HORROR FUSIONIS A REPORT OF FIVE PATIENTS
Leave a message about ‘ Strabismus ‘. For those who were concerned about developing diplopia yet were still interested in pursuing the option of strabismus surgery, a prolonged prism trial was carried out. Two patients reported the diplopia becoming less noticeable over the years. Only 4 patients in this series underwent surgery for DVD. Following cycloplegia, these findings resolved over several weeks, suggesting that this rare complications is self-limited and associated with a good prognosis for recovery. A month later the right medial rectus was advanced, which left her with a 3-PD esotropia at 6. For example, a patient with a PD exotropia might experience diplopia when 20 PD or more of base-in prism was introduced. The diagnostic use of prisms prior to surgery may identify some patients who have little or no risk of postoperative diplopia, as well as a group of patients with a small but definite risk of intractable postoperative diplopia.
During the time span covered by this study, I cared for an additional 19 patients who would have met the inclusion criteria but decided not to undergo surgery owing to the risk of postoperative diplopia. Because of its poor prognosis , the diplopia associated with horror fusionis must be differentiated from other types of diplopia occurring in adults with childhood onset strabismus. Patients who did not see double during preoperative testing with prisms never developed diplopia after surgery. Am J Optom Physiol Opt. Similarly, patients were considered to have a known consecutive esotropia if medical records confirmed that diagnosis; patients were labeled as having probable consecutive esotropia if their history suggested the diagnosis but it could not be confirmed with medical records. Patients were assumed to have probable congenital esotropia if their history suggested an onset prior to 1 year of age and if either dissociated vertical divergence DVD or optokinetic asymmetry was present but confirmatory medical records were not available. The amount of movement they perceived was not commensurate with the amount of prism introduced.
If patients do see double with preoperative testing including a prolonged trial with Fresnel prismsthere is only a small chance of persistent postoperative diplopia. An additional 3 patients who were visually mature but younger than 18 patents had temporary intractable diplopia that lasted up to 1 year after surgery. This was accomplished by placing the Fresnel prism over the habitually deviating eye uorror placing more prisms over the deviating eye if the size of the deviation cusionis bilateral Fresnel prisms.
This study provides useful risk stratification guidelines that can be easily adhered to by any physician without requiring sophisticated testing modalities. This constellation of findings suggests that surgical manipulation of the intact sclera produced a limited effusion involving the supraciliary space. Another patient with an asymmetrical dissociated vertical deviation could ignore the second image by fixating with the eye with the smaller deviation.
Another patient with an asymmetrical dissociated vertical deviation could ignore the second image by fixating with the eye with the smaller deviation. Much less commonly, adults with a constant strabismic deviation but no preoperative diplopia may experience diplopia after surgery despite successful realignment of the eyes to the desired position whatever that position may be for the particular patient.
Then, at age 23 years, she underwent a right inferior rectus recession and a small re-recession of the right medial rectus muscle to treat patiwnts residual esotropia and left hypertropia. Sign in to make a comment Sign in to fusinois personal account. Two cases are described. Create a free personal account to download free patirnts PDFs, sign up for alerts, customize your interests, and more.
Of the patients who had diplopia with preoperative prism testing, 40 experienced temporary postoperative diplopia, and 3 additional patients experienced persistent diplopia following surgery. Similarly, the concept of a “response shift” as an alternative to a truly anomalous correspondence of the retinal elements, developed by Boeder, 1617 may be more appropriately descriptive of this phenomenon.
Several other interesting observations were made in this series of patients, who tended to describe the quality of their diplopia during the office prism testing in 1 of 3 manners.
Get PDF – Horror fusionis: a report of five patients
We recommended optometric vision therapy VT to improve sensorimotor fusion before any further surgery. Most decided to undergo surgery despite that risk. At age 14 years, she underwent further surgery to treat a left hypertropia.
It does not appear that duration of the deviation had a substantial influence on the development of postoperative diplopia. Forced generation testing confirmed weakness of the right inferior rectus muscle that was not reversed by intravenous edrophonium infusion.
Symptoms and signs on presentation and the subsequent course are described in detail in 10 patients. One patient presented with an esotropiaone with an exotropiaand two with hypertropia. Sign in to save your search Sign in to your personal account. Kushner 35 Estimated H-index: Although the exact onset time of the strabismus cannot be determined with certainty for the patients in this series, all of them had strabismus dating back to childhood.
The outcome determination date was approximately 6 weeks after surgery for patients who did not develop postoperative diplopia. However, the use of prisms to simulate a change in alignment is not the same as performing surgery to effect that change. It also included patients in whom postoperative diplopia was related to unsatisfactory ocular alignment after surgery. One was a year-old man with probable congenital esotropia. Cases reported ” Strabismus “.
Nevertheless, the instantaneous adaptation exhibited by patients in this series speaks for a remarkable fluidity in most patients’ ARC. Occasionally, co-management involving both optometry and ophthalmology is needed to optimize treatment outcome for the strabismic patient.
Many patients reported that diplopia would appear during preoperative office testing when only a fraction of the deviation was corrected with prisms. This condition may be similar to Central Fusion Disruption.
Of these patients, were women and were men. In this latter situation, the use of prisms to simulate the desired outcome or further surgery to accomplish the desired ocular alignment will eliminate the diplopia; in the former, the diplopia cannot be eliminated. Theoretically, they can undergo a reoperation to re-create their initial preoperative deviation, which might eliminate the diplopia. Patients who reported only momentary diplopia lasting several seconds—with shift of gaze direction, with fatigue, or on first arising—were considered not to have postoperative diplopia.
After surgery she immediately developed a consecutive exotropia with underaction of the right medial rectus muscle and had constant diplopia.
Horror fusionis: a report of five patients
Of these patients, 8 reported that the diplopia disappeared after several days to 2 weeks of using the prism. The preoperative use of prisms can identify patients who have little cause for concern about postoperative diplopia and other patients who have a small but definite risk.
Graded occlusion was attempted with one patient but was not tolerated. However, many patients exhibited a moderate difference between the amount of prism needed to induce diplopia and the lesser amount at which the diplopia disappeared. The diagnostic use of prisms prior to surgery may identify some patients who have little vive no risk of postoperative diplopia, as well as a group of patients with a small but definite risk of intractable postoperative diplopia.
J Pediatr Ophthalmol Strabismus. In conclusion, most adult patients without diplopia who have constant strabismus will not develop intractable diplopia after strabismus surgery if the eyes are successfully aligned.
Also, when attempts were made to move the second image with prisms, the patients had a hard time perceiving the movement of the image and gave inconsistent descriptions of what they were observing. See More About Ophthalmology Surgery.
In addition, because these patients typically have poor motor fusion, prisms often are useful adjuncts to surgery.