Long-Term Outcome and Recurrence of Abnormal Head Posture after Surgery in Patients with Nystagmus

Hye Jin Seo; Young Woo Suh; Yoon Ae Cho

doi:10.3341/jkos.2015.56.2.263

Journal List > J Korean Ophthalmol Soc > v.56(2) > 1010196

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Seo, Suh, and Cho: Long-Term Outcome and Recurrence of Abnormal Head Posture after Surgery in Patients with Nystagmus

Original Article

J Korean Ophthalmol Soc 2015;56(2):263-269.

Published online: 6 September 2015

DOI: https://doi.org/10.3341/jkos.2015.56.2.263

Long-Term Outcome and Recurrence of Abnormal Head Posture after Surgery in Patients with Nystagmus

Hye Jin Seo, MD¹, Young Woo Suh, MD, PhD¹, Yoon Ae Cho, MD, PhD^2,

¹Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea

²Nune Eye Hospital, Seoul, Korea

Address reprint requests to Yoon Ae Cho, MD, PhD, Nune Eye Hospital, #404 Seolleung-ro, Gangnam-gu, Seoul 135-841, Korea, Tel: 82-1661-1175, Fax: 82-2-2086-7710 E-mail: earth317@yahoo.co.kr

Received 5 July 20145 January 2015 Accepted 27 January 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the long-term outcome and recurrence of abnormal head posture after modified Kestenbaum surgery in patients with nystagmus.

Methods

The medical records of 46 patients who underwent modified Kestenbaum procedure in horizontal recti muscles for nystagmus with abnormal head turn were retrospectively reviewed. We assessed the effect of surgery by comparing pre-operative and postoperative clinical data such as visual acuity (log MAR) and degree of head turn. A reoperation or abnormal head turn of 10° or more at final visit were defined as recurrence. Patients were divided into 2 groups according to the presence of recurrence or reoperation. Clinical factors associated with recurrence or reoperation were compared between the 2 groups.

Results

The mean visual acuity was 0.38 in the better eye and 0.42 in the worse eye before surgery, which improved to 0.15 and 0.21 after surgery (each p < 0.001), with a mean follow-up period of 124 months. The mean degree of head turn was 41.41° pre-operatively and was changed to 2.61° postoperatively (p < 0.001). The recurrence rate was 23.9% and the reoperation rate was 10.9%. Mental retardation, amblyopia, preoperative visual acuity, degree of head turn, and presence of strabismus were not as-sociated with recurrence or reoperation. The mean age at first surgery was significantly lower in the reoperation group (p = 0.009). The mean visual acuity in the better eye at postoperative 6 months and in better and worse eyes at postoperative 1 year was significantly worse in the reoperation group (p = 0.034, 0.012 and 0.009, respectively).

Conclusions

The visual acuity and head turn was improved after modified Kestenbaum surgery in patients with nystagmus and abnormal head posture. The reoperation rates were associated with earlier age of first operation and worse postoperative visual acuity. However, further prospective studies are necessary to clarify these factors.

Keywords: Abnormal head posture, Head turn, Kestenbaum, Nystagmus, Recurrence

References

1. Park HJ, Chang BL. Congenital nystagmus. J Korean Ophthalmol Soc. 1990; 31:343–50.

2. KSPOS. Current Concepts in Strabismus. 3rd ed.Goyang, Gyeonggido: Naewae Haksool;2013. p. 394–411.

3. Bae JH, Song JK. Surgical treatment of congenital nystagmus. J Korean Ophthalmol Soc. 1987; 28:811–6.

4. Lee JB, Lee IS, Kim HS, Han SH. The effect of modified kestenbum procedure (6-7-6-7mm) for abonormal heal position in in-fantile nystagmus. J Korean Ophthalmol Soc. 1997; 38:2207–13.

5. Kestenbaum A. [New operation for nystagmus]. Bull Soc Ophtalmol Fr. 1953; 6:599–602.

6. Anderson JR. Causes and treatment of congenital eccentric nystagmus. Br J Ophthalmol. 1953; 37:267–81.

7. Parks MM. Symposium: nystagmus. Congenital nystagmus surgery. Am Orthopt J. 1973; 23:35–9.

8. Calhoun JH, Harley RD. Surgery for abnormal head position in congenital nystagmus. Trans Am Ophthalmol Soc. 1973; 71:70–83. discussion 84-7.

9. Nelson LB, Ervin-Mulvey LD, Calhoun JH. . Surgical man-agement for abnormal head position in nystagmus: the augmented modified Kestenbaum procedure. Br J Ophthalmol. 1984; 68:796–800.

10. Mitchell PR, Wheeler MB, Parks MM. Kestenbaum surgical procedure for torticollis secondary to congenital nystagmus. J Pediatr Ophthalmol Strabismus. 1987; 24:87–93.

11. Taylor JN. Surgery for horizontal nystagmus-Anderson-Kestenbaum operation. Aust J Ophthalmol. 1973; 1:114–6.

12. Lee IS, Lee JB, Kim HS. . Modified Kestenbaum surgery for correction of abnormal head posture in infantile nystagmus: outcome in 63 patients with graded augmentaton. Binocul Vis Strabismus Q. 2000; 15:53–8.

13. Cho YA, Chung HR. Surgical treatment of asymmetric gaze nystagmus. J Korean Ophthalmol Soc. 1986; 27:191–8.

14. Chang YH, Chang JH, Han SH, Lee JB. Outcome study of two standard and graduated augmented modified Kestenbaum surgery protocols for abnormal head postures in infantile nystagmus. Binocul Vis Strabismus Q. 2007; 22:235–41.

15. Dell'Osso LF, Flynn JT. Congenital nystagmus surgery. A quantitative evaluation of the effects. Arch Ophthalmol. 1979; 97:462–9.

Figure 1.

Change in the visual acuity after the modified Kestenbaum surgery in the patients with nystagmus and abnor-mal head turn.

Figure 2.

Change in the degree of head turn after the modified Kestenbaum surgery in the patients with nystagmus and abnormal head turn.

Table 1.

Mean amount of resection and recession of horizontal muscles according to the degree of left head turn in various modified Kestenbaum procedures

Head turn (°)	RLR recession (mm)	RMR resection (mm)	LMR recession (mm)	LLR resection (mm)
20	6.0	5.0	4.0	7.5
25-30	7.5	5.5	5.6	7.5
35-50	8.5	6.6	6.4	8.8
55-60	9.3	7.3	7.0	9.8

RLR = right lateral rectus; RMR = right medial rectus; LMR = left medial rectus; LLR = left lateral rectus.

Table 2.

Preoperative types of strabismus and head posture in individual patients

No.	Preoperative types of strabismus	Preoperative head posture
1	40 PD left esotropia	Right head turning 70°
2	25 PD esotropia	Right head turning 25°
3	14 PD left esotropia	Left head turning 15°
4	14 PD right esotropia	Left head turning 40°

PD = prism diopters.

Table 3.

Change in the visual acuity after the modified Kestenbaum surgery in the patients with nystagmus and abnormal head turn

Eye	Preoperative VA (log MAR)	Postoperative VA (log MAR)
Eye	Preoperative VA (log MAR)	6 months	p-value^∗	1 year	p-value^∗	5 years	p-value^∗	Final visit	p-value^∗
Better eye	0.38	0.29	<0.001	0.27	<0.001	0.19	<0.001	0.15	<0.001
Worse eye	0.42	0.37	0.003	0.34	0.002	0.23	0.001	0.21	<0.001
Both eyes	0.32	0.24	<0.001	0.24	<0.001	0.15	<0.001	0.13	<0.001

VA = visual acuity.

^∗ Wilcoxon signed rank test, which compared preoperative and postoperative visual acuity.

Table 4.

Change in the degree of head turn after the modified Kestenbaum surgery in the patients with nystagmus and abnormal head turn

	Preoperative	Postoperative ^****
	Preoperative	6 months	p-value^∗	1 year	p-value^∗	5 years	p-value^∗	Final visit	p-value^∗
Head turn (°)	41.41	4.34	<0.001	4.51	<0.001	5.44	<0.001	2.61	<0.001

^∗ Wilcoxon signed rank test, which compared preoperative and postoperative degree of head turn.

Table 5.

Comparison of clinical characteristics between groups with and without the recurrence of head turn after the modified Kestenbaum surgery in the patients with nystagmus and abnormal head turn

	Recurrence group	Success group	p-value
Number of patients (%)	11 of 46 (23.9)	34 of 46 (73.9)
Presence of strabismus (%)^†	0 (0)	4 (11.8)	0.558
Presence of amblyopia (%)	8 (72.7)	25 (78.1)	1.000
Presence of mental retardation (%)	0 (0)	2 (5.9)	1.000
Age at the first surgery (years)^∗	5.9 ± 2.86	7.9 ± 4.14	0.174
Preop. head turn (°)^∗	42.27 ± 6.47	41.47 ± 11.11	0.893
Preop. VA (log MAR)^∗
Better eye	0.40 ± 0.31	0.38 ± 0.28	0.874
Worse eye	0.41 ± 0.29	0.42 ± 0.30	0.858
Both eyes	0.35 ± 0.28	0.31 ± 0.26	0.728
Postop. 6 momths head turn (°)^∗	7.60 ± 13.50	3.33 ± 4.36	0.361
Postop. 6 months VA (log MAR)^∗
Better eye	0.36 ± 0.24	0.25 ± 0.22	0.219
Worse eye	0.39 ± 0.25	0.34 ± 0.26	0.552
Both eyes	0.31 ± 0.26	0.21 ± 0.21	0.375
Postop. 1 year head turn (°)^∗	9.50 ± 14.18	3.00 ± 4.01	0.192
Postop. 1 year VA (log MAR)^∗
Better eye	0.33 ± 0.20	0.23 ± 0.22	0.111
Worse eye	0.44 ± 0.30	0.29 ± 0.24	0.115
Both eyes	0.27 ± 0.20	0.22 ± 0.24	0.341
Final head turn (°)^∗	7.73 ± 8.77	1.03 ± 1.87	0.012
Final VA (log MAR)^∗
Better eye	0.14 ± 0.15	0.15 ± 0.22	0.562
Worse eye	0.24 ± 0.23	0.20 ± 0.23	0.503
Both eyes	0.11 ± 0.16	0.13 ± 0.21	0.902

Values are presented as mean ±SD unless otherwise indicated. VA = visual acuity.

^∗ Mann-Whitney test

^† Chai-square test.

Table 6.

Comparison of clinical characteristics between groups with and without reoperation after the modified Kestenbaum surgery in the patients with nystagmus and abnormal head turn

	Reoperation group	Non-reoperation group	p-value
Number of patients (%)	5 of 46 (10.9)	40 of 46 (87.0)
Presence of strabismus (%)^†	0 (0)	4 (10.0)	1.000
Presence of amblyopia (%)	2 (40.0)	31 (77.5)	0.109
Presence of mental retardation (%)	0 (0)	2 (5)	1.000
Age at the first surgery (years)^∗	4.0 ± 1.55	7.8 ± 3.93	0.009
Preop. head turn (°)^∗	42.00 ± 6.71	41.63 ± 10.52	1.000
Preop. VA (log MAR)^∗
Better eye	0.47 ± 0.21	0.37 ± 0.29	0.378
Worse eye	0.47 ± 0.21	0.41 ± 0.30	0.554
Both eyes	0.47 ± 0.21	0.31 ± 0.27	0.182
Postop. 6 months head turn (°)^∗	15.00 ± 20.41	3.23 ± 4.09	0.121
Postop. 6 months VA (log MAR)^∗
Better eye	0.54 ± 0.15	0.25 ± 0.22	0.034
Worse eye	0.54 ± 0.15	0.34 ± 0.26	0.106
Both eyes	0.46 ± 0.28	0.21 ± 0.21	0.097
Postop. 1 year head turn (°)^∗	17.50 ± 20.21	3.18 ± 4.23	0.090
Postop. 1 year VA (log MAR)^∗
Better eye	0.49 ± 0.06	0.23 ± 0.21	0.012
Worse eye	0.69 ± 0.23	0.28 ± 0.24	0.008
Both eyes	0.44 ± 0.11	0.21 ± 0.23	0.028
Final head turn (°)^∗	0.00 ± 0.00	3.00 ± 5.58	0.106
Final VA (log MAR)^∗
Better eye	0.17 ± 0.22	0.14 ± 0.20	0.940
Worse eye	0.31 ± 0.33	0.20 ± 0.21	0.551
Both eyes	0.15 ± 0.23	0.13 ± 0.20	0.751

Values are presented as mean ± SD unless otherwise indicated. VA = visual acuity.

^∗ Mann-Whitney test

^† Chai-square test.

TOOLS

Similar articles