Surgical treatment of compensatory head position in congenital nystagmus

High-dose Anderson operation for nystagmus-related anomalous head turn

PURPOSE

To evaluate the effectiveness of a high-dose Anderson procedure (AP) to correct infantile nystagmus-related anomalous head turn (HT).

METHODS

Twenty-nine consecutive orthotropes with infantile nystagmus with and without associated sensory defect received high-dose AP. HT was measured while the patient tried to read letters at best-corrected visual acuity (BCVA) level at 5 m and 0.3 m. BCVA, binocular vision (BV), and alignment (prism and cover test) were measured. High-dose AP with recessions of 9-16 mm was performed. All measures were taken before and 3-6 and ≥ 8 months post surgery. Success was defined by postoperative HT ≤ 10°/HT ≤ 15°.

RESULTS

Medians and ranges (minimum-maximum) were:. Age at surgery was 7 years (4-44). HT at 5 m and HT at 0.3 m were 35° (20-40) and 20° (0-35), respectively. After 4 months (3-6), HT was 10° (- 3-20) and 5° (- 5-20); success rates were 74%/96% and 83%/96%. After 15 months (8-45), HT was 12° (0-20) and 6° (0-15); success rates were 46%/75% and 92%/100%; residual HT > 15° occurred in 5/9 cases with recessions < 13 mm and 1/15 cases with recessions ≥ 13 mm. With recessions ≥ 13 mm, 60% (95% confidence intervals (C.I.), 33-83%) achieved HT ≤ 10° and 93% (95% C.I. 66-99%) achieved HT ≤ 15°. Overcorrection did not occur. Anomalous head posture components in vertical and frontal planes did not improve. Residual motility was 30° (10-45). The mean BCVA improved by only 0.037 logMAR (p = 0.06). BV and ocular alignment were constant, except in 2 patients whose exophoria decompensated.

CONCLUSIONS

Kestenbaum surgery is a common procedure to correct infantile nystagmus-related HT. Anderson surgery is confined to bilateral yoke muscle recession; hence, less invasive but nevertheless comparably effective, high dosage is provided.

Graded Anderson procedure for correcting abnormal head posture in infantile nystagmus

PURPOSE

To describe the long-term results of Anderson procedure, which includes recession of the two extraocular yoke muscles responsible for eccentric eye position and abnormal head posture (AHP) in patients with infantile nystagmus.

METHODS

Retrospective data collection of patients who underwent an Anderson procedure at a single medical center by one surgeon from 2008 to 2016. The main outcome measure was the elimination of AHP following surgery.

RESULTS

Twenty-seven patients (18 males, 9 females) underwent an Anderson procedure during the study period. The average age at surgery was 8.6 ± 7.7 years and mean follow-up was 3.5 ± 2.4 years (range, 6 months-9 years). Before surgery all patients had AHP (17 left and 10 right head turns) greater than 25° (mean 40.1 ± 6.7°) that decreased significantly following surgery (mean 7.2 ± 7.6°, P < 0.001). Surgery resulted in complete elimination of AHP in 14 (52%) patients. In 10 (37%) patients the residual head turn was 15° or lower, and in only 3 (8%) the post-operative AHP was 25° or larger, requiring further surgery. It is important to note that none of the patients developed strabismus or duction limitation following surgery.

CONCLUSIONS

Long-term results following the Anderson procedure show a stable decrease in AHP in patients with infantile nystagmus, often resulting in complete restoration of normal head posture. Involved risks of strabismus and limitation of ocular motility appear to be low.

Long-term results of four horizontal rectus muscle recession in nystagmus treatment

PURPOSE

To report the long-term results of four horizontal rectus muscle recessions that were performed for infantile nystagmus syndrome treatment.

METHODS

In this case series, patients with infantile nystagmus syndrome who had four horizontal muscle recessions previously were recruited and ophthalmological examination and electronystagmography recordings were performed. Objectively, amplitude and frequency of nystagmus were measured from the recordings and the intensity was calculated. Visual acuity, stereopsis, and alignment were evaluated and compared with the preoperative and postoperative values.

RESULTS

The records of the 12 patients who had four horizontal rectus muscle recession surgery were evaluated and six patients (5 male, 1 female) who had regular follow-ups were included in this study. Mean follow-up was 14.17 ± 0.41 years (minimum 14 years, maximum 15 years) and mean age of patients at the last visit was 22 years (20-28 years). On subjective evaluation, two-thirds (4/6) of the patients were satisfied with the surgical results and had the impression that after surgery, nystagmus decreased in intensity and head posture improved. On objective evaluation, visual acuity was found to be the same, however, stereopsis improved (preoperatively and postoperatively median stereopsis was 600 sec arc vs 200 sec arc final). The decrease in nystagmus amplitude and frequency was still maintained.

CONCLUSIONS

Nystagmus surgery on four horizontal rectus muscles has positive effects on binocular function and nystagmus parameters in the long-term follow-up. As we could not treat the primary pathology, the visual acuity was about the same but the decrease in nystagmus amplitude and frequency was still maintained with better stereopsis, and patient satisfaction.

Improvement in visual acuity following surgery for correction of head posture in infantile nystagmus syndrome

PURPOSE

To report the effect of the abnormal head posture (AHP) correcting procedures on the visual acuity improvement in patients with infantile nystagmus syndrome (INS) and the visual acuity improvement outcomes in different AHP correcting surgeries in INS.

METHODS

This was a prospective, non-randomized, interventional study. Twenty-eight patients underwent the Anderson-Kestenbaum procedure or the modified Anderson procedure with or without tenotomy of at least one horizontal recti for correction of AHP. Best-corrected binocular null zone acuity and degree of AHP was recorded preoperatively and compared with those done 1 month postoperatively.

RESULTS

The average null zone logarithm of the minimum angle of resolution acuity was 0.42 preoperatively, which improved significantly to 0.33 postoperatively (P = .002). The AHP ranged from 10° to 40° (mean: 20.89°), which improved significantly to a mean of 3.21° (P = .000). No significant difference (P = .65) was found in the visual acuity improvement among patients who underwent the Anderson-Kestenbaum procedure or the modified Anderson procedure with or without tenotomy. No significant difference in the visual acuity improvement was seen in patients who underwent tenotomy of at least one horizontal rectus muscle along with the modified Anderson procedure compared to those who underwent the modified Anderson procedure alone (P = .28).

CONCLUSION

The procedures used mainly for correction of AHP in INS do yield significant improvement in the visual acuity. This improvement is seen in patients undergoing surgery for both horizontal and vertical AHP.

Secondary or new compensatory head posture after Anderson-Kestenbaum surgery

PURPOSE

To report clinical findings and surgical management of 4 patients with congenital nystagmus who presented with a new or reversal of their original horizontal compensatory head posture (CHP) after Anderson-Kestenbaum (A-K) surgery.

METHOD

Retrospective chart review.

RESULTS

All 4 patients demonstrated a 40°-45° horizontal face turn at the time of their initial surgery and 3 underwent 20% and one 30% augmented A-K surgery to correct the CHP. The new CHP or reversal of the original CHP was observed at a mean of 4 years (range 1-9 years) after the initial surgery. The reversed CHPs measured 20°, 40°, 20°, and 20°, respectively. These new or residual CHPs were surgically managed in 3 patients and an acceptable head position was achieved in all patients.

CONCLUSIONS

This series of patients points out the occurrence of secondary null points and reversed CHP after surgical correction of initial CHP.

Kestenbaum procedure with posterior fixation suture for anomalous head posture in infantile nystagmus

BACKGROUND

The purpose of this study was to report the effect of combining the Kestenbaum procedure with posterior fixation suture for infantile horizontal nystagmus with anomalous head posture (AHP) in children.

METHODS

Nine consecutive patients who underwent combined Kestenbaum procedure plus posterior fixation suture to the recessed muscles at the same time were retrospectively studied. All patients were orthotropic before surgery and were followed for at least 6 months. Pre- and postoperative AHP and binocular corrected visual acuity (BCVA), and ocular alignment were assessed.

RESULTS

Mean age at surgery was 4.8 +/- 1.5 years. The average follow-up was 29.7 months. The average head turn preoperatively was 27.4 degrees and postoperatively 7.2 degrees . The average net change in AHP was 24.8 degrees (P = 0.008). Seven of 9 patients (78%) achieved a residual head turn of 10 degrees or less. The average Log Mar BCVA was 0.33 preoperatively and 0.31 postoperatively (P = 0.68). Only 1 patient needed additional surgery for residual horizontal AHP. No patient developed strabismus.

CONCLUSION

Combined Kestenbaum procedure with posterior fixation suture was an effective and stable procedure in reducing AHP of the range of 20 degrees to 35 degrees in children with infantile nystagmus.

The effect of bilateral horizontal rectus recession on visual acuity, ocular deviation or head posture in patients with nystagmus

PURPOSE

This work was undertaken to evaluate the effect of bilateral horizontal rectus recession on visual acuity, ocular deviation and head posture in patients with nystagmus.

METHODS

Twenty patients underwent recession of 4 horizontal rectus muscles to dampen the nystagmus. At least 2 muscles were recessed posterior to the equator.

RESULTS

Monocular and binocular visual acuity improved from 1 to 3 Snellen lines after the procedure in 13 patients (76.5%). Visual changes in log MAR notations were statistically significant with Wilcoxon analysis in each and both eyes. Preoperative binocular visual acuity was 0.73 +/- 0.26 log MAR that reached to 0.62 +/- 0.32 log MAR after surgery (P = 0.02). The greatest improvement was observed in patients with congenital motor nystagmus. Ten patients had horizontal strabismus in addition to nystagmus before the surgery. One-millimeter additional recession of both medial rectus muscles caused an average reduction of 6 PD in esotropia. Corresponding figures for similar additional recessions of the lateral rectus muscles was 11 PD for correction of exotropia. Abnormal head posture decreased in all the cases and improved completely in most of them.

CONCLUSIONS

Large horizontal rectus recession can improve visual acuity and decrease nystagmus in sensory and motor types. By revision in surgical planning, strabismus and abnormal head posture can also be corrected.

Vertical rectus muscle surgery for nystagmus patients with vertical abnormal head posture

PURPOSE

To characterize the results of vertical rectus muscle recession, or recession and resection surgery for vertical abnormal head posture (VAHP) due to null-point nystagmus.

METHOD

This is a retrospective, noncomparative, consecutive case series of patients who underwent vertical rectus muscle recession alone, recession then resection, or combined recession/resection surgery for VAHP due to null-point nystagmus. The primary outcome measure was the amount of residual VAHP.

RESULTS

Twenty patients with VAHP due to null-point nystagmus were studied. The mean follow-up interval after surgery was 49 months (median: 44 months; range 9 to 124 months). Preoperative VAHP ranged from 10 degrees to 45 degrees, and the total amount of bilateral vertical rectus muscle recession, or recession and resection surgery, ranged from 8.5 to 20.0 mm per eye. After recession alone, 5/11 had residual VAHP < or = 5 degrees. The remaining six underwent subsequent resection or plication for residual VAHP > 10 degrees that resulted in residual VAHP < or = 5 degrees in each case. After combined recession/resection, 6/9 had residual VAHP < or = 5 degrees and the remaining three had VAHP < 10 degrees.

CONCLUSION

Large amounts of vertical rectus muscle surgery are indicated to successfully correct the VAHP associated with nystagmus with a vertical null point. Combined recession/resection of the appropriate vertical rectus muscles, instead of recession alone, appears to be a more effective procedure.

A case of different null zones for distance and near fixation

A compensatory head posture (CHP) is a common clinical feature of congenital motor nystagmus. It is usually caused by an eccentric null zone, which is the eye position where the nystagmus intensity (amplitude x frequency) is least. A patient adopts the posture to maximize the binocular visual acuity. Occasionally, a patient may have more than one null zone, leading to the adoption of different CHPs at various times. A 10-year-old boy with congenital motor nystagmus and orthophoria, and with good corrected vision in both eyes, presented with a face turn that had been noted since infancy. For distance fixation, he consistently adopted a left face turn due to a null zone in right gaze. For near fixation, he adopted a right face turn due to a null zone in left gaze. Eye movement recordings confirmed the different locations of the null zones for distance and near fixation. After a trial of base-out prisms to stimulate convergence, which eliminated his head posture at both positions, he underwent artificial divergence surgery. He has had a satisfactory result for 18 months after surgery with a satisfactory head posture and a well-controlled exophoria. Measures to induce convergence, with prisms and then surgery, can be an effective strategy to correct the head postures caused by two different null zones in a patient with congenital motor nystagmus.

Visual performance after congenital nystagmus surgery using extended hang back recession of the four horizontal rectus muscles

PURPOSE

To evaluate the results of surgical correction of congenital nystagmus based on the use of extensive recessions of the four horizontal rectus muscles. The outcome of this procedure in terms of visual performance of the patients has been analyzed in follow-ups of at least 1 year.

METHODS

Surgery was performed on 42 patients. An extended retroequatorial recession of the four horizontal rectus muscles was performed between 13 and 15 mm from the muscle insertion with hang back sutures in every case. Preoperatively, all cases showed either a horizontal pendular (4 cases) or jerk nystagmus (38 cases).

RESULTS

After surgery, all cases showed full preservation of ductions in all gaze positions. Torticollis decreased in all cases. Binocular best-corrected vision improved in 19 (45.2%) patients and in the remaining 23 (54.8%) it remained unchanged. Consecutive exotropia was observed postoperatively in 7 patients. A second surgical procedure was performed in 9 cases (21.4%) and a botulinum injection in 3 cases (7%). All cases of diplopia resolved. Patient satisfaction was high in 38 cases (96%).

CONCLUSIONS

Extended recession of horizontal rectus muscles using hang back sutures offers a good option for the surgical correction of sensorial and neuromuscular nystagmus, providing improvement in binocular best-corrected vision in 45% of the patients (21.4% more than 0.2 logMar units), a high satisfaction rate, and few associated complications. In patients with low vision this can be considered a success that may improve quality of life.

Surgical treatment in nystagmus

PURPOSE

To evaluate the effect of symmetric recession surgery on all four horizontal rectus muscles in the treatment of patients with congenital motor nystagmus and sensory nystagmus secondary to albinism, dyschromatopsia and degenerative myopia.

METHODS

Prospectively, four patients with a diagnosis of congenital motor nystagmus and eight patients with sensory nystagmus were operated on. The amount of recession was determined according to the ocular alignment of the patients. Electronystagmographic recordings were conducted in every patient pre-operatively and post-operatively, as well as an ophthalmological examination.

RESULTS

Mean age of the patients at the time of the first visit was 6.7 +/- 4.2 years (range 9 months to 14 years) and mean age at the time of operation was 8.3 +/- 2.7 years (range 6-14 years). In 8 cases an equal amount of weakening of the four horizontal recti was done, whereas in 2 cases more recession on the lateral recti due to exotropia and in 2 cases more recession on the medial recti due to esotropia was performed. Mean follow-up time was 15.8 months (min. 6 months, max. 28 months). Improvement in visual function was achieved in 7 patients. Amplitude decreased in 9 patients. One patient had a decrease in visual acuity due to progression of her primary macular degeneration. Improvement in head posture was seen in 3 patients and there was no change in the head posture in 2 patients. One patient acquired head posture after surgery. Restriction of motility was seen in none of the patients after surgery in spite of large amounts of recession. Recession of horizontal recti decreased nystagmus amplitude and frequency in 81.8% of patients. Improvement in visual function, measured as an increase in visual acuity in terms of Snellen lines, was achieved in 63.6% of patients.

CONCLUSION

Symmetric recession of the horizontal rectus muscles is shown to be a successful procedure to perform in nystagmus patients, resulting in an increase in visual acuity and a decrease in nystagmus amplitude and frequency. It is a reliable alternative to the Kestenbaum operation and is easier to perform surgically.

Surgery for vertical head position in null point nystagmus

PURPOSE

We applied the general concepts of Anderson and Kestenbaum to the management of patients with chin up or chin down head posture caused by vertical or horizontal nystagmus.

METHODS

We reviewed retrospective charts of seven patients with vertical plane torticollis who had surgical management of null point nystagmus.

RESULTS

Three patients with chin down head posture underwent successful treatment using large recessions of the superior rectus muscles combined with inferior oblique muscle anterior transposition. The four patients with chin up head posture were more resistant to surgical treatment. Two of the four required multiple surgical procedures for adequate correction, but had residual torticollis.

CONCLUSION

Bilateral superior rectus muscle recession combined with inferior oblique muscle anterior transposition is effective surgical management of vertical plane torticollis with chin down head posture caused by null point nystagmus. Although the treatment of patients with chin up head posture was less successful, surgically induced down-gaze deficits may be necessary to improve outcome.

Improvement of visual acuity after surgery for nystagmus

PURPOSE

The authors compared the preoperative and postoperative binocular visual acuities and eye movement recordings of patients who underwent eye muscle surgery consisting of the Anderson-Kestenbaum procedure or the artificial divergence procedure modeled after Cüppers, or a combination of both procedures, for the treatment of infantile nystagmus with head turn.

METHODS

Binocular visual acuities and eye movement recordings by electro-oculography (EOG) were compared preoperatively with those done within 3 weeks postoperatively. Shifting and broadening of the minimal intensity zone and foveation time and changing of the waveform were measured. The treatment of 6 of 18 patients was based on the artificial divergence principle; for 7 patients, treatment was in accordance with the Anderson-Kestenbaum principle; and 5 patients had combined procedures.

RESULTS

The improvement in binocular visual acuities was two Snellen lines or more in one of six patients in the artificial divergence group and four of five patients in the combined treatment group. The EOG recordings showed shifting of the minimal intensity zone toward the primary position in all three groups. A broadening of the minimal intensity zone occurred mostly in the artificial divergence and combined groups. Increases in foveation time and changes in waveforms from jerk to jerk with foveation were found in three of six patients in the artificial divergence group and in two of five patients in the combined group.

CONCLUSION

With less muscle surgery, the artificial divergence and combined operations gave better vision improvement than the Anderson-Kestenbaum operation.

Improvement of compensatory head postures after strabismus surgery

PURPOSE

To determine the incidence and relative frequencies of orientations of compensatory head postures (CHP) and success in surgically treating the CHP seen in patients with pure lateral rectus paresis (group I), superior oblique paresis (group II), Duane syndrome (group III), Brown syndrome (group IV), and congenital motor nystagmus (group V).

METHODS

The authors retrospectively reviewed all patients assessed and treated between 1985 and 1991 with these five conditions. Frequencies and orientations of the CHP were determined in all patients in each group. The success of surgery in eliminating the CHP in the subgroups of patients who underwent surgery to treat the CHP also was determined.

RESULTS

The frequencies of CHP were 29.0% of 93 group I cases, 71.2% of 139 group II cases, 68.1% of 91 group III cases, 17.4% of 35 group IV cases, and all 23 group V cases, for an overall incidence of 56.7% of 381 patients. For patients who underwent surgery to eliminate a CHP, success rates were 85.7% of 21 group I cases, 75.6% of 41 group II cases, 87.2% of 47 group III cases, 100% of 5 group IV cases, and 78.3% of 23 group V patients, for an overall success rate of 82.5% of 137 surgical cases.

CONCLUSION

Because CHP is seen frequently in strabismus and nystagmus disorders, ocular causes must be ruled out in any case of an anomalous head posture. Appropriately planned surgery for CHP caused by incomitant strabismus or eccentric nystagmus null zones has a high rate of success in eliminating CHP.

A surgical approach for Duane syndrome

Duane retraction syndrome (DRS) represents a spectrum of motility disorders in which the common feature is retraction of the affected eye on attempted adduction. Electrophysiologic and neuropathologic studies have shown that the underlying cause is anomalous innervation of the lateral rectus with the medial rectus and, at times, with vertical muscles in the affected eye. Clinical abnormalities observed in DRS can include any or all of the following: a deviation in the primary position; abnormal head position; severe retraction causing a pseudoptosis; and upshoots and/or downshoots associated with A, V, or X patterns. A surgical approach based on the analysis of these four features is presented, allowing the surgeon to devise an appropriate, individualized plan for a given case which can yield optimal results in one operation.