Tuesday, February 12, 2013

2/15/13 Cases

Here are two cases that we will be discussing during a webinar session 2/15/13. Both cases have had surgery for their strabismus. Your assignment is to review the clinical history and images, develop a surgical plan, and post your plan and reasoning in the comments section. You don't need to worry about specific surgical dosages, but should indicate which muscle you plan to work on, and whether you will weaken, strengthen, transpose, or otherwise modify the muscle.

I will moderate the comments and "publish" them after our session with a summary of our discussion. Please separate your comments into Case 1 and Case 2.

Case 1:
5y/o boy, history of shaken baby syndrome and optic atrophy OD>OS.
Va 20/200 OD, 20/40 OS. + RAPD OD
20ft: XT 40
13in: XT 35
Strongly prefers fixing with OS. Full versions. Mom wants his right eye to be straight before he enters kindergarten.

Representative image from healthinset.com


Q1.1 What is your surgical plan?

 Case 2:

7y/o girl brought in by mother because "eyes look funny". No prior injuries or surgery. Mom notes that patient has always tilted her head to the right.
Va 20/20 OU
Rotations: 2-3+ LIOOA
Primary: LH(T) 12
R gaze: LHT 15; L gaze: LHT 4
Down: LHT 6

L gaze
Q2.1 What measurements would you expect on head tilt to the right and left?
Q2.2 What would you expect with double Maddox rod testing?
Q2.3 What is your surgical plan?


  1. Q2.1: LHT>12 on head tilt to the left, <12 on head tilt to the right.
    Q2.2: Extorsion of the left eye
    Q2.3: left inferior oblique weakening

  2. Q1.1 After refractive correction and patching, bilateral lateral rectus recessions, or right lateral rectus recession and right medial rectus resection.

  3. Case 1: Sensory XT 2/2 ON atrophy 2/2 shaken baby syndrome. Would like to know if any improvement in VA with lenses. Surgery likely right lateral rectus recession and right medial rectus resection.

  4. Case 2: Would expect the left hypertropia to increase with left head tilt and to be minimal in right head tilt. Extorsion. Plan surgery for left inferior oblique myectomy

  5. Case 1:

    Q1.1: This is difficult surgically because the patient has no (or extremely little) ability to fuse the two eyes. So any surgical intervention in my opinion is likely to result in recurrence. If surgery is undertaken, I would only operate on OD, and would try a recess LR - resect MR.

    Case 2

    Q2.1 - Measurements depend on whether there is concurrent CN IV palsy or not. If there is CN IV palsy concurrently in this case, then one would expect increase LHT with L head tilt.

    Q2.2 - Excyclotorison

    Q2.3 - Inferior oblique myectomy