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-50- 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 with DHD and they consider that bilateral surgery is needed only occasionally for bilateral DHD when alternate fixation is present and when XT and DHD coexist. All our patients had DHD coexisting with DVD; 13 cases received bilateral surgery to treat both conditions, 5 underwent surgery just for the DVD because the horizontal deviation was small, and 2 patients received surgery for the horizontal deviation alone, despite the fact that they also had DVD. CONCLUSIONS DVD and DHD usually coexist. When the vertical or the horizontal deviation manifests frequently, a surgical plan to fix the drift of the eyes is needed. Bilateral surgery is proposed in order to address both conditions simultaneously. To obtain long-term control of the deviation in patients with dissociated strabismus is difficult; a successful outcome in the post-operative period does not guarantee final binocular alignment. In patients treated for dissociated strabismus we will always detect residual deviation when performing the cover test. The DVD never disappears completely, and the dissociated behavior in DHD persists when testing under a slow cover test as well. REFERENCES 1.Raab EL. Dissociative vertical deviation in combined motor anomalies. In: Proc Second Congress of the International Strabismological Association Marseille. Diffusion Generalle de Libraire 1974;149-151. 2. Kaar DJ ,Scott WE, Reese PD. Dissociated horizontal deviation:a case presentation. Paper presented at the AAPOS meeting Hawaii 1986. 3. Zubcov AA;Reinecke RD, Calhoun JH. Asymmetric horizontal tropias, DVD, and manifest latent nystagmus:An explanation of dissociated horizontal deviations. J Pediatr Ophthalmol Strabismus 1990;27:59-64. 4. Romero-Apis D, Castellanos-Bracamontes A. Dissociated horizontal deviation: clinical findings and surgical results in 20 patients. Binocular Vision Quarterly 1992;7:135-8. 5. Enke ES, Stewart SA, Scott WE, Wheeler DT. The prevalence of dissociated horizontal deviations in congenital esotropia. Am Orthoptic J 1994;44:109-11. 6. Wheeler DT, Enke ES, Scott WE. Surgical management of dissociated horizontal deviation associated with congenital esotropia. Binocul Vis Strabismus Q 1996;11:256-62. 7. Mattheus,S, Kommerell G;Reversed Fixation test as a means to differentiate between dissociated and nondissociated strabismus. Strabismus 1996;4:3-9. 8. Gräf M Dissociated horizontal deviations (DHD):Terminology, diagnosis and etiology th In:Faber TJ, ed. Trans of the 26 Meeting of the European Strabismological Association, Florence, June 2001, Tokyo, Japan:Swets & Zeitinger;2001, p 105-8. 9. Gräf M Dissociated horizontal deviations (DHD):Nomenclature and etiology: An orienting attempt in terminological confusion. Klin Monatsbl Augenheilkd 2001,218:401-5. 10. Brodsky MC, Gräf MH, Kommerell G. The reversed fixation test: a diagnostic test for d issociated horizontal devia tio n .A r c h Ophthalmol. 2005 Aug;123(8):1083-7. 11. Brodsky MC, Fray KJ. Dissociated horizontal deviation after surgery for infantile esotropia: clinical characteristics and proposed p a t h o p h ys i o l o g ic m e c h a n i s m s . A r c h Ophthalmol. 2007 Dec;125(12):1683-92. 12. Wilson ME, McClatchey SK. Dissociated horizontal deviation. J Pediatr Ophthalmol Strabismus 1991;28:90-5. 13. Wilson ME, Hutchinson AK, Saunders R, Outcomes from surgical treatment for dissociated horizontal deviation. AAPOS 2000; 4:94-101.
-51- Binocular Vision & Inferior Oblique Muscle Palsy with ‘Paradoxical’ V-Pattern Strabismus FIRST Quarter of 2011 Strabology Quarterly© E. Khawam, MD and D. Fahed, MD Volume 26 (No.1) A Medical Scientific e-Periodical Pages 51-60 Review and Case Report Inferior Oblique Muscle Palsy with “Paradoxical” V-Pattern Strabismus EDWARD KHAWAM, M.D. and DAOUD FAHED, M.D. from the Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon ABSTRACT: Background and Purpose: A- and V-patterns are commonly encountered with cyclovertical muscle palsies. Inferior oblique (IO) muscle palsy produces an A- pattern caused mainly by the decreasing abducting action of the IO in upgaze and an increasing abducting action of the superior oblique in downgaze. V-pattern association with an IO palsy has not been, to our knowledge, reported before. The purpose of our paper is to report a patient with IO palsy and a paradoxical V- pattern and explain the proposed pathophysiology behind the V-pattern. Case Report: We report a 67 year-old female with a 3 year history of diplopia. She met the Bielschowsky/Parks’ three-step test to identify an IO muscle palsy, and she showed all the usual criteria of an IO muscle palsy except for a paradoxical V-pattern. Conclusion: Many forces affect patterns in cyclovertical muscle palsies. A V- pattern in IO palsy can be explained by the spread of comitance resulting in inhibitional innervational pseudo-palsy of the superior rectus muscle resulting in V-exotropia or in inhibitional palsy of the contralateral superior oblique muscle resulting in V-esotropia. Received for consideration November 30,2010; accepted for publication January 07, 2011. Corresponding author: Edward Khawam, MD Pediatric Ophthalmology and Adult Strabismus American University of Beirut –Medical Center PO Box: 11-0236 Beirut, Lebanon Fax: +961-1-370837 Email: Edward_khawam@hotmail.com
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