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-44- Binocular Vision & Diagnosis and Surgical Treatm ent of Dissociated Horizontal Deviation Strabism us FIRST Quarter of 2011 Strabology Quarterly© S. Gam io, M D Volum e 26 (No.1) A M edical Scientific e-Periodical Pages 43-50 INTRODUCTION Dissociated strabismus represents a challenge for diagnosis and surgical treatment. It is commonly found in patients with early onset strabismus and profound sensorial anomalies. Diagnosis is not easy because the movement is slow and needs a more prolonged occlusion to appear; the amount of deviation is variable, intermittent and depends on attention. Besides, these patients usually show horizontal, vertical and torsional movements when performing the cover test and the amount of deviation is different when fixing with each eye. They also have head tilts and associated oblique muscles dysfunctions in many cases. Therefore, surgical treatment of patients with DVD (Dissociated Vertical Deviation) and DHD (Dissociatd Horizontal Deviation) requires a specific surgical approach. Longterm surgical results and recommendations for these cases remain sparse in literature. The purpose of this article is to report the clinical characteristics and the surgical outcomes of 20 patients with DVD and DHD who underwent surgery between 2000 and 2007 and have a mean of 35 months of postsurgical follow up. PATIENTS AND METHODS Retrospective record review of patients operated on for DVD and DHD between 2000 and 2007. (See Table 1, next page.) The diagnosis of DHD was made according to the detection of a different horizontal deviation when fixing with each eye during cover testing; unrelated to accommodation, muscle weakness or restriction which can induce a primary and secondary deviation. The horizontal deviation cannot be neutralized through the classical prism and alternating cover test. Alternate cover testing must be performed slowly allowing the nonfixing eye time for the slow drift to fully manifest. It is necessary to make the right eye fixate first and neutralize with prism the left eye deviation and then let the left eye fixate and neutralize the right eye deviation. Measuring horizontal and vertical dissociated deviations is complicated because we need to superimpose horizontal and vertical prisms over each eye. In addition, it is necessary to measure DVD and DHD with each eye fixating in all gaze positions (including head tilts) in order to have the necessary panorama to choose the best surgical procedure for each case. The Reversed Fixation Test (RFT) had been performed in 7 patients only before the surgery. During this test, the patient was asked to fixate through the prism that neutralized the deviation of the non-fixing eye and then the occluder was shifted to the fixing eye while being observed for any refixation movement when the cover test was performed. The test is positive when we can observe a refixation movement which can be measured placing prisms in front of this fixing eye. DHD is often observed to be larger with visual inattention than when the prism measurements are made and the eye position under general anesthesia usually shows greater deviation than the measured angle in the awake state. The following data were obtained: 1) age of strabismus onset 2) sex 3) history of
-45- Binocular Vision & Diagnosis and Surgical Treatm ent of Dissociated Horizontal Deviation Strabism us FIRST Quarter of 2011 Strabology Quarterly© S. Gam io, M D Volum e 26 (No.1) A M edical Scientific e-Periodical Pages 43-50 TABLE 1: Preop’ Clinical data of 20 patients with DHD and DVD Legend: Age( in years) VA: Visual Acuity;F:Female M:Male, OD:Right eye OS:Left eye. ET:esotropia,XT:exotropia DVD: Dissociated Vertical Deviation, IOOA:Inferior Oblique Overaction, SOOA: Superior Oblique Overaction. Direct: Direct Tilt I:Inverse Tilt . Bil MR rec: Bilateral Medial rectus Recession, IOAT: Inferior Oblique Anterior Transposition [and recession]
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