Wednesday, October 8, 2014

October 2014 Strabismus Rounds

So this is our 2nd strabismus rounds of the year- same rules as last time. Pick a case, devise a rational surgical plan, submit your plan in the comments section, and then go to the wet lab and show me what you can do.

Case 1: This 18 year old girl has had double vision since suffering a head injury in a car accident 6 months ago:

She has an inability to abduct the right eye past midline and has an otherwise normal ocular exam. She measures ET 35 in primary, ET 50+ in right gaze, and ET 10 in left gaze. (Top photo is left gaze, bottom photo is attempted right gaze.)

What is your surgical plan?

Case 2: This 15 year old boy has had double vision since suffering a concussion in a football game last year.

He had a left inferior oblique recession by a trusted colleague 3 months ago, but has persistent diplopia, especially in primary and right gaze. He has LHT 8 in primary, LHT 20 in right, orthotropia in left gaze, and LHT 8 in downgaze. Double Maddox Rod testing shows minimal (2 degrees) of excyclotorsion.

What is your surgical plan? (Hint- let's not mess with the obliques in the wet lab yet.)

Case 3: A 25 year old woman seeks your care for correction of her strabismus. She notes that she tends to adopt a chin-up head position.

You note XT25 in primary, increasing to XT 40 in upgaze, and XT 8 in downgaze. There is no inferior oblique or superior oblique dysfunction, and her ocular exam is normal. Of note, she was diagnosed with plagiocephly as an infant, but is otherwise healthy.

What is your surgical plan?

Thursday, July 31, 2014

August 2014 Strabismus Rounds

This is our first strabismus rounds for the year. I'll present 3 recent cases that have gone to the OR, and your job is to come up with a surgical plan for each and submit it in the comments section. The new twist for this year: you will demonstrate your ability to perform the surgery in the wet lab. So prior to the session, pick a case and a few friends, go to the wet lab, and record your surgical correction with the appropriate model.

Case 1: This is a 10 month old boy who has had crossed eyes since birth.

He cross-fixates, and does not object to occluding either eye. His ocular exam is otherwise normal, and his cycloplegic refraction is +1D in both eyes. His alignment is stable from his initial exam 2 months ago. You estimate he is ET 40 by Krimsky. What is your surgical plan?

Case 2: This is a 12 year old girl who has been concerned about her friends noticing her eye drifting.

You find her acuity to be 20/20 in both eyes without correction. Her X(T) measures 45PD, she becomes tropic spontaneously, and will often remain tropic through a blink. Her stereoacuity has decreased over the past 6 months from 40 sec to 200 sec. What is your surgical plan?

Case 3: This is a 7 year old girl, who had surgery for esotropia when she was 8 months old. For the past year, she has been turning her face to the right, and sometimes adopting a small tilt to the right.

Her acuity is 20/20 in both eyes without correction. You measure LHT 6 in forced primary gaze, LHT 15 in right gaze, Ortho in left gaze and downgaze. Her LHT increases on left head tilt. What is your surgical plan?

Friday, October 11, 2013

October 18 session

We'll be covering the chapters on Vertical and A- and V-patterns strabismus in an interactive session.
The link to the Brainshark is here.
As usual, 1st years review the chapter and lecture and send questions my way- either comment on the blog, or e-mail me. 2nd years should pull a relevant article and circulate it to the group prior to the session. 3rd years prepare a 5 minute teaching session for us.

I'll be doing a traditional lecture/webinar on the chapter on Special Forms of Strabismus. The slides (without audio) are here.

The link to the webinar is here

Monday, September 23, 2013

Exotropia webinar

For those who missed the exotropia talk in the classroom, the recording can be found here.

Friday, September 13, 2013

September 20 lectures

We will be covering Esotropia and Exotropia this week.

Both talks are on Brainshark:



The Exotropia talk has no audio- I will cover it in class as a webinar and add the link afterwards.

The Esotropia talk has audio. In class, we will have an open discussion about the work-up and management of ET:

Each 1st year should review the chapter in BCSC and review the Brainshark presentation. Add any questions or areas that need clarification in the comment section of this blog.

Each 2nd year should pull an article on esotropia, send it to all of us, and prepare a 2-3 minute "digest" of its clinical relevance.

Each 3rd year should create a 3-5 minute teaching session on some aspect of esotropia.

Wednesday, March 27, 2013

4/3/13 Cases

Case 3

36 y/o man with longstanding strabismus, concerned that left eye "goes off" and he has trouble in social situations.
No prior eye surgery or patching. Specs for myopia.


Va cc 20/20 ou

Rotations: Trace limitation to elevation in adduction OD

R gaze: LHT 8    Primary: LHT 12     L gaze: LHT 15

Double Maddox Rod: No torsion ou

Worth 4 dot: Suppresses left eye distance and near

Stereo: Nil

Displays a left head tilt ~5-10 degrees



Q 3.1 What is your working diagnosis? Are there additional tests that may help confirm your diagnosis?

Q3.2 What is your surgical plan?

Case 4

42 y/o woman with 2 day history of left-sided numbness (face, arm, torso, leg) and bilateral dysacusis, presents with "right eye turning in."
MRI shows 1.2 cm ring-enhancing lesion of  the right pons consistent with tumefactive demyelination.
Remote history of subfoveal CNV OD secondary to ocular histoplasmosis, had submacular surgery with no recurrence.


Va cc: 20/400 OD (central scotoma stable), 20/20 OS

Rotations: Severe limitation to abduction OD

R gaze: ET 45     Primary: ET 25     L gaze: ET 4

Ocular exam: Stable 2+ NS, foveal RPE atrophy; optic nerves pink and flat ou with no RAPD

Upper photo: Left gaze; Lower photo: Attempted right gaze   
Representative photo from


Q 4.1 Assuming her alignment is stable in 4-6 mos, what is your surgical plan?

Tuesday, February 19, 2013

2/15/13 Case Summary

We discussed Cases 1 and 2 during a webinar last Friday. The presentation is saved at:
Some of the audio is involved with the formatting and use of smartphones and tablets to answer the questions.

Summary of Case 1:

The patient has a sensory extropia secondary to traumatic optic neuropathy and correction can involve right lateral rectus recession and right medial rectus resection. Patients with one poor-seeing eye usually prefer to have surgery on that eye, and usually that is feasible.

There are some cases where the plan with the higher likelihood of success involves operating on the better seeing eye. In those cases, I try to explain to patient (or parent) how their goals are more likely to be achieved with surgery on the sound eye, and what to expect if surgery is only performed on the unsound eye. If they decide to only operate on the poor eye, then I operate on that eye only.

Summary of Case 2:

An intermittent hypertropia implies an early onset, which can be important when evaluating a patient with a "new" vertical deviation- if they are fusing a hypertropia >5PD, it's probably not an acute process.

The management of 4th nerve palsy with or without inferior oblique overaction has a number of options, determined by assessment of versions, torsion, head osition, and patient age. A general rule of strabismus surgery planning is to operate on the muscles with a field of action on the direction where the deviation is greatest. In this case, the left hypertropia is worse in right gaze, so the options are to work on the vertical recti of the right eye, or the obliques of the left eye.

Left inferior oblique myotomy/recession would correct the inferior oblique overaction and up to 12-15PD of hypertropia. It will have a modest incyclorsion. I've found a myotomy works well in children, but may leave residual deviations in adults. Myotomy is not adjustable; recession can be adjusted.

Left superior oblique tuck will improve the ability to depress in adduction, so can be considered in cases with moderate to severe superior oblique underaction. It will result in a large incyclorotation and may cause a Brown syndrome if the tuck is too tight. A tuck is not easily adjusted.

Left superior oblique Harada-Ito can cause a moderate to large incyclotorsion with minimal effect on vertical alignment. The procedure can be used as a solitary procedure for isolated torsion, or combined with other vertical muscle surgery. The Harada-Ito can be adjusted.

Right inferior rectus recession works well in adults and is easily adjusted. It can result in a moderate incyclotorsion, especially if it is displaced nasally. Inferior rectus recession should be avoided if there is minimal (or no) hypertropia in downgaze, as it may cause the hypertropia to "flip" in downgaze with difficulty reading post-operatively.