1/112. Acquired Pseudo-Brown's syndrome immediately following Ahmed valve glaucoma implant.A 76-year-old woman noted vertical and horizontal diplopia one day following placement of an Ahmed valve in the superonasal quadrant of her left eye. She was unable to elevate her left eye, especially in adduction. She refused implant removal and strabismus surgery alone failed to satisfactorily resolve her problem. On forced duction testing, the implant became wedged between the globe and orbit superonasally. Subsequent repositioning of the valve resulted in resolution of her motility problem. Implant-orbital disproportion can produce a pseudo-Brown's syndrome. Surgeons are encouraged to perform forced duction testing at the time of glaucoma implant placement to detect and prevent this complication.- - - - - - - - - - ranking = 1keywords = horizontal, vertical (Clic here for more details about this article) |
2/112. Restriction of elevation in abduction after inferior oblique anteriorization.PURPOSE: Inferior oblique anteriorization is gaining popularity for the treatment of dissociated vertical divergence associated with inferior oblique overaction. This procedure is based on the theory that moving the insertion of the inferior oblique muscle anterior to the equator changes its vector of force from one of elevation to one that opposes elevation. The purpose of this investigation is to describe, investigate the cause, and outline treatment for a complication I observed after inferior oblique anteriorization. This postoperative syndrome consists of a motility pattern that resembles marked residual inferior oblique overaction associated with a Y or V pattern. It is probably caused by a restriction of elevation of the abducting eye causing fixation duress, with a resultant upshoot of the contralateral adducting eye. methods: A retrospective chart review was conducted for all patients on whom I performed bilateral inferior oblique anteriorization for inferior oblique overaction associated with dissociated vertical divergence. patients in whom this postoperative syndrome developed were compared with those in whom it did not with respect to type and extent of surgery. In addition, cases of patients I treated or examined for this complication but whose inferior oblique anteriorization had been performed by other ophthalmologists were also analyzed. RESULTS: I performed bilateral inferior oblique anteriorization in 77 patients. In 29 patients the inferior oblique muscles were placed level with the insertions of the inferior rectus muscles, in 31 patients they were placed 1 mm anterior to the insertions of the inferior rectus muscles, and in 17 patients they were placed 2 mm anterior. The postoperative syndrome described here developed in two of the 77 patients; both had the inferior oblique muscles placed 2 mm anterior to the insertions of the inferior rectus muscle. These were also the only two patients in this series in whom the new insertion of the inferior oblique muscle was spread out laterally at the time of anteriorization. I have seen an additional six patients in whom this syndrome developed after undergoing operations by other ophthalmologists. In four, the inferior oblique muscles were placed 2 mm anterior to the insertions of the inferior rectus muscles, and in two they were placed 3 mm anterior. Of the eight patients I have observed with this complication, I reoperated on six. The surgical procedure consisted of denervation or extirpation of both inferior oblique muscles in four patients and conversion to standard recessions of the inferior oblique muscles in two patients. In all six patients,the versions were markedly improved and the Y orV pattern was eliminated after reoperation. CONCLUSIONS: Anteriorization of the inferior oblique muscles more than 1 mm anterior to the insertions of the inferior rectus muscle may cause a limitation of elevation in abduction, resulting in a Y or V pattern that mimics inferior oblique overaction. This may be more likely to occur if the new insertions of the inferior oblique muscles are spread out laterally at the time of anteriorization.- - - - - - - - - - ranking = 0.30758255458071keywords = vertical (Clic here for more details about this article) |
3/112. Normal reading despite limited eye movements.Many investigators have demonstrated that poor readers exhibit abnormal eye movements during reading. An association between defective vergence, accommodation, and poor reading skills has also been noted by some investigators. Children who are poor readers have been subjected to therapeutic interventions on the basis of the assumption that improving their eye movements, as part of a multifaceted program of "vision therapy," will yield commensurate improvement in reading performance. This approach has been controversial, and other authors have expressed opposing views. We report the ophthalmologic and reading assessments of two children with Mobius' syndrome who were average to above-average readers despite essentially absent horizontal eye movements.- - - - - - - - - - ranking = 0.84620872270964keywords = horizontal (Clic here for more details about this article) |
4/112. Fresnel membrane prisms: clinical experience.BACKGROUND: There are few published reports on the clinical application of Fresnel membrane prisms in the treatment of diplopia in adults. The authors describe the use of these prisms in patients with fourth and sixth cranial nerve palsies, restrictive motility caused by thyroid-related orbital disease, and convergence insufficiency. methods: Of 209 patients who had been treated with Fresnel prisms, 141 were selected. The database included patients from a private practice in Montreal, seen from 1988 to 1996, and patients seen by orthoptists in the ophthalmology department of a children's hospital in Montreal between 1992 and 1996. All the patients had diplopia associated with fourth (48 patients) or sixth (43 patients) cranial nerve palsy, thyroid-related orbitopathy (18 patients) or convergence insufficiency (32 patients). After qualitative and quantitative assessment of the ocular misalignment, a Fresnel prism was selected for power and axis and for appropriate location on the spectacle lens. Ocular dominance and side of paresis or restriction were also considered in the placement of the prism. The patient's response to treatment was documented. RESULTS: The Fresnel prisms were oriented horizontally in 72 patients (51%), vertically in 55 (39%) and obliquely in 14 (10%). They were placed on the spectacle lens before the nondominant eye in 127 cases (90%), either covering the entire lens, or on the upper or lower segment or both. The patients were followed for an average of 15 (range 2 to 96) months. Of the 141 patients 113 (80%) had a successful outcome, with relief of their diplopia. Twenty-seven patients (19%) eventually had the prismatic correction ground into the lens, 70 (50%) chose to wear the Fresnel prism on a permanent basis because incorporation into the lens was not possible or because of cost, and 17 (12%) used the Fresnel prism as a temporary device before or after surgery. Most patients who converted to incorporated prisms did so when the prismatic power became stable, usually after 6 to 8 months. Eight patients (6%) stopped using the prism because of associated side effects, such as blurred vision, persistent diplopia, torsion or optical aberrations. INTERPRETATION: The Fresnel prism is an excellent device in treating diplopia in adult patients. It is a reasonable permanent option when incorporating the prism into the spectacle lens is not possible. A fused blurred image caused by a Fresnel prism placed in front of the nondominant eye is preferable to double but clear images.- - - - - - - - - - ranking = 13.421744010171keywords = convergence, horizontal, vertical (Clic here for more details about this article) |
5/112. Orbital blowout fracture with persistent mobility deficit due to fibrosis of the inferior rectus muscle and perimuscular tissue.A case of orbital blowout fracture accompanied by fibrosis of the inferior rectus muscle resulting in an irreversible orbital mobility deficit is reported. An 8-year-old girl with an orbital blowout fracture was treated with steroids for 10 days, as with other cases in our department. She exhibited a disturbance of vertical eye movement and a positive forced duction test result. Although surgery was performed on day 13, and on day 27 due to poor recovery after the first operation, almost no improvement of the ocular movement was noted. The results of a traction test, performed during the second operation, suggested that the inferior rectus muscle had adhered to the periosteum. magnetic resonance imaging performed 3 days after the second operation revealed fibrosis of the inferior rectus muscle and perimuscular tissue, resulting in an irreversible disturbance of the vertical ocular movement. The present findings suggest that the need for and timing of surgery in patients with blowout fractures should be determined on an individual basis.- - - - - - - - - - ranking = 0.30758255458071keywords = vertical (Clic here for more details about this article) |
6/112. Paroxysmal tonic upgaze: physiopathological considerations in three additional cases.Paroxysmal tonic upgaze of childhood has been described as a benign distinctive syndrome of abnormal ocular movement, with or without concomitant ataxia. After the first observation of four children, a further 29 patients have been reported with a wide spectrum of neurologic abnormalities such as ataxia, unsteady of gait, learning disabilities and mental retardation at follow-up. Electroencephalograms were normal in all the subjects and magnetic resonance imaging showed deficient myelination in only one patient. Recently it has been suggested that paroxysmal tonic upgaze could be a heterogeneous syndrome, ranging from a simply age-dependent manifestation to a clinical appearance of a variety of disorders affecting the corticomesencephalic loop of vertical eye movement. Moreover, it also could be an early sign of more widespread neurologic dysfunction. We describe three patients who presented paroxysmal tonic upgaze; in one, ataxia was present; in the second child, ataxia and language disorder also were observed; and in the third patient paroxysmal tonic upgaze was associated with loss of muscle tone (drop-attack-like events). On magnetic resonance imaging, a pinealoma compressing the dorsal mesencephalic region was detected. On the basis of our observations, we suggest that any insult with periaqueductal mesencephalic gray-matter involvement could be considered the basic condition for this peculiar clinical manifestation.- - - - - - - - - - ranking = 0.15379127729036keywords = vertical (Clic here for more details about this article) |
7/112. Children with ocular motor apraxia type Cogan carry deletions in the gene (NPHP1) for juvenile nephronophthisis.Congenital ocular motor apraxia type Cogan is characterized by impairment of horizontal voluntary eye movements, ocular attraction movements, and optokinetic nystagmus. Two patients with congenital ocular motor apraxia type Cogan exhibited a newly recognized association with nephronophthisis type 1, an autosomal recessive kidney disease. Both patients possess large deletions of the NPHP1 gene. The deletion occurred on both chromosomes 2q13 in one patient and heterozygously in combination with a point mutation of the NPHP1 gene in the other. The findings will help to elucidate the pathogenetic processes involved.- - - - - - - - - - ranking = 17.904419766723keywords = nystagmus, horizontal (Clic here for more details about this article) |
8/112. Unilateral thalamic infarction and vertical gaze palsy: cause or coincidence?Although vertical gaze palsy (VGP) is commonly associated with lesions of the rostral mesencephalon, there is some evidence that VGP may also be caused by a unilateral thalamic lesion. The case of a 68-year-old man with persistent upward gaze palsy after a unilateral thalamic infarction, demonstrated on computed tomography and magnetic resonance imaging scans, is presented. Subsequent high-resolution magnetic resonance scanning, however, showed involvement of the rostral mesencephalon as well. The authors suggest that in previous patients with VGP ascribed to a unilateral thalamic infarction, a coexisting mesencephalic involvement may have been missed because of inappropriate imaging techniques. Strong evidence of unilateral thalamic infarction as a cause of VGP is still lacking.- - - - - - - - - - ranking = 0.76895638645178keywords = vertical (Clic here for more details about this article) |
9/112. Insights into the three-dimensional structure of the oculomotor nuclear complex and fascicles.The authors report the case of a patient with an ischemic lesion in the left midbrain. The patient presented with paresis of left inferior rectus, pupil, right superior rectus, convergence and transiently, of the left medial rectus. A lesion in the left dorsal midbrain close to the oculomotor nuclear complex, selectively involving the fascicles innervating the above muscles, is proposed. Fine magnetic resonance sections showed a consistent lesion in the left paramedian dorsal midbrain. A detailed, three-dimensional, schematic computer model of the oculomotor nucleus and fascicles was constructed. Using this model, the authors topographically validate the putative site of the lesion. The medial rectus subnucleus is divided into three subgroups, A, B, and C. Subgroup C is thought to be the site of the majority of neurons controlling convergence. In the above model, the putative lesion is closer to subgroup A than to C; this suggests that subgroup A, rather than subgroup C, may have a higher concentration of neurons involved in convergence.- - - - - - - - - - ranking = 18.632616015256keywords = convergence (Clic here for more details about this article) |
10/112. Treatment of subtotal medial rectus myectomy complicating functional endoscopic sinus surgery.During the past 2 decades, the introduction of functional endoscopic sinus surgery (FESS) has dramatically improved the treatment of sinus disorders. However, a variety of orbital complications have been reported, including optic nerve damage, hemorrhage, infection, compromise of the lacrimal drainage apparatus, and strabismus. At least 10 cases have reported damage to the medial rectus muscle. (1-8) Treatment options for such patients have been limited, especially because most are adults at risk for anterior segment ischemia after transposition of vertical rectus muscles. We describe 2 patients whose medial rectus myectomies were repaired by using nonabsorbable "hang-back" sutures in combination with a botulinum toxin (Botox) injection of the antagonist lateral rectus muscle. Good primary position alignment was achieved in both patients, and one patient was able to regain binocular function. We recommend this surgical approach, especially in patients at increased risk for anterior segment ischemia.- - - - - - - - - - ranking = 0.15379127729036keywords = vertical (Clic here for more details about this article) |
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