Search Results (15)

Background: This study aims to determine the normal values of orbital structures according to sex in healthy adults. Methods: Diameters of extraocular muscles, the width of the optic nerve sheath diameter, the length of the inter-zygomatic line, ocular bulb length, and globe position were measured in the T1-weighed MR (magnetic resonance) images in 204 orbits of 102 individuals. Results: The mean values of the diameters of the extraocular muscles in males and females were as follows: medial rectus, 3.96 ± 0.52 and 3.58 ± 0.53 mm; lateral rectus, 3.47 ± 0.61 and 3.15 ± 0.48 mm; inferior rectus, 4.47 ± 0.53 and 4.07 ± 0.48 mm; superior rectus, 4.44 ± 0.64 and 4.01 ± 0.56 mm; and superior oblique, 3.68 ± 0.49 and 3.45 ± 0.44 mm. The length of the interzygomatic line in males and females were 102.68 ± 3.89 and 96.95 ± 3.4 mm, the ocular bulb length was 23.33 ± 1.32 and 22.83 ± 1.1 mm, the globe position was 7.66 ± 1.33 and 7.3 ± 1.39 mm, and the width of the optic nerve sheath diameter was 4.65 ± 0.62 and 4.28 ± 0.51 mm, respectively. All measurements were significantly greater for males than for females (p < 0.05). Conclusions: We believe that a practical and quantitative method will be provided by this study for the diagnosis and determination of the normative values of orbital structures. Full article

Background: This report aims to supplement the existing knowledge on the inferior oblique muscle. In particular, this study presents detailed anatomical and histological data concerning the muscle’s entry point (or entry zone) of the nerve to the inferior oblique muscle. Particular attention was paid to the topographical relationships of the nerve to the inferior oblique muscle (NTIO), including the location of its entry point to the muscle’s belly and its anatomical variations. Methods: Sixty orbits from cadaveric hemi-heads fixed in 10% formalin were studied. The course of the NTIO was traced along the lateral border of the inferior rectus muscle as far as its entry point to the inferior oblique muscle. Particular attention was paid to the various ways in which the NTIO’s muscular sub-branches penetrated between the fibers of the inferior oblique muscle. Results: Three types of NTIO entries to the inferior oblique muscle’s belly were distinguished. In the most common type (48.3%), the nerve entered the muscle’s inferior (orbital) surface. In the next most common type (36.7%), terminal muscular sub-branches of the NTIO joined the superior (also referred to as ocular or global) surface of the inferior oblique muscle. In the remaining four cases (15%), the terminal sub-branches of the NTIO were divided into two main groups (superior and inferior) that joined both the superior and inferior surfaces of the muscle. Histological examination confirmed that the distal part of the NTIO shows a characteristic arcuate course (angulation) just before reaching the muscle’s belly. The process for splitting and forming separate muscular sub-branches of the NTIO was observed for all the examined histological specimens at the level of the nerve’s angulation. Conclusions: The presented findings enhance the understanding of the anatomical variations and precise distribution of motor sub-branches reaching the inferior oblique muscle, which may deepen anatomical knowledge and potentially enhance the management of ocular motor disorders. Full article

Background/Objectives: Posterior staphyloma (PS) is a hallmark of pathological myopia, corresponding to a circumscribed outpouching of the eyeball with choroidal thinning and inward scleral deformation at its edges. Its pathogenesis is still unclear, thus constituting a research priority as the prevalence of myopia is increasing worldwide. Recently, it has been suggested that the optic nerve sheaths or oblique muscles are potential promoters of PS through the traction or compression effect that they apply to the eye wall. The inferior oblique muscle (IOM) inserts 1–2 mm from the macula. The projection of its insertion is accessible using Optical Coherence Tomography (OCT). Before launching prospective studies, we sought to detect any choroidal thinning (ChT) in the temporal vicinity of the macula and to measure the distance between it and the fovea (FT-distance). Methods: This retrospective cross-sectional pilot study included 120 eyes. Using Spectralis^®-OCT, the area centered by the Bruch’s membrane opening–fovea axis was analyzed for ChT and FT-distance. Results: Of the 112 defined eyes, 70% (78 eyes) had ChT. Pachymetry was significantly thinner (p = 0.018) in eyes with than without ChT. The mean FT-distance was 3601.9 ± 93.6 µm. Conclusions: The location of ChT coincided with the insertion distance of the IOM, suggesting a link between them. The association between the presence of ChT and a thinner pachymetry suggests a reduced scleral resistance, as a thinner pachymetry is related to a thinner sclera. Our results suggest a link between ocular deformation and the IOM, which may be relevant for the pathogenesis of PS, warranting further investigation. Full article

Background: cervicogenic headaches are common and are believed to be the cause of dysfunction in the upper cervical spine. The mobility and the position of the atlas have been identified as a cause of upper cervical dysfunction. The mobility of the atlas is entirely under the control of the suboccipital muscles. The oblique capitis inferior muscle has a rotatory effect on the atlas when contracted. This study evaluated the immediate effects of a dry needling electrical stimulation-induced contraction of the left oblique capitis inferior muscle on the position and mobility of the atlas in the atlantoaxial joint. Methods: thirty-one subjects participated in this within-subject repeated measure study design. Each subject underwent a pre-measures neck flexion rotation test, palpation of the atlas position, and measurement of the length of the right oblique capitis inferior muscle with musculoskeletal ultrasound imaging. The pre-measures were repeated after two five-second tetanic contractions of the oblique capitis inferior muscle. Results: post-intervention analysis revealed significant changes in the length of the right oblique capitis inferior muscle. This length change correlated with the palpated positional default position immediately after the intervention. Conclusions: two five-second tetanic contractions of the left oblique capitis inferior muscle immediately affected the position of the atlas in the atlantoaxial joint. In our subjects, 90% displayed a positional default in the left rotation, and this was correlated with a change in the neck flexion rotation test. This study supports the notion that suboccipital muscle tonicity can result in mobility dysfunction and, thus, conditions such as cervicogenic headaches. Full article

Background: Graves’ ophthalmopathy (GO) is characterized by upper eyelid retraction (UER), the most prevalent clinical sign. We aimed to assess the clinical efficacy of a multimodal combination of steroids, 5-fluorouracil (5-FU), and botulinum neurotoxin A (BoNT-A) injections in managing UER with GO and analyze the clinical factors in relation to the injection response. Methods: A total of 37 eyes from 23 patients were enrolled for UER with GO. At the endocrinology clinic, the patients were referred to the ophthalmology clinic after taking antithyroid medication for an average of 5.76 months (13 patients), while 10 patients were initially diagnosed with GO and referred to the endocrinology clinic for management of the thyroid hormone function. They performed an orbital computed tomography (CT) scan and measured the cross-sectional area of the orbit, orbital fat, and each extra ocular muscle (EOM) except for the inferior oblique muscle 4 mm behind the eyeball. Each of the EOMs and orbital fat were calculated as a ratio to the total orbit area. A total of 0.1 cc of triamcinolone (40 mg/mL), dexamethasone (5 mg/mL), 5-FU, and BoNT-A (2.5 units) was injected transconjunctivally. Medical records were examined and photographs were utilized to assess MRD1, inferior palpebral fissure (IPF), and lid lag during down gaze before and after the injection. The patients were divided into two groups: responders (more than 1 mm decrease in MRD1 after injection) and non-responders. During the follow-up period (11.0 ± 11.6 months), any potential adverse effects were monitored. Results: CAS decreased from 3.0 ± 0.8 to 1.4 ± 0.5 after the injection, and MRD1 decreased from 5.0 ± 0.9 mm to 4.5 ± 1.3 mm. Sixty percent of the patients were responders. Before and after the injection, the difference between IPF and MRD1 in responders was 0.60 ± 1.10 mm and 0.90 ± 0.90 mm, respectively, whereas, in non-responders, it was −0.57 ± 0.88 mm and −0.15 ± 0.75 mm, respectively. In the responders, pre-injection IPF and FT4 were significantly higher (p < 0.05). Responders had a larger EOM cross-sectional area (153.5 ± 18.0 mm²), including a larger lateral rectus muscle cross-sectional area (37.6 ± 9.7 mm²) than non-responders (132.0 ± 27.9 mm²; 29.1 ± 8.1 mm²). In responders, the treatment effect on IPF and MRD1 remained consistent at 1.2 ± 3.4 mm and 1.2 ± 1.6 mm, respectively, during the latest follow-up assessment. Conclusions: The combination injection of corticosteroids, 5-FU, and BoNT-A would be effective, especially, in patients with hyperthyroidism and an elongated IPF. Additionally, an increase in EOM cross-sectional area on CT, up to 150 mm², may serve as an additional positive indicator for the use of multimodal injections in UER with GO. Full article

Strabismus can be caused by abnormal tension of the extraocular muscles (EOMs) attached to the eyeball in superior, inferior, lateral, medial, superior oblique, and inferior oblique positions. Evaluating the tension in each EOM is crucial for surgical planning in strabismus, which is conducted by adjusting the tension on the EOM. The purpose of this study was to develop a compact measuring device to non-invasively evaluate the active EOM tension. The proposed device employed a cotton-tipped medical swab to transfer the EOM tension connected to the force sensor as a non-invasive medium. The tilting angle of the swab and the force of active EOM tension were wirelessly transferred to a laptop computer for recording and real-time displaying of the measured values. The active EOM tensions for the four recti muscles were 101.7 ± 15.0 g (mean ± SD) for the lateral rectus; 88.0 ± 15.4 g for the medial rectus; 61.3 ± 6.8 g for the inferior rectus; and 121.3 ± 38.5 g for the superior rectus. These values were higher than the reported values of 45–60 g measured in previous studies. In the previous studies, however, the EOM was detached from the globe and attached to a strain gauge, and, thus, there were no passive elastic forces from ocular connective tissue, resulting in lower values compared with the current study. The previous methods were also complex and not suitable for clinical measurement. Thus, the proposed method, which is non-invasive and mimics the conventional force generation test with a cotton-tipped swab, could facilitate the evaluation of active EOM tension, both clinically in strabismus management and in research into understanding its pathophysiology. Full article

Temporomandibular disorder (TMD) is an umbrella term including pain problems involving the cranio-cervical region. It has been suggested that patients with TMD also exhibit cervical spine disturbances. Evidence suggests the presence of morphological changes in the deep cervical muscles in individuals with headaches. The objective of this study was to compare the morphology of the suboccipital muscles between women with TMD and healthy controls. An observational, cross-sectional case-control study was conducted. An ultrasound examination of the suboccipital musculature (rectus capitis posterior minor, rectus capitis posterior major, oblique capitis superior, oblique capitis inferior) was conducted in 20 women with myofascial TMD and 20 matched controls. The cross-sectional area (CSA), perimeter, depth, width, and length of each muscle were calculated by a blinded assessor. The results revealed that women with myofascial TMD pain exhibited bilaterally reduced thickness, CSA, and perimeter in all the suboccipital muscles when compared with healthy women. The width and depth of the suboccipital musculature were similar between women with myofascial TMD and pain-free controls. This study found morphological changes in the suboccipital muscles in women with myofascial TMD pain. These changes can be related to muscle atrophy and are similar to those previously found in women with headaches. Future studies are required to investigate the clinical relevance of these findings by determining if the specific treatment of these muscles could help clinically patients with myofascial TMD. Full article

Purpose: To evaluate ocular motility (OM) abnormalities associated with Ehlers-Danlos Syndrome (EDS). Materials and methods: In this cross-sectional observational study, patients with EDS underwent a complete orthoptic examination. The following orthoptic tests were performed: corneal light reflex test, stereoscopic test, cover test, OM assessment, evaluation of eye pain in different gaze positions and red filter test for diplopia. Results: The corneal light reflex test at 33 cm showed an intermittent divergent deviation in 31.7% of patients and an intermittent horizontal deviation associated with a vertical deviation in 4.9% of patients. A manifest strabismus was observed in 2.4% of patients, whereas 2.4% of patients showed a microstrabismus. The corneal light reflex test at 5 m revealed microstrabismus in 9.8% and manifest strabismus in 2.4% of our patients. Moreover, intermittent exotropia was observed in 2.4% of cases. No significant alterations involving the inferior rectus and the superior oblique muscles were observed. Significant associations were observed between medial rectus muscle deficit of both eyes with pain (p = 0.020) and diplopia (p = 0.014). Furthermore, a significant association between lateral rectus muscle alteration of both eyes and pain was observed (p = 0.004). Conclusions: Our results show various OM alterations in patients with EDS, specifically superior and medial rectus muscle hypofunction. A full orthoptic evaluation in these patients is recommendable to detect OM involvement and possible ligamentous laxity changes over time through an accurate OM assessment. Full article

Background: The aim is to evaluate the long-term efficacy of inferior oblique (IO) myectomy combined with Tenon’s capsule closure to prevent muscle reattachment to the sclera. Methods: We retrospectively reviewed the medical records of 18 patients with primary and secondary IO overaction who underwent IO myectomy accompanied by Tenon’s capsule closure. Patients were followed up for at least 1 year after the surgery. The main outcome measures included oblique muscle dysfunction, which was objectively graded through computerized analysis of nine-gaze photographs, and the amount of vertical deviation in the primary position using alternate prism cover testing. Results: After a mean follow up of 2.5 years, the grade of IO overaction decreased from +2.2 ± 1.0 to −0.8 ± 1.0 (p < 0.001). In patients with secondary IO overaction with superior oblique (SO) palsy, SO underaction improved from −2.2 ± 1.5 to −0.2 ± 1.8 (p = 0.006). Successful vertical deviation in the primary position of seven prism diopters or less was achieved in 83.3% of the patients. Underaction of the IO was observed in 11.1% of patients, whereas none of the patients showed antielevation syndrome. Conclusion: IO myectomy combined with Tenon’s capsule closure might be safe and effective for the treatment of primary and secondary IO overaction in the long term. Full article

Background: Manual pressure in the upper cervical spine is used to provoke and reduce the familiar migraine headache. Information is scarce on the segmental levels, myofascial structure provocation, and reduction occurrences. The required dosage (amount of pressure, number of repetitions, and duration) has not been objectified yet. Methods: Prospective observational study. Thirty patients with migraine were examined interictally. Manual pressure was applied at four sites: the posterior arch of C1, the articular pillar of C2, the rectus capitis posterior major muscle, and the obliquus capitis inferior muscle, bilaterally. On sites where the familiar headache was provoked, the pressure was sustained to induce pain reduction (three repetitions). Provocation of familiar headache (yes/no), headache intensity (numerical pain rating scale), time to obtain a reduction of the headache (seconds), and applied pressure (g/cm²) were recorded. Results: Provocation of the familiar headache occurred at the posterior arches C1 in 92%, and at one of the articular pillars of C2 in 65.3% of cases. At one of the rectus capitis major muscles, the familiar headache was provoked in 84.6% of cases; at one of the oblique capitis inferior muscles, the familiar headache was provoked in 76.9% of cases. The applied mean pressure ranged from 0.82 to 1.2 kg/cm². Maintaining the pressure reduced headache pain intensity significantly between the start and end of each of the three consecutive trials (p < 0.04). This reduction occurred faster in the third application than in the first application (p = 0.03). Conclusion: Manual pressure at upper cervical segments provokes familiar referred migraine headaches, with low manual pressure. Maintaining the pressure reduces the referred head pain significantly, indicating modulation of central nociceptive transmission. Full article

Background and objectives: To analyze demographic and clinical features of pattern strabismus patients and assess the relationship among these clinical variables and risk factors. Materials and Methods: Medical records of pattern strabismus patients who had undergone strabismus surgery at our center between 2014 and 2019 were retrospectively reviewed. Data collected included gender, age at onset, age at surgery, refraction, Cobb angle, pre- and post-operative deviations in the primary position, up- and downgaze, angle of ocular torsion, type/amount of pattern, grade of oblique muscle function and presence/grade of binocular function. To verify the clinical significance of the Cobb angle, 666 patients who had undergone surgery within one week after ocular trauma between 2015 and 2021 were enrolled as controls. Results: Of the 8738 patients with horizontal strabismus, 905 (507 males and 398 females) had pattern strabismus, accounting for 10.36%. Among these 905 patients, 313 showed an A-pattern and 592 showed a V-pattern. The predominant subtype was V-exotropia, followed by A-exotropia, V-esotropia and A-esotropia. Over half of these patients (54.6%) manifested an A- or V-pattern in childhood. The overall mean ± SD Cobb angle was 5.03 ± 4.06° and the prevalence of thoracic scoliosis was 12.4%, both of which were higher than that observed in normal controls (4.26 ± 3.36° and 7.8%). Within A-pattern patients, 80.2% had SOOA and 81.5% an intorsion, while in V-pattern patients, 81.5% had IOOA and 73.4% an extorsion. Patients with binocular function showed decreases in all of these percent values. Only 126 (13.9%) had binocular function, while 11.8% of A-pattern and 15.1% of V-pattern patients still maintained binocular function. Pre-operative horizontal deviation was negatively correlated with binocular function (r = −0.223, p < 0.0001), while the grade of oblique muscle overaction was positively correlated with the amount of pattern (r = 0.768, p < 0.0001) and ocular torsion (r = 0.794, p < 0.0001). There were no significant correlations between the Cobb angle and any of the other clinical variables. There were 724 patients (80.0%) who had received an oblique muscle procedure and 181 (20.0%) who received horizontal rectus muscle surgery. The most commonly used procedure consisted of horizontal rectus surgery plus inferior oblique myectomy (n = 293, 32.4%), followed by isolated horizontal rectus surgery (n = 122, 13.4%). Reductions of pattern were 14.67 ± 6.93 PD in response to horizontal rectus surgery and 18.26 ± 7.49 PD following oblique muscle surgery. Post-operative deviations were less in V- versus A-pattern strabismus. Post-operative binocular function was obtained in 276 of these patients (30.5%), which represented a 16.6% increase over that of pre-operative levels. The number of patients with binocular function in V-pattern strabismus was greater than that of A-pattern strabismus (p = 0.048). Conclusions: Of patients receiving horizontal strabismus surgery, 10.36% showed pattern strabismus. In these patients, 54.6% manifested an A- or V-pattern in childhood, and V-exotropia was the most frequent subtype. Pattern strabismus patients showed a high risk for developing scoliosis. Cyclovertical muscle surgery was performed in 724 of these patients (80.0%), and horizontal rectus surgery was effective in correcting relatively small levels of patterns. Binocular function represented an important factor as being involved with affecting the occurrence and development of pattern strabismus. Full article

Background: The aim was to investigate the effect of inferior oblique (IO) operation (IO myectomy or graded recession and anteriorization) for unilateral and bilateral superior oblique muscle palsy (SOP); Methods: A total of 167 eyes undergoing IO surgery by a single surgeon between 2008 and 2015 were retrospectively reviewed. The method for treating symmetric bilateral SOP was bilateral IO myectomy (n = 102) and the method for treating unilateral SOP or non-symmetric bilateral SOP was IO-graded recession and anteriorization (n = 65). Associated clinical results and other factors were analyzed; Results: Head tilt, vertical deviation, IO overaction, SO underaction degree and ocular torsion angle were all clearly changed, but there was no statistically significance between these two procedures. Mean preoperative torsional angle was 15.3 ± 6.4 degree, which decreased to 5.3 ± 2.7 degree after surgery. Preoperative torsional angle, IOOA and SOUA degree were all significantly affected in postoperative torsional angle (p = 0.025, 0.003 and 0.038). Horizontal rectus muscle and IO muscle operation did not interfere with each other’s results (p = 0.98); Conclusions: Symmetric bilateral SOP could be treated with bilateral IO myectomy and IO-graded recession and anteriorization should be reserved for unilateral SOP or non-symmetric bilateral SOP. Full article

Extraocular muscle (EOM) entrapment with resulting reduction in motility and diplopia is a known complication of orbital fractures. Less commonly, transection of the EOMs due to trauma, iatrogenic injury, or intentional myotomy may lead to persistent diplopia. The inferior oblique (IO) is often encountered during orbital surgery along the medial wall and floor, and may be disinserted to aid in visualization. The authors present a case of IO entrapment which occurred during zygomaticomaxillary fracture reduction. Intraoperatively, an IO transection was performed and the muscle was reattached within the orbit. Postoperatively, the patient did not develop diplopia or motility disruption. This technique may provide a useful solution to an unusual problem during orbital fracture repair. Full article

The aim of this article is to investigate a retrocaruncular approach for repairing medial orbital wall fractures. A total of 10 fresh cadaver orbits were dissected to investigate a transconjunctival approach to the orbit posterior to the caruncle. Medical records of consecutive patients with medial orbital wall fractures repaired via a retrocaruncular incision at Wilmer Eye Institute over a 10-year period were retrospectively reviewed. The study was approved by the Johns Hopkins Medical Institution's Institutional Review Board. Feasibility of this approach was clearly demonstrated on all cadavers. Horner muscle was observed to be directly attached to the caruncle and remained undisturbed throughout the retrocaruncular approach. For each of the 174 patients reviewed, this approach allowed successful access to the fracture and proper implant placement. The origin of the inferior oblique muscle was divided in only 19 patients. Sutures were not used for conjunctival incision closure in any patient. For 120 patients who underwent acute repair, the percentage with enophthalmos (≥2 mm) decreased from 34% preoperatively to 4% postoperatively; extraocular motility deficit decreased from 41 to 11%. Postoperative complications included recurrence of the preexisting retrobulbar hemorrhage, conjunctival granuloma, and temporary torsional diplopia, each in one patient. The retrocaruncular transconjunctival incision is an effective and safe approach for repairing medial orbital wall fractures with minimal complications. The retrocaruncular incision offers advantages over dividing the caruncle because Horner muscle is left undisturbed, and the incision heals well without suturing. Full article

The fracture of the medial orbital wall is relatively common in orbital trauma. Titanium mesh is possibly the actual standard material for orbital wall reconstruction. When the floor of the orbit and the medial wall are simultaneously affected, one larger mesh gives better results than two independent meshes that need to be fixated independently. However, large meshes need a wider surgical field. To gain sufficient exposure to the medial and inferior orbital walls simultaneously, we present an approach that combines the transconjunctival and transcaruncular incisions, detaching if needed the inferior oblique muscle and, placing our mesh, repositioning it beside the lacrimal duct. This technique should not entirely displace traditional approaches, but it widens the surgical exposure for middle- and upper-third facial trauma. This alternative has minimum morbidity and can save a great deal of surgery time. Full article