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PURPOSE: The aim of this study is to report the results of large bilateral superior rectus hang-back recession in patients with dissociated vertical deviation. MATERIAL AND METHODS: Retrospective analysis of patients with dissociated vertical deviation treated in the Department of Ophthalmology between 2011 and 2013. Our enrolment criteria included vertical strabismus angle over 15Δ and the absence of inferior or superior oblique overaction in patients who underwent bilateral superior rectus recession ranging from 8 mm to 12 mm. The surgical outcomes were evaluated. RESULTS: Nine patients at the age of 14 to 46 years were included in the study. The mean vertical angle of deviation in the non-dominant eye was 22.8Δ ± 5.3Δ. The mean amount of recession was 9.8 ± 1.4 mm. CONCLUSIONS: Large bilateral hang-back recession of the superior rectus muscles effectively reduces the vertical angle in patients with dissociated vertical deviation without concomitant oblique muscle overaction. dissociated vertical deviation (OVO), strabismus surgery, large recession of superior rectus muscles.

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PURPOSE: To present the results of management of patients with persistent diplopia after orbital reconstructive surgery with respect to the type of ocular motility impairment pattern. METHODS: All patients referred during a 2-year period because of persistent diplopia after surgical repair of orbital fracture were categorized according to the degree and pattern of ocular motility impairment on the basis of orthoptic examination 3-4 weeks postoperatively. Patients were followed for a mean period of 10.5 months (range, 6-12 months), during which adequate treatment was implemented. RESULTS: A total of 52 patients were included in the study (45 males; mean age, 41.8 ± 16.6 years). Most could be divided into 1 of 4 groups according to the type of ocular motility impairment. The follow-up orthoptic examination revealed resolution of diplopia in 9 patients (15%) and persistent but unbothersome diplopia in 26 (43.4%). Significant diplopia was treated conservatively in 3 patients (5%) and with strabismus surgery in 14 (23.3%) cases. CONCLUSIONS: The results of this study indicate that in most cases of persistent diplopia after reconstructive surgery for orbital fractures, symptoms resolve over time without treatment; nevertheless, strabismus surgery is unavoidable in some cases.

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BACKGROUND: Eye injuries are one of the most common sequelae of facial trauma. On the other hand extraocular muscle involvement entails the ocular motility disorders and double vision. The aim of this study was to assess the impact of orbital trauma on the social and professional activities of patients. MATERIALS AND METHODS: The material consisted of 44 patients after orbital trauma. The objective assessment of the ocular apparatus, especially eye alignment and subjective complaints was performed. All patients were interviewed with a questionnaire in order to assess the impact of visual disorders on daily, and socio-professional activities. RESULTS: The patients were mostly manual workers, living in urban areas, in whom assaults were the main cause of injury. Most of them showed good visual acuity, but 59% exhibited double vision. The ability to perform the former occupation was retained in 45.5% and 20.5% of workers could not perform the former job. Total or partial inability to work was certified in 23% of subjects. Orbital trauma also affected the functional vision of patients and decreased their quality of life; 30% of patients felt significant limitations in social function and 12% remained dependent on others for their daily activities. CONCLUSIONS: Orbital trauma and resulting double vision is an important factor influencing the professional activity. Double vision limits the ability to return to work, despite the lack of damage to the eyeballs and preserved good visual acuity. Orbital trauma causing diplopia does not significantly affect the social activities of the patients or their ability to drive.

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PURPOSE: Patients with VIth nerve palsy that does not resolve within 6 months should undergo surgery. The most common procedure used in such cases is transposition of a whole or a part of a vertical rectus muscle combined or not with a resection of the lateral rectus muscle. Commonly, a simultaneous recession of medial rectus muscle with or without prior injection of botulinum toxin is performed. The aim of our study was to evaluate the results of vertical rectus transposition performed in patients with abducens nerve palsy. METHODS: Nine cases of abducens nerve palsy ware retrospectively analyzed. All patients underwent full ophthalmic and orthoptic examination before and after surgery. All patients underwent vertical rectus muscle transposition to the lateral rectus insertion in the affected eye. Additional procedures included Jensen procedure, botulinum toxin injection, resection of the lateral rectus, recession of the medial rectus on the same side with or without adjustable sutures, and Foster modification of lateral rectus posterior fixation. RESULTS: In all cases, we found a varying degree of postoperative improvement. There was a significant reduction in the strabismus angle for distance and near, increase in abduction of the affected eye, and broadening of the field of binocular single vision. CONCLUSIONS: The vertical rectus muscle transposition technique is a safe and successful method of treatment in abducens nerve palsy. Its use together with additional procedures and modifications allows one to achieve orthophoria, improvement of abduction, and larger field of binocular single vision.

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PURPOSE: The aim of the study was to evaluate the results of surgical treatment of children with primary exotropia, operated on before 14 years of age. MATERIAL AND METHODS: The study included 62 children with primary, constant and intermittent exotropia operated on before 14 years of age. The patients were divided into two age groups. The first one consisted of children 2 to 6 years old (mean 4.75 +/- 1.12)--12 girls and 8 boys, the second group consisted of children 7 to 14 years old (mean 9.3 +/- 2.1)--30 girls and 12 boys. Follow-up period was 3.5 years in group I and 4.5 years in group II. History, visual acuity and refraction were obtained in all cases. Horizontal and vertical angles for distance and near, before and after the surgery was measured as well. The postoperative horizontal angle drift was estimated in both groups and function of binocular vision assessed, before and after the surgery. RESULTS: In both age groups we found no statistical difference between mean angle values before and few weeks after the surgery. However in long-term results, angle for distance was lower in younger children, especially in those with intermittent strabismus. The postoperative angle drift was lower in younger group with intermittent strabismus comparing to the older group, so they achieved a better final surgical outcome. The functional results in both age groups did not differ significantly. CONCLUSIONS: Early surgery on divergent strabismus makes the prognosis better, especially in intermittent strabismus. Children that are operated on early, seem to have smaller postoperative angle drift.

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PURPOSE: A-V strabismus patterns may occur with or without oblique muscles overaction and thus require different surgical approach. The aim of our study was to evaluate the efficacy of unilateral vs bilateral surgery for A and V pattern strabismus in children with oblique muscles overaction. MATERIAL AND METHODS: A retrospective review of 45 children with oblique muscles overaction was performed. All children underwent unilateral or bilateral oblique weakening procedures over a period of 2 years. The mean reduction of A-V pattern angle was measured in all groups. RESULTS: Among the patients with V pattern, treated with unilateral surgery the mean angle reduction was 11.8delta +/- 6.26delta and among those who underwent bilateral procedure it was 17.06delta +/- 8.46delta. In A pattern group the mean angle reduction were 8.0delta +/- 2.82delta and 15.0delta +/- 8.9delta respectively. CONCLUSIONS: The bilateral oblique weakening procedure is significantly more effective (p < 0.01) in reducing the angle in A-V patterns than the unilateral surgery. It appears that in A pattern with superior oblique overaction the bilateral surgery gives better results than in V pattern with inferior oblique overaction.

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PURPOSE: To analyze the results of strabismus surgery after previous cataract extraction with primary or secondary IOL implantation and to determine predicting factors of squint. MATERIAL AND METHODS: Eight patients with squint deviation after cataract surgery with primary or secondary IOL implantation were enrolled into this study. Each patient had complete ophthalmologic and orthoptic examination. Patients were divided into two groups. Group I consisted of 5 patients with secondary IOL implantation after traumatic cataract surgery, and group II consisted of 3 patients without ocular trauma, with primary IOL implantation. Five patients from both of groups had diplopia after IOL implantation. RESULTS: Strabismus surgery was performed in all cases. Surgery was combined with preoperative botuline toxin injections and Fresnel prism correction. Two patients were treated with adjustable suture technique. Treatment was successful in all cases. Five patients had no diplopia in primary position, two of them had occasional diplopia in secondary positions, while 3 patients with pour visual acuity achieved only esthetic effect. CONCLUSIONS: 1. Strabismus surgery in patients with pseudophakia is a complicated procedure which can optimize visual alignment, improve binocular vision and reduce diplopia. 2. Patients with diplopia or squint after IOL implantation ought to be informed about the possibility of strabismus surgery, both for diplopia and esthetic effect.

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UNLABELLED: Oblique muscles motility disorders may influence the magnitude of dissociated vertical deviation (DVD), resulting in greater vertical deviation in abduction and smaller in adduction. The diagnosis of this pattern of dissociation is essential for the selection of appropriate surgical management. PURPOSE: The aim of this study was to assess optimal diagnostic and treatment procedures in patients with incomitant dissociated vertical deviation, superior oblique overaction and esotropia. PATIENTS AND METHODS: Five patients with the constellation of esotropia, bilateral superior oblique overaction, A-pattern, and incomitant dissociated vertical deviation are presented. In each case the magnitude of vertical deviation was greater in abduction and minimal or absent in adduction. Four patients underwent asymmetric bilateral superior rectus recessions and partial tenotomy of the posterior and middle fibers of superior oblique tendons. In one case additional surgery of horizontal muscles was performed. RESULTS: In all cases the A-pattern, DVD was markedly reduced or eliminated, and comitancy was achieved. CONCLUSION: Recognition of the described pattern is important in selecting appropriate surgical management. Asymmetric bilateral superior rectus recessions and partial tenotomy of the posterior and middle fibers of superior oblique tendons is useful in reducing the A-pattern and incommitancy in DVD.

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PURPOSE: Analysis of effects of non-operative treatment of diplopia complicating cataract surgery with IOL implantation or secondary IOL implantation. MATERIAL AND METHODS: 22 patients with diplopia occurring after cataract surgery with IOL implantation or secondary IOL implantation were enrolled into the study. Only the patients who were not eligible for surgery or declined surgical treatment, were included. Each patient had complete ophthalmic and orthoptic examination with Hess-screen-test and prism alternate cover tests. Predicting factors of persistent diplopia were determined. RESULTS: The therapy consisted of prism correction in 77.3% of patients and prism with botulin toxin injections in 9.1% of patients. In two persons diplopia persisted due to cyclotrophia and decentration of IOL, and these patients were eventually treated surgically. The treatment was succesful in 72.7% of patients in whom single vision was achieved. In 18.2% of patients occasional diplopia was found and in 9.1% the therapy was not effective. Disorders precipitated by prolonged cataract--related occlusion and uncorrected aphakia, disorders resulting from surgical trauma to extraocular muscles (retrobulbar or peribulbar anesthesia) and preexisting complications of ocular alignment, all predict related persistent diplopia after IOL implantation. CONCLUSIONS: (1) Cataract surgery with IOL and secondary IOL implantation should be performed before the loss of binocular function. (2) Retrobulbar and peribulbar anesthesia may cause surgical muscular trauma, therefore topical anesthesia is recomended. (3) Prism correction (with or without botulin toxin injection) is an effective therapy.

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Ophthalmologists specialised in strabology are faced with the dilemma which method of strabismus measurement gives the most reliable results. The correct measurement result is of a primary importance when a squint surgery is to be performed. The aim of this study was to compare two methods of the angle measurement: synoptophore testing and PCT. The study consisted of 200 squint angle measurements including PCT for distance and near as well as objective strabismus angle measurement with synoptophore. One hundred measurements of ET and one hundred measurements of XT were done. Significant differences between results of synoptophore and PCT method were noticed for patients both type of strabismus. Measurement performed with synoptophore shows the increase of convergence in most cases.

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The aim of the study is to evaluate the use of botuline A (BTXA) as a form of treatment for squinting patients with onerous diplopia. Two patients with exotropia and one patient with esotropia had injections of BTX A to the lateral rectus muscles of the affected side. The number of injections ranged from 1 to 2. Two patients went on to have surgery. All patients in our study found that BTX A improved their symptoms of diplopia. We conclude that BTX A has an important role in the treatment of squinting patients with burdensome diplopia.

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PURPOSE: The presentation of complex procedures in preoperative diagnosis, allowing the evaluation of reaction of a patient with bilateral STD syndrome, to a potential change in the long-lasting ocular motility disturbances and corrective head position. MATERIAL AND METHODS: The botuline toxin was injected into the medial rectus muscle of the eye with greater motility disturbance in convergent strabismus. It was discovered during preparation for cataract surgery in a 45 years old female with STD Syndrome I type. Due to reduced visual acuity the diagnosis of binocular vision were performed after bilateral cataract surgery. We were afraid that the fixed sensory status of the patient would change, and therefore we performed botuline injections. Strabismus angle, ocular motility and diplopia were assessed and compared. RESULTS: The reduction of strabismus angle was achieved with no diplopia. The patient no longer needed the corrective head position, with binocular vision present while looking straight ahead. Also, a slight improvement was obtained in the abduction motility of the eye to which botuline toxin was injected. CONCLUSION: Preoperative diagnostic botuline toxin injection into the rectus medial muscle of the eye with greater motility disturbance, gives an effect of strabismus reduction. This allows for further decisions of whether, and what type of surgical treatment should be performed.

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PURPOSE: The aim of this study is to present the results of surgery in intermittent divergent strabismus with adjustable sutures, and to compare them to the results of conventional technique. MATERIAL AND METHODS: The study group consisted of 25 patients operated in our department because of intermittent divergent squint with adjustable sutures--group I and with conventional technique--group II. The age range was from 17 to 46 years in group I and from 14 to 37 years in group II. The results were compared in both of groups. We assessed the possibility of postoperative eye alignment in hypercorrection from +4D to +6D (recession/resection) and from +6D to +8D (bilateral recession). Number of patients without a precise effect was calculated. The eye alignment was changed in the immediate postoperative period. Quantity of postoperative drift in both groups was estimated. RESULTS: The intended eye alignment from +4D to +6D was achieved in 29% and from +6D to +8D in 31% of patients with adjustable sutures (group I). The eye alignment in the group II operated with conventional technique was 21% from +4D to +6D and 19% from +6D to +8D. CONCLUSIONS: The use of adjustable sutures in the intermittent divergent strabismus resulted in more correct alignment and avoidance of diplopia. This method enables also to limit or enlarge extent of the surgery and leads to significant decrease of the need for surgical interventions.

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PURPOSE: To present complete process of pre-operative strabismus diagnosis, which can be used for prediction of post-operative diplopia in adolescents and adults. MATERIAL AND METHODS: The study involved three patients, who were qualified for the surgical treatment of strabismus. Complete pre-operative diagnosis predicting potential post-operative diplopia was performed in all patients. The prismatic test for diplopia, hyperfunctional muscle botuline toxin injection, and prism correction were performed RESULTS: Regarding the results of tests, two patients were qualified for surgical treatment. None of them suffered from diplopia after this treatment. The third patient in pre-operative tests showed unacceptably high risk of intolerable diplopia. CONCLUSIONS: Post-operative diplopia in adolescents and adults represents a serious problem, especially in susceptible patients. Accurate and complete pre-operative diagnosis allows for risk reduction in post-operative diplopia. The predictive test for post-operative diplopia, botuline toxin injection and prism correction in isolation are not always able, to give a reliable indication, as to the sensory status following strabismus surgery. A combination of the three above mentioned techniques give more reliable diagnosis. For patients, who can possibly suffer from post-operative diplopia, the adjustable suture technique should be applied.

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PURPOSE: This report presents two clinical interested cases. The main indication to intervene was diplopia, despite of macula damages and amblyopia. MATERIAL AND METHODS: We describe two clinical interested cases of divergent squint caused by sensory deprivation in course of permanent macula damage. Every patient was observed at least 5 years. We estimated decrease of diplopia and final eye alignment. RESULTS: Both patients did not complain of diplopia, we confirmed very good cosmetic effect and fixed angle of squint. CONCLUSIONS: Diplopia can exist even in cases with squint and macula damages. In spite of this, we can obtain postoperative improvement.

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