Anterior Segment Ischemia After Strabismus Surgery for IIIrd Nerve Palsy. Tenley Bower, MD, ARCT Michael Flanders, MD
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1 Anterior Segment Ischemia After Strabismus Surgery for IIIrd Nerve Palsy Tenley Bower, MD, ARCT Michael Flanders, MD
2 Outline 1. Bilateral nuclear 3rd nerve palsy + vertical gaze palsy 2. Strabismus Surgery 3. Anterior Segment Ischemia
3 Case History 41 yo F, hx of dizziness x 5 yrs, head CT January 1, 28 CT: basilar artery aneurysm, 15 mm diameter Neurology, Interventional Radiology Informed Consent uncertain benefits + endovascular risks described SAH risk, death
4 Cerebral Angiogram Pre-Embolization Post-Embolization Basilar Artery Aneurysm Basilar Artery Coil Posterior Cerebral Artery Superior Cerebellar Artery Anterior Inferior Cerebellar Artery CN III CN VI Posterior Inferior Cerebellar Artery Vertebral Artery Vertebral Artery Cross Filling
5 Case History Post-op SAME day Hx - drowsiness, oculomotor paresis, bilateral ptosis, paresis of Rt arm Suspect basilar artery thrombosis ~ repeat cerebral angio Angiogram - occlusion of midbrain perforating arteries
6 MRI Thalamus Basilar Artery Aneurysm Post Embolization Pons
7 Case - Neuro Follow-Up July 28 EOM gradually improved, especially left eye Better function of eyelids ou September 28 Left pupil + EOM normal Right eye EOM still problematic
8 April 28, 21 - Ophthalmology c/o diplopia POHx - nil VA - 6/7.5 OD, 6/6 OS Pupils - OD 3 mm, poor reaction; OS 2 mm, normal IOP + anterior segment normal
9 April 28, 21 RXT 7 RHT 3 Bilateral Nuclear 3rd Nerve Palsy (superior division recovery) + Bilateral Vertical Gaze Palsy Saccades
10 CN III CN III Pathway
11 CN III CN III Pathway
12 Bilateral Nuclear IIIrd Palsy Superior Division Recovery Inferior Division Remains RXT 7 RHT 3 Bilateral Vertical Gaze Palsy upils - OD 3 mm, poor reaction OS 2mm, normal reaction Saccades
13 Gaze Palsy rimlf (vertical mvt) PPRF (horizontal mvt)
14 Gaze Palsy Artery of Percheron Thalamus Basilar Artery
15 Plan for Strabismus Treatment RMR resect/rlr recess + RSR recess/rir resect Written consent 1. No binocular vision possible 2. Will definitely see double after 3. Impossible to have full correction of RXT 4. ASI possible - operate on all 4 rectus muscles RXT 7 RHT 3 Saccades
16 Post Op #1 - April 28, 21 RSR recess 8mm + RIR resect 5mm (adjustable) RXT 7 RHT small OD Elevation -2
17 Post-Op #2 - October 2, 21 RMR resect 9.5mm + RLR recess 12mm (adjustable)
18 ASI - Clinical Findings Incidence = < 1/13, Signs: mild, self-limited iritis iris ischemia + atrophy striate keratopathy posterior synechiae cataract phthisis bulbi
19 Post-Op Course VA IOP Cornea AC cells Right Pupil PF gtt Pred po Tobra dex Mydriacyl Phenylep Tropic 21-Oct-1 2/7-1+ DM folds 1+ cells sluggish q2h 8 mg qid bid 5-Nov-1 2/5+ <8 haze 5 o clock occ cells PS inferiorly q2h 3mg D/C D/C bid 21-Jan-11 2/2 1 clear occ cells, 1+ flare atrophy inferonasal tid 3mg D/C April 2/2 12 clear occ pig D/C D/C
20 Iris FA Few days after 2nd strabismus surgery Early - delayed filling inferonasally Late
21 Iris FA 3 months after 2nd strabismus surgery unctate 5 o clock + stromal opacification Early - leakage in inferonasal area Late - leakage
22 Conclusion Embolization treatment can lead to CN palsies Difficult case - large XT, hypertropia + paretic muscles ASI - no proven treatment Usually good prognosis Pre-Op Post-Op #1 Post-Op #2 5 months post 2nd OR
23 References Brooner G, Zarbin MA, Bhagat N. Anterior ischemia after posterior segment surgery. Ophthalmol Clin N Am 24; 17: Fishman PH, Repka MX, Green WR. A primate model of anterior segment ischemia after strabismus surgery. Ophthalmology 199; 97: France TD, Simon JW. Anterior segment ischemia syndrome following muscle surgery: the AAPO&S experience. J Pediatr Ophthalmol and Strabismus 1986; 23: Freedman HL, Waltman DD, Patterson JH. Preservation of Anterior ciliary vessels during strabismus surgery: a nonmicroscopic technique. J of Pediatr Ophthalmol and Strabismus 1992; 29:383. Hayreh SS, Scott WE. Fluorescein iris angiography. Arch Ophthalmol 1978; 96: Johnson MS, Christiansen SP, Rath PP. Anterior ciliary circulation from the horizontal rectus muscles. Strabimsus 29; 17:458. McKeown CA, Lambert HM, Shore JW. Preservation of anterior ciliary vessels during extraocular muscle surgery. Ophthalmology 1989; 96: Murdock TJ, Mills MD. Anterior segment ischemia after strabismus surgery with microvascular dissection. J of AAPOS 2; 4: Olver JM, Lee JP. Recovery of anterior segment circulation after strabismus surgery in adult patients. Ophthalmology 1992; 99: Saunders RA, Bluestein EC, Wilson ME et al. Anterior segment ischemia after strabismus surgery. Surv Ophthalmol 1994; 38: Shah PK, Narendran V, Tawansy KA et al. Intravitreal bevacizmab for post laser anterior segment ischemia in aggressive retinopathy of prematurity. Indian J of Ophthalmol 27;55: Simon JW. Complications of strabismus surgery. Curr Opin in Ophthalmology. 21; 21: Vila-Coro AA. Vascular microdissection in strabismus surgery. Arch Ophthalmol199; 18:
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