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Background and Objective: The main objective of the study was to study the pattern of strabismus, determine the type of refractive error and measure the angle of deviation, determine streoacuity by WFDT in 0-18 years of age group. Methods: This was a prospective cross-sectional observational study. Total 50 patients were taken. Patients of 0-18 years of age presenting with squint included in study. Patients were evaluated for VA, both distance and near vision without glasses as well as BCVA tested. Anterior segment evaluation using slit lamp, cycloplegic refraction using atropine (0-9 years) or cyclopentolate (10-18 years), fundus examination, PBCT, WFDT test done. Results: In study, total 50 subjects of 0-18 years of age group was taken. In them boys were more than girls. 49(98%) had comitant strabismus and 1(2%) had incomitant strabismus. 32(64%) had esotropia and 18(36%) had exotropia. Among esotropia 11(34.37%) had accommodative esotropia, 13(40.62%) had partially accommodative, 7(21.87%) had non accommodative, 1(3.12%) had restrictive esotropia. Among exotropia 9(50%) had basic exotropia, 6(33.33%) had divergence excess and 3(16.66%) had convergence insufficiency. 14(28%) had amblyopia. 32(64%) had hypermetropia and 18(36%) had Myopia. 33(64%) had central fixation and 12(24%) had eccentric fixation. In binocularity, 6(12%) had ARC, 25(50%) had unilateral suppression, 10(20%) had alternate suppression. Conclusions: Comitant squint was more common than incomitant squint. Among comitant squint, esotropia was more common than exotropia. Keywords: Esotropia, Exotropia, Refractive error, Strabismus.

Introduction : Incomitant strabismus typically results in intractable diplopia, blepharoptosis, ocular motility disturbance, disturbance in pupil reaction and an unacceptable compensatory head or face posture. A complete clinico etiological profile is necessary for identifying the underlying risk factors and etiology pertaining to paralytic and restrictive strabismus which is imperative in prevention , early detection, managing the etiology and timely recovery in these patients. Objective: To study the clinico-etiological profile of patients with paralytic and restrictive strabismus in a tertiary eye hospital. Material and Methods: Patients reporting to a tertiary eye hospital in north India and diagnosed with paralytic and restrictive strabismus, over a period of one year , were enrolled in the present study . Patients were subjected to detailed ocular examination and evaluated for ocular motility or related disorders. This included detailed clinical history, ophthalmic examination, orthoptic workup , sensory evaluation, diplopia charting, Hess charting, slit lamp examination and fundus examination . In patients of suspected restricted strabismus, forced duction test was performed. Relevant systemic investigations including blood pressure , blood sugar and lipid profile were carried out . M.R.I orbit was done in every patient. Neuroimaging was advised in those patients where indicated. Results: 48 patients were diagnosed with incomitant strabismus and enrolled in the study. 81.3%were of paralytic strabismus while 18.8 % were of restrictive strabismus. In the group of paralytic strabismus, 43.8 % patients had sixth nerve palsy , 27.1% patients had third nerve palsy , 6.3% patients had fourth nerve palsy and combined nerve palsy patients were 4.2%. Analysing the etiology, out of total patients of paralytic strabismus, 48.7% of cases were idiopathic, 25.6% were post traumatic, 15.4% were due to microvascular causes , 5.1% of cases were due to intracranial anomalies an

Surgery for strabismus secondary to orbital fracture reconstruction surgery has had low success rates and high reoperation rates due to its incomitant nature and complex underlying mechanisms. There has been no consensus as to which of the various methods for improving the surgical results are best. We proposed a modified target angle criteria that combined the regular target angle and a favorable Hess area ratio percentage (HAR%) threshold to evaluate surgical results within the first postoperative week and conducted a retrospective chart review. According to the criteria of the modified target angle at the first postoperative week, a total of 63 patients were divided into two groups: Group 1, patients who fulfilled the criteria (49 patients); and Group 2, those who did not (14 patients). Sex, type of fracture, and the use of porous polyethylene sheets and titanium mesh during reconstruction surgery were significantly different between the groups. Group 1 showed a significantly higher percentage of patients who met the criteria of HAR% > 65% at the first week and >85% (i.e., a successful outcome) at the 6-month visit (p < 0.01). Additionally, Group 1 had a higher HAR% at the first postoperative week (p < 0.01). In conclusion, the patients meeting the criteria of the modified target angle at the first postoperative week had a favorable outcome at the 6-month visit in both ocular alignment and ocular movement.

To study the value of functional multislice computed tomography (MSCT) of the orbits in examination of patients with complex incomitant strabismus.The study included 34 patients. In 8 (23.5%) out of 34 patients, strabismus occurred as the result of an orbital injury. In some patients, incomitant strabismus was a complication of: retrobulbar injection of drugs (4 cases (11.7%)); endoscopic sinus surgery (6 cases (17.6%)); reconstructive surgery of orbits (7 cases (20.6%)). In 9 cases (26.5%), incomitant strabismus was detected in patients with thyroid eye disease (TED), of them 5 (14.7%) had previously undergone balanced orbital decompression (BOD). All patients underwent functional MSCT of the orbits.Complete absence of the contractile function of the studied muscles was noted in 6 cases with loss of ocular motility in one or several directions of gaze. Contraction of the injured muscle and its fixation in the area of iatrogenic defect in the orbital wall was observed in 6 patients with severe limitation of ocular motility. limitation of the excursion of the inferior and/or medial rectus muscles due to their fixation in the fracture of the orbital wall was observed in 5 patients after orbital trauma. Signs of contracture of the inferior rectus muscle were revealed in 4 cases of strabismus that occurred after retrobulbar anesthesia. Pronounced increase in the lateral dimensions of the extraocular muscles was determined in 4 patients with TED, as well as in patients who had underwent BOD. Displacement of the lateral and medial rectus muscles into the formed bony windows with a change in the vector of their action was observed in patients who had underwent BOD.The data obtained with functional MSCT of the orbits in 34 patients allowed more accurate characterization of the oculomotor disorders and evaluation of the functional state of the extraocular muscles.Изучить эффективность функциональной мультиспиральной компьютерной томографии орбит в обследовании пациентов со сложными случаями несодружественного косоглазия.В исследование включены 34 пациента. У 8 (23,5%) из 34 пациентов косоглазие возникло в результате травмы орбиты. У ряда пациентов несодружественное косоглазие явилось осложнением ретробульбарной инъекции лекарственных препаратов (4 (11,7%) случая), эндоскопической хирургии придаточных пазух носа (6 (17,6%) случаев), реконструктивных операций на орбите (7 (20,6%) случаев). В 9 (26,5%) наблюдениях несодружественное косоглазие выявлено у пациентов с эндокринной офтальмопатией (ЭОП), из них 5 (14,7%) пациентам ранее выполнена сбалансированная костная декомпрессия орбиты (СКДО). Всем пациентам проведена функциональная мультиспиральная компьютерная томография орбит.В 6 случаях при отсутствующей подвижности глаза в одном или нескольких направлениях взора отмечено полное отсутствие сократительной функции исследуемых мышц. У 6 пациентов с выраженным ограничением подвижности выявлены сокращение поврежденной мышцы и ее фиксация в области ятрогенного дефекта стенки орбиты. У 5 пациентов после орбитальной травмы выявлено ограничение экскурсии нижней и/или внутренней прямых мышц, обусловленное их фиксацией в зоне перелома стенки орбиты. В 4 случаях косоглазия, возникшего после проведения ретробульбарной анестезии, обнаружены признаки контрактуры нижней прямой мышцы. У 4 пациентов с ЭОП, а также у пациентов, перенесших СКДО, определяли выраженное увеличение поперечных размеров экстраокулярных мышц. У пациентов после СКДО наблюдали смещение наружной и внутренней прямых мышц в сформированные костные окна с изменением вектора их действия.Полученные при функциональной мультиспиральной компьютерной томографии орбит данные обследования 34 пациентов позволили уточнить характер глазодвигательных нарушений и оценить функциональное состояние экстраокулярных мышц.

Purpose To evaluate the resection-recession procedure on a single muscle for the management of incomitant strabismus using an alternative calculation. Methods The medical records of adult patients undergoing combined adjustable resection-recession surgery on a single rectus muscle at one institution from 2008 to 2019 were reviewed retrospectively. Each patient had a full orthoptic evaluation before and at least 10 weeks after surgery. The main outcome measure was alignment at last follow-up examination in the primary position and eccentric gaze (field of action). Results A total of 20 procedures in 20 patients were included. The etiology was paretic in 14 cases and restrictive in 6. All rectus muscles were operated. An adjustable suture technique was used in every case, but only 5 required adjustment. The average length of follow-up was 1.7 years (range, 2.4 months to 11.1 years). Postoperative reduction of deviation in eccentric gaze was observed in all patients and averaged 70% (range, 5Δ-48Δ). The technique was particularly helpful for the inferior rectus muscle (85.8% reduction), followed by the medial rectus (66%), lateral rectus (55%), and superior rectus muscles (55%). Three-quarters of the patients became orthotropic in primary position. Good results were noted for both paretic and restrictive etiologies (64%, 83%, resp., reduction in eccentric gaze). Four of 20 patients (20%) were overcorrected in eccentric gaze. One patient required prism to control a small comitant deviation (6Δ). No complications or muscle slippage occurred. Conclusions In our study cohort, the resection-recession operation was effective in reducing incomitance when used on any of the four rectus muscles.

Purpose: To describe the clinical characteristics and surgical outcomes of acquired comitant esotropia with symptomatic diplopia. Methods: The clinical features and surgical outcomes of 27 patients with diplopia due to acquired comitant esotropia were retrospectively reviewed. Exclusion criteria were a history of prematurity, cerebral palsy, head trauma, or febrile illness before the onset of acquired comitant esotropia, incomitant strabismus, accommodative spasm, and divergence paralysis. Neurological evaluation and neuroimaging was normal in all patients. Results: Mean age at onset of esotropia and diplopia was 17.8 ± 10.3 years (range: 6 to 44 years). Eighteen patients had simple myopia (range: −0.25 to −7.75 diopters [D]), 5 patients had hypermetropia (range: 0.50 to 1.50 D), and 4 patients had emmetropia. The angle of deviation prior to surgery was 35.6 ± 10.3 prism diopters (PD) for far and 38.0 ± 10.5 PD for near fixation. Twenty-three patients (85%) were prism responders. A history of excessive near work (≥ 4 hours a day) with digital displays was present in 21 (78%) patients. Diplopia resolved and some level of stereovision was achieved in all patients postoperatively. Three patients had recurrence of esotropia in long-term follow-up. Conclusions: The differentiation of a serious pathology from a straightforward optically or medically treatable condition in patients with a subacute or chronic history of diplopia is challenging for the clinician. The recognition of acquired comitant esotropia due to presumed intensive near activities with digital display may avoid time-consuming and costly laboratory investigations. Most of the patients in this series were prism responders and surgery for the prism-adapted angle was successful in restoring binocular vision. [ J Pediatr Ophthalmol Strabismus . 2020;57(4):251–256.]

Congenital cranial dysinnervation disorders, also known as CCDDs, are characterized by aberrant innervation to extraocular and facial muscles resulting in unusual forms of incomitant strabismus. Anomalous innervation to extraocular muscles can result in a wide variety of phenotypes causing various clinical conditions such as Duane syndrome, congenital fibrosis of the extraocular muscles, and Möbius syndrome. We report a case of bilateral dysinnervation disorder causing atypical ocular movements in both eyes as the patient changes fixation from one eye to the other and from right gaze to left gaze that fits with the wider diagnosis of CCDDs.

Purpose To describe a small series of patients with glaucoma whose strabismus and binocular diplopia were due to advanced visual field loss and inability to maintain sensory and motor fusion. Methods This study is an observational case series of 3 patients with binocular diplopia, associated with variable strabismus, which was due to advanced visual field loss. Results Specific characteristics of the strabismus associated with advanced glaucomatous visual field loss were a subjective floating second image and marked variability of the prism and alternate cover measurements. Measured hypertropia changed in magnitude over a few seconds or a few minutes (even in 1 patient to a hypotropia), which distinguishes this specific type of strabismus from other types of comitant or incomitant strabismus associated with glaucoma. Although visual acuity was 20/400 or better in both eyes in all patients, there was advanced visual field loss in at least one eye. All patients responded poorly to prism, but their symptoms improved with a Bangerter filter applied to the spectacle lens or a MIN occlusion lens to further blur the worse-seeing eye. Conclusions Variable strabismus associated with advanced glaucomatous visual field loss appears to be a distinct clinical entity that should be distinguished from other types of strabismus associated with glaucoma. Management of this specific type of strabismus is limited by inadequate visual field to fuse, analogous to hemifield slide, and therefore prism and/or strabismus surgery is unlikely to be successful. Primary treatment options include optical blur with Bangerter filters or a MIN occlusion lens although some patients prefer to ignore the second image.

Some other forms of Incomitant strabismus can be congenital (Duanes, Browns, DVD) or acquired (Blow out fracture). They share the unifying feature of different deviation in different direction of gaze but also have various characteristic associated findings. This chapter describes the clinical features of other common forms of incomitant strabismus along with investigation modalities and treatment options.

Purpose Using high-resolution magnetic resonance imaging (MRI), we investigated whether rectus pulleys are significantly displaced in superior oblique (SO) palsy and whether displacements account for strabismus patterns. Design Prospective case-control study. Participants Twenty-four patients diagnosed with SO palsy based on atrophy of the SO muscle on MRI and 19 age-matched orthotropic control subjects. Methods High-resolution, surface coil MRI scans were obtained in multiple, contiguous, quasicoronal planes during monocular central gaze fixation. Pulley locations in oculocentric coordinates in the following subgroups of patients with SO palsy were compared with normal results in subgroups of patients with SO palsy: unilateral versus bilateral, congenital versus acquired, and isotropic (round) versus anisotropic (elongated) SO atrophy. Expected effects of pulley displacements were modeled using Orbit 1.8 (Eidactics, San Francisco, CA) computational simulation. Main Outcome Measures Rectus pulley positions and ocular torsion. Results Rectus pulleys typically were displaced in SO palsy. In unilateral SO palsy, on average the medial rectus (MR) pulley was displaced 1.1 mm superiorly, the superior rectus (SR) pulley was displaced 0.8 mm temporally, and the inferior rectus (IR) pulley was displaced 0.6 mm superiorly and 0.9 mm nasally from normal. Displacements were similar in bilateral SO palsy, with the SR pulley additionally displaced 0.9 mm superiorly. However, the lateral rectus pulley was not displaced in either unilateral or bilateral SO palsy. The SR and MR pulleys were displaced in congenital SO palsy, whereas the IR and MR pulleys were displaced in acquired palsy. Pulley positions did not differ between isotropic and anisotropic palsy or between patients with cyclotropia of less than 7° versus cyclotropia of 7° or more. Simulations predicted that the observed pulley displacements alone could cause patterns of incomitant strabismus typical of SO palsy, without requiring any abnormality of SO or inferior oblique strength. Conclusions Rectus pulley displacements alone, without abnormal oblique muscle contractility, can create the clinical patterns of incomitant strabismus in SO palsy. This finding supports accumulating evidence that clinical binocular misalignment patterns are not reliable indicators of contractile function of the SO muscle. Ocular torsion does not correlate with and thus cannot account for pulley displacements in SO palsy.

Differentiation between comitant and incomitant strabismus is an important task for the general ophthalmologist managing strabismus. The paralyses or restrictions underlying incomitant strabismus may imply potentially dangerous disorders that should be treated promptly. Early detection and proper management are necessary to achieve good clinical outcome.

Congenital fibrosis of the extraocular muscles type 2 (CFEOM2) is a distinct non-syndromic form of congenital incomitant strabismus secondary to orbital dysinnervation from recessive mutations in the gene PHOX2A. The phenotype includes bilateral ptosis, very large angle exotropia, ophthalmoplegia, and poorly-reactive pupils. Other than amblyopia, afferent visual dysfunction has not been considered part of CFEOM2; however, we have repeatedly observed non-amblyopic subnormal vision in affected patients. The purpose of this study was to document this recurrent feature of the phenotype.A retrospective case series (2002-2012).Eighteen patients (four families) were identified; all affected individuals had confirmed homozygous recessive PHOX2A mutations except one individual for whom genetic testing was not done because of multiple genetically confirmed family members. Age at assessment ranged from 5-62 years old (median 10 years old). All patients had decreased best-corrected visual acuity not completely explainable by amblyopia in both the preferred and non-preferred eye. In those patients who had further ancillary testing, visual fields (five patients) and electroretinography (10 patients) confirmed abnormalities not ascribable to amblyopia.In addition to a distinct form of congenital incomitant strabismus, the phenotype of CFEOM2 includes subnormal vision consistent with retinal dysfunction. This could be the direct result of PHOX2A mutations or a secondary effect of orbital dysinnervation.

Strabismus which is known as misalignment of eyes, is characterized with stable or intermittent aberrance of eye movements along with reduced binocular vision and it is composed of a heterogeneous group of diseases which are generally concluded with ambliyopia. There are variable classifications of strabismus. We can separate manifest strabismus into two, as concomitant and incomitant. Concomitant strabismus which is often observed in children is a form of strabismus, in which squinting eye accompanies with fixed eye in every view position and the angle of eye shearing is identical in every view position. Whereas, incomitant strabismus is frequently observed in adults, the angle of eye shearing is different in every view position and it is a paralytic form of strabismus which occurs due to the paralysis of one or more of the eye muscles. The genetics of the concomitant strabismus is not precisely enlightened because of its complicated structure. Although, incomitant form of strabismus is observed in lesser extent in the general population; its genetics are enlightened more compared to the concomitant form of strabismus. Mitochondrial cytopathies are composed of a group of diseases that occur as the result of deletion or mutation of maternally transmitted mitochondrial DNA (MtDNA) and this group of disorders causes the disruption of ATP (adenosine triphosphate) production. In the result of mutations that have occurred in the mitochondrial cytopathies; at the first place are organs which OZET Sasilik gozlerde kayma olarak bilinen sabit veya aralikli olarak goz hareketlerinde sapma ve azalmis binokuler gorme ile karakterize genellikle ambliyopi ile sonuclanan heterojen bir grup hastaliktan olusmaktadir. Sasiligin degisik siniflamalari mevcuttur. Manifest sasiliklari; konkomitant ve inkomitant olarak ikiye ayirabiliriz. Konkomitant sasilik; cocuklarda sik gorulen, kayan gozun her bakis pozisyonunda fikse eden goze eslik ettigi ve kayma acisinin her bakis pozisyonunda ayni oldugu bir sasilik formudur. Inkomitant sasilik ise eriskinlerde sik gorulen, kayma acisinin her bakis pozisyonunda farkli oldugu, bir veya birden fazla goz kasinin felcine bagli olarak ortaya cikan (paralitik) bir sasilik formudur. Konkomitant sasiligin genetigi karmasik yapisindan dolayi tam olarak aydinlatilamamistir. Inkomitant form toplumda daha az gorulmesine ragmen, genetigi konkomitant forma gore daha fazla aydinlatilabilmistir. Mitokondriyal sitopatiler; anneden aktarilan mitokondriyal DNA’nin (MtDNA) silinmesi veya mutasyonu sonucu olusan ve adenozin trifosfat (ATP) uretiminin bozulmasina yol acan bir grup hastaliktan olusmaktadir. Mitokondriyal sitopatilerde olusan mutasyonlar sonucunda oncelikle kaslarin yogun oldugu, oksidatif fosforilasyon ihtiyacinin fazla oldugu organlar onemli derecede etkilenmektedir. Goz kapaklarindan ekstraokuler kaslara, retinaya kadar tum gorme sistemi yuksek oksidatif fosforilasyona ihtiyac duymaktadir. 1 Dr. Abdurrahman Yurtarslani Ankara Onkoloji Egitim ve Arastirma Hastanesi, Goz Hastaliklari Bolumu, ANKARA 2 Dr. Abdurrahman Yurtarslani Ankara Onkoloji Egitim ve Arastirma Hastanesi, Tibbi Genetik Bolumu, ANKARA Gelis Tarihi / Received : Kabul Tarihi / Accepted : Iletisim / Corresponding Author : Rahmi DUMAN Dr. Abdurrahman Yurtarslani Ankara Onkoloji Egitim ve Arastirma Hastanesi, Goz Hast. Bol., ANKARA Tel : +90 555 247 35 00 E-posta / E-mail : drrahmi42@yahoo.com 07.12.2013 14.01.2014 DOI ID : 10.5505/TurkHijyen.2014.34635 Turk Hijyen ve Deneysel Biyoloji Dergisi Duman R, Kaymak A, Balci M. Bir halk sagligi problemi olan sasiliklarin mitokondriyal sitopatilerle birlikteligi. Turk Hij Den Biyol Derg, 2014; 71(3): 147-54. Cilt 71  Sayi 3  2014 Turk Hij Den Biyol Derg 148 Gozlerde kayma olarak bilinen sasilik, herhangi bir bakis yonunde iki gozun gorme eksenlerinin paralel olmamasi durumuna denilir. Iki goz arasinda koordinasyon eksikligi sonucu olusan sasilik; sabit veya aralikli olarak goz hareketlerinde sapmaya neden olur. Sonuclari bakimindan yasam kalitesini olumsuz yonde etkileyebilen sasilik heterojen bir grup hastaliktan olusmaktadir. Sasilik gorulme sikligi; beyaz irkta %2-4, Afrika ve Asya’da ise %0,6’dir (1). Amerika ve Avrupa’da ezotropya, Afrika ve Asya’da ekzotropya daha sik gorulmektedir (2). Sasiligin cok cesitli siniflandirmalari mevcuttur. Sasilik, primer olarak karsimiza cikabildigi gibi sendromik formlar olarak da gorulebilmektedir. Sendromik olarak ortaya cikan sasiliklarin kalitim paterni, primer olarak gorulen sasiliklarin kalitim paterninden daha iyi aciklanmistir. Ozellikle mitokondriyal DNA mutasyonlari ve silinmeleri sonucu olusan kronik progressif eksternal oftalmopleji (KPEO) ve Kearns-Sayre Sendromunun (KSS) kalitimi konusunda cok fazla veri elde edilmistir. Mitokondriyal Sitopatiler Ile Iliskili Sasiliklar Mitokondriyal sitopatiler; cocukluk caginda baslayan laktik asidoz, anemi, miyopati, norolojik anormallikler, endokrin bozukluklar, bobrek hastaliklari, sensorinoral isitme bozukluklari ve renal distrofi ile karakterize bir grup hastaliktan olusmaktadir. Iskelet kasi biyopsilerinde gozlenen ragged-red lifler (duzensiz kirmizi) ve anormal mitokondriyal yapi hastaligin onemli patolojik bulgularidir (3). GIRIS MITOKONDRIYAL SITOPATILER VE SASILIK Bu yuzden goz ilk etkilenen organlardan birisidir. Mitokondriyal sitopatilerde en sik gozlenen bulgular ise sasilik ve pitozistir. Mitokondriyal DNA mutasyonlari ve silinmeleri sonucu olusan ozel sasilik tipleri ise kronik progressif eksternal oftalmopleji (KPEO) ve Kearns-Sayre Sendromu (KSS)’dur. Sasilikta genetigin rolunun aydinlatilmasi hastalik patogenezinin daha iyi anlasilmasina ve daha etkin tedavi protokolleri gelistirilmesine basamak olacaktir. Mevcut tedavi yontemleri ile tedavide yetersiz kaldigimiz olgulari daha siki takip etmemizi ve farkli tedavi yontemleri gelistirmemizi saglayacaktir. Bu derlemede; klinikte cok kolay birbirine karisabilecek olan inkomitant sasiliklarin bir bolumunu olusturan mitokondriyal sitopatilerle birlikte gorulen sasiliklarin klinik ve genetik ozelliklerini ortaya koymayi amacladik. Anahtar Kelimeler: Mitokondri, DNA, sasilik, oftalmopleji, eksternal, kronik, progressif contain high proportion of muscle and have excessive oxidative phosphorylation requirement, are affected significantly. All visual system, from eyelids to extraocular muscles and retina, needs excessive oxidative phosphorylation. For this reason, the eye is one of the organs that is affected primarily. Most frequently observed findings in mitochondrial cytopathies are strabismus and ptosis. Specific strabismus types that are formed in the result of mitochondrial DNA mutations and deletions are Chronic Progressive External Ophthalmoplegia (CPEO) and Kearns-Sayre Syndrome (KSS). The enlightening of the role of genetics on strabismus is going to be a step toward better understanding of disease pathogenesis and for creating more effective treatment protocols. Additionally, this will provide us to develop distinct treatment methods; and to follow-up cases more tightly, which are not treated efficiently with existing treatment methods. In this review, we purposed to compile the clinical and genetic features of strabismus that is observed with mitochondrial cytopathies, which constitute the one part of incomitant strabismuses that can be very easily intermingled with each other.

Sixth nerve palsy is a cause of incomitant esotropia that increases in the field of action of the paralytic lateral rectus muscle. Acquired palsies are much more common than congenital, and etiologies include trauma, neoplasm, elevated intracranial pressure, infection, and inflammation, as well as other miscellaneous and idiopathic causes. Due to the high association of sixth nerve palsy with brain tumors in children, neuroimaging is generally indicated. Sixth nerve palsies must be distinguished from entities such as Duane retraction syndrome and Mobius syndrome, both of which possess distinct clinical features that are not present in isolated sixth nerve palsy. Partial or complete recovery of acquired sixth nerve palsies are common, compelling observation until at least 6 months of stable misalignment prior to surgical intervention. Conservative management seeks to avoid amblyopia if the palsy occurs during the period of visual development or to relieve diplopia if it occurs after visual maturation. The goal of surgical management, often utilizing muscle transposition procedures, is to restore binocularity in primary gaze and provide the greatest field of single binocular vision.

Brown syndrome is an incomitant strabismus syndrome characterized by inability of the eye to elevate during adduction. • Primary Brown syndrome is thought to occur due to the inability of the superior oblique tendon to stretch.However, there are many secondary causes of this condition that must be ruled out. • Despite significant misalignment of the eyes during upgaze, patients with Brown syndrome usually do not have decreased vision or diplopia with primary gaze. • Unlike paralytic strabismus, forced duction tests demonstrate restriction and a Parks’ three-step test does not demonstrate a paralytic muscle. Spontaneous resolution is frequent, and surgical management typically is not indicated because of the high incidence of postoperative symptomatic superior oblique palsy.

Comitant strabismus is a common condition affecting infants, children and adults. Its impact on the affected patient may be severe resulting in visual loss, lack of binocularity, diplopia, social stigma and multiple corrective surgeries within the affected individual’s lifespan. It is therefore important that this prevalent disorder should be better understood.We review the current understanding of the demographics and what is known of the etiology, risk factors and genetics of strabismus. We stress the importance of careful clinical assessment in classifying strabismus, and the common pitfalls in the measurement and pre-operative sensory work-up of the strabismic patient. The fact strabismus is comitant does not indicate it is benign: acute onset of comitant esotropia may be a presenting sign of pontine or cerebellar tumor.Lastly, we review the impact of genetics on our understanding of strabismus. While the causes of many types of congenital incomitant strabismus have been elucidated through careful observation and genetic screening, the genetics of comitant strabismus are more complex and multifactorial. Only through careful study and recruitment of large groups of affected individuals and families can we start to answer the question: why is this group of patients pre-disposed to develop strabismus. Doing so will help identify patients at risk, to spare them from the significant morbidity associated with this common disorder.

To report the results of bupivacaine injection into the extraocular muscles to treat horizontal strabismus, both exotropia and esotropia.Bupivacaine, 4.5 ml of a 0.50% solution, was injected into the medial rectus muscle in each of 14 exotropic patients and into the lateral rectus muscle in each of 6 esotropic patients with electromyographic control. The measures of alignment were made before the procedure and 1, 3, 6, and 12 months after injection.Of 20 patients, 15 had improved ocular alignment with the average change of 8.46, 8.2, 8.33 and 9 prism diopters (PD) at 1,3, 6 and 12 months, respectively. Two of 5 (40%) incomitant strabismus patients and 13 of 15 (86.66%) comitant strabismus patients had improvement in ocular alignment. Eleven of 14 exotropic patient and 4 of 6 esotropic patients had improvement in ocular alignment, averaging 9.73, 9.36, 9.54 and 6 PD in the exotropic group and 5, 5, 5, and 10.5 PD in the esotropic group. There was no serious complication from the injections.Bupivacaine injection improved ocular alignment in some patients. Denervated extraocular muscle did not respond well to bupivacaine. Bupivacaine improved ocular alignment equally in esotropic and exotropic patients.

Purpose To describe the effects of extraocular muscle extirpation performed after previous eye muscle surgery in a 20-year-old woman with infantile nystagmus syndrome (INS) for whom we have 19 years of follow-up data. Methods Clinical examinations were performed. Eye movement data analysis was carried out using the eXpanded Nystagmus Acuity Function (NAFX) and longest foveation domain (LFD). Results The patient re-presented to the authors at age 20, 2 years after bilateral anterior myectomy of the horizontal rectus muscles, bilateral anterior nasal transposition of the inferior oblique muscle, and bilateral superior oblique recessions. Evaluation revealed deterioration in nystagmus at lateral gaze angles, new incomitant strabismus with severe loss of convergence, limited ductions, saccadic hypometria, slow saccades, and hypo-accommodation. Also, there was a pre- to post-extirpation minimal change of 21% in her peak NAFX, a 50% decrease in LFD, plus a predominant, asymmetric, multiplanar oscillation. Conclusions It appears that in this patient, horizontal extirpation failed to abolish the nystagmus and caused significant, new, symptomatic deficits interfering with many of the patient's visual functions.

A prospective ophthalmological study was done in 86 out of a total of 100 Swedes with established thalidomide embryopathy. Forty-six (54%) of all examined individuals had eye findings, which made the eye the second most commonly affected organ in thalidomide embryopathy only surpassed by upper limbs (81%). Forty-three patients (50%) had ocular motility defects, mostly incomitant strabismus. Facial palsy and abnormal lacrimation each occurred in 17 (20%) individuals. One patient had coloboma of the uvea and optic disc and another two had coloboma of the optic disc. Infrequent anomalies were microphthalmos, congenital glaucoma, lipodermoid, and large refractive errors. The observed ocular motility defects, facial palsy and abnormal lacrimation occurred with early induced defects in thalidomide embryopathy, but not with isolated late occurring anomalies. This suggests that thalidomide exerts its effects on the development of these structures early in the teratogenic period, probably mainly during the fourth week of development.

An abnormal head posture (AHP), or torticollis, is a common condition in children, with an estimated incidence of 1.3%. This condition is encountered commonly by primary care family pediatricians. AHP can be congenital or ac- quired. The cause of the AHP can be ocular, orthopedic and neurologic. The orthopedic causes of AHP include congenital muscular torticollis due to tightness of the sternocleidomastoid muscle, Klippel- Feil anomaly and brachial plexus injury. Neurologic causes of AHP are mainly related to brain tumors, postinflammatory central nervous system conditions, psy- chomotor delay and focal dystonia. Other less common reasons for AHP are: Sandifer syndrome (hiatal hernia associated with gastro- esophageal reflux) and unilateral hearing loss. Numerous ocular conditions can cause AHP or "ocular torticollis". Among them: superior oblique muscle palsy, lateral rectus muscle palsy, nystagmus, vertically incomitant horizontal strabismus (A or V patterns), Brown's syndrome, Duane's syndrome, refractive errors and DVD. The AHP can take the form of head tilt, face turn, chin up, chin down or combined, depending on the specific etiology. However, there are many variations and the type of the head posture cannot reliably predict the underlying cause. Since the etiology is not always obvious, these patients must be carefully evaluated, and sometimes a multidisciplinary approach is needed, including examinations by ophthalmologist, neurologist and orthopedist. Ocular AHP is usually an attempt to improve visual acuity or binocularity. Some patients adopt the head posture to avoid diplopia caused by incomitant strabismus, those with nystagmus adopt a head position that brings the eyes to the null point (where the oscillations dampen or markedly diminish). Ocular AHP is usually a binocular phenomenon. Rarely, ab- normal head position can be acquired following visual loss in one eye. The majority of these ocular conditions require eye muscle surgery. Different ocular etiologies of AHP require different surgical strategy, for this reason careful etiological diagnosis is important. The purpose of this article is to review the ocular conditions that cause AHP, their relative frequency, indication for sur- gery and the appropriate surgical treatment.

To determine the efficiency of mapping out the field of single binocular vision in patients with incomitant strabismus using a modification of the Lancaster Test (Matta Map).The Matta Map is a simple variant of the Lancaster Screen in which a patient does not use the red-green fusion-dissociating spectacles while tracking a projected target and reporting if it is single or doubled in the nine cardinal positions of gaze. With this tool, we are able to map out the field of single binocular vision. Multiple patients with various types of incomitant strabismus were evaluated. Some patients with stable incomitant strabismus underwent multiple evaluations over time to assess reproducibility of results.The Matta Map appears to be very useful in measuring the field of single binocular vision. The results are reproducible and consistent with the patient's incomitant strabismus and symptoms.The Matta Map is a rapid, quick, inexpensive and reliable method for measuring a patient's field of single binocular vision and to follow a patient's symptoms and their progress over time.

The authors report a case of hydrogel scleral explant (MIRAgel) causing an incomitant strabismus, diplopia, enophthalmos and a dehiscence in the roof of the orbit secondary to pressure-related atrophy due to swelling of the explant occurring 10 years after its placement.

Strabismus may result from abnormal innervation, structure, or function of the extraocular muscles. Abnormalities of the orbital bones or masses within the orbit may also cause strabismus due to indirect effects on the extraocular muscles. This paper reviews some disorders of the orbit that are associated with strabismus, including craniofacial malformations, orbital masses, trauma, and anomalous orbital structures.