surgical methods
- •Surgical results of lateral rectus muscle recession in intermittent exotropia in children
- •Outcomes of consecutive exotropia surgery
- •Surgical ancorage of the lateral rectus muscle to the periosteum of the orbit: a new tool to tuckle retraction in Duane syndrome and exotropia in 3rd cranial nerve palsy
- •Excessive recession of horizontal rectus muscles in surgical treatment of congenital nystagmus
- •Impact on deviation in primary position of vertical shift of horizontal recti muscles insertion
- •Use of augmented transposition surgery for complex starbismus
- •Posters
- •Binocular functions in anisometropic and strabismic anisometropic amblyopes
- •Thickness of the retinal nerve fiber layer and macular thickness and volume in patients with strabismic amblyopia
- •Evaluation of intranasal midazolam in young strabismic children undergoing refraction and fundus examination
- •Dissociated Vertical Deviation and its relationship with time and type of surgery in infantile esotropia
- •Ocular abnormalities associated with cerebral palsy
- •Moebius syndrome with limb abnormalities
- •Long-term binocular functional outcome after strabismus surgery in a case of cyclic esotropia
- •Influence of orbital factor on development and outcome of surgery for intermittent exotropia
- •Ocular motility problems following treatment for uveal malignant melanoma
- •Recurrent strabismus caused by orbital tumour arising from pulley smooth muscle tissue?
- •The functional outcome of very late surgery in infantile strabismus
- •A binocular scanning laser ophthalmoscope
- •A new scoring method for lees charts
- •About a case of children’s myasthenia gravis
- •Strabismus after in-vitro fertilization
- •Surgical treatment of strabismus fixus with high myopia
- •Carotid Doppler Ultrasonography in congenital IVth nerve palsy
- •Effects of recession strabismus surgery on corneal topography
- •The effectiveness of Faden operation in different types of deviation
- •The Brückner test as a screening tool for the detection of significant refractive errors
- •Outcome of surgical management in adults with congenital unilateral superior oblique palsy
- •Surgical treatment of upshoot and downshoots in Duane’s retraction syndrome
- •Changes in corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery
- •The oculocardiac reflex in strabismus surgery
- •Globe retraction in a patient with nanophthalmos
- •Surgical treatment of consecutive exotropia
- •Epiblepharon and Mobius syndrome: a rare association
- •Assessment of the risk of endophthalmitis in accidental globe penetration during strabismus surgery
- •Assessment of the rate of nausea & vomiting and pain in strabismic patients anesthetized by propofol
- •The effects of experimentally induced spherical myopic anisometropia on stereoacuity
- •Refractive surgery: strabologic patients management
- •Glomus jugulare tumour presenting with VIth nerve palsy
- •Influence of near correction on visual perception and perceptional organization skills in Down Syndrome children
- •Surgical management of complete oculomotor nerve palsy
- •Etiology of paralytic strabismus
- •Transposition procedure for abducens palsy: 10 year-results
- •Inferior oblique muscle surgery for dissociated vertical deviation
- •Hiper maximum lateral rectus recession operation of adults with large angle exotropia
- •Surgical outcome in superior oblique muscle palsy
- •Medical detective
- •Minutes of the general business meeting
- •By-Laws
- •Membership roster
- •Author Index
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Outcomes of surgery for vertical strabismus in thyroid-associated ophthalmopathy
A.C. Bates, G.G.W. Adams, J.F. Acheson & J.P. Lee
Moorfields Eye Hospital, London, UK
ABSTRACT: At our institution the preferred surgical management of large-angle vertical strabismus secondary to thyroid-associated ophthalmopathy is inferior rectus recession combined with contralateral superior rectus recession. We report the results of surgery on 31 patients. 16 patients had a good result with this one procedure. 8 patients had an over-correction requiring further rectus muscle surgery or botulinum toxin treatment.
1INTRODUCTION
Restrictive strabismus secondary to thyroid-associated ophthalmopathy is commonly managed by recession of the muscles most affected by fibrosis and contracture. The inferior rectus muscle is the most frequently affected extraocular muscle and in asymmetrically affected cases a large vertical deviation can result (Flanders & Hastings 1997). Although unilateral inferior rectus recession using adjustable sutures has been advocated in vertical strabismus, a tendency to overcorrection in downgaze has been reported (Lueder et al. 1992); in another series 9 out of 14 patients undergoing unilateral adjustable surgery suffered a progressive overcorrection in the primary position (Sprunger & Helveston 1993). Other authors have suggested performing inferior rectus recession combined with contralateral superior rectus recession to avoid these consequences (Weir & Ansons 2004). The four consultant strabismologists at our institution utilise the latter procedure with adjustable sutures in large-angle vertical strabismus, performing bilateral inferior rectus recession in more symmetrically affected cases, or unilateral inferior rectus recession in vertical strabismus of a smaller magnitude. We reviewed the results of inferior rectus recession combined with contralateral superior rectus recession.
2METHODS
37 patients operated on over a ten-year period by four consultant teams were retrospectively identified from the surgical diaries kept at Moorfields Eye Hospital. Five case notes were unavailable and one patient was excluded as 3-month post-operative data were unavailable. 21 patients were female, 10 were male. The mean age at surgery was 56.6 years, with a range from 34 to 81 years. Four patients had previously undergone bilateral orbital decompression surgery; four had undergone decompression surgery ipsilateral to the hypotropic eye preceding strabismus surgery. No patients had undergone any strabismus surgery previously, or had been diagnosed with any co-existing ocular motility disorder.
The mean pre-operative prism cover test angle in the distance was 32 prism dioptres (SD 9.4 prism dioptres, range 16–56 prism dioptres). 13 patients were operated on with both muscles on adjustable sutures, 10 patients only had the inferior rectus recession on an adjustable suture, and 8 patients only had the superior rectus recession on an adjustable suture. The mean amount of inferior rectus recession was 4.3 mm (range 2–6 mm), the mean amount of superior rectus recession was 4.4 mm (range 2–6 mm). All patients had orthoptic measurements at 3 months postoperatively, 30 patients had orthoptic measurements at 2 weeks post-operatively, and 13 patients had orthoptic measurements immediately after post-operative adjustment.
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3RESULTS
All 13 patients for which orthoptic measurements immediately post-adjustment were available were left under-corrected with a mean prism cover test angle in the distance of 8.8 prism dioptres (range 3–16 prism dioptres). At 3 months post-operatively the mean vertical deviation was 8.5 prism dioptres (n 31, SD 9.6 prism dioptres, range 0–30 prism dioptres). There was a tendency to further correction from 2 weeks to 3 months post-operatively with a mean shift of 6.6 prism dioptres (n 30). 16 patients (52%) had just this one procedure, of which 9 were phoric and free of diplopia in primary position and down-gaze, 2 were phoric and free of diplopia in the primary position and ignored diplopia in down-gaze, 2 patients were suppressing and cosmetically happy, and 3 patients had a small incorporated prism.
6 patients (19%) went on to further surgery on the vertical rectus muscles for an over-correction, 2 patients had botulinum toxin treatment to the contralateral inferior rectus for over-correction, 3 patients had oblique surgery for incomitant strabismus out of the primary position, 2 patients went on to have esotropia surgery, one patient had surgery for an under-correction, and one patient underwent further orbital decompression surgery. Excluding the latter patient, of the 14 patients who had further strabismus procedures 9 were phoric in the primary position after one procedure, and 3 were phoric after two procedures. One patient continues with regular botulinum toxin treatment and one continues to wear a fresnel prism.
4DISCUSSION
Our study shows that this procedure was effective in about half of the patients as a single operation. A quarter of patients went on to have either surgery or botulinum toxin treatment for an overcorrection. These patients had a similar mean pre-op deviation and similar amounts of recession surgery compared to the group as a whole. In the literature various factors have been implicated in the tendency to overcorrection following inferior rectus recession in thyroid-associated ophthalmopathy. A “masked” restriction of the ipsilateral superior rectus or contralateral inferior rectus that is uncovered by recession of the more restricted inferior rectus has been suggested. It has also been suggested that the association of the inferior rectus muscle with the inferior oblique and Lockwood’s ligament can cause delayed attachment of the inferior rectus to the globe. More recently, the use of non-absorbable sutures has been advocated to prevent this complication (Parsa, C., Soltan-Sanjari, M. & Guyton, D., in press). In order to try and prevent over-correction, one consultant changed from only putting the inferior rectus on an adjustable suture to only putting the superior rectus on an adjustable suture during the time period covered in this study.
The management of strabismus secondary to thyroid-associated ophthalmopathy is not always straight-forward. Patients should be counselled that the first operation for large-angle vertical strabismus only succeeds in around half of cases, but that all but a small minority of cases achieve a good result within three procedures.
REFERENCES
Flanders, M. & Hastings, M. 1997. Diagnosis and surgical management of strabismus associated with thyroidrelated orbitopathy. J Pediatr Opthalmol Strabismus 34: 333–340.
Lueder, G.T., Scott, W.E., Kutschke, P.J. & Keech, R.V. 1992. Long-term results of adjustable suture surgery for strabismus secondary to thyroid ophthalmopathy. Ophthalmology 99(6): 993–997.
Sprunger, D.T. & Helveston, E.M. 1993. Progressive overcorrection after inferior rectus recession. J Pediatr Opthalmol Strabismus 30: 145–148
Weir, C. & Ansons, A.M. 2004. Management of large vertical deviations in thyroid eye disease. In de Faber, J.H.N. (ed.), Trans 28th Meeting Europ Strabismolog Assoc: 261–263. London: Taylor & Francis.
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