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Pseudostrabismus Caused by Abnormal Configuration of the Upper Eyelid Margins
PSEUDOSTRABISMUS CAUSED BY ABNORMAL CONFIGURATION O F T H E U P P E R EYELID MARGINS MARTIN J. URIST,
M.D.
Chicago, Illinois
Pseudostrabismus is an apparent deviation of the eyes. It is commonly seen in children with epicanthus or with a large positive or negative angle kappa. Less commonly it oc curs with an abnormal interpupillary dis tance and with abnormalities in the shape of the skull or thickness of the skin surround ing the orbits.1"3 When the eyes are in primary position the apex of the concavity of the upper eyelid margin lies directly over the apex of the up per corneal limbus and pupillary center. I have seen five patients who had a displace ment of the apex of the upper eyelid margin concavity laterally from the center of the pu pil. All of them complained that their eyes were crossed and they did indeed appear to be esotropic although strabismus was absent on examination with the cover test. To my knowledge, this type of strabismus has not been previously reported. CASE DESCRIPTIONS
Cases 1 and 2 were children who were brought to the clinic because their parents thought their eyes looked crossed. On exami nation, strabismus was absent although esotropia appeared to be present because the apices of the concavities of the upper eyelid margins were displaced laterally from the centers of their pupils (Fig. 1). Cases 3, 4, and 5 were patients with exotropias who, after surgery, complained their eyes looked as though they were turned in. On examination in each case, strabismus was absent but pseudostrabismus was present From the Motility Clinic of the Illinois Eye and Ear Infirmary, University of Illinois College of Medicine, Chicago, Illinois. Reprint requests to Martin J. Urist, M.D., Illi nois Eye and Ear Infirmary, 1853 West Taylor Street, Chicago, Illinois 60612.
Fig. 1 (Urist). Two patients who complained of esotropia, but who had no strabismus. Top: In Case 1, the apices of the upper eyelid margin con cavities are displaced about 6 mm laterally from the centers of the pupils in both eyes. Bottom: In Case 2, the apex of the right upper eyelid margin concavity is displaced about 5 mm laterally and in the left eye, it is displaced about 7 mm laterally from the pupillary centers.
due to a lateral displacement of the apices of their upper eyelid margin concavities. One of these patients (Case 3) was a 39year-old woman with a constant alternating exotropia present since she was nine years of age (Fig. 2 ) . Following two operations in which the total muscle surgery done ( 12 mm lateral rectus muscle recession and 16 mm medial rectus muscle resection in the right eye, and an 8 mm lateral rectus muscle reces sion and 8 mm medial rectus muscle resec tion in the left), there was no deviation for distance, near, or up and down, yet the eyes appeared to be esotropic. Another (Case 4) was a 30-year-old man with a congenital right angle exotropia (Fig. 3). Following surgery in which bilateral 8
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Fig. 2 (Urist). Case 3. Top: Preoperatively, this patient had 45 degrees of exotropia in each eye. In the left eye, the apex of the concavity of the upper eyelid margin is about 5 mm lateral to the pupillary center, and in the right eye, the apex of the concavity of the upper eye lid margin is about 4 mm lateral to the pupillary center. Bottom: Postoperative orthotropia. In the right eye the apex of the concavity of the upper eyelid margin is about 6 mm lateral to the pupillary center. In the left eye, the apex of the con cavity of the upper eyelid margin is about 7 mm lateral to the pupillary center. mm lateral and medial muscle resections were done, there was no deviation but the eyes appeared to be esotropic. Examina tion of the preoperative pictures revealed a bilateral displacement of the apices of the concavities of the upper eyelid margins lat erally from the pupillary centers. In Case 5, this 10-year-old girl with an in
termittent exotropia (Fig. 4) had had a 12 mm recession of the left lateral rectus muscle. Following this surgery, even though she had a residual small intermittent exotropia, she appeared to be esotropic. Examination of the preoperative pictures showed that there was a lateral displacement of the apices of the concavities of the upper eyelid margins.
Fig. 3 (Urist). Case 4. Top: Preoperatively, this patient had 45 degrees of exotropia in each eye. In the left eye the apex of the concavity of the upper eyelid margin is about 5 mm lateral to the pupillary center. In the right eye the apex of the concavity of the upper eyelid margin is about 4 mm lateral to the pupillary center. Bottom: Postoperative orthotropia. In the right eye, the apex of the concavity of the upper eyelid margin is about 8 mm lateral to the center of the pupil. In the left eye, the apex of the con cavity of the upper eyelid margin is about 7 mm lateral to the center of the pupil.
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Fig. 4 (Urist). Case 5. Top : Preoperatively, this patient had 45 degrees of exotropia in each eye. In the left eye the apex of the concavity of the upper eyelid margin is about 6 mm lateral to the pupillary center. In the right eye, the apex of the concavity of the upper eyelid margin is about 4 mm lateral to the pupil lary center. Bottom: Postoperative orthotropia. The apex of the concavity of the upper eyelid margin in each eye is about 6 mm lateral to its pupillary center. COMMENT
All three patients with exotropia who had no strabismus postoperatively complained that their eyes were turned in after surgery. It is a good practice to examine preopera tively the relation of the apices of the upper eyelid margin concavities to the pupillary centers. Where displacement of the apices occurs the patient can be forewarned of the possibility of obtaining a poor cosmetic re sult postoperatively when the eyes have been straightened. SUMMARY
Pseudostrabismus which was due to a lat eral displacement of the apex of the concav ity of the upper eyelid margin from the cen
ter of the pupil was seen in five patients. All five· complained that their eyes turned in, al though they were found to have no deviation on examination. By examining the relation ship between the apex of the upper eyelid margin concavity and the center of the pupil before surgery, the surgeon can prepare himself and his patient for the possibility of a postoperative pseudostrabismus. REFERENCES
1. Hugonnier, R., and Hugonnier, S. C. : Strabis mus, Heterophoria, Oculomotor Paralysis. St. Louis, C. V. Mosby, 1969, p. 329. 2. Lyle, T. K., and Bridgeman, G. J. : Squint. London, Bailliere, Tindall and Cox, 1969, p. 124. 3. Duke-Elder, S. : Textbook of Ophthalmology, vol. 4. St. Louis, C. V. Mosby, 1949, p. 3814.
M.D.
Chicago, Illinois
Pseudostrabismus is an apparent deviation of the eyes. It is commonly seen in children with epicanthus or with a large positive or negative angle kappa. Less commonly it oc curs with an abnormal interpupillary dis tance and with abnormalities in the shape of the skull or thickness of the skin surround ing the orbits.1"3 When the eyes are in primary position the apex of the concavity of the upper eyelid margin lies directly over the apex of the up per corneal limbus and pupillary center. I have seen five patients who had a displace ment of the apex of the upper eyelid margin concavity laterally from the center of the pu pil. All of them complained that their eyes were crossed and they did indeed appear to be esotropic although strabismus was absent on examination with the cover test. To my knowledge, this type of strabismus has not been previously reported. CASE DESCRIPTIONS
Cases 1 and 2 were children who were brought to the clinic because their parents thought their eyes looked crossed. On exami nation, strabismus was absent although esotropia appeared to be present because the apices of the concavities of the upper eyelid margins were displaced laterally from the centers of their pupils (Fig. 1). Cases 3, 4, and 5 were patients with exotropias who, after surgery, complained their eyes looked as though they were turned in. On examination in each case, strabismus was absent but pseudostrabismus was present From the Motility Clinic of the Illinois Eye and Ear Infirmary, University of Illinois College of Medicine, Chicago, Illinois. Reprint requests to Martin J. Urist, M.D., Illi nois Eye and Ear Infirmary, 1853 West Taylor Street, Chicago, Illinois 60612.
Fig. 1 (Urist). Two patients who complained of esotropia, but who had no strabismus. Top: In Case 1, the apices of the upper eyelid margin con cavities are displaced about 6 mm laterally from the centers of the pupils in both eyes. Bottom: In Case 2, the apex of the right upper eyelid margin concavity is displaced about 5 mm laterally and in the left eye, it is displaced about 7 mm laterally from the pupillary centers.
due to a lateral displacement of the apices of their upper eyelid margin concavities. One of these patients (Case 3) was a 39year-old woman with a constant alternating exotropia present since she was nine years of age (Fig. 2 ) . Following two operations in which the total muscle surgery done ( 12 mm lateral rectus muscle recession and 16 mm medial rectus muscle resection in the right eye, and an 8 mm lateral rectus muscle reces sion and 8 mm medial rectus muscle resec tion in the left), there was no deviation for distance, near, or up and down, yet the eyes appeared to be esotropic. Another (Case 4) was a 30-year-old man with a congenital right angle exotropia (Fig. 3). Following surgery in which bilateral 8
455
456
AMERICAN JOURNAL OF OPHTHALMOLOGY
MARCH, 1973
Fig. 2 (Urist). Case 3. Top: Preoperatively, this patient had 45 degrees of exotropia in each eye. In the left eye, the apex of the concavity of the upper eyelid margin is about 5 mm lateral to the pupillary center, and in the right eye, the apex of the concavity of the upper eye lid margin is about 4 mm lateral to the pupillary center. Bottom: Postoperative orthotropia. In the right eye the apex of the concavity of the upper eyelid margin is about 6 mm lateral to the pupillary center. In the left eye, the apex of the con cavity of the upper eyelid margin is about 7 mm lateral to the pupillary center. mm lateral and medial muscle resections were done, there was no deviation but the eyes appeared to be esotropic. Examina tion of the preoperative pictures revealed a bilateral displacement of the apices of the concavities of the upper eyelid margins lat erally from the pupillary centers. In Case 5, this 10-year-old girl with an in
termittent exotropia (Fig. 4) had had a 12 mm recession of the left lateral rectus muscle. Following this surgery, even though she had a residual small intermittent exotropia, she appeared to be esotropic. Examination of the preoperative pictures showed that there was a lateral displacement of the apices of the concavities of the upper eyelid margins.
Fig. 3 (Urist). Case 4. Top: Preoperatively, this patient had 45 degrees of exotropia in each eye. In the left eye the apex of the concavity of the upper eyelid margin is about 5 mm lateral to the pupillary center. In the right eye the apex of the concavity of the upper eyelid margin is about 4 mm lateral to the pupillary center. Bottom: Postoperative orthotropia. In the right eye, the apex of the concavity of the upper eyelid margin is about 8 mm lateral to the center of the pupil. In the left eye, the apex of the con cavity of the upper eyelid margin is about 7 mm lateral to the center of the pupil.
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Fig. 4 (Urist). Case 5. Top : Preoperatively, this patient had 45 degrees of exotropia in each eye. In the left eye the apex of the concavity of the upper eyelid margin is about 6 mm lateral to the pupillary center. In the right eye, the apex of the concavity of the upper eyelid margin is about 4 mm lateral to the pupil lary center. Bottom: Postoperative orthotropia. The apex of the concavity of the upper eyelid margin in each eye is about 6 mm lateral to its pupillary center. COMMENT
All three patients with exotropia who had no strabismus postoperatively complained that their eyes were turned in after surgery. It is a good practice to examine preopera tively the relation of the apices of the upper eyelid margin concavities to the pupillary centers. Where displacement of the apices occurs the patient can be forewarned of the possibility of obtaining a poor cosmetic re sult postoperatively when the eyes have been straightened. SUMMARY
Pseudostrabismus which was due to a lat eral displacement of the apex of the concav ity of the upper eyelid margin from the cen
ter of the pupil was seen in five patients. All five· complained that their eyes turned in, al though they were found to have no deviation on examination. By examining the relation ship between the apex of the upper eyelid margin concavity and the center of the pupil before surgery, the surgeon can prepare himself and his patient for the possibility of a postoperative pseudostrabismus. REFERENCES
1. Hugonnier, R., and Hugonnier, S. C. : Strabis mus, Heterophoria, Oculomotor Paralysis. St. Louis, C. V. Mosby, 1969, p. 329. 2. Lyle, T. K., and Bridgeman, G. J. : Squint. London, Bailliere, Tindall and Cox, 1969, p. 124. 3. Duke-Elder, S. : Textbook of Ophthalmology, vol. 4. St. Louis, C. V. Mosby, 1949, p. 3814.