Dr. Goldchmit is a Doctor of Medicine at the São Paulo Federal University at São Paulo, Brazil. He is also a Professor and Chief of the Strabismus Section at the CEMA Hospital at São Paulo, Brazil in addition to being an Executive-Director at the Strabos Institute in São Paulo, Brazil Mauro Goldchmit pursued his undergraduate education at the Santo Amaro Medical School, São
Paulo, Brazil form 1980-1986, followed by a Residency in Ophthalmology at Santa Casa de São Paulo at São Paulo, Brazil from 1987-1989. He then went on to do a Fellowship in Strabismus at the Santa Casa de São Paulo, São Paulo, Brazil in 1989, followed by Neuro-Ophthalmology Fellowship from São Paulo Federal University, São Paulo, Brazil in 1989. He subsequently went on to do a Pediatric Ophthalmology and Strabismus Fellowship at the Smith-Kettlewell Eye Research Institute, San Francisco, USA in 1990.

Dr. Goldchmit got his Master Degree in Ophthalmology from the São Paulo Federal University, São Paulo, Brazil in 1992, following which he acquired his Doctors Degree in Ophthalmology from the São Paulo Federal University, São Paulo, Brazil in 1997.
He was the President of the Brazilian Strabismological Society from 1997 – 1999 & the President of the Latin American Council of Ophthalmology from 1998 – 2000.

A paralytic strabismus, as there is an imbalance of innervational forces, by itself represents a particular challenge for the surgeon in terms of expectations of results to obtain single binocular vision in a wide visual field. This case is all the more complex because the patient presents with previous surgeries (two in this case) in the sound eye. The complexity in terms of what to do increases when there are no previous surgical reports available and we are facing a patient with an anomalous head position that needs to have a new procedure on the sound eye to correct his torticollis. Saying that, surgeons might differ in terms of approach to a complex case like this but there are some guidelines that must be followed and will be discussed in answering the author’s questions.

1) How would you manage the case at this juncture?
First and most important is to explain the whole scenario to the patient and family that the only way to correct his torticollis is operating on the sound eye with all the attendant risks that it may not be possible to have a perfect outcome and finally that he will get a secondary exotropia on the left eye that will need to be fixed later on.
Considering:
a) we don’t have information about what was done,
b) in order to correct the huge torticollis we have to operate on the only eye with vision and
c) the author has mentioned that there is a positive traction test indicating a tight right medial rectus that was found 12 mm from the limbus
My first approach would be to re-recess the tight right medial rectus as much as possible with no risk of overcorrection since we are dealing with a 6th nerve paralysis. All intraoperative tests (forced traction, spring-back balance forces) should be used to check the eye position under general anestesia. As the patient has a very large torticollis, the medial rectus recession alone will probably not solve the problem. Then you have to consider if and what was done to the other muscles. If the vertical muscles were not operated on, I would add a transposition of the temporal halves of the vertical rectus to the LR insertion.

2) Would you consider additional surgery? If so, what procedure would you opt for?
The author’s option was to perform vertical rectus transpositions with augmentation sutures. The point is that the tightness of the medial rectus was not addressed. If there was a residual esotropia after the procedure, I would perform a medial rectus re-recession at this moment with a risk of anterior segment ischemia near zero.

3) How would you manage the case now?
The procedure done on the right eye was able to correct the head turn but, with any type of surgery on the fixing eye the result will be a secondary exotropia. We observed on the photos and the vídeo a strong limitation of adduction that was not present before. As this is the result after one year it is not related to the BTX-A injection but due to the vertical rectus transposition with augmentation sutures and not to the previous medial rectus recession. If we decide to improve this adduction deficit we’ll cause a recurrent right esotropia and have a recurrence of the torticollis. Unfortunatelly this limitation is a price to be paid to eliminate the torticollis. As the patient / family don’t want further surgery on the fixing eye, I would perform a left recess-resection surgery.

4) This patient had a history of two previous surgeries in his only seeing RE. What is the risk of loosing sight (the only seeing eye) because of ASI or endophthalmitis with a 3rd procedure?
ASI is a rare complication described in the literature. Most of the cases are mild with good resolution. This was one of the reasons for choosing transposition of the temporal halves of the vertical rectus to preserve ciliary arteries (the author had tried with partial success to spare ciliary vessels). Maintaining the medial cilliary vessels from the vertical muscles and the one from the lateral rectus (medial rectus was already operated on), I would not worry about ASI in a young patient. Endophthalmitis should be considered, in my opinion, to have extremely low risk as any other strabismus procedure.

5) Do you think an informed consent would prevent a law suit in case of a sight threatening complication?
The Informed Consent is an ethical and legal requirement, mandatory prior to any medical procedure. Parents and patient must receive all information about the risks and possibility of complications involved, including an extremely clear explanation on the chances of permanent visual loss, as the case refers to a patient who effectively has a single eye.
This particular case has one aspect that brings extra legal issues, as the patient is a 14 years old teenager. This topic must be considered, as in some countries, patients between 11 and 17 years old, have the right to express their will, and that must be considered in the final decision. A recommendation would be that the consent should be obtained from both: patient and parents.
As the patient brings the willingness to be submitted to the surgery and the parents are also in agreement, they must be fully informed about the potential risks.
Physicians must be aware that even though all the elements required in an Informed Consent are fulfilled, the risk of malpractice lawsuits should always be considered, but a document written up meticulously will be a powerful preventive tool.
When specific ethical issues are involved, like in this case that the patient is under 18 years old, the recommendation to bring a psychologist into the process of obtaining the consent would be appropriate in some countries.

6) Lateral rectus simple periost fixation didnot totally eliminate abduction and the reinseriton to the sclera. In order to achieve complete reduction of the abduction, is resection and burying of the LR with Tenon’s sufficient? Is oblique muscle weakening essential in order to achieve such an effect?
I have no relevant experience to comment on this. I don’t think that inferior oblique weakening will be effective in correcting the residual exotropia. I would prefer a medial rectus resection.

7) How would you approach to the disfiguring difference of the motility pattern because of the longer and faster saccades of the left eye of this patient?
This will be more difficult as the larger and faster saccades of the left non-visual functioning eye is a result of the right eye horizontal limitation that creates those movements. A possible alternative is a resection of the medial rectus adding a posterior myopexy.

8) How would you compare the different transposition techniques in terms of efficiency and / or ease of revision?
There are several factors involved on a surgery revision and one that is not known is how much of scar and/or adhesion each patient will present. This might result in more or less difficulty for the surgeon to find the muscles and modify what was previously done. It is not just a matter of which technique was used.