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Answers: 2007 series -  September 11, 2007 Lecture 16 of 52  NEXT»

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This 37-year-old female was referred by her cataract surgeon who wanted to have the eyes aligned before attempting to remove mature cataracts from this patient.  The surgeon felt that with the eyes deviated as they are, cataract surgery would be difficult or even impossible.  This woman reported having very poor vision all of her life, even before the cataracts developed.  She never wore glasses, but said that she could see things reasonably clear only if they were held just a few inches in front of her eyes.  Both eyes are down and there is no abduction.  Actually the eyes are nearly fixed. It is impossible to do a refraction because of the lens opacities.  The woman has very “prominent” eyes and she states that this has been so all of her life.  She is otherwise in good health.  She denies any recent weight loss or rapid heart beat.

1.  The patient is eager to have her eyes aligned so that she can go ahead with the surgery.  What is the first test that you would perform?   
 

c -- axial length measurement with the A or B scan

The easiest test to perform in the usual clinical setting and the one that will give the most information is axial length measurements.  Of course forced ductions will be done eventually, but this will probably take place at the time of surgery.  The history pretty much rules out thyroid disease, but blood testing can be done at some time during the workup.  It is not very likely that this patient has myasthenia.  Results of the axial length measurement revealed globes that are 30 mm in length. (What is the normal axial length?)

 

2.  What test would you do next?  
 

b -- CT scan of the orbits

If you look at the CT images above you will see the huge globes filling the orbits and also that the lateral rectus muscles have been displaced downward as a result of this enlarged globe that has ruptured the superior lateral intermuscular fascia prolapsing the globe and moving the lateral recti down where they act at depressors.

 

3.  The most likely treatment for this condition would be: 
 

c -- eye muscle surgery

This patient will benefit from eye muscle surgery.  The most likely procedure to succeed is a large bimedial rectus recession with repositioning of the lateral recti by repair of the damaged superior temporal fascia.

 


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