Can Ocular Torsion be Measured Using the Slitlamp Biomicroscope?

Kothari, Mihir; G, Venkatesan; Shah, Jugal P; Kothari, Kulin; Nirmalan, Praveen K

doi:10.4103/0301-4738.15284

Cited by 29 publications

(29 citation statements)

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“…Ophthalmoscopy using a quantitative technique for fundus torsion demonstrated 30° right fundus excycloposition and 25° left excycloposition. 9 Routine MRI revealed no lesion along the subarachnoid oculomotor nerve, no evidence of infarction in the midbrain, or any lesion in apical orbital portion of inferior division of the oculomotor nerve. High-resolution surface coil MRI of the orbits demonstrated profound atrophy of the deep portion of the right medial rectus muscle (Figure 3) and a small enhancing lesion (3.3 × 2.8 mm) in the path of the intraorbital motor nerve to the right medial rectus muscle (Figure 4) compatible with schwannoma.…”

Section: Resultsmentioning

confidence: 90%

Isolated schwannoma involving extraocular muscles

Yülek¹,

Demer

2016

Journal of American Association for Pediatric Ophthalmology and

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Background Progressive strabismus initially considered idiopathic may be caused by isolated schwannomas of motor nerves to extraocular muscles, detectable only on careful imaging. This study reviewed clinical experience of a referral practice in identifying schwannomas on magnetic resonance imaging (MRI). Methods We reviewed 647 cases imaged for strabismus to identify presumed cranial nerve schwannomas, identified by gadodiamide-enhanced, high-resolution surface coil orbital MRI and thin-section cranial MRI. Clinical features and management were correlated with MRI. Results Schwannomas were identified as fusiform intraneural enlargements in 8 cases: 1 affecting the trochlear nerve; 2, the abducens nerve; and 5 the oculomotor nerve. Involved muscles were atrophic. Both abducens schwannomas, 1 superior oblique, and 1 oculomotor schwannoma were subarachnoid; 3 were intraorbital, and bilateral oculomotor lesions of 1 case extended from cavernous sinus to orbit. Associated strabismus progressed for 3-17 years. Abducens schwannoma caused esotropia; trochlear schwannoma caused hypertropia and cyclotropia. Intracranial oculomotor schwannoma caused mydriasis and exotropia. Intraorbital schwannoma caused exotropia with or without hypertropia. Since lesion diameters were 3–9 mm, 6 had been previously missed on routine MRI. Conclusions Progressive, acquired strabismus may be caused by isolated cranial nerve schwannomas, representing about 1% of strabismus cases in this study, involving the oculomotor more than abducens nerve. Because most schwannomas are small and deep in the orbit, findings could be readily missed by routine imaging, leading to a possible diagnosis of idiopathic strabismus. Schwannomas should be suspected when extraocular muscles are atrophic, but the causative lesions themselves are identifiable only using targeted, high resolution MRI.

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Section: Resultsmentioning

confidence: 90%

Isolated schwannoma involving extraocular muscles

Yülek¹,

Demer

2016

Journal of American Association for Pediatric Ophthalmology and

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“…Fundus torsion was objectively determined by slitlamp measurement of the fovea to optic disc angle. 10,11 External ocular adnexa were examined to evaluate baggy eye-lids, deep superior sulcus deformity, aponeurotic ptosis, and blepharoplasty scars.…”

Section: Methodsmentioning

confidence: 99%

Sagging Eye Syndrome

Zia¹,

Demer²

2013

JAMA Ophthalmol

154

109

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Importance: Recognition of sagging eye syndrome (SES) as the cause of chronic or acute acquired diplopia may avert neurologic evaluation and imaging in most cases.Objectives: To determine whether SES results from inferior shift of lateral rectus (LR) extraocular muscle (EOM) pulleys and to investigate anatomic correlates of strabismus in SES. Design and Setting:We used magnetic resonance imaging to evaluate rectus EOMs, pulleys, and the LRsuperior rectus (SR) band ligament at an eye institute.Participants: Patients with acquired diplopia suspected of having SES. We studied 56 orbits of 11 men and 17 women (mean [SD] age of 69.4 [11.9] years) clinically diagnosed with SES. Data were obtained from 25 orbits of 14 control participants age-matched to SES and from 52 orbits of 28 younger controls (23 [4.6] years).Main Outcome Measures: Rectus pulley locations compared with age-matched norms and lengths of the LR-SR band ligament and rectus EOMs. Data were correlated with facial features, binocular alignment, and fundus torsion.Results: Patients with SES commonly exhibited blepharoptosis and superior sulcus defect. Significant inferolateral LR pulley displacement was confirmed in SES, but the spectrum of abnormalities was extended to peripheral displacement of all other rectus pulleys and lateral displacement of the inferior rectus pulley, with elongation of rectus EOMs (PϽ .001). Symmetrical LR sag was associated with divergence paralysis esotropia and asymmetrical LR sag greater than 1 mm with cyclovertical strabismus. The LR-SR band was ruptured in 91% of patients with SES.Conclusions and Relevance: Widespread rectus pulley displacement and EOM elongation, associated with LR-SR band rupture, causes acquired vertical and horizontal strabismus. Small-angle esotropia or hypertropia may result from common involutional changes in EOMs and orbital connective tissues that may be suspected from features evident on external examination.

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“…The normal DFA is 5.6°-8°. [2][3][4][5][6][7] The increase of the DFA above the normal values gives an estimate of the magnitude of fundus extorsion. Our study M A N U S C R I P T…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8] In normal subjects, the fovea is in level with the lower fourth of the optic disk. If the eye is extorted, the fovea falls below the level of the optic disk.…”

Section: Accepted Manuscriptmentioning

confidence: 99%