Preoperative evaluation and surgical technique of functional and cosmetic aspects in zygomatic complex fracture patients

The zygomatico-maxillary complex functions as the principle buttress of the face and is the cornerstone to an individual’s aesthetic appearance. Its fracture not only creates cosmetic deformities owing to its position and facial contour, but can also cause disruption of ocular and mandibular functions. The aim of this study was to evaluate the quality, efficacy and impact of internal fixation of zygomatic complex fractures on functional and cosmetic outcomes. A prospective study was carried out on 100 patients who were divided according to the classification and the severity of injury. Subjective evaluation was submitted based on the patient’s perception of signs and symptoms in the preoperative and postoperative periods. Intraoperative and postoperative assessment of bone reduction quality was made according to the type of the fracture and related difficulties; also, the difference between these groups was observed as functional and esthetic outcome. To optimize the treatment of zygomatic bone fractures, a pre-designed questionnaire was used for subjective evaluation of symptoms and treatment outcome. In 70% of cases, ophthalmologic consultation was taken and was most common in type VII fractures (100% cases). Neurosensory disturbance was the most common finding (60%), followed by diplopia (56R%), pain upon mouth opening (54%) and malar depression (50%). Out of all possible 400 fracture sites in 100 patients of zygomatic complex fractures, 266 (66.5%) fractures were detected by clinical examination, in contrast to 330 (82.5%) on radiological examination, which were highest at zygomatic-maxillary buttress (93%) followed by infraorbital rim (91%) and almost equal among fronto-zygomatic site (72%) and zygomatic arch (74%). The scores from the questionnaire for annoyance were significantly higher for paraesthesia (23%) than for trismus (10%), pain (8.5%), or deformity (8.25%). Residual deformity and pain significantly influenced the total satisfaction. Conclusively, there are many treatment modalities available for zygomatic complex fractures, and the preferred methods should be selected on the basis of fracture type, fracture severity, pre-operative signs and symptoms. Regarding the requirements of fracture site exposure and actual fixation, one priority should be to minimize postoperative complications, morbidity and residual deformities.

Successful treatment of diplopia with prism improves health-related quality of life

PURPOSE

To report change in strabismus-specific health-related quality of life (HRQOL) following treatment with prism.

DESIGN

Retrospective cross-sectional study.

METHODS

Thirty-four patients with diplopia (median age 63, range 14-84 years) completed the Adult Strabismus-20 questionnaire (100-0, best to worst HRQOL) and a diplopia questionnaire in a clinical practice before prism and in prism correction. Before prism, diplopia was "sometimes" or worse for reading and/or straight-ahead distance. Prism treatment success was defined as diplopia rated "never" or "rarely" on the diplopia questionnaire for reading and straight-ahead distance. Failure was defined as worsening or no change in diplopia. For both successes and failures, mean Adult Strabismus-20 scores were compared before prism and in prism correction. Each of the 4 Adult Strabismus-20 domains (self-perception, interactions, reading function, and general function) was analyzed separately.

RESULTS

Twenty-three of 34 (68%) were successes and 11 (32%) were failures. For successes, reading function improved from 57 ± 27 (SD) before prism to 69 ± 27 in-prism correction (difference 12 ± 20, 95% CI 3.2-20.8, P = .02) and general function improved from 66 ± 25 to 80 ± 18 (difference 14 ± 22, 95% CI 5.0-23.6, P = .003). Self-perception and interaction domains remained unchanged (P > .2). For failures there was no significant change in Adult Strabismus-20 score on any domain (P > .4).

CONCLUSIONS

Successful correction of diplopia with prism is associated with improvement in strabismus-specific HRQOL, specifically reading function and general function.

Improvement in specific function-related quality-of-life concerns after strabismus surgery in nondiplopic adults

BACKGROUND

We have previously reported improvement in psychosocial scores after strabismus surgery on the patient-derived health-related quality of life (HRQOL) Adult Strabismus 20 (AS-20) questionnaire in adults with nondiplopic strabismus. Unexpectedly, we also found improvement in the function domain. The aim of the present study was to identify which specific aspects of function-related quality of life improved postoperatively.

METHODS

We retrospectively identified non diplopic adult patients with a history of childhood onset strabismus who underwent surgery and who had preoperative and 1-year postoperative AS-20 questionnaires (scored from 0 [worst] to 100 [best]). Change in scores for each item was evaluated using signed-rank tests.

RESULTS

A total of 20 patients were included. Of the 10 function-related AS-20 items, 9 showed significant mean improvement postoperatively (improvement ranged from 12.5 to 32.5 points, all P < 0.05). Rasch-derived mean scores improved in both reading function and general function domains (71.0 to 86.5 and 66.4 to 87.5, respectively; both P < 0.0001). Specific areas of function-related benefit were concentration, depth perception, hobbies, strain, reading, stress, and worry.

CONCLUSIONS

We found specific function-related quality of life benefits after strabismus surgery in nondiplopic adult patients, particularly those with childhood onset strabismus.

[Muscle weakness and tolerance of low doses of rocuronium in healthy awake volunteers breathing spontaneously]

OBJECTIVES

To study muscle weakness caused by low doses of rocuronium and rocuronium intolerance in healthy volunteers, with the general aim of producing brief skeletal-muscle relaxation that would have potential applications in clinical situations.

PATIENTS AND METHODS

After receiving authorization from the clinical research ethics committee of our hospital, we set out to study the effects on subjective and objective muscle strength of injecting 3 doses of rocuronium (0.1 mg x kg(-1), 0.05 mg x kg(-2), and 0.075 mg x kg(-1)) in healthy volunteers, each dose on a different day. Objective muscle strength was measured using a hand dynamometer. We also recorded the development of expected adverse effects (diplopia, dysarthria, and dysphagia).

RESULTS

Five volunteers (all authors) were studied. In the first subject, the dose of 0.1 mg x kg(-1) of rocuronium was unsatisfactory because it was too strong, causing extreme skeletal-muscle weakness and discomfort due to diplopia, dysarthria, and dysphagia. The dose of 0.05 mg x kg(-1) was well tolerated but caused no subjective feeling of weakness or any effect measurable on dynamometry. These doses were not administered to the other subjects. In the 4 remaining volunteers, the dose of 0.075 mg x kg(-1) caused a brief feeling of muscle weakness that was considered to be acceptable, though the findings were compromised by 2 technically defective baseline dynamometry readings. The volunteers also reported brief, mild discomfort, principally due to dysphagia.

CONCLUSIONS

Doses of 0.075 mg x kg(-1) of rocuronium in healthy awake subjects breathing spontaneously are acceptably tolerated and cause brief muscle weakness that may be of use in situations that require skeletal muscle relaxation at specific moments.

Development of a quality-of-life questionnaire for adults with strabismus

PURPOSE

We report the development of a patient-derived, health-related quality-of-life (HRQOL) questionnaire for adults with strabismus.

DESIGN

Cross-sectional study.

PARTICIPANTS

Twenty-nine patients with strabismus in a first phase, and 32 patients with strabismus, 18 patients with other eye diseases, and 13 visually normal adults in a second phase.

METHODS

Individual patient interviews generated 181 questionnaire items. For item reduction, we asked 29 patients with strabismus to complete the 181-item questionnaire, analyzed responses, and performed factor analysis. Two prominent factors were identified, and the 10 items with the highest correlation with each factor were selected. The final 20-item questionnaire (10 psychosocial items and 10 function items) was administered to an additional 32 patients with strabismus (22 with diplopia, 10 without diplopia), 13 visually normal adults, and 18 patients with other eye diseases. A 5-point Likert-type scale was used for responses (never = 100, rarely = 75, sometimes = 50, often = 25, and always = 0). Median overall questionnaire scores and psychosocial and function subscale scores, ranging from 0 (worst HRQOL) to 100 (best HRQOL), were compared across groups.

MAIN OUTCOME MEASURES

The HRQOL questionnaire response scores.

RESULTS

Median overall scores were statistically significantly lower (worse quality of life) for patients with strabismus (56) compared with visually normal adults (95; P<0.001) and patients with other eye diseases (86; P<0.001). Median scores on the psychosocial subscale were significantly lower for strabismus patients (69) compared with visually normal adults (99; P<0.001) and patients with other eye diseases (94; P<0.001). For the function subscale, median scores were again significantly lower for strabismus patients (43) compared with visually normal adults (91; P<0.001) and patients with other eye diseases (78; P<0.001).

CONCLUSIONS

We have developed a 20-item, patient-derived, HRQOL questionnaire specific for adults with strabismus, with subscales to assess psychosocial and function concerns. This 20-item, condition-specific questionnaire will be useful for assessing HRQOL in individual strabismus patients and also as an outcome measure for clinical trials.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

The effects of strabismus on quality of life in adults

PURPOSE

As a first step in the development of a health-related quality of life (HRQOL) instrument, we conducted in-depth interviews to identify the specific concerns of adults with strabismus.

DESIGN

Prospective cross-sectional study.

METHODS

Thirty adults with strabismus, 17 with diplopia, and 13 without were recruited. Individual interviews, using 11 open-ended questions, were audiotaped, transcribed, and transcripts reviewed independently by three investigators. Phrases regarding how strabismus affected everyday life were grouped into topic areas and the frequency of each topic analyzed for subjects with and without diplopia.

RESULTS

A total of 1,508 phrases were extracted: 207 (14%) of 1,508 were excluded because they did not pertain to HRQOL. From the remaining 1,301 phrases, 48 topic areas were apparent. For patients with diplopia, the most frequently occurring topics were: nonspecific negative feeling (15/17; 88%) ("really hard"); general disability (15/17; 88%) ("affects everything"); and driving (14/17; 82%). In those without diplopia, the most frequently mentioned topics were appearance to others (12/13; 92%) ("people notice my eyes") followed by problems with eye contact (10/13; 77%) and interpersonal relationships (10/13; 77%). Of the topics that were common to both groups (n = 42), two of the most frequent were driving and nonspecific negative feeling.

CONCLUSIONS

Multiple individual interviews revealed many topics that negatively affect quality of life in patients with strabismus. The frequency and type of concerns confirm the importance of HRQOL assessment as an important aspect of strabismus management.

Ocular psychiatric disorders in maxillofacial injuries. Two case reports and a review of psychogenic ocular symptoms

Ocular signs and symptoms associated with facial trauma can be a manifestation of an underlying psychiatric disorder which may exist prior to the traumatic incident, or even develop as a result of the stressful traumatic experience in a psychologically vulnerable individual. Two such cases are presented. A brief review of psychogenic ocular symptoms as well as suggestions for evaluation and treatment are discussed.

Depth perception during diplopia is direct

Although depth is experienced with targets at large disparities when they are seen as double or diplopic, whether that depth is as direct as with fused targets has been a matter of considerable uncertainty. Researchers have often claimed that judgments of the depth of diplopic targets during simple near/far tasks rely upon indirect associations with eye-muscle proprioception or a copy of the vergence drive signal. We designed a four-alternative task that could not be performed without a direct appreciation of depth. Observers judged the depths of each of two Gabor stereo pairs presented simultaneously. Disparities were always above each observer's measured diplopia threshold. The signs of the disparities were varied independently and observers reported the perceived depth near and far for each target. Our results demonstrate conclusively that depth during diplopia requires neither proprioception nor an efferent copy but is direct.

Consequences of monocular diplopia for the contrast sensitivity function

Though the human eye generally creates a single image on the retina, the literature contains many examples showing perceptual monocular diplopia. Previously, monocular diplopia resulting from astigmatic defocus has been demonstrated to cause a notch (local minimum) in the contrast sensitivity function (CSF). We examine Verhoeff's (1900) model which explains how monocular diplopia can occur through an interaction between defocus and common ocular aberrations. From the measured ocular transverse aberration function and from the measured monocular diplopia of three cyclopleged subjects we predicted multiple notches in the CSF with hyperopic spherical defocus. Monochromatic and polychromatic CSF were measured for vertical gratings with best refraction and with simulated myopia and hyperopia. Multiple notches in CSF were observed experimentally. Notches in the polychromatic CSF were smaller and broader than those found in the monochromatic CSF. Our aberration model was successful in predicting notches in the CSF with hyperopic spherical defocus. The implications for clinical measurement of CSF are discussed.

Slab-off prisms

1. There are three grinding techniques for slab-off prism effects: front surface slab-off; bicentric grinding; and reverse slab-off. 2. The front surface slab-off and bicentric produce base-up prism in the lower section of the lens. Reverse slab-off produces base-down prism in the inferior portion of the lens. 3. The slab-off prism process is used to correct vertical diplopia in the reading position. Use of slab-off prism in glasses is expensive and should only be considered for stable deviations.

[Disturbing physiologic diplopia (author's transl)]

Spontaneously observed physiologic diplopia seems to be a pathologic condition caused by a disturbance of high cerebral functions, especially of attention. In a personally observed case an organic psychosyndrome was present. The aetiology and an effective therapy are still unknown. Further studies of similar cases may promote explanation.