Anterior segment ischemia following vertical muscle transposition and botulinum toxin injection

A Rare Case of Anterior Segment Ischemia Following Wright's Modification of the Hummelsheim Procedure for Total Lateral Rectus Muscle Palsy

A 53-year-old woman presented with diplopia and deviation of the left eye for the past 3 years. She had non-resolving isolated left lateral rectus palsy. She underwent a medial rectus recession and Hummelsheim (Wright's modification) procedure in her left eye. Postoperatively, the anterior segment ischemia resolved with steroids. [J Pediatr Ophthalmol Strabismus. 2019;56:e53-e56.].

Quantitative measurement of retinal vascular diameter changes in the early postoperative period after strabismus surgery

PURPOSE

To investigate quantitatively the retinal vascular diameter changes before and after strabismus surgery, analyzing the potential hemodynamic changes that may occur in the retinal circulation.

METHODS

Consecutive patients with horizontal strabismus who underwent strabismus surgery were prospectively enrolled. Color fundus photographs were taken of each eye before and 1 day after surgery. The retinal vessel diameters were measured using computer-assisted quantitative assessment software. Paired-sample t test was used to evaluate the central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), and arteriovenous ratio (AVR) before and 1 day after surgery. We also analyzed those changes in different subgroups according to surgical protocols.

RESULTS

A total of 217 eyes of 148 patients were included. Compared with the data before surgery, the mean CRAE significantly increased 1 day after surgery (P = 0.01), so did the AVR (P = 0.003). There was no significant difference with respect to CRVE (P = 0.43). The CRAE and AVR were not significantly different in the lateral rectus recession group.

CONCLUSIONS

Strabismus surgery on horizontal rectus muscles may change retinal hemodynamics by increasing the central retinal arteriolar diameter during the early postoperative period.

Outcomes After Superior Rectus Transposition and Medial Rectus Recession Versus Vertical Recti Transposition for Sixth Nerve Palsy

PURPOSE

To compare the effectiveness of superior rectus transposition and medial rectus recession (SRT/MRc) vs inferior and superior rectus transposition (VRT) for acquired sixth nerve palsy.

DESIGN

Consecutive, interventional case series.

METHODS

The medical records of a consecutive series of patients with acquired sixth nerve palsy who underwent VRT or SRT/MRc by a single surgeon were reviewed. The preoperative and postoperative findings were compared between the 2 groups.

RESULTS

Eight patients (mean age, 46.8 years) underwent SRT/MRc and 8 patients underwent VRT (mean age, 51.1 years). Lateral fixation was performed on all but 4 patients in the VRT group. Preoperative esotropia in primary position and abduction deficit were similar in both groups (SRT/MRc, 41.9 prism diopter [PD], -4.6; VRT, 55.6 PD, -4.5; P = .195, 1.0). The SRT/MRc group underwent a mean MR recession of 6 (range, 5-7) mm. Four patients in the VRT later underwent MR recession (mean 5.3 mm, range 5-6 mm). In addition, 5 patients in the VRT group had 1 or more botulinum toxin injections in the medial rectus muscle. No additional procedures were performed in the SRT/MR group. Fewer additional procedures were performed with SRT/MR (SRT/MR, 0; VRT, 1.8 ± 1.2; P < .010). At last follow-up, residual esotropia (SRT/MRc, 7.1 PD; VRT, 10.3 PD; P = .442) was similar in both groups, but abduction was better in the SRT/MRc group (SRT/MR, -3.0 ± 0.7; VRT, -3.8 ± 0.4; P = .038). There were no new persistent vertical deviations or torsional diplopia.

CONCLUSIONS

Final outcomes were similar with SRT/MRc vs VRT. However, fewer additional surgical procedures were needed with SRT/MR.

Long-term results of vertical rectus muscle transposition and botulinum toxin for sixth nerve palsy

PURPOSE

To report the long-term outcome of full-tendon vertical rectus muscle transposition combined with chemodenervation of the ipsilateral medial rectus muscle for acquired chronic sixth (abducens) nerve palsy.

METHODS

A retrospective study of all patients treated for severe abduction deficit with transposition plus botulinum toxin over the course of 11 years. Minimum follow-up was 12 months. Main outcome measures were the surgical result and its stability.

RESULTS

A total of 22 patients were included. Mean age at the time of surgery was 41.7 ± 19.1 years (range, 4.5-69). The etiologies for the palsy were head trauma (11), tumor (10), and idiopathic (1). Mean follow-up time was 44.2 ± 37.4 months (range, 12-123). The average distance deviation was 38.1(Δ) ± 11.6(Δ) preoperatively, 4.0(Δ) ± 16.1(Δ) 3 months after the operation (p = 0.0004), and 7.9(Δ) ± 8.8(Δ) at 12 months (p = 0.0003), with no subsequent change. At the final examination, on average 44.2 months after the operation, 13 patients (59%) were within 10(Δ) of alignment, 2 (1%) were overcorrected, and 7 (32%) had vertical deviations. The majority of patients (73%) had no double vision in the primary position. No patient developed anterior segment ischemia.

CONCLUSIONS

Vertical rectus muscle transposition combined with intraoperative botulinum toxin injection into the ipsilateral medial rectus muscle improved alignment in patients with complete chronic sixth nerve palsy. While the effects of treatment may have diminished slightly during the first year after surgery, they remained stable thereafter.

Botulinum-A toxin in the treatment of craniocervical muscle spasms: short- and long-term, local and systemic effects

Botulinum toxin has become the initial treatment of choice for the management of essential blepharospasm, hemifacial spasm and other craniocervical dystonias. Numerous studies have confirmed a 90% to 95% response rate. Although a number of common side effects have been reported, the occurrence and incidence of rare local complications remains poorly understood. More importantly, the acute and chronic distant effects of botulinum toxin have not been clearly elucidated. A better understanding of such effects is essential if clinicians are to appropriately advise patients on the use of this therapeutic modality. This article is based on the Duke University experience in the management of over 500 patients with craniocervical spasm disorders, combined with a review of the published literature. These disorders include essential blepharospasm, oromandibular dystonia, hemifacial spasm, and torticollis. The incidence of side effects following more than 6000 treatments with botulinum toxin is presented. Pertinent research relating to the causes of these complications is also reviewed. The most common complications of treatment with botulinum toxin are related to acute local effects resulting from chemodenervation. The most important clinical effect in this group is weakening of the levator muscle resulting in ptosis, and the corneal consequences of lagophthalmos. The latter includes exposure keratitis, dry eyes, blurred vision, and hypersecretion epiphora. Less common local effects include facial numbness, diplopia, and ectropion. Some distant effects are being observed with increasing frequency. These include pruritus, dysphagia, nausea, and a flu-like syndrome. Most significant, however, are the rare reports of generalized weakness and the documentation of EMG abnormalities distant to the site of toxin injection. This has been seen with injections for both blepharospasm and torticollis. Until further studies on the long-term distant complications of botulinum toxin are available, it is recommended that patients receive as few life-time doses of toxin as possible, consistent with adequate management of their spasms. The practice of reinjecting patients routinely every three months, or at the first return of mild spasms should be discouraged.