29TH EUROPEAN STRABISMOLOGICAL ASSOCIATION MEETING
TRANSACTIONS
29th European Strabismological Association Meeting
TRANSACTIONS IZMIR, TURKEY, JUNE 1–4, 2004
Edited by:
Jan-Tjeerd de Faber The Rotterdam Eye Hospital Rotterdam, The Netherlands
© European Strabismological Association (ESA) 2005
This edition published in the Taylor & Francis e-Library, 2006. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” All rights reserved. No part of this publication or the information contained herein may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, by photocopying, recording or otherwise, without written prior permission from the publishers. Although all care is taken to ensure the integrity and quality of this publication and the information herein, no responsibility is assumed by the publishers nor the author for any damage to property or persons as a result of operation or use of this publication and/or the information contained herein. ISBN 04 1537 211 9 (Print Edition) ESA nor Taylor & Francis Group plc. can be held responsible for errors or for any consequences arising from the use of the information contained in this book. The appearance of scientific reports or any material in this book does not constitute an endorsement or approval by ESA or Taylor & Francis Group plc. of the findings, data, conclusions, recommendations, procedures, results or any other aspects of the content of this book.
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Table of Contents
Preface
XIII
J.T.H.N. de Faber
Executive Committee of the European Strabismological Association ESA meeting organization 2004
XV XVII
ESA lectures
XIX
Foreword by the President
XXI
M. Spiritus
Special lecture: History of strabismology
XXIII
G.K. von Noorden, USA.
Macular translocation surgery
XXIX
V. Herzau, J. Mielke, H-S. Walter & K.U. Bartz-Schmidt, Germany.
Session 12: Amblyopia Effects of early and late onset strabismic amblyopia on magnocellular and parvocellular visual function. J. Sloper, A. Davis, M. Neveu, C. Hogg, M. Morgan & G. Holder, UK.
3
MRI measurements of horizontal rectus muscles in esotropia: the . role of amblyopia F. Mehmet Mutlu, G. Dinçer, H. Durukan, T. Mumcuog˘ lu & H. I brahim Altınsoy, Turkey.
7
Combined optical and atropine penalization in treatment of amblyopia S. Zıylan, Ö. Yabas & D. Serin, Turkey.
11
Telescopic spectacle therapy in amblyopia and its efficacy in cases over 9 years of age . U. Arslan, H. Atilla, A. I dil & N. Erkam, Turkey.
15
Treatment of anisometropic amblyopia with no or minimal patching O.M. Hakim & K.W. Wright, Saudi Arabia.
21
Session 3: Sensorial aspects Binocular functions in pseudophacic patients in early postoperative period I. Akyol-Salman, M. Arslankurt, O. Dursun, A. Yazıcı & O. Baykal, Turkey.
29
The age-related decline in stereopsis as measured by different stereotests L. Garnham & J. Sloper, UK.
33
Visual recognition time in strabismus: small-angle versus large-angle deviation C. Bellusci, C. Schiavi, R. Bolzani, M.G. Benassi & E.C. Campos, Italy.
35
V
Session 4: Botulinum toxin Botulinum toxin for strabismus treatment in brain injury patients S. Moguel, Mexico.
41
Botulinum toxin-A injection in acute complete sixth nerve palsy M.R. Talebnejad, A. Alavi & A. Attarzadeh, Iran.
45
The role of Botulinum toxin A in augmentation of the effect of recess resect surgery A.S. Topalog ˘ lu, S.B. Özkan & S. Aydın, Turkey.
49
Does Botulinum Toxin have a role in the treatment of secondary strabismus? E. Dawson, A. Sainari & J.P. Lee, UK.
53
Session 5: Various aspects Evaluation of the effect of strabismus surgery on retrobulbar blood flow with. Doppler US A. Ipek Akyüz Ünsal, A. Ünsal, S.B. Özkan & C.Z. Karaman, Turkey.
57
Computer assisted parent’s vision screening in children M. Altıeri, S. Chatterjee, A. Gibson, P. Addison & A. Assaf, UK.
61
Acquired neurological nystagmus: clinical and surgical approach A.C. Spielmann, France.
65
Session 6: Adjustable surgery Strabismus surgery under topical lidocaine gel O.M. Hakim & Y.G. El-Hag, Saudi Arabia.
71
When should the amount of surgery be adjusted during conventional muscel surgery? A. Roth & C. Speeg-Schatz, Switzerland.
77
Non-absorbable sutures should be used for adjustable inferior rectus muscle recessions C.F. Parsa, M. Soltan-Sanjari & D.L. Guyton, USA.
81
Session 7: Physiology and refractive surgery Metabolic changes in brain related to strabismus registered by brain SPECT S. Moguel & L. Orozco, Mexico.
87
Histological analysis of the efferent innervation of human extraocular muscle fibres I-B. Kjellevold Haugen & J.R. Bruenech, Norway.
91
Effect of refractive surgery on ocular alignment and binocular vision in patients with manifest or intermittent strabismus D.J.M. Godts, J. Claeys, P. Schraepen & M.J. Tassignon, Belgium.
95
Diplopia and strabismus after refractive surgery R. Gomez de Liaño, G. Franco Iglesias & P. Gomez de Liaño, Spain.
99
VI
Session 8: Various surgical methods Does the bilateral inferior obliques anterior tranposition influence the amount of surgery on the horizontal muscles? D. Cioplean & L. Teodorescu, Romania.
105
Efficacy of the anterior transposition of the inferior oblique as a secondary procedure in cases of recurrent DVD V. Paris, Belgium.
109
Mechanical and histopathological effects of ADCON – L conventional and polymer coated liposomes in an experimental strabismus surgery model B. Sönmez, S¸. Gedık, Ç. Karaca, E.C. S¸ener, A.S¸. S¸anaç & T. Eldem, Turkey.
113
Outcomes of surgery for vertical strabismus in thyroid-associated ophthalmopathy A.C. Bates, G.G.W. Adams, J.F. Acheson & J.P. Lee, UK.
117
Session 9: Brown’s syndrome and congenital fibrosis syndrome Surgical findings in Brown’s syndrome S. Akar, B. Gökyig˘ it, K. Gök & Ö.F. Yılmaz, Turkey.
121
A new surgery technique in Brown’s syndrome B. Gökyig˘it, S. Akar & Ö.F. Yılmaz, Turkey.
125
Long term outcome of silicone expander for Brown’s syndrome H.K. Keskinbora & N.K. Pulur, Turkey.
131
Outcome of strabismus surgery in congenital Fibrosis of Extraocular Muscles (CEOEM) E.C. S¸ener, B.T. Öztürk & A.S¸. S¸anaç, Turkey.
135
Surgical management in a newly identified CFEOM/postaxial oligo-syndactyly syndrome A. Gezer & T. Tükel, Turkey.
137
Session 10: Superior oblique paresis Superior oblique palsy: a ten year survey M. Farvardin & A. Alavi, Iran.
143
Results of different surgical procedures in superior oblique palsy ˘ it, P.K. Hekimhan & Ö.F. Yılmaz, Turkey. S. Akar, B. Gökyig
147
How predictable is muscles surgery in superior oblique palsy? L. Teodorescu & D. Cioplean, Romania.
153
Anterior transposition of the inferior oblique muscle for treatment of unilateral superior oblique palsy with 16 to 25 prism diopters hyperdeviation in primary position M. Farvardin, A. Atarzadeh & A. Alavi, Iran.
155
Familial congenital superior oblique palsy M. Farvardin, A. Banihashemi & M. Saadat, Iran.
159
VII
Session 11: Surgery in exotropia and special surgical methods Surgical results of lateral rectus muscle recession in intermittent exotropia in children R. Venkateshwar Rao, J. Singh & M.K. Aasuri, India.
165
Outcomes of consecutive exotropia surgery A.C. Bates, H. Newman, C. Hayden & J.P. Lee, UK.
169
Surgical ancorage of the lateral rectus muscle to the periostium of the orbit: a new tool to tuckle retraction in Duane syndrome and exotropia in 3rd cranial nerve palsy C. Schiavi, C. Bellusci, M. Fresina & E.C. Campos, Italy.
173
Excessive recession of horizontal rectus muscles in surgical treatment of congenital nystagmus M. Dogan, S. Akar, B. Gökyi˘git & Ö.F. Yılmaz, Turkey.
177
Impact on deviation in primary position of vertical shift of horizontal recti muscles insertion R. dell’Omo, A. Salerni, S. Petroni, L. Guccione, G. Savino & A. Dickmann, Italy.
181
Use. of augmented transposition surgery for complex strabismus H.I . Altınsoy, F.M. Mutlu, Y. Uysal & S. Çelebi, Turkey.
185
Posters Binocular functions in anisometropic and strabismic anisometropic amblyopes I. Aykol-Salman, Y. Karabela & O. Baykal, Turkey.
191
Thickness of the retinal nerve fiber layer and macular thickness and volume in patients with strabismic amblyopia Ö. Altıntas¸, N. Yüksel, B. Özkan & Y. Çag˘lar, Turkey.
195
Evaluation of intranasal midazolam in young strabismic children undergoing refraction and fundus examination . Ö. Altıntas¸, V.L. Karabas¸, G. Demirci, I . Onur & Y. Çag˘lar, Turkey.
199
Dissociated Vertical Deviation and its relationship with time and type of surgery in infantile esotropia U. Arslan, H. Atilla & N. Erkam, Turkey.
203
Ocular abnormalities associated with cerebral palsy H. Atilla, F. Batiog˘lu, E. Can & N. Erkam, Turkey.
207
Alexander the Great’s abnormal headposture due to Brown’s syndrome? B. de Vries, The Netherlands.
211
Role of spectacle correction and orthoptic exercises in non-surgical management of exodeviations F. Sezen, Ö. Balcı & A. Gezer, Turkey.
213
VIII
Moebius syndrome with limb abnormalities E. Bas¸ar & T. Aras, Turkey.
217
Long-term binocular functional outcome after strabismus surgery in a case of cyclic esotropia B. Venkateshwar Rao & P. Sahare, India.
221
Interrelationship of binocular and monocular functions in anisometropic amblyopia I.M. Boychuk, Ukraine.
227
Influence of orbital factor on development and outcome of surgery for intermittent exotropia Y.A. Cho, S. Kim & S. Yi, Korea.
231
Ocular motility problems following treatment for uveal malignant melanoma E. Dawson & J.P. Lee, UK.
235
Recurrent strabismus caused by orbital tumour arising from pulley smooth muscle tissue? P.Ph. van den Broek, J.T.H.N. de Faber, A.D.A. Paridaens & M. Kliffen, The Netherlands.
237
The functional outcome of very late surgery in infantile strabismus E.Ch. Schwarz, K.S. Kunert, G. Wunsch & H. Zappe, Germany.
239
A binocular scanning laser ophthalmoscope O. Ehrt, Germany.
243
The effect of reducing anticipation anxiety by psychoeducation techniques on vasovagal responses during manipulation of adjustable sutures O. Elibol, L. Karabas¸ , Ö. Altıntas¸ & Y. Çag˘lar, Turkey.
247
A new scoring method for lees charts M. Eliaçik, S. Akar, B. Yilmaz, B. Gökyi˘git & Ö.F. Yılmaz, Turkey.
251
About a case of children’s myasthenia gravis D.F. Agrafojo, P.M. Enrile & J.P. Fabré, Spain.
255
Strabismus after in-vitro fertilization R. Gomez de Lia n˜ o, I. Genol, I. Iglesias, Y. Fernandez & M. Barrio, Spain.
261
Surgical treatment of strabismus fixus with high myopia B. Gökyi˘git, S. Akar, A. Basoglu, O. Oral & Ö.F. Yılmaz, Turkey.
265
Carotid Doppler Ultrasonography in congenital IVth nerve palsy B. Gökyi˘git, S. Akar & Ö.F. Yılmaz, Turkey.
269
Effects of recession strabismus surgery on corneal topography A. Inal, B. Inal, S. Akar, B. Gökyi˘git & Ö.F. Yılmaz, Turkey.
275
The effectiveness of Faden operations in different types of deviations A. Inal, N. Ünal, B. Gökyi˘git, S. Akar & Ö.F. Yılmaz, Turkey.
279
IX
The Brückner test as a screening tool for the detection of significant refractive errors J.W.R. Pott, Y.G.L. Sie-Oh, M. Broer van Dijk & B. de Vries, The Netherlands.
283
Outcome of surgical management in adults with congenital unilateral superior oblique palsy . B. Kaczmarek, E. Wójcik, A. Ma˛droszkiewicz & M. Pociej-zero, Poland.
287
Inhibitional palsy of the contralateral superior rectus muscle in a patient with superior oblique paresis B. Kaczmarek, E. Wójcik & C. Bilska, Poland.
289
Surgical treatment of upshoot and downshoot in Duane’s retraction syndrome Ç. Karaca, A.S¸. S¸ anaç & B. Sönmez, Turkey.
291
Changes in corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery J.B. Lee, J.H. Chang, S.H. Han & Y.-H. Chang, Korea.
295
Surgery of the inferior oblique muscle in bilateral asymmetric paralysis of the superior oblique V. Oguz, M. Yolar, H. Tolun & S. Özkan, Turkey.
299
The oculocardiac reflex in strabismus surgery A. Özbek, S. Akar, B. Gökyi˘git, G. Eren & A. Öner, Turkey.
303
Globe retraction in a patient with nanophthalmos S. Öner, A.F. Nohutçu & H.N. Ortak, Turkey.
307
Surgical treatment of consecutive exotropia A. Öztürk, S. Akar, B. Gökyig˘it, Ö.F. Öge, Z. Bayraktar & Ö.F. Yılmaz, Turkey.
309
Epiblepharon and Mobius syndrome: a rare association B. Venkateshwar Rao & P. Sahare, India.
313
Assessment of the risk of endophthalmitis in accidental globe penetration during strabismus surgery A.A.S. Moghaddam, A. Kargozar & T. Rashed, Iran.
317
Assessment of the rate of nausea & vomiting and pain in strabismic patients anesthetized by propofol A.A.S. Moghaddam, Iran.
323
The effect of experimentally induced spherical myopic anisometropia on stereoacuity A.A.S. Moghaddam, A. Kargozar & M.E. Ravazi, Iran.
327
Refractive surgery: strabologic patients management L. Sabetti, L. D’Alessandri, A. Fiasca & K. Salvatori, Italy.
331
Glomus jugulare tumour presenting with VIth nerve palsy A.G. Sainani, E. Dawson & J.P. Lee, UK.
335
X
Influence of near correction on visual perception and perceptional organization skills down syndrome G. S¸ atirtav, E.C. S¸ ener, A.S¸. S¸ anaç & E. Erdog˘an Bakar, Turkey.
339
Surgical management of complete oculomotor nerve palsy N. Sefi Yurdakul, S. Ugurlu & A. Maden, Turkey.
343
Etiology of paralytic strabismus N. Sefi Yurdakul, S. Ugurlu, G. Aydeniz & A. Maden, Turkey.
347
Clinical, pedigree and genetic analysis of congenital fibrosis of extraocular muscles B.T. Öztürk, E.C. S¸ ener, A.S¸ . S¸anaç, N. Akarsu, K. Yamada & E.C. Engle, Turkey.
351
Abnormal lateral rectus insertion associated with V-pattern exotropia and up-shoot . Y. Uysal, F.M. Mutlu, C. Erdurman, H.I . Altınsoy, S.M.Z. Bayraktar & D. Ceyhan, Turkey.
355
Transposition procedures for abducens palsy: 10 year-results ˇ eh˚uˇrek, Czech Republic. R. Autrata, K. Vodicˇ ková & J. R
359
Inferior oblique muscle surgery for dissociated vertical deviation ˇ ehu˚ ˇrek, Czech Republic. R. Autrata, K. Vodicˇ ková & J. R
365
Congenital fibrosis of extraocular (CFEOM) muscles associated with musculoskeletal abnormalities C. Yıldırım, S. Tatlipinar, E. Kiter, F. Duzcan, V. Yaylali & S. Özden, Turkey.
371
Hiper maximum lateral rectus recession operation of adults with large angle exotropia B. Yılmaz, B.Gökyig˘it, S. Akar & Ö.F. Yılmaz, Turkey.
375
Surgical outcome in superior oblique palsy S. Zıylan, A. Yigit, Ö. Yabas, D. Serin, S. Hoca & I. Daruga, Turkey.
381
Medical detective W. Duifhuizen–Visscher, W.J. van der Linden, M. Tjon Fo Sang & M. Wefers Bettink–Remeijer, The Netherlands.
385
Minutes of the business meeting 2004
389
By-laws
393
Membership roster
397
Author index
413
XI
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Preface
The 29th ESA meeting took place in Izmir, Turkey, from June 1–4, 2004. The organising committee under the inspiring leadership of Prof. Dr. Seyhan B. Ozkan performed an excellent job. In Izmir and the nearby Ephesus we had an unforgettable strabismus meeting, with an absolute highlight: the special open-air lecture on the History of Strabismology by Gunter K. von Noorden in the Ephesus Antique Theater with a spectacular sunset postponing the lecture for an hour, followed by a great performance of the State Folk Dance Ensemble. The icing on the cake was the gala diner under a full moon in the Celsius Library. I would like to thank all authors who delivered their transactions in time. I am grateful to the Council and Members of the ESA for having me selected as the editor of the Transactions. I would like to thank my wife Cris for her invaluable secretarial assistance and moral support. Jan-Tjeerd de Faber, editor Rotterdam, July 2004
XIII
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Executive Committee of the European Strabismological Association
Until June 2004 M. SPIRITUS S.B. OZKAN J. LEE A. PECHEREAU C. SCHIAVI O.H. HAUGEN R. LIANO de GOMEZ H.D. SCHWORM J.T. de FABER
BELGIUM TURKEY UNITED KINGDOM FRANCE ITALY NORWAY SPAIN GERMANY THE NETHERLANDS
PRESIDENT VICE-PRESIDENT VICE-PRESIDENT VICE-PRESIDENT SECRETARY/ TREASURER COUNCILLOR COUNCILLOR COUNCILLOR EDITOR
TURKEY NORWAY UNITED KINGDOM FRANCE ITALY GREECE SPAIN GERMANY THE NETHERLANDS
PRESIDENT VICE-PRESIDENT VICE-PRESIDENT VICE-PRESIDENT SECRETARY/TREASURER COUNCILLOR COUNCILLOR COUNCILLOR EDITOR
After June 2004 S.B. OZKAN O. HAUGEN J. LEE A. PECHEREAU C. SCHIAVI A. DAMANAKIS R. LIANO de GOMEZ H.D. SCHWORM J.T. de FABER
XV
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
ESA meeting organization 2004
Scientific Committee V. Herzau (Chair) E. Campos J. Elston S.B. Ozkan Poster Committee J. Lee H.I. Altinsoy O. Haugen Local Organizer S.B. Ozkan
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
ESA lectures
1995: Joseph Lang (Switzerland) 1996: Gunter K. von Noorden (USA) 1997: Peter Fells (England) 1999: Emilio C. Campos (Italy) 2001: Guntram Kommerell (Germany) 2003: Gunnar Lennerstrand (Sweden)
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Foreword by the President
As President of the European Strabismological Association, I would like to welcome everybody of you – members and non-members – for being here and to participate in the 29th E.S.A. meeting. Some are coming from far away and overseas. On behalf of the ESA members, I would like to greet all of you, colleagues, orthoptists and friends. We are thankful to Seyhan Ozkan, for having accepted to organise this meeting, in the nice city of Izmir, formerly named Smyrna; an ancient harbour city and important trade centre located at the crossroads of civilisations and cultures; an area which brings us to the backgrounds of our speciality. In that historical context, Dr S. Ozkan had the marvellous idea to invite Prof. Dr Gunter K. von Noorden to deliver a lecture on the “History of Strabismology” in the Antique City of Ephesus. As you all know, Dr von Noorden is the editor of an excellent and fascinating book on the History of Strabismology in the five continents; a book, I strongly recommend each of you to purchase. I also wish to thank the scientific and poster committees chaired by our colleague V. Herzau. Besides the many oral and posters presentations, a Symposium on “Strabismus and Binocular Problems after Ocular Surgery”, will be moderated by J. Elston and E.C. Campos will conduct a Round Table discussion on “What’s new in Amblyopia”. Last year, ESA celebrated the 20th anniversary of its existence. For the last twenty years, ESA did not stop growing. One of the aims of ESA is to provide an educational program for young ophthalmologists. This year ESA innovates by organising early-morning courses. In Bergen, the proposal to create an ESA fellowship has been favourably accepted by the Council and the General Assembly. Currently, regulations of the ESA fellowship have been worked out. Recently, the secretary-treasurer, C. Schiavi sent all ESA members a questionnaire. If you are willing to host an ophthalmologist, please fill in and send the questionnaire back to our secretary-treasurer. I am convinced that once again, these three days will give us the opportunity to share ideas and reward us with new knowledge and, that here specifically in a country that straddles two continents, where west meets east, we will make new friends and deepen friendship between all of us. Lastly, I will have completed my presidency with the Izmir meeting. I have special thanks to all the committee members who have held important offices during those last years. I thank you for your support. Micheline Spiritus
XXI
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Special lecture: History of Strabismology G.K. von Noorden Longboat Key, Florida (USA)
Johann Wolfgang von Goethe stated in the introduction to his History of Color Vision, that “History is a burden rather than a joy for the young for they want to create a history of their own. But those advanced in age and education recognize most gratefully how much valuable and useful information has been passed on to them by their predecessors.”1 During work on our book “History of Strabismology”3 on which most of this lecture is based, I learned to appreciate just how much we owe to our scientific forefathers. Only certain highlights in the evolution of our specialty will be presented in this lecture and the reader is referred to our book and a previous publication2 for pertinent illustrations and much more detail. The word strabismus probably originates from the noun strebloi (Greek for squinter) and the verb strebloun (to turn) and appears for the first time in the writings of Hippocrates (460–377 BC). Hippocrates was also first to point out the hereditary nature of strabismus. Since strabismus causes a conspicuous alteration of facial configuration it is not surprising that this condition was noted even in the earliest depictions of the human face. For example, the statue of a Pharaoh of the 3rd Dynasty (2778–2723 BC) clearly shows esotropia. Other depictions of severe esotropia can be found on the painted lid of a sarcophagus from the 13th century BC or in a statue from the tomb of a Chinese emperor of the 3rd century BC. Scientific strabismology did not begin until the 19th century and earlier mentioning of this condition and its treatment was often shrouded in superstition and quackery. For instance, the Papyrus Ebers (1553–1550 BC) records treatment of “distortion of the eyes” with equal parts of turtle brain and spices. Despite the unscientific nature of such treatment and the perceived causes of strabismus in earlier times there was an occasional flash of brilliance and extraordinary insight by some authors. For instance, Celsus (25 BC–50 AC) of Rome distinguished paralytic from non-paralytic strabismus and Galen (131–201 AC), also from Rome, described all 6 extraocular muscles, recognized the oblique muscles as the principal cyclorotators, and considered strabismus as a loss of equilibrium between agonistic and antagonistic muscles. Paulus of Aegina (625–690) designed masks “to guide the positions of the eye” and recognized an “obscuration of vision from invisible causes”, perhaps the first description of amblyopia? Throughout the history of ophthalmology and well into the 20th century we find the notion that strabismus should be treated by forcing the eyes into certain gaze positions by masks designed for eso- and exotropia. The elaborate illustrations of such masks by Georg Bartisch of Dresden in his first textbook of ophthalmology in the German language (1583) are well known. Treating strabismus by blocking vision in certain gaze position has survived well into our time as “sector occlusion.” Other methods to correct strabismus by active visual stimulation consisted of dyed pieces of wool attached to the temples of an esotropic child or attaching an object to the tip of the nose in exotropia. We should note in passing that esotropia was considered a sign of beauty in the Mayan culture. A ball of bees wax dangling before the eyes of an infant was thought to stimulate convergence and (hopefully) induce esotropia! The Law of Reciprocal Innervation, a fundamental aspect of ocular motility was clearly and without the help of electromyography defined during the 17th century by the Frenchman René Descartes (1596–1650) and long before being refined and confirmed by Charles S. Sherrington (1859–1952) of England. Another surprisingly advanced concept concerns the treatment of strabismic amblyopia. During a visit to an eye hospital in Riyad (Saudi-Arabia) I became XXIII
acquainted with an ophthalmologist (Dr. M.Z. Wafai, Damascus) who was in the process of translating into English an ancient book on “Vision and Perception” by Thabit Ibn Qurrah Al-Harani. Al-Harani had lived in Mesopotamia during the 9th century AC. Knowing of my interest in amblyopia Dr. Wahai directed my attention to a passage in this book, which stated that: “strabismus should be treated by patching the normal eye. Once you do that, the visual power will go in it’s entirety to the deviated eye whose vision will return to normal. You should not release the normal eye (from treatment) until the vision in the deviated eye has completely returned to normal.” Clearly, Al-Harani practiced occlusion treatment for amblyopia as we know it today and nearly 900 years prior to the French naturalist de Buffon (1707–1788) who is often credited for having originated occlusion therapy. However, we may find it difficult to agree with our Mesopotamian colleague from ancient times when he goes on to write “such patients must also be purged, should bathe every second day and be made to sneeze by putting the juice of olive leaves into their noses.” A noteworthy event in the history of strabismus occurred during the early 18th century with the appearance of an itinerant English “oculist” known as the Chevalier John Taylor who lectured and performed eye surgery in several Western European countries. His self-glorification and shameless publicity stunts would make even the most aggressive advertising of some of our contemporary “laser surgeons” appear exercises in modesty. He introduced himself as “the inventor of ophthalmology, sent by God to cure blindness on earth.” Instead Taylor left a trail of deteriorating eyesight and blindness behind him wherever he performed. One of his unfortunate victims was Johann Sebastian Bach. Taylor claimed widely to have discovered how to cure strabismus by a “fast, nearly painless operation without risk.” This operation actually consisted of excising a piece of conjunctiva from the fornix after which the fixating eye was patched. The operated eye straightened and the spectators applauded spontaneously, thinking that a miracle had been performed when the operated eye straightened after applying a bandage to the fixating eye. The patient was instructed not to remove the bandage until several days later. Of course, by that time Taylor had been paid and he and his retinue had long left town. Despite this obvious quackery Taylor’s writings contain several noteworthy truisms. He provided precise drawings of the decussation of the optic nerve fibers in the chiasm and wrote that by dividing a nerve or muscle the disturbance of equilibrium of agonistic and antagonistic muscles may be restored. However, nobody had ever witnessed him actually doing a neurotomy or myotomy. Nearly 100 years passed since Taylor’s exploits on the European continent before an event occurred that marked the beginning of strabismology as we know it today. The orthopedic surgeon Georg Stromeyer (1804–1876) had published in 1836 that he performed a myotomy of the medial rectus muscle in a cadaver and suggested that this operation may be useful in strabismus. Johannes F. Dieffenbach (1792–1847), Professor of Surgery at the University of Berlin picked up on this idea and performed the first myotomy of the medial rectus muscle in a 7-year old esotropic boy on October 26, 1839. Only 17 days later (sic) this case was published in the Medicinische Zeitung. Just 3 days after Dieffenbach, Flaurent Cunier (1812–1853) of Brussels had also performed a myotomy, this one on the lateral rectus muscle in an exotropic patient and reported his case in the Annales d’Oculistique (which he had founded a year earlier) but not until 1840. The American surgeon William Gibson (1788–1868) of Baltimore wrote in 1841 that he had actually done myotomies of the extraocular muscles in several patients as early as 1818 but had given up on this procedure because of several unsatisfactory results. Since he had not published his results at the time they were obtained the priority of having performed the first myotomy for strabismus clearly belongs to Dieffenbach. News of this procedure spread like a wildfire throughout the world with hundreds of cases being reported from London and Boston within months after Dieffenbach’s first case. Within 2 years he had operated on 1200 cases! But the results were often satisfactory and large overcorrections (the Berliners called them Dieffenbachers) were frequent. Re-operations became necessary and Dieffenbach introduced an advancement of the myotomized muscle followed by myotomy of the lateral rectus muscle. A suture (called Faden in German) was then passed through the tendon of the lateral rectus and taped to the bridge of the nose and to the opposite cheek to keep the eye in an esotropic position. Dieffenbach called this traction suture a Fadenoperation and it is as XXIV
unfortunate as it is confounding that this term was re-introduced by Cüppers (1975) to describe what is better called retroequatorial myopexy or posterior fixation of an extraocular muscle. By the middle of the 19th century the myotomy had become discredited and it was not until Albrecht von Graefe (1828–1870) of Berlin, one of the founders of modern ophthalmology, introduced the controlled tenotomy, which rekindled the interest in and improved the results of strabismus surgery. Von Graefe published extensively on trochlear paralysis, ocular torsion, eccentric fixation, anomalous retinal correspondence, paradoxical diplopia and introduced the cover test. His friend Frans Cornelius Donders (1818–1889) of Holland was first to recognize uncorrected hypermetropia as a frequent causes of esotropia and clearly defined the association of accommodation with convergence. Albrecht von Graefe’s cousin and student Alfred Graefe (1833–1899) pioneered the surgical treatment of paralytic strabismus and introduced surgery on the vertical rectus muscles. Strabismology had emerged as a scientific discipline. At about the same time, physiological optics established itself as a new discipline. Hermann von Helmholtz (1821–1894) of Königsberg, the inventor of the ophthalmoscope, studied the physiology of normal binocular vision, of retinal rivalry, diplopia, normal and abnormal retinal correspondence. Ewald Hering (1834–1918) of Leipzig introduce the law of equal innervation and found that visual objects, separated in subjective visual space, are localized subjectively in a common visual direction. Charles Wheatstone (1802–1875) of England invented the mirror stereoscope and Peter L. Panum (1820–1885) of Kiel made a major contribution to spatial vision by explaining the basis of stereopsis. Without a clear understanding of the physiology and pathophysiology of binocular vision discovered by these and other scientists during the 19th century, strabismology would be no more than a quasi orthopedic subspecialty. Indeed, these men and their students were the giants of the past on whose shoulders we stand today, trying to catch a glimpse of the future, as the saying goes. The 19th century witnessed also the first attempts to treat strabismus by visual exercises. A pioneer in this area was Emile Javal (1839–1907) of Paris a former mining engineer whose father suffered from a consecutive exotropia after having undergone myotomy of the medial rectus muscle and whose daughter had esotropia. He studied medicine, became an ophthalmologist, modified the stereoscope of Wheatstone (1838) and invented numerous instruments for the training of binocular function. This was the beginning of orthoptics. Javal also introduced atropine to treat amblyopia by penalization of the sound eye, and miotics to treat esotropia. His Manuel du Strabisme (1836) became a big success in France. Ernest Maddox (1863–1933) of England invented numerous instruments for the training of binocular functions that bear his name and his daughter Mary became the first orthoptist. A countryman of his was Claud Worth (1896– 1936) whose book Squint, its Causes and Treatment (1903) appeared in 6 editions. Three additional editions appeared after his death and were written by Bernard Chavasse (1880–1941) and T. Keith Lyle (1904–1987) and Bridgeman. This book was based on clinical observation in 2,337 cases of strabismus and became the major text for many years in the Anglophonic parts of the world. Strabismology in the United States was largely oriented towards Europe until the first part of the 20th century when American ophthalmologists began making important contributions to strabismology. Lucien Howe (1848–1928) of Buffalo, New York published 2 volumes in The Muscles of the Eye, measured the muscle force of extraocular muscles and saccadic velocity. Oscar Wilkinson (1870–1945) published an excellent book on Strabismus: Its Etiology and Treatment in 1927. Other major contributions were by Alexander Duane (1858–1926) provided a classification of exotropia that is still in use and described the alternate prism and cover test. In 1922 J. Chalmer Jameson introduced scleral suturing of a recessed muscle. Walter Fink (1895–1969) described new techniques for surgery of the oblique muscles and Richard Scobee (1914–1952) published his book on the Oculorotatory Muscles, which was the only American teaching text available when I began my training in ophthalmology in 1956. Frank Costenbader (1905–1978) was one of the most prominent leaders in strabismology at that time, the first to devote his practice exclusively to pediatric ophthalmology and a pioneer of early surgery. XXV
A major impetus for the development of strabismology in the United States was the arrival on the American scene of one of Europe’s greatest strabismologists, Alfred Bielschowsky (1871–1940). Bielschowsky had studied ophthalmology under Carl H. Sattler (1880–1958) in Leipzig. Sattler had a deep interest in strabismus and was the only strong proponent of energetic occlusion treatment for amblyopia of his time. In fact, during the first part of the 20th century many ophthalmologists still believed that amblyopia was the cause rather than the consequence of strabismus! The University Eye Clinic in Leipzig was adjacent to the Physiological Institute, which was under the direction of no other than Ewald Hering. Close contacts and a spirit of collaboration existed between the young doctors of both institutions and it was in this fertile medium that Bielschowsky’s first publications originated. The paper that launched Bielschowsky’s career of becoming the foremost strabismologist of his time was on “Monocular diplopia without physical cause with comments on how a stabismic person sees” (Arch. Ophthal. 46: 143–83, 1898). He reported in minute detail the case of a young man with longstanding amblyopia who had lost his good eye after a perforating injury and now complained of monocular diplopia. Both Hering and Sattler were baffled by this case. After months of studying the patient Bielschowsky came to the conclusion that the double vision was caused by a competition between normal and abnormal relative localization, producing simultaneous localization of one visual object in two different visual directions. With today’s emphasis on evidence based medicine and prospective, multi-center, double-blind studies it is often overlooked that meticulous observation of an individual patient, a precise analysis of subjective complaints and the application of simple psychophysical tests in the office have led to far-reaching discoveries in the field of strabismus. Bielschowsky’s description of monocular diplopia from a sensory cause and Hering’s discovery of the law of common visual directions by a simple but brilliant experiment, are cases in point. Bielschowsky eventually became professor and chair at the University Eye Clinic, first in Marburg and later in Breslau (then in Germany but now in Poland) and rapidly rose to a position of pre-eminence in the field of strabismus and neuro-ophthalmology. Among his numerous contributions were the physiology of involuntary fusional movements, the head tilt test, internuclear ophthalmoplegia, the doll’s head phenomenon, the clinical features and mechanism of dissociated vertical deviations, divergence paralysis, and the after-image test (with Hering). In 1934 the Nazis had come to power and anti-Semitism was on the rise in Germany. Bielschowsky, who was of Jewish background, was forced to resign his position in Breslau and immigrated to the USA where he joined a group of outstanding visual scientists and clinicians at the Dartmouth Eye Institute in New Hampshire. Among these were Adelbert Ames, Paul Boeder, Hermann Burian, David Cogan, Walter Lancaster, Arthur Linksz, and Werner Herzau. What was Germany’s loss of a great man became a huge gain for America. In he single-handedly put strabismus on the map in America, as Paul Boeder once told me. After Bielschowsky’s death, his student Hermann Burian (1900–1972) continued to unravel the mysteries of sensorial adaptations in strabismus and followed in his foot steps in becoming one of America’s leading strabismologists. Only a few years after Bielschowsky’s departure from Germany, World War II with all its devastation erupted. Millions of people were displaced from their homes during and after the war and in the course of this chaos the treatment of strabismus and amblyopia became a matter of small importance and was neglected. Thus, in the early fifties of the last century when things began to return to normal the eye clinics of Europe were flooded with older children with severe, untreated amblyopia and eccentric fixation. They were now at an age at which compliance with occlusion treatment could no longer be expected. A new era of strabismology began at this point in time with the introductions of pleoptics by Alfred Bangerter (1909–2002) of Switzerland and Curt Cüppers (1910–1995) of Germany. These authors developed several and separate methods, called pleoptics, to treat amblyopia in older children by active and passive stimulation of the fovea of the amblyopic eye. These clever and original approaches were aimed at normalizing the fixation behavior and creating awareness of the physiological visual direction of the fovea. So-called Sehschulen (schools for vision) sprouted in Switzerland to which amblyopic children were admitted and treated with daily training sessions as inpatients. Pleoptics rapidly spread to the rest of XXVI
Europe, the U.K., the United States, South America, Australia and Japan. However, the initial enthusiasm waned eventually and studies appeared that showed that the same results could be obtained by energetic occlusion treatment. Pleoptics is rarely practiced today. Early visual screening and early, energetic treatment of amblyopia have vastly diminished the prevalence of neglected amblyopia with eccentric fixation, at least in developed countries. A direct outgrowth of pleoptics was a renewed interest in amblyopia and strabismus, which eventually led to major advances in diagnosis, pathophysiology and treatment during the second half of the 20th century. As an example of this progress I list just a few advances that have occurred during my own professional lifetime: muscle transpositions, surgical treatment of cyclotropia, forced duction test and the recognition of mechanical factors in strabismus, estimation of generated muscle force, alphabetical patterns and their surgical treatment, a better understanding of the mechanism and pathophysiology of different forms of amblyopia through animal experiments, recognition of the sensitive period in infancy, early surgery for congenital esotropia, retroequatorial myopexy, surgical treatment of abnormal head positions secondary to nystagmus and of nystagmus itself, botulinum injections, spatula needles, synthetic sutures, outpatient surgery and re-introduction and refinement of adjustable sutures. Many strabismologists who contributed to this recent progress are still alive and active. Future historians will evaluate their contributions through the filter of time because the presence must first become the past to be counted as history.
REFERENCES 1. von Goethe J.W. (1982) Materialien zur Geschichte der Farbenlehre, Johann Wolfgang von Goethe Werke; vol. 14, Hamburg, C.Beck, p. 7 2. von Noorden G.K. (2001) The development of the art and science of strabismology outside North America, Parts I and II, JAAPOS 5:65–69, 134–138 3. von Noorden G.K. (ed.) (2002) The History of Strabismology, JP Wayenborgh, Oostende, Belgium
XXVII
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Macular translocation surgery Volker Herzau, Jörg Mielke, Hans-Sebastian Walter & Karl Ulrich Bartz-Schmidt University Eye Clinic Tübingen, Germany
1
INTRODUCTION
Macular translocation is a new surgical method for the treatment of age related macular degeneration. The method was first described by Machemer and Steinhorst in 1993 (Machemer and Steinhorst 1993). The principle consists in a rotation of the retina around the optic nerve head after a peripheral circular retinotomy. This positions the fovea away from the subretinal pathology to an area of undisturbed choroid overlying normal pigment epithelium. Figure 1 shows the fundus of a right eye after upward rotation of the fovea. The new site of the fovea can be estimated between the large temporal retinal vessels. The choroidal scar temporal from the optic nerve head marks the primary location of the fovea.
2
SENSORY LOCALIZATION PROBLEMS AFTER MACULAR TRANSLOCATION
The possible profit regarding the visual acuity is paid at the price of a torsional misalignment of the retinal meridians, which provides the perception of contour orientation in the operated on eye. Binocularly, a cyclotropia is produced mostly between 30 and 50 degrees, larger than occurs under any other pathophysiologic condition. Apart from the effect on the visual acuity the sensorial consequence of macular translocation is binocular intractable torsional diplopia with a double image which is additionally vertically and horizontally displaced, unless there is total exclusion of one eye because of a pre-existing strabismus, or the patient has learned to ignore the disturbing image of one eye.
Figure 1.
Fundus photograph of RE after clockwise macular translocation of 45 degrees.
XXIX
Fove a
The transposition creates: 1. Incyclotropia 2. Exotropia 3. Hypotropia
45˚ Papilla
Figure 2.
Upward rotation of the right macula, schematically.
Figure 3. Gaze straight ahead after macular translocation of the right eye. Above: Left eye fixates, below: right eye fixates, see text.
A simple diagram shows the postoperative situation on the fundus of an operated right eye. The fovea is rotated upward 45°. When a primarily orthotropic patient fixates with his left eye the fixated object projects on the right rotated retina below and temporally in relation to the fovea. When the fixation switches to the right eye both eyes move upwards and to the left. In orthoptic terms there is a right hypo- and exotropia additionally to the incyclotropia. Figure 3 shows a patient after macular translocation of the right eye. In the upper photo she looks straight ahead with her left non-operated eye. The corneal reflexes are in normal position. On the lower photograph she fixates with her right eye. The right corneal reflex is displaced downward and somewhat temporally. The reflex on the left cornea demonstrates the exo- and hypertropia of the left eye. After Freedman there is no clear relationship between incyclotorsion and hypotropia (Freedman, Holgado et al. 2003). The cyclotropia leads to a severe disturbance in the peripheral visual orientation under binocular conditions of seeing, even when the partner eye has a large central scotoma, and the patient has therefore no double image in the visual field centre. Under monocular conditions an adaptation of the subjective absolute localization to the objective contour orientation develops in a few days when the patient is in a normal environment with known outlines (Seaber and Machemer 1997; Tschermak 1931). But the subjective horizontal in the dark shows again a tilt corresponding to the objective rotation of the retina. XXX
Table 1.
Dosis-effect relationship of different procedures for counterrotation.
Method
Effect on subjective cyclotropia
Strabismus surgery for incyclotropia after macular translocation superior oblique recession/tenotomy 15° inferior oblique advancement 17,8° 3,7 16,8° 4,8
n
Authors
2 6 8
Akyurt, 2002 Freedman, 2003 TÜBINGEN 2004
superior oblique recession/tenotomy inferior oblique advancement supraposition of rectus externus
24,5° 5,6 24,4° 6,0
8 43
Freedman, 2003 TÜBINGEN 2004
superior oblique recession/tenotomy inferior oblique advancement vertical transposition of 2 horiz. recti
19,8° 3,5 22° (20–25) 36° 38,2° 6,3
8 4 15 24
Akyurt, 2002 Neugebauer, 2002 Freedman, 2002 Freedman, 2003
superior oblique recession/tenotomy inferior oblique advancement partial transposition of 4 recti
21,6°(6–31) 35° 9,7 (17–56)
23 27
Neugebauer, 2002 Abdel-Meguid, 2003
superior oblique transposition inferior oblique advancement
27,8 1,8
superior oblique transposition inferior oblique advancement vertical transposition of 2 horiz. recti
40–45°
5
Akurt, 2002 Fricke, 2002
Despite this monocular adaptation most patients tilt their head to the side of the operated eye when the macula was rotated upwards as in most cases. The head tilt takes place unconsciously and the patient is not aware of it. Obviously, there exist subcortical connections between the subjective contour orientation and the vestibular apparatus, which try to diminish a retinal tilt. This observation corresponds to the findings of an experiment in normal observers. In this experiment a large visual stimulus with vertical stripes was tilted and the stimulated eye reacted with a partial compensating static torsional movement (Heßel and Herzau 1984). A further aspect of a possible sensorial problem after macular translocation arises from the fact that the rotation involves the retina only and not the optic nerve. The line of photoreceptors, which provides the perception of horizontal, is thus not shifted in a straight but in a curved line. The amount of torsion increases therefore from the blind spot in the temporal periphery to the center of the visual field; and straight contours should be perceived not only tilted but also curved. The patients do not report corresponding complaints, but the different torsional angle depending on eccentricity is certainly a further obstacle for binocular fusion.
3
TREATMENT FOR BINOCULAR PROBLEMS AFTER MACULAR TRANSLOCATION SURGERY
The major complaint from all these disturbances of binocular vision after macular translocation is the image tilt. It requires a counterrotation of the globe by muscle surgery either in the same session when the retinal rotation is done (Eckardt, Eckardt et al. 1999; Fujikado, Shimojyo et al. 2002) or at a later stage. In most cases counterrotation is carried out together with the silicon oil removal 3 to 6 month later. The stepwise procedure has the advantage that a subjective measurement of the induced cyclotropia is possible and that the amount of dosage can be adjusted. Furthermore, it can be judged if a counterrotation is actually necessary in the individual patient. XXXI
Figure 4. Schematic drawing of inferior oblique advancement with secured superior oblique tenotomy (center), and rectus externus supraposition (right picture), see text.
The assessment of the cyclodeviation is mostly done with the double Maddox-rod technique for measurement of the subjective horizontal and the cyclotropia. We use in Germany preferably the Harms tangent screen for both. A literature survey of the different procedures for counterrotation and the respective rotational effect is given in table 1. Our observations in Tübingen are included. Only excyclorotational operations are taken into account. In almost all cases a combined surgery of the oblique muscles of the involved eye was done with large recession or tenotomy of the superior oblique and maximum advancement of the inferior oblique. But the rotational effect of 16 degrees is not sufficient in almost all cases. Further muscle displacements are therefore added. This includes the vertical transposition of one or both horizontal rectus muscles, or a partial transposition of all four rectus muscles. In the latter method only stripes of the rectus muscles were transposed by crossing the stripes under the not sectioned part of the muscle in a clockwise direction in the right eye and in a counterclockwise direction in the left eye. The stripes are then fixated at the insertion of the adjoining rectus muscle. It is obvious that a re-operation after this procedure will be difficult. The described cyclorotational effect of these 3 to 6 muscle operations is quite different in the literature. There is a range between 20 and 38 degrees, which can be possibly explained by a different manoeuvre on the oblique muscles. Our standard procedure up to now was a three or four muscle surgery as depicted in figure 4. The left picture shows a right eye from the temporal side preoperatively with the insertions of both oblique muscles. In the center the inferior oblique muscle is advanced to the superior oblique insertion, and a superior oblique tenotomy has been done, secured by a loose suture. This rotates the globe about 17 degrees outwards. The rotation is then augmented by a vertical transposition of the lateral rectus muscle or of both horizontal recti. Because the macular translocation produces incyclotropias of mostly 30 to 50° many patients are not freed from their image tilting after the first operation. Further surgery on the other eye is then necessary. At the second muscle operation additional deviations, such as an exotropia can be taken into account. An other option, which induces a stronger excyclorotational effect, is the transposition of the superior oblique tendon from the upper temporal to the lower nasal quadrant at the nasal inferior rectus insertion by crossing the tendon under the medial rectus muscle. In combination with inferior oblique advancement and vertical transposition of two horizontal recti effects up to 45° are published. The described muscle surgery with very large dosage for a comitant deviation induces necessarily unwanted incomitances, as the photographs in different gaze positions demonstrate (fig. 5). The operation on the oblique muscles for incyclotropia produces a depression deficit with a V-phenomenon similar to a long-standing superior oblique palsy. It reduces the hypotropia in primary position, but in down gaze an eso- and hypertropia with diplopia can occur. A vertical transposition of the horizontal recti may partly diminish the V-effect. In the primary position the cyclotropia and the hypotropia of the left eye are almost repaired in this patient, but the corneal reflex of the left fixating eye is still displaced downward. We explain XXXII
Figure 5. First postoperative day after an excyclorotational procedure of the left eye as in figure 4.
Figure 6. Residual incyclotropia after macular translocation and muscular counterrotation, see text.
this finding by the different centres of rotation: The retinal surgery rotates around the optic nerve head, the muscular counterrotation around the posterior pole of the globe. Figure 5 shows the central fundus of a right eye after macular translocation and after muscular counterrotation, which has reduced the incyclotropia from 35 to 10 degrees. The chorioidal scar marks the posterior pole of the globe around which the counterrotation has taken place. By this, the muscle surgery rotates the optic nerve head upwards and shifts the fovea only a small amount temporally. To fixate with the fovea the patient has therefore to rotate the eye upwards, which moves the corneal light reflex downwards. The indication for the correction of a residual horizontal or vertical strabismus should be made dependent on the degree of problems with diplopia. Many of the patients do not suffer so much from double vision once the cyclotropia has been successfully treated. Obviously, when the double image is not tilted it can be suppressed much easier. Scotomata in the visual field centre of the non-fixating eye hinder additionally the perception of a double image. In cases with disturbing vertical or horizontal diplopia often a prismatic correction is sufficient to provide a diplopia free field around the primary position, otherwise conventional eye muscle surgery is necessary, taking into account the blood supply of the anterior segment. In general, the better the visual outcome from the macular transposition the more binocular problems arise. ACKNOWLEDGEMENT This study has been supported by the Tistou and Charlotte Kerstan Stiftung XXXIII
REFERENCES Abdel-Meguid, A., A. Lappas, et al. 2003. One year follow up of macular translocation with 360 degree retinotomy in patients with age related macular degeneration. Br J Ophthalmol 87: 615–621. Akyurt, A. 2002. Die Zyklotropie nach der Makulatranslokation und deren chirurgische Behandlung. Klin Monatsbl Augenheilkd 219(1–2): 50–54. Eckardt, C., U. Eckardt, et al. 1999. Macular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 237(4): 313–325. Freedman, S. F., M. D. Gearinger, et al. 2003. Measurement of ocular torsion after macular translocation: disc fovea angle and Maddox rod. J Aapos 7(2): 103–107. Freedman, S. F., S. Holgado, et al. 2003. Management of ocular torsion and diplopia after macular translocation for age-related macular degeneration: prospective clinical study. Am J Ophthalmol 136(4): 640–648. Fricke, J. and A. Neugebauer 2002. Augenmuskelchirurgische Gegenrotation nach Makulatranslokation. Ophthalmologe 99(3): 160–163. Fujikado, T., H. Shimojyo, et al. 2002. Effect of simultaneous oblique muscle surgery in foveal translocation by 360 degrees retinotomy. Graefes Arch Clin Exp Ophthalmol 240(1): 21–30. Heßel, L. and V. Herzau 1984. Erfolgt die fusionale Zyklovergenz nach dem Hering’schen Gesetz? orthoptikpleoptik 11: 45–51. Machemer, R. and U. H. Steinhorst 1993. Retinal separation, retinotomy, and macular relocation: II. A surgical approach for age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 231: 635–641. Neugebauer, A., J. Fricke, et al. 2002. Zyklotropie bei Makulatranslokation. Mögliche augenmuskelchirurgische Lösungen. Ophthalmologe 99(1): 10–14. Seaber, J. H. and R. Machemer 1997. Adaptation to monocular torsion after macular translocation. Graefes Arch Clin Exp Ophthalmol 235(2): 76–81. Tschermak, A. 1931. Optischer Raumsinn. In: A. Bethe, G. v. Bergmann et al. (eds.), Handbuch der normalen und pathologischen Physiologie, Band XII, 2. Hälfte: 834, Berlin: J. Springer
XXXIV
Session 1⫹2: Amblyopia
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Effects of early and late onset strabismic amblyopia on magnocellular and parvocellular visual function John J Sloper, Alison R Davis, Magella M Neveu & Chris R Hogg Moorfields Eye Hospital, City Road, London, U.K.
Michael J Morgan & Graham E Holder City University, London, U.K.
ABSTRACT: Contrast sensitivities were measured to an achromatic 0.8 c.p.d. grating with rapid onset to measure magnocellular sensitivity and to a red-green isoluminant grating of 3.2 c.p.d. and a slow onset to assess parvocellular function. Fifteen early and fourteen late onset strabismic amblyopes with similar ranges of visual acuity were studied and the data compared with those from 15 age-matched normal subjects. Both luminance and colour CS were significantly lower in the amblyopic than fellow eyes of all amblyopes. For luminance CS this difference was due both to an increased CS in the fellow eye and a reduced CS in the amblyopic eye. Colour CS was greatly reduced in both the amblyopic and fellow eyes of early and late onset strabismic amblyopes compared to normal. The reduction of colour CS compared to luminance CS was significantly greater in the amblyopic eyes of late onset than early onset amblyopes. 1
INTRODUCTION
Evidence from primate studies has shown that monocular visual deprivation has different effects on the anatomy of the magnocellular (M) and parvocellular (P) pathways depending on age of onset of the deprivation (Headon, Sloper, Hiorns and Powell 1985; Sloper 1993). In human strabismic amblyopes, pattern appearance VEPs and contrast sensitivity to a 3.2 c.p.d. achromatic grating show marked differences in the changes found between strabismic amblyopes with an onset before or after 18 months of age indicating the presence of two distinctly different periods of developmental sensitivity in man (Davis, Sloper, Neveu, Hogg, Morgan and Holder 2003). The present study has used luminance and colour contrast sensitivity (CS) measurements to see whether adult human strabismic amblyopes show differences in the function of their M and P pathways and whether these differ with age of onset. 2
METHODS
Contrast sensitivities were measured with a staircase method using an achromatic 0.8 c.p.d. grating with rapid onset to measure magnocellular sensitivity and a red-green isoluminant grating of 3.2 c.p.d. and a slow onset to assess parvocellular function. Fifteen early and fourteen late onset strabismic amblyopes with similar ranges of visual acuity were studied and the data compared to those from 15 age-matched normal control subjects. 3
RESULTS
Both luminance and colour CS were significantly lower in the amblyopic than fellow eyes of all amblyopes (Figs 1 & 2; both P 0.01: paired t-tests). For luminance CS this difference was due 3
Figure 1.
Luminance contrast sensitivities. Error bars 1 s.d.
Figure 2.
Colour contrast sensitivities. Error bars 1 s.d.
both to an increased CS in the fellow eye and a reduced CS in the amblyopic eye. Colour CS was reduced in both the amblyopic and fellow eyes of early and late onset strabismic amblyopes compared to normal (all P 0.001 unpaired t-tests). The reduction of colour CS compared to luminance CS was quantified by calculating the ratio:
This ratio approaches one as colour CS declines relative to Luminance CS. The mean ratio for normal subjects was 0.78. This was increased in the amblyopic eyes of early and late onset groups (Fig. 3; both P 0.001; unpaired t-test c.f. normal) and in the fellow eyes of both groups (Fig. 3; both P 0.05; unpaired t-test c.f. normal). The difference between amblyopic and fellow eyes was significant for both and early and late onset groups (both P 0.05; paired t-test). The ratio was significantly greater in the amblyopic eyes of the late onset than early onset group indicating greater relative depression of parvocellular function in the late onset group (Fig. 3, P 0.05; unpaired t-test). 4
Figure 3.
4
Ratios of magnocellular to parvocellular contrast sensitivity (see text). Error bars 1 s.d.
DISCUSSION
Amblyopic eyes of adult strabismic amblyopes show reduced contrast sensitivity to both a parvocellular and magnocellular biased stimulus when compared to the sensitivity of the fellow eye. However, when compared to normal subjects, both amblyopic and fellow eyes show a depression of parvocellular sensitivity compared to normal, with more reduction in the amblyopic eye. The difference between amblyopic and fellow eyes in sensitivity to a magnocellular stimulus is as much due to an increase in sensitivity of the fellow eye as to reduced sensitivity of the amblyopic eye. Thus in both amblyopic and fellow eyes there is a reduction in parvocellular sensitivity relative to magnocellular sensitivity. This was confirmed by calculating a ratio of parvocellular to magnocellular sensitivity. There is an interesting parallel between this and the relative reduction of parvocellular to magnocellular cell size seen for both deprived and undeprived LGN cells following long-term visual deprivation in non-human primates (Headon, Sloper, Hiorns and Powell 1985) The difference in sensitivity between magno and parvocellular pathways is more marked in the amblyopes with an age of onset after 18 months of age. This is in keeping with the evidence for differences between the anatomical effects of early and late onset visual deprivation in primates (Headon, Sloper, Hiorns and Powell 1985; Sloper 1993) and the electrophysiological and psychophysical differences between early and late onset human strabismic amblyopes (Davis, Sloper, Neveu, Hogg, Morgan and Holder 2003)
REFERENCES Davis, A.R., Sloper, J.J., Neveu, M.M., Hogg, C.R., Morgan, M.J. & Holder, G.E. (2003). Electrophysiological and psychophysical Differences bcetween Early- and Late-Onset Strabismic Amblyopia. Investigative Ophthalmology and Visual Science, 44: 610–617. Headon, M.P., Sloper, J.J., Hiorns, R.W. & Powell, T.P.S. (1985). Effects of Monocular Closure at Different Ages on Deprived and Undeprived Cells in the Primate Lateral Geniculate Nucleus. Developmental Brain Research, 18: 57–78. Sloper, J.J. (1993). Edridge-Green Lecture. Competition and Cooperation in Visual Development. Eye, 7: 319–331.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
MRI measurements of horizontal rectus muscles in esotropia: the role of amblyopia . F.M. Mutlu, G. Dinçer, H. Durukan, T. Mumcuog ˘ lu & H.I. Altnsoy GATA Department of Ophthalmology, Ankara, TURKEY
ABSTRACT: Purpose: To evaluate the thickness of horizontal rectus muscles in patients with esotropia by using magnetic resonance imaging (MRI), and to determine the effect of amblyopia on muscle tickness. Methods: Eighteen orthotropic volunteers and 50 patients with non-refractive and non-acommodative esotropia underwent orbital imaging prospectively. Esotropic patients were divided into 2 groups according to existance of amblyopia: Group I, 26 patients with amblyopia; group II, 24 patients with good visual acuity and alternating fixation. MRI was performed by using a fixation target and occluding each eye separetely. All MRI images were performed with axial T1 weighting by using 2 mm slice tickness. Mean tickness of horizontal rectus muscles of both groups were compared with that of the control group of the same age and sex. Results: The thickest MR (3.84 0.88 mm) and the thinnest lateral rectus (1.92 0.68 mm) values were with the amblyopic eye of group I. Lateral rectus thickness in the amblyopic eye of group I (1.92 0.68 mm) was thinner than both group II (2.37 0.59 mm) and controls (2.91 0.94 mm) (respectively p 0.029; p 0.000) The difference between the mean tickness of the medial rectus muscles of amblyopic eye of group I (3.84 0.88 mm) and controls (3.16 0.60 mm) was also significant (p 0.001). Conclusions: There are significant morphometric changes of horizontal rectus muscles in patients with non-refractive and non-acommodative esotropia and amblyopia. Further studies are necessary for different types of strabismus, and the correlation between our findings and surgical outcomes.
1
INTRODUCTION
Strabismus is a frequently encountered ophthalmic problem which results in visual, cosmetic and socioeconomic problems. Several mechanisms have been suggested to explain this challenging problem. So far, there is no data to explain whether strabismus occured due to central or peripheral nervous system abnormalities or anomalies of extraocular muscles (EOM) or both. Whatever the mechanism, EOMs should be affected morphologically. The outcomes of strabismus surgery may be corralated with various factors one of which is morphological (Domenici-Lombardo, 1992) and structural (Martinez, 1980) abnormalities of extraocular muscles. Besides, Weakly et al. (1997) reported a correlation between the surgical outcomes of esotropia with and without amblyopia. The aim of the present study is to evaluate the thickness of horizontal rectus muscles in esotropic patients by using magnetic resonance imaging, and to determine the effect of amblyopia on muscle tickness.
2
METHODS
The MRI studies were done on 50 consecutive patients with esotropia (all males with a range of age of 20 to 25 years of age), and 18 sex and age matched healty volunteer subjects with normal eyes, 7
visual acuity and ocular motility at the Ophthalmology Department of our institution between January 2001 and April 2002. All patients with non-refractive and non-acommodative esotropia (onset of esotropia prior to 5 year of age and refractive error less than 3.00 spherical equivalent) included the study in group I and II. Patients of group I had amblyopia but group II patients did not have amblyopia. Those with associated features below were not included the study. The history of previous ocular surgery or inflammation (Domenici-Lombardo, 1992), ocular and systemic pathologies such as diabetes mellitus (Martinez, 1980), thyroid disease, high myopia, orbital or rethinal pathologies (Weakley, 1997) amblyopia other than strabismic, visual acuity less than 0.2 Snellen lines in amblyopic eye (Byrne, 1991), paralytic or restrictive strabismus (Lee, 2001). All subjects underwent a complete ocular examination, with particular attention to ocular motility. A total of 50 patiens with esotropia were divided into 2 groups. Group I comprised of 26 esotropia patients with amblyopia, and group II comprised of 24 esotropia patiens without amblyopia and with alternating fixation. All subjects were examined by 1.5 Tesla, superconducting MRI scanner (Vision Plus, Siemens, Erlangen, Germany) using a circulary polarized head coil. After apropriate localization and fixation of the head with standard fixation devices, scout images were obtained in three orhogonal planes. Contiguous axial T1 weighted (583/15 ms, TR/TE, one exitation) spin-echo images parallel to the optic nerves seen on saggital scout images were obtained by using 2 mm slice thickness without any intersection gap, 220 220 mm field of view (FOV) and 256 256 matrix size. Each eye was imaged separetely, while the other was occluded. The imaging eye was fixed by using a 1.5-cmdiameter, black fixation target located in head coil 17 cm away from anterior eye plain. After adjusment of appropriate window settings, horizontal diameters of medial and lateral rectus muscles were measured directly with a calipper on magnified images with the same magnification factor and then converted to true dimentions in millimeters by using standard reference scale of the system. Results are reported as the mean standard deviation (SD). Differences between the groups were tested for significance by Kruskall Wallis, Bonferroni adjusted Mann-Whitney U test, t-Test and Chi-Square test. Differences were considered significant at p 0.05. Statistical analysis was performed with Statistical Package for the Social Sciences for Windows (SPSS Inc, version 10.0, Chicago, Il, USA). 3
RESULTS
All subjects were males. The mean age of control group was 21.3 1.4 years (range 21 to 23 years), and 21.8 1.6 years (range 20 to 24 years) for patients with esotropia (p 0.887). There was no difference between group I and II according to age (p 0.780), gender, angle of deviation (p 0.191) and laterality (p 0.893). Mean values and ranges for thickness of medial and lateral rectus of all groups are given in Table 1. Table 1.
Muscle thickness of fixating and deviating eyes within groups. MR
LRV
Groups
Mean SD (mm)
Range (mm)
Mean SD (mm)
Range (mm)
Control (n 36)
3.16 0.60
2.00–4.00
2.91 0.94
1.50–4.00
I DE (n 26) FE (n 26)
3.84 0.88 3.53 1.17
2.50–6.00 2.00–6.00
1.92 0.68 2.46 1.24
1.00–3.00 1.00–4.00
II DE (n 24) FE (n 24)
3.45 0.91 3.50 0.62
2.00–5.00 2.50–4.00
2.37 0.59 2.20 0.70
1.50–3.50 1.50–3.50
SD: Standard deviation; MR: Medial rectus; LR: Lateral rectus; DE: Deviating eye; FE: Fixating eye.
8
The differences between thickness of medial and lateral rectus of group I and controls were significant (p 0.001; p 0.000, respectively). So, MR muscle is thicker and LR muscle is thinner in deviating eye of patients with esotropia and amblyopia with respect to controls. In contrast, there was no difference between the thickness of MR and LR of controls and fixating eye of group I patients (p 0.158; p 0.106, respectively). LR thickness of deviating and fixating eyes of group II were significantly thinner with respect to controls (p 0.03; p 0.02). LR muscle thickness of deviating (amblyopic) eyes of group I is significantly thinner than group II (p 0.029). The differences of thickness of MR and LR of fixating eyes of both group I and II were insignificant (p 0.810; p 0.609, respectively). 4
CONCLUSION
The pathogenesis of strabismus is unclear. Some believe that mechanical factors related with anomalies of the EOMs or their tendinous insertion cause strabismus while others support the hypothesis that strabismus is mainly due to central or pheriferal innervational factors. Strabismus can be with good visual acuity or amblyopia. Consistent with Weakley’s study [ ] we have seen that surgical results of esotropic patients with amblyopia is poor with respect to the patients without amblyopia (Weakley, 1997). Additionally, we have seen that thickness of medial or lateral recti may vary significantly in some patients with esotropia. Although various reports have been published, there is no report that evaluates the correlation between thickness of EOM and amblyopia in patients with esotropia. The aim of our study was to evaluate the thickness of horizontal rectus muscles in esotropic patients by using magnetic resonance imaging (MRI), and to determine the correlation of amblyopia and horizontal rectus muscle thickness. Morphological and structural properties of EOMs have been investigated using different techniques such as histopathology, ecography (Demer, 1994a), computer tomography (CT) (Lee, 2001) and magnetic resonance imaging (MRI) (Bloom, 1993). These techniques could provide useful information for clinical diagnosis, classification, and treatment of EOM disorders. Although non-invasive, standardized echography has disadvantage of significant variabilities in echographic measurements. CT has been used in evaluation of EOM. However, the exposure to X-ray radiation is a significant disadvantage of the CT. Recently, MRI has been widely used in clinical diagnosis of different ocular motor disorders. It is possible to demostrate morphological and morphometric changes of EOMs with MRI. Muscle thickness, a morphometric analysis, can give useful information about the changes of EOM in different types of strabismus. Measuring the thickness of an EOM by MRI is the one of the methods to quantitatively evaluate the size of EOMs in a practically, easy-to-use and noninvasively. We considered only cases with the same sex and the same age group. All pathologic eyes which are of potential for changes in EOMs were excluded from the study. Although there is no study that reports the effect of deviation angle to the muscle thickness, we considered the cases with 20 to 45 prism diopter deviation, and the difference between mean of the deviation angle of group I and II was insignificant. Although cross-sectional area of EOMs by using coronal sections may give useful information about the thickness of EOMs, we prefered to use data obtained on axial sections to calculate the thickness for EOMs. It is reported that visualization of an EOM is optimal if the plane of the section is parallel to the course of the muscle on CT scans. The size and shape of recti muscles are depended on the direction of the patient’s gaze, with contracted muscles having a greater cross-sectional area (Demer, 1994b). For this reason each eye of patients and controls were occluded seperately, and subjects were asked to maintain their fixation to fixation target during the scans to prevent asymmetric extraocular muscle contraction. Tian et al. also used similar monoocular fixation in their study (Tian, 2000). Scheiber et al. reported that a fixation target located 10 to 30 cm far from the anterior eye plain can result in acommodation and convergence reflex in binocular viewing, and the measurements of EOM thickness can be affected (Scheiber, 1997). For this reason, we patched one eye of each patient, and all patients used the same fixation target for each eye seperately to take the measurements at the same position. 9
Although there was no difference between the thickness of horizontal EOMs of deviating and fixating eyes of esotropic patients with and without amblyopia, the LR muscle thickness of deviating eye of amblyopic patients and LR muscle thickness of both eyes of non-amblyopic patients were thinner with respect to controls. Additionally, MR muscle of deviating eye of amblyopic patients (group II) is thicker with respect to controls. LR muscle of deviating eye of esotropic patients with amblyopia (group I) is thinner with respect to esotropic patients without amblyopia (group II). There is no difference between MR thickness of esotropic patients with or without amblyopia. LR muscle thickness of all esotropic patients, especially patients with amblyopia, is thinner with respect to controls. Although there are significant morphometric changes of medial and lateral recti of esotropic patients, it should be speculative to conclude whether these morphometric changes are cause or result of strabismus. However, changes of EOM thickness are significant in patients with amblyopia with respect to patients with alternating fixation in concommitant strabismus. This finding maybe explain poor surgical outcome on patients with strabismus and amblyopia. Further studies are necessary for deviation angle and morphometric changes, and surgical success in patients with concommitant strabismus and amblyopia.
REFERENCES Bloom J. N. et al. 1993. A magnetic resonance imaging study of horizontal rectus muscle palsies. J Pedatr Ophthalmol Strabismus 30: 296–300. Demer J. L. et al. 1994a. Comparison of standardized echography with magnetic resonance imaging to measure extraocular muscle size. Am J Ophthalmol. 118: 351–361. Demer J. L. et al. 1994b. Quantitative magnetic resonance morphometry of extraocular muscles: a new diagnostic tool in paralytic strabismus. J Pediatr Ophthalmol Strabismus 31: 177–88. Domenici-Lombardo L. et al. 1992. Extraocular muscles in congenital strabismus: muscle fiber and nerve ending ultrastructure according to different regions. Ophthalmologica 205: 29–39. Lee J. S. et al. 2001. Normative measurement of Korean orbital structures revealed by computerized Tomography. Acta Ophthalmol. 79: 197–200. Martinez A. J. et al. 1980. Structural features of extraocular muscles of children with strabismus. Arch Ophthalmol. 98: 533–9. Scheiber C. et al. 1997. Technique for MRI of ocular motility. J Comput Assist Tomogr. 21: 442–6. Tian S. et al. 2000. MRI measurements of normal extraocularmuscles and other orbital structures. Graefes Arch Clin Exp Ophthalmol. 238: 393–404. Weakley D. R. & Holland D. R. 1997. Effect of ongoing treatment of amblyopia on surgical outcome in esotropia. J Pediatr Ophthalmol. Strab. 34: 275–278.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Combined optical and atropine penalization in the treatment of amblyopia S. Zıylan, Ö. Yabas & D. Serin Sisli Etfal Education and Research Hospital, Istanbul, Turkey
ABSTRACT: We aimed to evaluate the effectiveness of combined optical and atropine therapy in the treatment of anisometropic or strabismic amblyopia. Patients in the penalization group were instructed to instill 1 drop of 1% atropine sulphate in the fellow eye daily and their spectacle prescription for the fellow eye was replaced with a plano lens. A control group was treated with full time patching. The treatment continued until the visual acuity of the amblyopic eye became 1.0 or stayed the same after 3 consecutive visits. The mean follow-up was 6 months. At the end of the therapy, improvement of visual acuity did not show significant difference between the two groups. Combined optical and atropine therapy is effective as an alternative or supportive therapy for anisometropic or strabismic amblyopia.
1
INTRODUCTION
Amblyopia is defined as a decrease of visual acuity in one eye caused by abnormal binocular interaction or occurring in one or both eyes as a result of pattern vision deprivation during visual immaturity for which no cause can be detected during the physical examination of the eye(s) and which in appropriate cases is reversible by therapeutic measures (von Noorden 1977). Amblyopia occurs in approximately 2% of the population and it is the most common cause of decreased vision in childhood. The basic strategy for treating amblyopia is to provide a clear retinal image first and then correct ocular dominance. Correction of ocular dominance is accomplished by forcing fixation to the amblyopic eye by patching or blurring the vision of the sound eye (penalization) (Wright 1995). Patching by patching has been the mainstay of amblyopia treatment (von Noorden 2002). However, there are some disadvantages of patching treatment such as its high cost, allergic skin reactions and social stigmatization. These factors lead to noncompliance and failure of therapy (Simons 1996, Woodroff 1994). Optical and atropine penalization have been found to be effective as alternatives to patching in suitable cases and these two methods might have an additive effect when combined (Foley-Nolan et al. 1997, Repka & Ray 1993, France & France 1999). This study aimed to evaluate the effectiveness of combined optical and atropine penalization as an alternative to patching in the treatment of anisometropic or strabismic amblyopia.
2
METHODS
In this study, we reviewed two groups of patients with anisometropic or strabismic amblyopia. The first group consisted of patients receiving combined optical and atropine therapy (COAT group). The second group, identified as the patch group, included patients receiving full time patching therapy. The following data were recorded for each patient at the initial visit: age, gender, cycloplegic refraction, best corrected visual acuity, type of amblyopia and type and amount of strabismus if present. Follow up visits were made every 3 to 4 weeks. The treatment continued at least for 11
3 months unless the visual acuity (VA) of both eyes became equal earlier. The treatment was discontinued if the VA of the amblyopic eye stayed the same after 3 consecutive visits. Long term follow up visits were made at 2 to 6 month intervals. Refraction was documented at the initial visit by cycloplegic retinoscopy 30 minutes after one drop of 1% cyclopentolate in each eye. Spherical equivalent was calculated as the algebraic sum of the sphere power and half of the cylinder power. VA of each eye was measured with Snellen linear optotypes or the tumbling E chart at each visit and converted to logMAR units for statistical analysis. In the evaluation of the data unpaired and paired Student’s t tests and chi-square analysis were used. In strabismic patients, the amount of strabismus was measured with simultaneous prism cover test at distance and near. 2.1
COAT group
This group of patients either was noncompliant to patching therapy or failed to show any improvement despite apparent compliance. Before starting COAT patients had stopped patching for at least 3 months. At the initial visit the full cycloplegic refraction was prescribed to the amblyopic eye, while the prescription for the sound eye was replaced with a plano lens. Also patients were instructed to instill one drop of 1% atropine sulphate in the sound eye daily. The near vision of the sound eye was blurred by the iatrogenic accommodation paralysis that atropine provided and its distance VA was decreased with the plano lens. By penalizing the sound with these methods the amblyopic eye was forced to take up fixation. At follow up visits, VA of both eyes was recorded. Compliance was confirmed with dynamic retinoscopy. It was ensured at each follow up visit that the corrected VA of the amblyopic eye was higher than the uncorrected VA of the atropinized sound eye at distance and near. After the discontinuation of therapy, patients resumed full spectacle prescription. At long term follow up visits part time patching was started as maintenance therapy if necessary. The VA of the amblyopic eye at the last visit was recorded as the long term follow up VA. 2.2
Patch group
At the initial visit the full cycloplegic refraction was prescribed to both eyes. Patients were instructed to occlude the sound eye with adhesive skin patches during waking hours. At follow up visits VA of both eyes was recorded. For patients who responded well to the treatment the amount of patching could be reduced. Compliance was determined by questioning the parents. At long term follow up visits maintenance therapy with part time patching was offered if necessary. The VA of the amblyopic eye at the last visit was recorded as the long term follow up VA.
3
RESULTS
30 patients were treated with combined optical and atropine penalization and 20 patients were treated with full time patching. The age range was 3 to 8 years. There was no difference between groups concerning years of age (p 0.05). Between the two groups there was a small but significant difference for initial VA (p 0.001). Patients in the patch group had lower initial VA than the ones in the COAT group. The mean duration of therapy was 3.73 (SD: 1.46) months in the COAT group and 3.95 (SD: 1.39) months in the patch group (p 0.05). The mean refractive errors of the amblyopic and fellow eyes in COAT were 5.09 1.84 and 4.08 1.97 respectively, while the mean refractive errors of the amblyopic and fellow eyes in patch group were 4.80 1.78 and 3.60 2.01 (p 0.05). The improvement in VA in both treatment groups was significantly high (p 0.001). There was no significant difference between the groups regarding the efficacy of treatment (p 0.05). The improvement in VA was similar in strabismic and anisometropic amblyopic patients (p 0.05) in both groups. 12
Table 1.
Types of amblyopia among treatment groups. Type of amblyopia
Groups
Strabismic
Anisometropic
COAT Patch
19 11
12 8
Table 2.
Mean visual acuities before and at the end of therapy. COAT
Pre-treatment Post-treatment p
Table 3.
Patch
LogMAR
Snellen
LogMAR
Snellen
0.49 0.21 0.17 0.13 0.0001
0.35 0.69
0.75 0.30 0.26 0.16 0.0001
0.22 0.57
Improvement in visual acuity at the end of treatment. COAT
Improvement in VA
Patch
Snellen lines
LogMAR (%)
Snellen lines
LogMAR (%)
p
0.34
63.40 21.95
0.35
64.41 22.86
0.05
When we stratified both treatment groups as initial VA 20/40 and initial VA 20/40, we did not find any significant difference in the amount of improvement (p 0.05). Ten patients in the COAT group and ten in the patch group were evaluated for long term visual outcome. The mean long term follow up time was 24 months in the COAT group and 23 months in the patch group. There was no significant difference between the VA at the end of treatment and VA at the end of long term follow up (p 0.05). 4
DISCUSSION
Amblyopia is one of the leading causes of monocular visual loss. Occlusion therapy, described 250 years ago, is still accepted as the gold standard. However, occlusion is beset with compliance problems, adhesive sensitivity, stigmatization and regression. Also, occlusion may not be an ideal solution in latent nystagmus and intermittent strabismus. In these situations, penalization therapy might be especially successful (Kaye et al. 2002). Pharmacological penalization has often been reserved for patients who are noncompliant with occlusion (Repka & Ray 1993). In a multicenter randomized trial comparing atropine with patching, the effect of atropine alone was comparable with full time occlusion (The Pediatric eye disease investigator group 2003). In another study of this group it was pointed out that although both atropine and patching were well tolerated, atropine was the favored choice of parents (The Pediatric eye disease investigator group 2002). In our study group the compliance rate for COAT was 97%. According to Simons et al. occlusion or atropine treatment did not cause any different outcome on either VA or binocularity measures. They also claimed that penalization is an attractive alternative for parents’ and patients’ acceptability (Simons 1997). In Repka & Ray’s study, it is stated that pharmacological penalization is best used by patients with high degrees of amblyopia (20/60), where as optical penalization is best reserved for 13
patients with lesser amblyopia (20/25–20/60) (Repka & Ray 1993). In our study, when amblyopes were stratified as VA 20/40 and VA 20/40, difference in the magnitude of improvement was not significant in neither of the treatment groups (p 0.05). Our data suggest that COAT can be as successful as patching in mild and moderate amblyopia. As Kaye et al suggest, COAT has a more rapid effect than a single modality penalization therapy but it produces a potentially higher risk of reverse amblyopia (Kaye et al. 2002). Reverse amblyopia in occlusion therapy was more common in a different study (Repka & Ray 1993). North & Kelly reported that 2 of their 189 patients suffered from permanent amblyopia after pharmacological penalization (North & Kelly 1991). In our study we also were faced with reverse amblyopia in two cases. One family is lost to follow up because of reverse patching. We think that close follow up is very important in penalization therapy.
5
CONCLUSIONS
This study can not prove one treatment is superior over to the other. In our experience, combined optical and atropine therapy is as effective as patching and can be used as an alternative or supportive treatment to occlusion therapy in the management of amblyopia in chosen subjects, especially in school age children.
REFERENCES Foley-Nolan A. et al. 1997. Atropine penalisation versus occlusion as primary treatment for amblyopia. Br J Ophthalmol 81: 5–7 Kaye et al. 2002. Combined optical and atropine penalization for the treatment of strabismic and anisometropic amblyopia. Journal of AAPOS 6: 289–93 Noorden G. K von 1997. Mechanisms of amblyopia. Doc Ophthalmol 34: 93 Noorden G. K von 2002. Binocular vision and ocular motility: 546. St Louis: Mosby North R. V. & Kelly M. E. 1991. Atropine occlusion in the treatment of strabismic amblyopia and its effect upon the non-amblyopic eye. Ophthalmic Physiol Opt 11: 113–7 The pediatric eye disease investigator group 2002. A randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol 120: 268–78 The pediatric eye disease investigator group 2003. A comparison of atropine and patching treatments for moderate amblyopia by patient age, cause of amblyopia, depth of amblyopia, and other factors. Ophthalmology 110: 1632–8 Repka M. X. & Ray J. M. 1993. The efficacy of optical and pharmacological penalization. Ophthalmology 100: 769–74 Simons K. 1996. Preschool vision screening: rationale, methodology, outcome. Surv Ophthalmol 41: 3–30 Thomas D. F. & Leslie W. F. 1999. Optical penalization can improve vision after occlusion treatment. Journal of AAPOS 3(4): 241–4 Woodroff G. 1994. Factors affecting the outcome of children treated for amblyopia. Eye 8(6): 623–6. Wright K. W. 1995. Pediatric ophthalmology and strabismus: 130 St.Louis: Mosby
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Telescopic spectacle therapy in amblyopia and its efficacy in cases over 9 years of age . Umut Arslan, Huban Atilla, Aysun Idil & Necile Erkam Ankara University School of Medicine, Department of Ophthalmology Ankara/TURKEY
ABSTRACT: Purpose: To investigate the efficacy and applicability of telescopic spectacle in amblyopia therapy in association with occlusion, and to obtain the effects of this therapy in cases over 9 years of age. Material and Method: Ninety-eight cases with monocular amblyopia (visual acuity of the better eye was 20/20) were included in the study between May 2002 and November 2003 and 4 groups were formed according to telescopic spectacles prescription and the age. Group A was composed of 34 cases over 9 years of age for whom telescopic spectacles and patching therapies were given, group B included 32 cases over 9 years of age for whom only patching was given, 18 cases that are younger than 9 years of age in group C had telescopic spectacles and patching therapies and 14 cases, younger than 9 years of age in group D had only patching therapy. Groups were compared in terms of compliance to the therapy, visual improvement, and binocular functions. VEP amplitudes and latencies were compared for objective evidence of improvement. Results: Statistically significant increase in visual acuity was obtained in all cases who showed compliance to therapy regardless of the age. However, binocular functions were significantly better and improved more rapidly in cases less than 9 years of age.The increase in VEP amplitude was statistically significantly higher in group A after the treatment (p 0.05). Conclusion: It was found that telescopic spectacles prescription in association with patching therapy increased the compliance to the amblyopia treatment 1.4 to 2.7 folds and significant visual acuity increase can be obtained in cases over 9 years of age. Prescription of telescopic spectacles together with patching therapy is an efficient method that can be used in amblyopia therapy since it increases compliance to therapy and it creates intense visual stimulation.
1
INTRODUCTION
Amblyopia is the visual defect that is more frequently unilateral, and that can be bilateral with less frequency, and can persist despite the correction of refraction error without any pathology in the eye itself and visual tracts. Frequency of vision loss because of amblyopia is higher than that of all the visual losses because of other eye disorders including traumas in the first 45 years of age (1). The prevalence of amblyopia is reported to be 2–4% in developing and some developed countries (2–5). The best results in amblyopia treatment are obtained before 6 years of age, and success rates decrease as the age of the patient increases. An important obstacle for amblyopia treatment is the poor response to treatment after 9 years of age, at which the neural plasticity is completed (6). Most of the cases are either diagnosed too late, or the treatment delays because of compliance problems. Many cases are left without treatment for all their lives because of the belief that response to treatment is impossible after 9 years of age. Clinical observations and reports about visual improvement in the amblyopic eye of the amblyopia cases over 9 years of age that lose their good eyes with some reason indicate that neural plasticity continue, although with some slowing down (1, 7–8). The most important two factors in the treatment 15
of amblyopia are the maintenance of clear visual stimulation, and compliance to the therapy (9). Telescopic lenses are tools used in the rehabilitation of low vision that ensure enlargement and zooming of objects, seeing details, and thus providing powerful stimulation of the retina with clear visual transmissions. The purpose of this study is to investigate the efficacy and applicability of telescopic lenses as a new treatment method in amblyopia which hasn’t been reported previously under the light of our knowledge and whether it is possible or not to obtain response treatment to amblyopia cases over 9 years of age.
2
MATERIAL AND METHODS
Prospectively, 98 cases with monocular amblyopia that were followed in our department and were recently diagnosed between May 2002 and November 2003, were included in the study. In all cases, corrected and uncorrected visual acuity measurements were performed with the same Snellen visual acuity chart under similar illumination conditions, alternating prism-cover test, and/or Krimsky test, eye movements, Worth 4-Dot test, and Titmus stereotest, retinoscopy with cycloplegia, anterior segment and fundus examinations were performed. For all the cases that were included in the telescopic spectacle program, examination with near and distance with technique LVA (Low Vision Aids) and exercises for adaptation to telescopic lenses were given and pattern Visual Evoked Potential (VEP) was performed by 100% contrast with 1 Hz frequency on both eyes with 64 stimulations. Power of the LVA was calculated according to Kestenbaum rule (reciprocal of visual acuity) considering the initial visual acuity of the patient. Cases were examined in 4 groups with similar characteristics according to telescopic spectacles or 9 years of age limit, and the type of amblyopia was not taken into consideration. Groups were formed as follows: Group A 34 cases over 9 years of age, for whom patching of the good eye and telescopic lenses on the amblyopic eye were given (by adding the correction of the refractive error on the base lens whenever needed). Group B 32 cases over 9 years of age, for whom patching of the good eye was applied, without telescopic lens prescription (with correction of the refractive error). Group C 18 cases under 9 years of age, for whom patching of the good eye and telescopic lenses on the amblyopic eye were given (by adding the correction of the refractive error on the base lens whenever needed). Group D 14 cases under 9 years of age, for whom patching of the good eye, without telescopic lens (with correction of the refractive error). For all cases patching therapy for a total of 4–6 hours/day was given. At least 2 hours/day of near work or the total period of patching was considered for compliance and compliance score was evaluated as following; Near-work activities for at least 2 hours/day and at least 20 days/month Near-work activities for 1–2 hours/day and at least 20 days/month, or at least 2 hours/day and 10–20 days/month Near-work activities for 45 minutes–1 hour/day and at least 20 days/month, or at least 1–2 hours/day and 10–20 days/month Near-work activities for less than 45 minutes/day or less than 10 days/month.
() () () ()
According to the questionnaire; cases with () and () scores were considered as compliant, whereas those with () and () were considered as noncompliant. The therapy period was determined to be at least ‘AGE 2 WEEKS’ weeks (for example; 9 2 11, for age 9), and until there were no differences in the visual acuity and binocular functions in three successive examinations. Cases that were 9 years of age or under were examined once a month, and cases over 9 years of age were examined in every two months. Cycloplegic retinoscopy was repeated for all the cases at the end of the therapy. 16
At the end of the therapy, compliance to the therapy, visual acuities, changes in binocular functions, and pattern VEP changes were compared within and between the groups. The statistical analysis was performed with Wilcoxon test when comparing the results within the same group, and with Mann-Whitney test for comparisons between the groups.
3
RESULTS
In Group A (n 34 cases) with telescopic spectacles, 19 (56%) were males and 15 (44%) were females. The mean age of the cases was 15.5 years (min10–max 42). Left eye was amblyopic in twenty-three cases (67.6%), and right eye in 11 cases (32.4%). The type of the amblyopia was; anisometropic in 14 cases (41%), strabismic in 13 cases (38%), anisometropic and strabismic in 4 cases (12%), deprivation amblyopia in 3 cases (9%). Galileo telescope 2.2x was prescribed for 3 (8.8%), Kepler telescope 3.1x for 9 cases (26.5%), Kepler telescope 4.2x for 12 cases (35.3%), and Kepler telescope 6.0x for 10 cases (29.4%) in addition to patching therapy. Telescopes with 4.2x and 6.0x magnifying power were adjustable for near- and distance vision, telescopes with 2.2x and 3.1x magnifying power were fixed for infinity, and 3.0 D near vision corrections for 33 cm were added to the prescription. Before treatment, the mean visual acuity was 0.16 (0.0160.4) and 0.36 after therapy (0.0160.9) and the difference was statistically significant (p 0.001). Before therapy stereopsis was not detectable in 22 cases, and mean value for 12 cases that was detectable was 908.3 sec arc (3000 100) and 168.3 sec arc (800 60) after therapy and the difference was statistically significant (p 0.05). For 6 cases that did not have stereopsis before therapy, mean stereopsis of 600 sec of arc was detected after therapy. Before therapy fusion at distance was present in 3 cases (8.8%), in 9 cases (23%) after therapy. Thirty-two cases (94.1%) were determined to be compliant with the patching therapy. In control visits, 6 months after the completion of the therapy, it was observed that there was regression in the visual acuity of one line in one case with 20 PD esotropia (2.9%) and strabismus surgery was recommended for this case. According to the VEP results recorded before and after therapy of the 18 cases in group-A; in all cases that had increase in visual acuity as 3 Snellen lines and over , increase in amplitude and shortening in latency were observed. In 9 cases with visual acuity increase under 3 lines, 4 cases had amplitude increase and 7 cases had shortening in latency. Differences in amplitude (p 0.05) and latency (p 0.01) were statistically significant. Visual acuity increase over 9 years of age was supported with VEP findings objectively. In Group B (n 32) without telescopic spectacles, 20 (62.5%) were males, and 12 (37.5%) were females. The mean age of the cases was 19.8 years (min 10–max 43). Left eye was amblyopic in 17 cases (53.1%), and right eye in 15 cases (46.9%). The type of the amblyopia was; anisometropic in 12 cases (37.5%), strabismic in 14 cases (43.75%), anisometropic and strabismic in 4 cases (12.5%), deprivation amblyopia in 2 cases (6.25%). Compliance with patching therapy was 34.4% (in 11 cases). It was noted that the compliant cases were either with initial functional visual acuity or in ages still obedient to parents. One case with ansiometropic amblyopia and recurrent malign melanoma of conjunctiva in the good eye had exanteration and the initial corrected visual acuity that was 0.1 in the amblyopic eye before exanteration was found to be 0.4 in the last control. In compliant cases, the mean corrected visual acuity before treatment was 0.18 (0.03–0.6) and 0.23 (0.030.7) after treatment. Prior to therapy stereopsis was found in 15 cases and mean stereopsis was 633.3 sec of arc (3000 100) and after treatment it was 486.6 (3000 100) sec of arc. None of the 17 cases that had no stereopsis prior to therapy obtained stereopsis after therapy. The differences of visual acuity (p 0.001) and stereopsis (p 0.05) before and after therapy were statistically significant. Before therapy fusion at distance was present in 4 cases (12.5%); after therapy it was present in 7 cases (21.8%). Regression in visual acuity was observed in none of the cases in the control visit 6 months after the completion of therapy. 17
When we compared group-A and B; compliance to patching was higher in telescopic spectacle group (p 0.01). Telescopic spectacles increased compliance to patching therapy 2.7 folds in cases over 9 years of age. The increase in visual acuity (p 0.05) and stereopsis (p 0.05) was statistically significantly higher in group-A. Of the 18 cases using telescopic spectacles under 9 years of age (Group C), 9 were males (50%), and 9 were females (50%). The mean age of the cases was 8.2 years (min 7–max 9). Left eye was amblyopic in 12 cases (66.7%), and right eye in 6 cases (33.3%). The type of the amblyopia was; anisometropic in 7 cases (38.9%), strabismic in 8 cases (44.4%), anisometropic and strabismic in 3 cases (16.7%). In association with patching therapy; Galileo telescope 2.2x was prescribed for 1 case (5.6%), Kepler telescope 3.1x for 12 cases (66.7%), together with near vision add of 3.0 D. Kepler telescope 4.2x was prescribed for 4cases (22.1%), and Kepler telescope 6.0x for 1 case (5.6%). Seventeen cases (94.4%) was compliant to the patching therapy in this group. In compliant cases, before treatment the mean corrected visual acuity was 0.13 (0.03–0.2) and 0.38 (0.1–0.7) after treatment. Before treatment stereopsis was found in 9 cases with a mean value of 1778 sec of arc (3000 800); after treatment it was 151.1 sec arc (800 60). The differences of visual acuity (p 0.001) and stereopsis (p 0.01) before and after therapy were statistically significant. For one case that didn’t have stereopsis before therapy, 200 sec of arc was detected in the last visit. Fusion at distance before therapy was detected in 3 cases (16.7%) and after therapy it was present in 8 cases (44.4%). In control visit 6 months after the completion of the therapy, it was observed that the visual acuity of only one case (5.6%) regressed one line. Strabismus surgery was recommended for this case that had 30 PD esotropia. Of the 14 cases not using telescopic spectacles under 9 years of age (Group D), 8 were females (57.1%), and 6 were males (42.9%). The mean age of the cases was 8 years (min 6–max 9). Left eye was amblyopic in 10 cases (71.4%), and right eye in 4 cases (28.6%). The type of the amblyopia was; anisometropic in 5 cases (35.7%), strabismic in 6 cases (42.8%), anisometropic and strabismic in 3 cases (21.5%). Compliance with patching therapy was seen in 9 cases of this group (64.3%). In compliant cases, before treatment the mean corrected visual acuity was 0.19 (0.083 – 0.6) and 0.34 (0.083 – 0.6) after treatment. Before treatment stereopsis was found in 5 cases with a mean value of 1600 sec arc (3000 400) and 312 sec arc (800 60) after treatment. The differences in visual acuity (p 0.001) and stereopsis (p 0.05) before and after therapy were statistically significant. One case acquired 800 sec of arc of stereopsis at the end of therapy. Fusion at distance before therapy was present in 2 cases (14.3%) and in 6 cases (42.8%) after therapy. No regression was observed in any of the cases in the control visits 3 and 6 months after the completion of the therapy. When we compared group-C and D; compliance with the patching therapy in group using telescopic spectacles was significantly higher than the group not using (p 0.05). Telescopic spectacles increased compliance to patching therapy 1.4 folds in 9 years of age and under group. In compliant cases the differences in visual acuity (p 0.05) and stereopsis (p 0.05) was statistically insignificant. When cases using telescopic spectacles are compared according to the age (group A-C); the difference in visual acuity ( p 0.05) was statistically insignificant; however the improvement in stereopsis ( p 0.01) in group under 9 years of age was higher than the group over 9 years of age. None of the cases had complaint of diplopia after completion of therapy.
4
DISCUSSION
In treatment of amblyopia it in believed that the treatment must be given in younger ages and that the period of treatment prolongs with the increasing age and benefit reduces. Particularly for cases over 9 years of age that are recently diagnosed, there is doubt about whether treatment should be given or not. The origins of these doubts are restrictions of the therapy on the social life of the 18
patient, slow or insufficient response to therapy, and the possibility of diplopia if fusion cannot be obtained even if a response to therapy can be achieved. For the success of patching therapy, several researchers investigated the role of the age factor and reported diverse results. Epelbaum et al. (11) found that the reduction of the difference between the eyes was 70% when patching was applied in 21 months of age and concluded that the critical period could be extended as far as 10 years of age. Eibschits et al. (12) reported that success in patients that were treated between 1–2.5 years of age was 65%, however, the success ratio decreased to 3% in cases whose strabismus was not treated till 8–9 years of age; and Flynn and Cassady (13) reported that the required period increased and success ratios reduced in patients that were treated after 5 years of age. Ates et al. (14) similarly concluded that treatment in later periods reduced the success. Cleary (15), however, unlike the previous studies, reported that visual gain did not differ in different age groups. Oliver (16), Hiscox (17), and Levartovsky (18) concluded that the most important factor that influenced success was the compliance of the patient, not the age. It has been observed that the compliance of the patient decreased considerably in children with low initial visual acuity, in children over 8 years of age, and particularly in cases with both of these characteristics (16). Lithander (19) and Fulton (20) concluded that age was an important factor not in determining the success of the therapy, but it was indeed important in determining the length of the therapy. The critical period in the development of amblyopia is related to the neural maturation, and is considered as the period covering 2 months–9 years; however, it is not clearly known that how long this period really is. The studies show that amblyopia does not develop if pathologies like blepharoptosis, macular hemorrhage, and congenital cataract are corrected within the first 2 months of age (10). The fact that best results with patching therapy, optic and orthoptic methods are obtained till 9 years of age indicates that can be the neural maturation is completed till that period. However, the visual gain achieved in the amblyopic eye of adults who lost the good eye for any reason (1, 7) indicates that the neural plasticity continues in a continuous dynamic fashion although with reduced speed (1,7–9,15–20). In that point, the conclusion that the treatment of amblyopia should be a treatment strategy consisting of three stages. These strategies are: 1) Maintenance of best corrected, clear vision 2) Continuality of visual stimulation (Compliance with therapy) 3) Providing the representation of the clear visual stimulation sustainable in neural level. When these three strategies are performed simultaneously, it can be proposed that significant improvements in visual acuity and binocular functions will be achieved. Visual acuity less than 0.3, which is the limit of functional seeing, is a condition that restricts the daily activities of the individual (21). The failure of the amblyopia therapy in adults appears to be the result of the unwillingness of the adults for restricting their daily activities with a non-functional visual acuity and not complying with the treatment, rather than the completion of neural plasticity which is an information still under discussion. Patching therapy in children is a situation that creates stress, and children insist on seeing with their good eyes. Nearly all children resist against patching and parents have the most important role in compliance with therapy. Newsham reported 23% non-compliance to therapy and the reason for this non-compliance was related to insufficient information given to the parents and reluctance of parents to patch as well as the resistance of children (22). Loudon et al. (23) found non-compliance in 34% of the cases and proposed that there was a parallelism between compliance and visual gain. The achievement of visual acuity with telescopic lenses provides the ease of reading of written texts like books, newspapers, study notes, etc. when applying patching and consequently the compliance of the patient increases with the removal of restriction. In our study, we observed that application of telescopic spectacles increased compliance to therapy 1.4 to 2.7 folds in all cases over and under 9 years of age. As a result; telescopic lenses are efficient tools in amblyopia therapy by increasing the compliance of the patient to patching therapy and also increasing the intensity of the visual stimulation so 19
that it is possible to obtain response to the treatment in cases over 9 years of age. The success in the treatment of amblyopia depends on the compliance of the patient as well as the age of the patient that can be more important in determining the length of the treatment period.
REFERENCES 1. Sanaç AS ¸, S ¸ ener EC. Ambliyopi ve tedavisi:S ¸ asilik ve Tedavisi 2001; 83–94 2. Williams C, Northstone K, Harrad RA et al. Amblyopia treatment outcomes after preschool screening and school entry screening: observational data from a prospective cohort study. Br J Ophthalmol 2003; 87(8), 988–93 3. Rose K, Younan C, Morgan I, Mitchell P. Prevalance of undetected ocular conditions in a pilot sample of school children. Clin Experiment Ophthalmol 2003 Jun; 31(3): 237–40 4. Dostalek M, Benesova J. Some recruitment aspects of population photoscreening of amblyogenic factors at children younger one year. Acta Medica 2002; 45(4): 161–6 5. Williams C, Northstone K, Harrad RA et al. Amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomised trial. BMJ 2002 Jun 29; 324(7353): 1549 6. Clarke MP, Wright CM, Hrisos S et al. Randomised controlled trial of treatment of unilateral visual impairment detected at preschool vision screening. BMJ 2003 Nov 29; 327(7426): 1251 7. Rahi J, Logan S, Timms C et al. Risk, causes and outcomes of visual impairment after loss of vision in the non-amblyopic eye: a population-based study. Lancet 2002 Aug 24; 360(9333): 597–602 8. Hittner HA, Fernandez KM. Successful amblyopia therapy initiated after age 7 years. Arch Ophthalmol 2000; 118: 1535–41 9. Loudon SE, Polling JR, Simonsz HJ. A preliminary report about the relation between visual acuity increase and compliance in patching therapy for amblyopia. Strabismus. 2002 Jun; 10(2): 79–82 10. Ansons AM, Davis H. Amblyopia: Diagnosis and Management of Ocular Motility Disorders 2001; 213–25 11. Epelbaum M, Milleret C, Buisseret P, Dufier JL. The sensitive period for strabismic amblyopia in humans. Ophthalmology 1993; 100: 323–7 12. Eibschitz N, Friedman Z, Newmann E. Comparative result of amblyopia treatment. Metabol Ophthalmol 1978; 2: 111–2 13. Flynn JT, Cassady JC. Current trends in amblyopia therapy. Ophthalmology 1978; 84: 428–50 14. Ates M, Zengin N, Özbayrak N, Okka M, Okudan S, Gündüz K. Strabismik ambliyopide degis¸ik yas¸ gruplarinda kisa süreli oklüzyon ve CAM tedavisinin ambliyopi bas¸ari indeksi ile deg˘erlendirilmesi. T Klin Oftalmoloji 1996; 5: 138–41 15. Cleary M. Efficacy of occlusion for strabismic amblyopia: can an optimal duration be identified? Br J Ophthalmol 2000; 84: 572–8 16. Oliver M et al. Compliance and results of treatment for amblyopia in children more than 8 years old. Am J Ophthalmol 1986; 102: 340–5 17. Hiscox F et al. Occlusion for amblyopia : A comprehensive survey of outcome. Eye 1992; 6: 300–4 18. Levartovsky S et al. Factors affecting long term results of successfully treated amblyopia: Age at beginning of treatment and age at cessation of monitoring. J Pediatr Ophthalmol Strabismus 1992; 29: 219–23 19. Lithander J, Sjöstrand J. Anisometropic and strabismic amblyopia in the age group 2 years and above: prospective study of the results of treatment. Br J Ophthalmol 1991; 75: 111–6 20. Fulton AB, Mayer DL. Esotropic children with amblyopia: effects of patching on acuity. Graefes Arch Clin Exp Ophthalmol 1988; 226: 309–12 . 21. Idil A. Körlük ve Az Görmenin Tanimi: Halk Sag˘lig˘i Açisindan Göz Hastaliklari 1999; 14–16 22. Newsham D. Parental non-concordance with occlusion therapy. Br J Ophthalmol 2000; 84: 957–62 23. Loudon SE, Polling JR, Simonsz HJ. Electronically measured compliance with occlusion therapy for amblyopia is related to visual acuity increase. Graefes Arch Clin Exp Ophthalmol 2003; 241(3): 176–80
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Treatment of anisometropic amblyopia with no or minimal patching O.M. Hakim Magraby Eye Center, Madina munwara, Saudi Arabia
K.W. Wright Cedars-Sinai Medical Center, Los Angeles, CA
ABSTRACT: Purpose: Standard treatment of anisometropic amblyopia sited by most pediatric ophthalmology texts is prescribing optical correction, and full time occlusion of the sound eye. Here in we report results of prescribing optical correction, with no or minimal occlusion therapy. Methods: 49 consecutive anisometropic patients without strabismus were retrospectively studied. All received full cycloplegic spectacle correction, but no occlusion therapy for the first 3 weeks. If vision did not significantly improve with spectacles alone then the sound eye was patched for 2 to 4 hours per day. Results: 14/49 (29%) patients improved to 20/30 or better without patching. 35/49 (71%) patients (age 4 to 11 yr.) received minimal patching and their pre treatment VA ranged from CF to 20/70. Final VA was 20/30 or better in 23/35 (66%) patients. Conclusion: Visual acuity of patients with anisometropic amblyopia can improve markedly with the use of spectacles alone, or minimal part time patching.
1
INTRODUCTION
Anisometropia, or the difference in the refractive error between the two eyes of an individual, is a well-known cause of amblyopia. It is widely believed that patching of the better seeing eye can improve vision in the affected eye (Helveston E & Ellis F 1980). Unsurprisingly, widely differing treatment regimens have been promoted; some practitioners favoring full time (von Noorden G.K. 1990; Nelson B.L. et al. 1991) while others just a few minutes occlusion each day (Watson et al. 1985). The purpose of this study is to examine the effectiveness of correction of the refractive errors alone or with minimal patching on the improvement of amblyopia.
2
SUBJECTS AND METHODS
150 charts of amblyopic patients were retrospectively reviewed. All patients included in the study had anisometropia and amblyopia. Patients with strabismus, with a previous history of amblyopia treatment or with possibly organic causes of amblyopia were excluded from the study. Also, only patients whose treatment was followed for at least 3 months were included. Anisometropia was defined as a difference in refractive error of 3.50 diopters or more for myopic patients, 2.00 diopters or more for hyperopic patients and 1.50 diopters or more for astigmatic patients. Monocular visual acuity was measured using the snellen letter at 20 feet and all children were capable of reading letters directly from the acuity chart. Amblyopia was defined as a difference in vision of two lines or greater with the acuity in the amblyopic eye being less than 20/40. All refractive errors were corrected based on cycloplegic refraction that was performed by installing three drops of 1.0% cyclopentolate hydrochloride in each eye five minutes apart. Treatment consisted of giving the patients their refractive correction without patching on a full-time basis. After three weeks visual acuity was checked and if there was improvement, they continue 21
using glasses without patching and were followed every three weeks and up to six months to monitor visual acuity. If vision did not improve, the good eye was patched minimally and the patients returned every three weeks for visual acuity measurement. Minimal patching was defined as patching 2 to 4 hours a day with an average 3 hours per day. Statistical analysis was performed by transforming the snellen visual acuity to the logarithm of the minimal angle of resolution (log MAR) visual acuity.
3
RESULTS
Of the 150 reviewed charts of amblyopic patients, only 49 patients had the prerequisite inclusion criteria. Patients were divided into non-patch and minimal patch groups. 3.1.
Non-patch group
This consisted of 14 patients (29%), between 4 to 7 years of age {mean 5.8 (SD 2.5) years} who had improved with correction of refraction only. This group is divided by type of anisometropia into three sub-groups; myopic, hyperopic, and astigmatic ones. The number of patients, the mean amount and ranges of anisometropia for each sub-group are listed in table 1. In astigmatic patients, refractive error was determined in plus cylinder form. During the six months of follow up, changes in the visual acuity were recorded. (Tab. 2). The mean visual acuity at the beginning of treatment and after six months for the three subgroups is listed in table 3. At the time of wearing glasses the average visual acuity for the patients of this group was 20/80 with a range 20/200 to 20/50. The average final visual acuity at the end of follow up was 20/27 (0.15 0.12 Log MAR) with a range 20/30 to 20/20 (P .0001).
Table 1.
Patient population and refraction of the non-patch group.
Type of anisometropia
No. of patients
Mean amount of anisometropia
Range
Myopia Hyperopia Astigmatism
8 4 2
4.50 D (SD 1.25) 2.50 D (SD 0.75) 2.36 D (SD 0.85)
3.50 to –6.00 2.00 to 3.50 2.00 to 4.00
Table 2.
Visual acuity improvement with optical correction only.
Initial VA
VA after 3 weeks
VA after 12 weeks
VA after 6 months
20/50-20/100 (n 7) 20/100-20/200 (n 7)
20/60–20/80 (n 9) 20/100–20/120 (n 5)
20/20–20/30 (n 12) 20/40–20/50 (n 2)
20/20–20/25 (n 11) 20/30 (n 3)
Table 3.
Mean visual acuity results. Mean snellen visual acuity
Type
At the beginning
After six months
Myopia Hyperopia Astigmatism
20/70 20/60 20/50
20/25 20/30 20/30
22
3.2
Minimal patch group
This consisted of 35 patients (71%), between 4 to 11 years of age who received minimal patching (average 3 hours/day). This group is also divided by type of anisometropia into three sub-groups. The number of patients, the mean amount and ranges of anisometropia for each group are listed in table 4. In astigmatic patients, refractive error was determined in plus cylinder form. During the six months of follow up, changes in the visual acuity were recorded. (Tab. 5). The mean visual acuity at the beginning of treatment and after six months for the three subgroups is listed in table 6. At the time of examination the average visual acuity for the patients of this group was 20/100 with a range from 20/400 to 20/70. The average final visual acuity at the end of follow up was 20/35 (0.15 0.12 Log MAR) with a range 20/30 to 20/35 (P .001). The best achieved visual acuity for the three groups combined was significantly related to the initial visual acuity by Mann-Whitney Rank Sum Test (P 0.001). 4
DISCUSSION
Anisometropic amblyopia is a reduced corrected visual acuity without evidence of organic eye disease. It is caused by unequal refractive errors during a sensitive period of visual development in early childhood (Stewart et al. 2003). The most common treatment for unilateral amblyopia is occlusion of the dominant eye with an opaque patch to promote visual function in the amblyopic eye (Kutschke et al. 1991). In this study, a good visual outcome was achieved in all our cases of pure anisometropic amblyopia either with spectacles alone or with minimal patching (2–4 hours/day). This minimizes the burden placed on the child and the parents (Watson et al. 1985) and avoids the complications of amblyopia and strabismus, which could be induced by full time patching (Kutschke et al. 1991). Table 4.
Patient population and refraction of the minimal-patch group.
Type of anisometropia
No. of patients
Mean refraction
Range
Myopia Hyperopia Astigmatism
23 8 4
6.50 D (SD 1.75) 3.50 D (SD 1.25) 3.00 D (SD 1.15)
3.50 to –7.50 2.00 to 4.50 2.00 to 5.50
Table 5.
Visual acuity improvement with minimal patching (average 3 hours/day).
Initial VA
VA after 3 weeks
VA after 12 weeks
VA after 6 months
20/70–20/100 (n 6) 20/100–20/200 (n 24) 20/200–20/400 (n 5)
20/40–20/80 (n 17) 20/100–20/200 (n 18)
20/25–20/40 (n 25) 20/50–20/100 (n 10)
20/20–20/30 (n 23) 20/40 (n 12)
Table 6.
Mean visual acuity results. Mean snellen visual acuity
Type of anisometropia
At the beginning
After six months
Myopia Hyperopia Astigmatism
20/80 20/70 20/50
20/30 20/35 20/35
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Experiments in monkeys have shown that early monocular eyelid suture, a model of amblyopia caused by cataract, results in shrinkage of the eye’s ocular dominance columns in striate cortex because of contraction of their geniculocortical terminal arbors (Wiesel & Hubel 1963; Hubel & Wiesel 1964). It is proposed that visual deprivation produces amblyopia by causing the deprived eye to become disconnected from the cortical circuits required for the normal processing of retinal input (Horton & Hocking 1997). The fellow eye is thought to have established a competitive advantage over the amblyopic eye which can only be overcome if visual input to the fellow is restricted. It is on this understanding that treatment of amblyopia by occlusion draws its empirical support. Among humans the most common cause of amblyopia is not cataract but strabismus or anisometropia (von Noorden GK 1990). However, recent work had proven that anisometropia may induce amblyopia without shrinkage of ocular dominance columns in the visual cortex, implying that this form of amblyopia has a different cortical basis than amblyopia produced by early, severe form deprivation (cataract, lid suture) (Horton & Stryker 1993; Horton et al. 1997). It is proposed that in milder form of human amblyopia-namely, those caused by later acquired media opacity or anisometropia the ocular dominance columns in layer IVc are normal but neural connections are perturbed between layer IVc and other cortical layers (Horton & Stryker 1993). This could explain the improvement in our patients who received no or minimal occlusion therapy. Spectacles alone, in place of spectacles plus occlusion, are used widely in UK (Tan et al. 2003) for the initial treatment of anisometropic amblyopia. In agree with Moseley (Moseley et al. 2002), we have shown that simply correcting the optical defect associated with an amblyopic eye can lead in some cases to substantial gains in visual acuity. While accepting that occlusion is beneficial for patients whose visual acuity did not improve with optical correction only, there are sound reasons for adopting a general therapeutic principlenamely, to prescribe the smallest occlusion dose to bring an effective treatment response (Kutschke et al. 1991; Moseley et al. 1997). This point is illustrated by recent studies which concluded that two hours of daily patching produces an improvement in visual acuity that is of similar magnitude to improvement produced by 6 hours daily patching in treating moderate amblyopia (Repka et al. 2003) and that Six hours of daily patching produces an improvement in visual acuity that is of similar magnitude to the improvement produced by full-time patching in treating severe amblyopia (Holmes et al. 2003). In our study we could get improvement in visual acuity with prescribed daily patching 2–4 hours. It is acknowledged that this study is not randomly controlled and that we did not investigate the effects of age, severity of amblyopia, or differing occlusion regimens, which remain to be examined in future randomized controlled studies. In conclusion, we recommend a general therapeutic principle on treating anisometropic patients – namely, to start by optical correction only for few weeks and if no improvement is achieved, prescribe minimal patching. This can eliminate the need for conventional patch treatment in some case, while reducing the amount of patching required in other cases.
REFERENCES Helveston, E. and F. Ellis. 1980. Amblyopia. In Pediatric ophthalmology practice. 59–68. St. louis: C V mosby. Holmes, J. M., R. T. Kraker, R. W. Beck, E. E. Birch, S. A. Cotter, D. F. Everett, R. W. Hertle, G. E. Quinn, M. X. Repka, M. M. Scheiman and D. K. Wallace. 2003. A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmology 110: 2075–2087. Horton, J. C., D. R. Hocking. and L. Kiorpes. 1997. Pattern of ocular dominance columns and cytochrome oxidase activity in a macaque monkey with naturally occurring anisometropic amblyopia. Vis. Neurosci. 14: 681–689. Horton, J. C. and M. P. Stryker. 1993. Amblyopia induced by anisometropia without shrinkage of ocular dominance columns in human striate cortex. Proc. Natl. Acad. Sci. U. S. A 90: 5494–5498. Horton, J. C. and D. R. Hocking. 1997. Timing of the Critical Period for Plasticity of Ocular Dominance Columns in Macaque Striate Cortex. J. Neurosci. 17: 3684–3709.
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Hubel, D. H. and T. N. Wiesel. 1964. Effects of monocular deprivation in kittens. Naunyn Schmiedebergs Arch. Pharmacol. 248: 492–497. Kutschke, P. J., W. E. Scott and R. V. Keech. 1991. Anisometropic amblyopia. Ophthalmology 98: 258–263. Moseley, M. J., A. R. Fielder. M. Irwin. H. S. Jones and R. J. Auld. 1997. Effectiveness of occlusion therapy in ametropic amblyopia: a pilot study. Br J Ophthalmol 81: 956–961. Moseley, M. J., M. Neufeld, B. McCarry, A. Charnock, R. McNamara, T. Rice and A. Fielder, 2002. Remediation of refractive amblyopia by optical correction alone. Ophthalmic and Physiological Optics 22: 296–299. Nelson, B. L, J. H. Calhoun and R. D. Harley. 1991. Amblyopia. In pediatric ophthalmology. 107–118. W. B. Saunders company. Repka, M. X., R. W. Beck, J. M. Holmes, E. E. Birch, D. L. Chandler, S. A. Cotter, R. W. Hertle, R. T. Kraker, P. S. Moke, G. E. Quinn and M. M. Scheiman. 2003. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch. Ophthalmol. 121: 603–611. Stewart, C. E., M. J. Moseley and A. R. Fielder. 2003. Defining and measuring treatment outcome in unilateral amblyopia. Br J Ophthalmol 87: 1229–1231. Tan, J. H. Y., J. R. Thompson, and I. Gottlob. 2003. Differences in the management of amblyopia between European countries. Br J Ophthalmol 87: 291–296. von Noorden GK. 1990. In Binocular vision and ocular motility. 457–478. St Louis: C V Mosby. Watson, P. G., A. S. Sanac and M. S. Pickering. 1985. A comparison of various methods of treatment of amblyopia. A block study. Trans. Ophthalmol Soc. U. K. 104 (Pt 3): 319–328. Wiesel, T. N. and D. H. Hubel. 1963. Effects of visual deprivation in morphology and physiology of cells in the cats lateral geniculate body. J Neurophysiol. 26: 978–993.
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Session 3: Sensorial aspects
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Binocular functions in pseudophakic patients in early postoperative period I. Akyol-Salman, M. Arslankurt, O. Dursun, A. Yazıcı & O. Baykal Ataturk University Faculty of Medicine, Department of Ophthalmology, Erzurum, Turkey
ABSTRACT: To investigate binocular functions of patients in the early postoperative period following phacoemulsification and posterior chamber lens implantation, 54 unilateral (Group A) and 30 bilateral (Group B) pseudophakics were evaluated with Synoptophore and Titmus test at 4th and 12th weeks postoperatively. Significant improvement in binocular functions was observed in most of the patients of both groups during the follow up period. 70.23% and 76.19% of patients had good stereoacuity of 5 circles or less, at 4th and 12th weeks respectively. Interestingly, in some operated eyes with good visual acuities, suppression was noted. This study has shown that after the cataract surgery, the improvement of the binocular functions of the patients was observed with the evolution of time, and this improvement was not only related to the improvement of the visual acuities of the operated eyes.
1
INTRODUCTION
Although the success of cataract surgery is generally measured in terms of improved visual acuity, the more important measure may be the patient’s binocular vision. As stated by Von Noorden & Campos (2002), binocular vision provides better exteroception of form and color and better appreciation of the dynamic relationship of body to the environment, facilitating control of manipulation, reaching, and balance. Therefore, in the present study we evaluated binocular functions of patients after the cataract surgery in the early postoperative period.
2
MATERIALS AND METHODS
Group A consisted of 54 unilateral pseudophakic patients with the mean age of 56.90 years 12.78. Group B consisted of 30 bilateral pseudophakic patients with the mean age of 61.40 years 14.74. In all cases, sutureless phacoemulsification and posterior chamber hydrophylic acrylic intraocular lens implantation was performed under topical anesthesia. Cases with pathologic changes in the macular area, previous history of anisometropia and amblyopia, high myopia, those with ocular deviations and eye pathology other than cataract were excluded from the study. Patients were evaluated at 4th and 12th weeks postoperatively. Visual acuities and refractive errors were measured. The determination of stereoacuity was done with Titmus Stereotest. The grades of binocular vision were evaluated by Synoptophore. Independent-samples T test, unpaired samplesT test, Fisher’s exact test, and correlation analysis were used for statistical analysis of datas. 3
RESULTS
In Group A, the mean best corrected distance visual acuities of the nonoperated eyes were 20/30 and 20/30; and those of the operated eyes were 20/25 and 20/24, at 4th and 12th weeks respectively. 29
The mean best corrected distance visual acuities in Group B were 20/27 and 20/27 in those eyes operated on first; 20/23 and 20/22 in those operated on second, at 4th and 12th weeks respectively. Statistically significant difference was not observed among the groups (P 0.05), but significantly higher visual acuities were noted at 12th week in both groups (P 0.05). Simultaneous perception was present in all patients. Fusion was observed in 48 patients (88.9%) of Group A, in 28 patients (93.3%) of Group B at 4th week; in 52 patients (96.3%) of Group A, in 28 patients (93.3%) of Group B at 12th week. Suppression, in patients without fusion, was noted in operated eyes in Group A, and in secondly operated eyes in Group B. In those patients with suppression the mean best corrected distance visual acuities were 20/31 with the range of 20/64–20/20 in suppressed eyes, and 20/26 with the range of 20/40–20/20 in the fellow eyes. Stereopsis was observed in 38 patients (70.4%) of Group A, in 25 patients (83.3%) of Group B at 4th week; in 45 patients (83.3%) of Group A, in 27 patients (90%) of Group B at 12th week. The mean stereoacuity values were 5.30 and 6.41 circles in Group A; 4.97 and 6.53 circles in Group B at 4th and 12th weeks respectively. 70.23% and 76.19% of patients had good stereoacuity of 5 circles or less, at 4th and 12th weeks respectively. Regarding fusion, stereopsis, and stereoacuities, statistically significant difference was not observed among the groups (P 0.05), but observed between those on 4th and 12th weeks postoperatively. No correlation existed between the visual acuities and the binocular functions-stereoacuities in either group of patients (P 0.05). 4
DISCUSSION
Significant improvement in binocular functions was observed during the follow up of the patients in the early postoperative period after the cataract operations. As noted in literature, after the cataract removal and intraocular lens implantation, improved vision may supply the necessary stimulus for binocular functions (Hamed et al. 1987). Therefore, one of the reasons for the improvement in binocular functions of our patients may be the improvement in the visual acuities of them during this period. However, statistically significant linear correlation was not found. The possibility of the adaptation of cortex to the newly formed retinal images during this period may also be another factor associated with the improvements. In the patients without fusion, interestingly, suppression was found in the operated eyes with favorable visual acuities, and even in some of those with higher visual acuities, regarding the fellow eye. In respect to these findings, the factors other than the level of visual acuities seem to influence fusion and occurrence of suppression in the patients. It is generally assumed that if fusion is developed in childhood and maintained until visual maturity is reached; the ability to fuse can not be lost. It is also thought that if fusion is disrupted later in life, it can be regained once good visual acuity and ocular alignment are reestablished, even after an interval of several years. However, some reports emphasized the significance of the interval over which fusion was prevented when giving a prognosis for the restoration of binocular vision in patients with cataract (Ruben 1962, Pratt-Johnson et al. 1989). As indicated in reports, the central fusion disruption associated with prolonged sensory deprivation of the eyes from the cataract, and the prolonged asymmetry of sensory input produced by cataract may also be the important determinants of binocular functions. However, we could not evaluated these findings in our patients, since, the data about the binocular functions of the patients before the cataract formation and about the interval over which the patients were unable to fuse because of cataract were not available. The inhibitory interactions between the two eyes regarding the ocular dominance, and the age related decrease in cerebral and binocular functions (Wright & Wormald 1992) could be the other possible mechanisms may be involved in the mechanisms of suppression in the present study.
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5
CONCLUSIONS
Although the success of cataract surgery is generally measured in terms of improved visual acuity, the more important measure may be the patient’s binocular vision. After the cataract surgery, the improvement of the binocular functions of the patients was observed with time, and this improvement was not only related to the improvement of the visual acuities of the operated eyes.
REFERENCES Hamed, L.M., Helveston, E.M. & Ellis, F.D. 1987. Persistent Binocular diplopia after cataract surgery. Am J Ophthalmol 103: 741–744. Pratt-Johnson, J.A. & Tillson, G. 1989. Intractable diplopia after vision restoration in unilateral cataract. Am J Ophthalmol 107: 23–26. Ruben, C.M. 1962. Unilateral aphakia. Br Orthopt 19: 39–43. Wright, L.A. & Wormald, R.P.L. 1992. Stereopsis and ageing. Eye 6: 473–476. Von Noorden, G.K. & Campos, E.C. 2002. Binocular vision and ocular motility: Theory and management of strabismus. St. Louis: Mosby.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
The age-related decline in stereopsis as measured by different stereotests L. Garnham & J. Sloper Moorfields Eye Hospital, London, England
ABSTRACT: Stereoacuity declines with age. This study has examined whether a drop in stereoacuity is found using a range of stereo tests. Sixty subjects, aged 17–83 years had their stereoacuity assessed using the TNO, Titmus, Frisby and Frisby-Davis distance tests. All had good vision in each eye and no ophthalmic disease. Motor fusion was also assessed. Stereoacuity declined with age with a marked drop in 5 subjects over 55 years with the TNO test. Much better stereoacuity was found in these 5 cases with the other stereo tests. Results of random-dot stereotests should be interpreted with caution in older patients.
1
INTRODUCTION
Stereoacuity declines with age, with a “catastrophic drop” having been described in some elderly subjects using a random dot stereotest1. Because stereoacuity depends on cortical disparity detecting neurons, the decline in stereoacuity has also been interpreted as showing declining cortical function. The present study has examined whether a similar drop in stereoacuity is found using a range of stereo tests, which utilize different types of stimulus. 2
METHOD
Stereoacuity has been measured in 60 normal subjects aged 17–83 years by the same observer using TNO, Titmus, Frisby near and Frisby-Davis distance stereotests. All subjects had a best corrected Snellen acuity of 6/9 in each eye and had no ophthalmic disease. An Orthoptic examination was carried out including assessing motor fusion for near and distance using prisms. 3
RESULTS
For all tests stereoacuity declined with age, but the change was most marked for the TNO test. Five subjects aged over 55 years showed a marked drop in to screening or absent levels of stereoacuity, but all these subjects were able to achieve 200 seconds of arc or better with the Titmus test and 340 seconds of arc or better with the Frisby test. There was a small decline in the base-out fusion range measured for distance, but no significant change in the base-in fusion range for distance or in that measured for near. 4
DISCUSSION
The results of all 4 stereotests show that there is some decline of stereoacuity with age for both near and distance. It seems likely that this reflects some decline in the function of cortical disparity detectors with age. Some older patients showed a much greater reduction in stereoacuity with the TNO test. 33
The five patients with very poor TNO but good stereoacuity with the Titmus test are of particular interest. They have good cortical disparity detectors as they have good stereo to a contoured stimulus. The most likely explanation for this was that their fusion reflex was not able to fully overcome the dissociative effect of the TNO test. In the real world most judgements of depth are performed utilising the disparity of contours, which is more like the stimuli utilised by the Titmus test.
5
CONCLUSIONS
The large drop seen in some older subjects using the TNO test is probably due to the dissociative effect of the test on fusion rather than a loss of cortical disparity detectors. Results of random dot stereo tests should be interpreted with caution in older patients.
REFERENCES Zaroff, C.M. 2003. Variation in stereoacuity: normative description, fixation disparity, and the roles of gender and aging. Invest Ophthalmol Vis Sci: 44: 891–900.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Visual recognition time in strabismus: small-angle versus large-angle deviation C. Bellusci1, C. Schiavi1, R. Bolzani2, M.G. Benassi2 & E.C. Campos1 1
Ophthalmology Unit and 2Department of Psychology, University of Bologna, Bologna, Italy
ABSTRACT: To measure the possible differences in monocular detection time of a threshold visual acuity stimulus generated on a computer screen (recognition time, RT) between patients with small-angle and large-angle strabismus. Five patients with small-angle esotropia ( 7°) and five with large-angle esotropia (15–20°) were tested. Six age-matched normal subjects served as control. The recognition time (RT 1) of the threshold stimulus was measured in both eyes sequentially. Moreover, we measured the recognition time 2 (RT 2) defined as the time necessary for identifying the same threshold visual acuity stimulus generated in the moment in which fixation is taken up by one eye after occlusion of the fellow eye. The ANOVA for repeated measures indicated that mean RT 2 was significantly longer in large-angle strabismic eyes when compared with that of normal control eyes. We hypothesized that alternating strabismus patients may have a significant advantage in maintaining a small-angle deviation.
1
INTRODUCTION
A surgically-induced change in the mechanics of the eye muscles is usually quite stable, even if under- and over-corrections occur. The stability of surgical results, in the range from orthotropia to small-angle strabismus, is attributable to several mechanisms. Among them are strabismus surgery per se and anomalous binocular vision supported by anomalous retinal correspondence, typical of microstrabismus (von Noorden & Campos 2002). Iso-acuity as well as free alternation of fixation are also relevant (Campos 1995). The weight of proprioception from the extra-ocular muscles, which has been demonstrated to exist, remains to be established (Lennerstrand 1997). Insufficient data are available on further elements involved in supporting the stability of the angle of deviation after strabismus surgery. We hypothesized the presence of an advantage of small-angle versus large-angle strabismus, because in the first instance alternation of fixation is obtained more rapidly. The purpose of the present investigation was to evaluate possible differences in rapidity of detection of a threshold visual acuity stimulus (recognition time, RT) between patients with smallangle and large-angle free alternating strabismus. There is, to our knowledge, no evidence in the literature on RT measurements in strabismus patients.
2 2.1
MATERIALS AND METHODS Subjects with strabismus
Ten patients with comitant convergent strabismus (esotropia) participated in these experiments (age range 10 to 18 years, mean: 14.6; SD: 2.2). Patients were divided in two groups: patients with small-angle esotropia with free alternation (deviation: 4–7 degrees, n 5), patients with largeangle esotropia with free alternation (deviation: 15–20 degrees, n 5). These subjects underwent complete eye examination and the angle of deviation was measured with the prism cover test. 35
Only patients with early-onset comitant strabismus with free alternation were included in the study. No patient had ever undergone extraocular muscles surgery. All patients had visual acuity in both eyes (corrected or uncorrected) of 6/6 without amblyopia with refractive errors ranging from 1 to 1.5 sphere diopters. In all patients no positive response was obtained at the TNO stereo-test. 2.2
Control subjects
Six healthy volunteers served as controls (age range: 12 to 17 years, mean: 14.5; SD: 2.1). Visual acuity in these subjects was at least 6/6 with correction of the refractive errors. Stereoacuity values at the TNO test were 60 sec of arc or better. 2.3
Experimental procedures
In a dark room, subjects were seated 3 meters in front of a computer monitor used to generate visual stimuli. For all subjects, corrected visual acuity of each eye was measured with Snellen Es (linear scale) generated on the screen. Subjects had to recognize at least 4 out of 5 central Es to define visual acuity threshold (method of ascending limits). Subjects were positioned at a chin-rest and fixated a central small spot of white light generated on the computer screen. All subjects were instructed to press on an infrared mouse when the E orientation was discriminated. Recognition time of the threshold stimulus (RT 1) was measured in both eyes sequentially and the order of the eyes was randomized. After a variable interval (5–10 sec), an assistant pressed the spacing bar of the computer keyboard; the light spot disappeared and an E stimulus appeared in the center of the monitor. The target for RT 1 was a single E of the threshold visual acuity size, obtained during the first part of the experiment. The infrared mouse was again used for signaling E orientation. The E disappeared and the program automatically measured the time from the appearance of the E stimulus to the pressure on the mouse button. Ten practice trials were given before the measurements were begun. Experiments were repeated four times and measurements were taken only when the stimulus was identified correctly in all four experiments. Data from the two eyes were combined. Using the same setting, a measure of recognition time (RT 2) was taken after a fixation switch. The time for recognizing the threshold visual acuity stimulus was measured from the moment in which a cover was moved from the eye to be examined to the fellow eye. The cover movement was mechanical and was driven by the computer. Subjects fixated the central luminous spot: after an interval of occlusion of the examined eye varied randomly (5–10 sec), the cover was moved to the fellow eye. Simultaneously, an E stimulus appeared on the computer screen. Subjects pressed the mouse button when the stimulus was recognized and the program automatically measured the time from the appearance of the E stimulus till the pressure on the mouse button. Ten trials were performed before obtaining four valid measurements that were taken only when the stimulus was identified correctly in all four experiments. The mean RT 1 and RT 2 with standard errors (SE) was calculated in both small-angle and large-angle strabismus groups and in controls. Moreover, the absolute difference ( RT) between the mean value of RT 1 and RT 2 was calculated for both eyes in all subjects. Recognition time 1 in fact, is the interval between the appearance of the E stimulus on the monitor and the observer’s finger pressing the mouse; recognition time 2 is the interval between the appearance of the E stimulus, the fixation switch saccade to foveate the target and hitting the mouse. Therefore, we obtained a value ( RT) related to the rapidity and accuracy of the fixation switch saccade of the eye redressing from the position of deviation. The mean
RT with standard deviation (SD) was calculated for the three different study groups. 2.4
Data analysis
The General Linear Model was applied for a Multivariate Analysis of Variance to analyze the difference both in RTs (RT 1, RT 2) and in RT between strabismus groups and normal control group. The dependent measure was the length of the response. 36
3
RESULTS
The Multivariate Analysis of Variance for repeated measures indicated that there was a statistically significant difference in RT 2 between the groups (F2,12 29.9; p 0.001). Significant interactions were found between groups and RT (F2,12 40.2; p 0.001). No differences were found in RT 1 between the three different study groups. Figure 1 shows the mean (SE) RT 1 and RT 2 both in small- and large-angle strabismus groups and in controls. The mean RT 1 was 470.6 (27.0) msec in small-angle strabismus group and 524.2 (24.2) msec in large-angle strabismus group; both of these means were not significantly different from that of the normal control group (mean: 412.1 22.0 msec). The mean RT 2 in large-angle strabismus group was 938.2 (34.7) msec, significantly larger than that one of normal subjects (mean: 529.7 31.7 msec; p 0.001). On the contrary, in small-angle strabismus group the mean RT 2 was 541.5 (38.8) msec with no statistically significant difference with respect to normal control group. Figure 2 summarizes the RT in the three different study groups. The mean RT was 414.0 (47.8) msec in large-angle strabismus group, significantly longer than in normal control group (mean: 117.6 10.3 msec; p 0.001). No significant differences in RT between small-angle strabismus patients and controls were found.
Recognition time (msec)
1200 RT 1 RT 2
1000 800 600 400 200 0 Controls
SAS
LAS
Figure 1. Means of recognition time 1 (RT 1, empty bars) and recognition time 2 (RT 2, grey bars). Vertical lines indicate the SE. * Significant difference (p 0.001) with respect to controls. SAS: small-angle strabismus group, LAS: large-angle strabismus group.
600
⌬RT (msec)
500 400 300 200 100 0 SAS
Controls
LAS
Figure 2. Means with standard deviation of RT. Vertical lines indicate the extreme values and horizontal bold lines indicate the median values. * Significant difference (p 0.001) with respect to controls. SAS: small-angle strabismus group, LAS: large-angle strabismus group.
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4
DISCUSSION
The basic result of this study is that RT 2 in large-angle strabismus patients was significantly longer in comparison to that observed in normal subjects. In contrast, RT 2 was not significantly increased in small-angle free alternating patients as compared to normals. This could be simply explained with the amplitude of fixation switch saccades, obviously shorter in small-angle than in largeangle deviations. Strabismus patients usually changed fixation from one eye to the other by a conjugate saccade, whose duration is about 80 msec (Steinbach 1981). In our experiments we found that
RT (RT 2–RT 1) values were reasonably close to this duration (100 msec) in small-angle strabismus group as well in normal subjects. It is interesting in our results that the difference in RT between small-angle and large-angle strabismus groups is very large (about 300 msec). This difference cannot be explained by the typical duration of the saccades. Probably, there are some other variables that prolong RT 2 in large-angle strabismus patients. We hypothesized that RT 2 was longer in large-angle strabismus group probably because of multiple re-fixation saccades involved when an eye of a patient with large-angle strabismus takes up fixation (Ciuffreda 1979, Kapoula 1997). It may be plausible that patients with smallangle strabismus do not need to make many re-fixation saccades. The target will be falling on a closer retinal proximity to the previous fixation. The retinal architecture is such that an object falling closer to the fovea is likely to be located with more accuracy (von Noorden & Campos 2002). Moreover, we did not find any significant difference in RT 2 between small-angle strabismus patients and normal subjects. It can be speculated that the large reduction in RT 2 of small-angle as compared to large-angle strabismus could be the result of an adaptive mechanism occurring in small-angle strabismus patients but not in large-angle deviations. Our data could confirm the hypothesis that a small-angle deviation offers besides an anomalous binocular vision also an improvement of monocular visual performance. The improvement could be the result of central adaptation, e.g. more efficient tuning of motor commands when the two eyes are better aligned (Bagolini 1976a, b, Bucci 2002, Campos 1978). There is in fact, a close relationship between level of binocular function and eye-muscle proprioception, and the interaction between them is altered by the presence of strabismus (Lennerstrand 1997). As a consequence, it could be speculated that signals related to the eye-muscle proprioception originated from the two eyes are relatively more integrated in presence of small-angle strabismus rather than in large-angle deviation. REFERENCES 1. Bagolini B. (1976). Part I. Sensorial anomalies in strabismus: suppression, anomalous correspondence, amblyopia. Doc. Ophthalmol. 41:1–22. 2. Bagolini B. (1976). Part II. Sensorio-motorial anomalies in strabismus: anomalous movements. Doc. Ophthalmol. 41:23–41. 3. Bucci MP, Kapoula Z, Yang Q, Roussat B, Bremond-Gignac D. (2002). Binocular coordination of saccades in children with strabismus before and after surgery. Invest Ophthalmol Vis Sci. 43:1040–1047. 4. Campos EC, Zanasi MR. (1978). Die anomalen Fusionsbewegungen: der senso-motorische Aspekt des anomalen Binokularsehens. Albrecht Von Graefes Arch. Klin. Exp. Ophthalmol. 205(2):101–111. 5. Campos EC. (1995). Amblyopia. Survey Ophthalmology 40:23–39. 6. Ciuffreda KJ, Kenyon RV, Stark L, (1979 May). Abnormal saccadic substitution during small-amplitude pursuit tracking in amblyopic eyes. Invest Ophthalmol Vis Sci. 18(5):506–16. 7. Kapoula Z, Bucci MP, Eggert T, Garraud L. (1997). Impairment of the binocular coordination of saccades in strabismus. Vision Res. 37:2757–2766. 8. Lennerstrand G, Tian S, Han Y. (1997). Effects of eye muscle propriocpetive activation on eye position in normal and exotropic subjects. Graefe’s Arch. Clin. Exp. Ophthalmol. 235:63–69. 9. Steinbach MJ. (1981). Alternating exotropia: temporal course of the switch in suppression. Invest Ophthalmol Vis Sci. 20:129–133. 10. von Noorden GK, Campos EC. (2002). Binocular vision and ocular motility. Theory and management of strabismus. 6th ed. St Louis, MO: Mosby.
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Session 4: Botulinum toxin
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Botulinum toxin in strabismus treatment of brain injury patients S. Moguel “20 de Noviembre” Hospital, Mexico City, D.F. México
ABSTRACT: Objective: Psychomotor retardation is present in 3% of population. Strabismus is associated 80%. This study is to determine the efficacy of Botulinum toxin in strabismus related to brain damage. Methods: Treatment was made with direct technique of Botulinum toxin considering age, strabismus type, number of injections, response and brain disease. Results: We analyze 30 patients 3.5 / 3 years old for 12.7 / 7.3 months. Eighty percent had moderate psychomotor retardation and 20% had a severe one. Good response: 44%, regular: 24%. Toxin applications: 1.7 / 1. Age and type of strabismus was not related to success of treatment (X2: 9.4, 7.8 to hypothesis). First application of toxin determined the response to treatment (Fisher test: 0.05). Moderate retardation was related to better response. Bad results was related to unstable brain disease. Conclusions: Because of bad prognosis to surgery in patients with brain damage, the use of Botulinum toxin must be considered as the first choice.
1
INTRODUCTION
Psychomotor retardation (PR) is found in 2–3% in general population, and is related to strabismus in 80%. Treatment of strabismus in these patients is not easy because of the conditions of health. Delay of treatment provokes the lose of sensorial and visual development and motor anomalies. The early surgery is always avoided because it frequently conduces to over-correction. The poor capacity to fusion of patients with brain damage is another cause of bad prognosis in visual development and surgery treatment. Because of these reasons there are several untreated patients that can be approached by an alternative treatment with botulinum toxin. This is based in our previous investigations in strabismus associated to systemic diseases where safety and efficacy of BT was proved. (Moguel 1997). This investigation is adhered to regulations for studies to high risk patients of Helsinki Declaration, Hong Kong 1989, and General Law of Health II-3, Mexico.
2
METHODS
This is a retrospective, longitudinal, descriptive and observational investigation, from Jan to Dec 2000, including patients with psychomotor retardation, brain damage and strabismus, under chemo-denervation treatment using type “A” Botulinum toxin for extraocular muscles. The authorization request for use of BT was signed by a legal tutor. The state of the neurological disease was evaluated for Neurology Services. Direct application technique of Botulinum toxin without any electromyographic control following instructions of Moguel method (Moguel 1997): Type “A” Botulinum toxin is diluted to obtain 5 UI/0.1 cc. Topical anesthesia is made with proparacaine drops, and pressing firmly in the conjunctiva area of the muscle to be injected. 41
BT injection is made using an insulin syringe and passing it throughout conjunctiva and releasing BT as deep as possible to reach a major muscular mass. The good effect and safety of this direct technique without any electromyographic control has been proved in previous investigations. General anesthesia is used in non cooperative patients. (Moguel 2000). Follow up was made until 6 months. Response to treatment was reported as: “Good” strabismus until 10 prismatic dioptria; “Regular”: strabismus corrected 50%; “Bad”: strabismus corrected less of 50%. Descriptive statistics were applied.
3
RESULTS
We studied 30 patients, 14 females (46.6%), 16 males (53.3%); Age 3.5 +/ 3 years old. Age groups were: 0–12 months: 2 patients (6.6%), 13–35 months: 13 patients (43.3%), 36–60 months: 7 patients (23.3%), older than 61 months: 8 patients (26.6%) (Figures 1–2). Types of strabismus were: 15 esotropic (50%), 13 with exotropia (43%) and 2 intermittent exotropia (7%). Grade of psychomotor retardation reported by Paido-psychiatry was: 24 children (80%) with a moderated retardation, and 6(20%) with severe retardation. Follow up was 12.7 / 7.3 months. The sessions of BT treatment were: 15 patients (50%) needed only one application, 12(40%) 2 applications, 3(10%) 4 injections (1.7 / 1). The BT doses were: 10.41 / 1.2 UI; Good results were related with an average of 5.19 / 0.5 UI; bad results were related with average doses of 13 / 1 UI. We got Good results in 13 childrens (43.33%), Regular in 7 (23.33%), and Bad in 10 (33.33%). (Fig. 2). The variables showed: Results about age: The group 1–5 years gave the best and the worst results to BT. Exposing it to Xi2 0.05 with table of contingency 3X3 selecting 4 grades of liberty, resulting in 3.51, by this way X2calculated (3.51) X2table (9.488), it means that the grade of resolution after BT is independent to age in the moment of treatment.
Figure 1.
Premature patient before treatment.
Figure 2.
Patient after BT injection.
42
Results about application: We demonstrated that 83.33% had a good response with only one application of BT, and the next applications didn’t increase those good results significantly. It was tested with Null-alternate hypothesis with Xi2 0.05 with table of contingency 3X3 selecting 4 grades of liberty, resulting in 22.6, by this way X2calculated (22.6) X2table (9.488) to alternate hypothesis, it means that grade of correction is related to the first BT application. (3 tables 2X2 to number of doses: Xi2 and Fisher test with 0.05 and 2 grades of liberty, demonstrated that the very first application of BT determines the grade of response and prognosis to BT treatment) Results about type of strabismus: Although best results was obtained in patients with diagnosis of esotropia (9 children corresponding to 69.23%) and bad ones to exotropia (6 children), we tested it with Null-alternate hypothesis with Xi2 0.05 with table of contingency 3X2 selecting 2 grades of liberty, resulting in 3.6, by this way X2calculated (3.6) X2table (5.99) accepting null hypothesis, it means that grade of correction after BT applications is independent of type of strabismus. Results about psychomotor retardation: Comparing the 13 patients with good results and moderated mental retardation and the bad results group (10 patients) with 20% severe retardation: The Xi2 test (X2calculated 9.29 X2table 5.99) showed that the grade of response to BT depends to better mental health. Results about etiology and stability of mental retardation : Nine patients (30%) had paroxysmal disorder with epilepsy, seven patients (23.33%) with brain damage secondary to prematurity, seven 7 patients (23.33%) were idiopathic, two patients (6.66%) had chromosomal diseases, two patients (6.66%) had cerebrovascular disorders and one had a brain tumor (3.33%). We found better responses in patients with more stable neurological disease (prematurity, idiopathic, chromosomal disease and brain atrophy) and less BT effect, bad results and a major variability of strabismus angle in patients with non-stable disease (epilepsy, cerebrovascular brain disease, hydrocephalus and brain tumor) (Fig. 3). The best results were related to brain damage secondary to prematurity, and the worst were found in paroxysmal disorders.
4
DISCUSSION
The presence of psychomotor retardation and brain damage are very important factors for a bad development of binocular cortical centers, provoking poor potential of fusion, and probably causing the high percentage of strabismus in those patients. The neurological damage during the first years of life impedes the health of visual and sensorial development, even more, a surgery under compromised health causes retardation of treatment and permit consequently the organic changes in muscles. The instability of brain damage provokes relapses of strabismus, not only in the same pattern but also in different ones as a new strabismus. To postpone the treatment of strabismus is the rule in these patients to avoid the risk of a general anesthesia because of their liability. In many cases the strabismus treatment is made lately or never. Direct technique of chemodenervation with “A” Botulinum toxin proposed by Moguel since 1995 has demonstrated to be enough, safe and effective in strabismus treatment, without any electromyography control with less risk of bleeding or posterior diffusion to another muscles because it doesn’t penetrate to muscular cone. (Moguel 2003). Our previous investigations of strabismus in patients with systemic diseases, chronic diseases, instability, progressives or unknown prognosis even for life, have demonstrated that this treatment does not expose the patients to an unacceptable risk and can be used for strabismus under neurological damage. The possibility to do an early treatment for strabismus can avoid secondary changes in muscles, and visual deterioration. (Moguel 1999, Moguel 2003, Cordonnier 1994, Mc Neer 1994, Huber 1996). In many cases of brain damage the type of strabismus associated is paralytic and knowing the good effect of BT in paralytics we could hope good results in brain diseases (Huber 1996). We can receive now premature children until 500 mg weight who were born with a brain immaturity and retardation in visual evolution and strabismus. In these patients we do not need to wait a better state and we can initiate an early treatment since the first months of life (McNeer 1994). 43
In patients with brain steam alterations and damage in conjugated ocular movement but also esotropia, the cephalic position to compensate diplopia is uncomfortable and not easy to perform. For example in bilateral ponds lesions, the BT treatment is useful to get a better position of head. According to this we demonstrated the efficacy of BT treatment in patients with strabismus and brain damage or psychomotor retardation, the response with the very first injection and the better results in stable neurological disease and even the potential of fusion.
5
CONCLUSIONS
BT treatment for strabismus in patients with psychomotor retardation or brain damage is a very good alternative to offer an early, efficient and safe rehabilitation of visual and sensorial function. We could demonstrate that there is no relation of response to BT treatment to either age or type, so we can begin treatment even in older children. The response to BT can be seen from the first application and it is better with a more stable disease and a better potential of fusion. The safety of the direct technique demonstrated in other systemic diseases permits to offer an alternative treatment in premature children even from the first months of life with less risk of anesthesia. Because of unknown answer of patients with mental retardation to BT we suggest 2.5 UI to begin treatment, and increase it as necessary. We conclude that because of difficulty of strabismus treatment in patients with brain damage and psychomotor retardation the chemodenervation with “A” BT must be considered the first choice.
REFERENCES Cordonnier, M. & Van Nechel, C. et al. 1994. Le Traitment du strabisme par la toxine botulique. J Fr Ophtalmol 12: 755–768. Huber, A. 1996. Botulinum toxin in the treatment of paralytic strabismus. Neuro-Ophthalmol 16: 11–14. McNeer, K.W. et all. 1994. Observations on bilateral simultaneous botulinum toxin injection in infantile esotropia. J Pediatr Ophthalmol Strabismus 31: 214–219. Moguel-Ancheita, S. 1997. Indications of botulinum toxin in strabismus. Rev Mex Oftalmol 71(5): 194–200. Moguel-Ancheita, S. 1999. Horizontal gaze palsy. Rev Mex Oftalmol 73(3): 125–130. Moguel-Ancheita, S. 2000. Botulinum toxin for strabismus treatment. Rev Mex Pediatr 67(4): 166–171. Moguel-Ancheita, S. 2000. Ocular miasthenia. Rev Mex Otalmol 74(2): 90–94. Moguel-Ancheita, S. 2003. Botulinum toxin as a treatment for strabismus in systemic diseases. Arch Soc Esp Oftalmol 78: 9–14.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Botulinum toxin-A injection in acute complete sixth nerve palsy Mohammad Reza Talebnejad, Alireza Alavi & Abbas Attarzadeh Shiraz University of Medical Sciences, Shiraz, Iran
ABSTRACT: Purpose: To evaluate the effects of botulinum toxin-A as an alternate to surgery in acute complete sixth nerve palsy and to decrease the disease course. Materials and methods: 30 patients ranging from 9 mo to 70 yr with acute complete sixth nerve palsy received 2.5 units of botulinum toxin-A injection in the medial rectus muscle within one month from the onset of palsy. Toxin was injected directly into the muscle belly under local (25 cases) or general (5 cases) anesthesia. At the 1st, 7th, 30th, 90th and 180th day, binocular field, abduction and any residual deviation were measured. Results: 24(80%) patients had full abduction after 3 months and 6(20%) had 10° abduction. Among treatment failures, 3 were traumatic and 3 were tumoral. Binocular diplopia free field was 75° in 22(73%). 22(73%) had no residual esotropia although 8(27%) patients had 10–50° residual esotropia which required surgery. No cases of exotropia, or globe perforation was encountered. Conclusion: Injecting botulinum toxin-A is a simple and safe way of treating acute complete sixth nerve palsy and eliminating the need for invasive surgical manipulations.
1
MATERIAL AND METHODS
A total of 30 patients (22 males and 8 females) with acute complete sixth nerve palsy referred to OPD clinics and Khalili hospital A&E wards, Shiraz University of Medical Sciences, Shiraz, IRAN were studied. Depending upon clinical findings, thorough history taking and physical examination and any necessary para-clinical work-up was performed. Among these patients, 9 were traumatic, 6 were hypertensive or had atherosclerosis, 6 were diabetic, 6 were due to brain tumor, 1 had giant cell arteritis, 1 was congenital and 1 had an unknown cause. Of these patients 24 had unilateral acute sixth nerve palsy and 6 had bilateral sixth nerve palsy. Informed consent was taken from the patients. All of the injections were performed between two weeks and one month after onset of palsy. The botulinum-A toxin, used was Dysport™. Each Dysport vial constitutes 500 units of toxin in the form of solid powder. Each vial was prepared with 5cc normal saline and 0.1cc (containing 10 units of Dysport, equivalent to 2.5 units of Botox™) was injected into the muscle. Local anesthesia with lidocaine and tetracaine drop was used in adult patients, while in the children the toxin injection was performed under Ketamine anesthesia. The surgical field was prepared, the medial rectus insertion was grasped firmly with forceps, the eye was rotated to the primary position. Then 0.1cc (10 units) of Dysport solution was injected 5–10 mm from the medial rectus insertion, parallel to medial orbital wall, inside the bulk of muscle through a 27 gauge needle (without any EMG guide). The needle was held for 5–10 seconds inside the muscle before retrieval, to prevent leakage of Dysport to the adjacent muscles. The patients were visited after one day, one week, one month, 3 months and 6 months from the injection. During the follow up visits all of the patients were examined to detect any improvements in position and movements of the eye. Abduction, binocular single visual field and any residual esotropia were checked for. 45
2
RESULTS
Twenty four patients (80%) had full abduction after 2–3 months. The remainder six (20%) had under 10 degrees abduction after six months and considered as treatment failures. (Table 1). Among treatment failures two were traumatic and two had brain tumor. Regarding binocular visual fields, twenty two patients (73%) had 75 degrees of single binocular visual field without diplopia eight patients (27%) had only 10–20 degrees of binocular visual field and complained of diplopia outside this range (Table 2) After 3 months twenty two patients (73%) had no deviation or were esophoric, while eight patients (23%) had 10–50 prism diopters esotropia (Table 3). The most frequent complications were vertical and horizontal deviations. Ptosis and diplopia. All of these were transient and resolved within 2–3 months after injection. No cases of globe perforation, or retro-bulbar hemorrhage was encountered.
3
DISCUSSION
Sixth cranial nerve due to its long tortuous course and its passage through the cavernous sinus is vulnerable to various pathologies and palsy. A patient with sixth nerve palsy develops esotropia resulting in medial rectus contracture and fibrosis. If medial rectus contracture develops, surgery becomes difficult and complicated. Some of the patients with sixth nerve palsy recover spontaneously within six months. There are contradicting reports about the effect of injecting botulinum toxin in acute unilateral sixth nerve palsy. Some reports fail to show beneficial effects from prophylactic injection of botulinum toxin1. This may be due to high rates of spontaneous recovery (73%) in acute sixth nerve palsy 4. In a recent study, subtenon injection of botulinum toxin showed comparable results to that obtained using EMG guided injection 2. In this study we tried to prevent medial rectus contracture with injecting botulinum toxin in the medial rectus during the 1st month of palsy. Twenty four (80%) of our patients had full abduction after three months and twenty two (73%) had more than 75 degrees binocular fields and no deviation. Table 1. group.
Improvements of abduction in study
Count
Percentage (%)
Abduction
24 6
80 20
Full abduction 10° abduction
Table 2. Improvement of binocular field in study group. Count
Percentage (%)
Binocular field
22 8
73 27
75° 10–20°
Table 3.
Residual esotropia in study group.
Count
Percentage (%)
Residual ET
22 8
73 27
No ET 10–50 PD ET
46
None of these complained of diplopia. Surgery was performed under local anesthesia in all cooperative patients without EMG guide and without any significant complication. It seems that botulinum toxin injection inside medial rectus in acute VI the nerve palsy is a simple, safe and cheap way to treat diplopia esotropia and face turn in patients with acute VI the nerve palsy. It has a high success rate and eliminates the need for transposition surgery, which has the risk of anterior segment ischemia especially in the elderly. In bilateral sixth nerve palsy it seems that surgery is necessary, but botulinum toxin injection during the acute phase may be useful to reduce the complications of surgery.
4
CONCLUSION
According to the results of our study we recommend botulinum toxin injection into the medial rectus of patients with acute sixth nerve palsy (with any cause) within the 1st month from the onset of palsy. This policy has a good success and low complication rate.
REFRENCES 1. Buncic JR. (1996). Sixth nerve palsy. In Good WV, Hoyt CS (eds): Strabismus Management. p 271, Boston, Butterworth-Heinemann. 2. Holmes JM, Droste PJ, Beck RW. (1996). The natural history of acute traumatic sixth nerve palsy or paresis. J AAPOS 2(5):265–8. 3. Kao LY, Chao AN. (2003). Subtenon injection of botulinum toxin for treatment of traumatic sixth nerve palsy. J Pediatr Ophthalmol Strabismus 40(1):27–30. 4. Lee J, Harris S, Cohen J, et al. 1994. Results of prospective randomized trial of botulinum toxin therapy in acute unilateral sixth nerve palsy. J Pediatr Ophthalmol Strabismus 31(5):283–6.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
The role of Botulinum toxin A in augmentation of the effect of recess resect surgery A.S. Topalog˘lu, S.B. Özkan & S. Aydın Adnan Menderes University Medical School Department of Ophthalmology, Aydın, Turkey
ABSTRACT: This study evaluates the efficiency of intraoperative botulinum toxin A (BTA) injection as an adjunct to the surgical treatment of large-angle esotropia or exotropia. Ten patients were included in the study. Mean age of the patients was 27 20. Seven patients had esotropia and 3 patients had exotropia, with a deviation greater than 60 prism diopters (PD). Five units of BTA was injected into one of the recessed horizontal rectus muscles in all of the patients intraoperatively. The average follow-up was 14 10 months. The average final deviations in the esotropia and exotropia groups were 13 9.6 PD and 4.7 5 PD respectively. The final deviation was within 10 PD in 70% of the patients. Our results suggest that combined use of BTA and surgery may prove useful to reduce the number of muscles to be operated on in large angle deviations.
1
INTRODUCTION
Botulinum toxin A (BTA) was introduced by Scott7 (1980) as an alternative to traditional strabismus surgery. Subsequent studies showed that BTA is safe and effective in the management of certain types of strabismus. BTA causes a temporary flaccid paralysis of the injected muscle, resulting reduced or even reversed deviation due to unopposed action of the ipsilateral antagonist muscle. Large-angle horizontal deviations may require 3 or more horizontal rectus muscles to be operated on. However, combined use of BTA with surgery may have an additive and permanent effect on the angle of deviation. In the presented study, we analysed our data to assess the efficiency of intraoperative BTA injection as an adjunct to the surgical treatment of large-angle esotropia or exotropia. 2
METHOD
Ten patients (5 male and 5 female) with large-angle esotropia or exotropia who were evaluated at Adnan Menderes University between 2000 and 2003 comprised the study population. They all had undergone a complete preoperative and postoperative eye examination and an orthoptic assessment. Of these 10 patients, 3 had infantile esotropia, 2 had non-refractive accommodative esotropia, 1 had partial accommodative esotropia, 1 had basic esotropia, 2 had basic exotropia and 1 had sensoriel exotropia. Our inclusion criteria was a follow-up period of 8 months or more. Five units of BTA was injected into one of the recessed horizontal rectus muscle in all of the patients intraoperatively. The esotropic and the exotropic patients were evaluated separately. 3
RESULTS
Mean age of the patients was 27 20 (5–55). The average follow-up was 14 10 months (8–40 months). Follow-up was more than 12 months except for the patient who achieved fusion and stereopsis. Fusion was not demonstrated in any of the patients preoperatively. The average preoperative 49
esodeviation was 73.6 16.5 PD and exodeviation was 76.7 5.8 PD. Four esotropia patients underwent monocular recession (5 mm), and resection (9 0.8 mm). Two esotropia patients underwent 2 muscle recession (5 mm) and 1 muscle resection (8.5 2.1 mm). One esotropia patient underwent one muscle resection (9 mm) and BTA injection into the previously recessed muscle. Three exotropia patients underwent monocular recession (9.3 0.6 mm), and resection (8.6 1.2 mm). The average final deviation in the esotropia group was 13 9.6 PD whereas in the exotropia group it was 4.7 5 PD. One of our patients developed fusion and stereopsis (480 sec of arc) on the postoperative 3rd month. The final deviation was within 10 PD in 70% of the patients.
4
DISCUSSION
This study was performed to evaluate the results of our experience on combined use of BTA with recess resect surgery. Our results suggest that BTA injection may have a permanent additive effect on the final deviation. Owen4 (1990) et al evaluated the effect of intraoperative BTA and monoocular recession resection surgery in 3 large-angle exotropia patients, with a deviation greater than 70 PD. In that study, 3 patients underwent monocular recession (10 mm) and resection (10 mm) along with intraoperative BTA injection of 10 units into the recessed muscle. All three patients were reported to have satisfactory cosmetic results. They concluded that intraoperative BTA injection provided an alternative for the surgical correction of large-angle exotropia by operating only on two horizontal rectus muscles. In our study, although improvement in binocular vision was obtained in only one patient, in most of our patients satisfactory results were obtained in long term. Our results suggest that there may be other possible mechanisms responsible for the long term additive effect of BTA. BTA acts selectively on peripheral cholinergic nerve endings to inhibit acetylcholine release6. The toxin binds to the specific receptor on the cell surface. The drug induces a severe muscle palsy without causing damage to the rectus muscle or the peripheral nerve. The goal of this treatment is to create adequate weakness of sufficient duration in the injected muscle so that it becomes slightly atrophied and stretched while the antagonist muscle takes up the slack with some degree of contracture3. Scott8 (1994) showed that the number of sarcomers in the contracted and shortened muscle decreased whereas it increased in the stretched muscle. This mechanism may be responsible for the permanent additive effect of BTA. During the period of induced paralysis, the ipsilateral antagonist rectus muscle develops contractile changes. Even after full recovery from the paralysis, a permanent disturbance of the pattern of motor innervation in the treated muscle was demonstrated1. The toxin alters the passive stiffness in eye muscles which suggests that toxin has fiber-specific consequences that permanently alter the muscle behavior5. Kranje2 (2001) et al studied the long term changes of extraocular muscles after BTA injection into the medial rectus muscles of adult rats. Muscle cross sections were examined immunohistochemically on the eighth month. Examinations showed that myosin heavy chain (MyHc) profile shifted toward slower isoforms whereas specific extraocular MyHc isoform MyHceom dissappeared and could not be detected. Their results suggested that long-lasting changes in BTA-paralyzed ocular medial rectus muscles most probably reflect the inability to regain their unique functional characteristics after new motor and plate formation and recovery of muscle contraction. The possible alterations in sarcomer number and histochemical properties of the extraocular muscles seem responsible for the permanent augmentation effect of BTA with recess resect surgery. 5
CONCLUSION
Our results suggest that combined use of BTA and surgery is a good alternative instead of 3 or 4 muscle surgery to reduce the number of extraocular muscles to be operated on in large-angle esotropia and exotropia. 50
REFERENCES 1. Duchen LW, Strich SJ. 1967. Demonstration of morphological abnormalities of motor nerve fibres after botulinum toxin injection in adult albino mice. J Physiol (Lond):189:2–4. 2. Kranje BS, Sketelj J, D’Albis A, Erzen I. 2001. Long-term changes in myosin heavy chain composition after botulinum toxin A injection into rat medial rectus muscle. Invest Ophthalmol Vis Sci:42(13):3158–64. 3. Osako M, Keltner JL. 1991. Botulinum A toxin (Oculinum) in Ophthalmology. Surv Ophthalmol:36:28–46. 4. Owens PL, Strominger MB, Rubin PA, Veronneau-Troutman S. 1990. Large-angle exotropia corrected by intraoperative botulinum toxin A and monocular recession resection surgery. Graefes Arch Clin Exp Ophthalmol:228(5):401–6. 5. Porter JD. 1995. Extraocular muscles. Surv Ophthalmol:39:451–484. 6. Rosenbaum AL. 1996. The current use of Botulinum toxin therapy in strabismus. Arch Ophthalmol:114(2): 213–4. 7. Scott AB. 1980. Botulinum injection into extraocular muscles as an alternative to strabismus surgery. Ophthalmology:87:1044–1049. 8. Scott AB. 1994. Change of eye muscle sarcomers according to eye position. J Pediatr Ophthalmol Strabismus:31:85–88.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Does Botulinum Toxin have a role in the treatment of secondary strabismus? E.L.M. Dawson, A. Sainari & J.P. Lee Moorfields Eye Hospital, London, England
ABSTRACT: The toxin clinic database was reviewed, identifying patients with strabismus secondary to permanent or temporary impairment of vision. Five hundred and three patients fulfilled our criteria. There were 301 males and 202 females, with a mean age at treatment of 35 years. Three hundred and eighty three patients (76%) had exotropia, 114 (22.5%) had esotropia and 6 (1.5%) had vertical strabismus. Reduced vision secondary to trauma accounted for 45% (227) of patients. Other causes were congenital anomalies 121 (24%), refractive error 30 (6%), retinal detachment 20 (4%), senile cataract 24 (5%), corneal problems 19 (4%), glaucoma 10 (2%) and 52 (10%). Ninety nine (20%) patients were managed with continued toxin treatment. Two hundred and eighteen patients (43%) proceeded to surgery. Forty patients (8%) required no further treatment as they regained binocularity by injection alone.
1
INTRODUCTION
Botulinum Toxin has been used for the treatment of strabismus at our tertiary referral centre since 1982. Sensory strabismus results from a permanent or temporary impairment in visual acuity. These patients comprise a significant proportion of the clinic population, approximately 9%. Not only is the impairment in visual acuity a cause for the deviation, it is believed also to affect the stability of any corrective strabismus surgery. Control by non-surgical means therefore assumes greater importance in the management of secondary deviations. Our aim is to define the role of Botulinum Toxin in patients with secondary strabismus. 2
METHOD
A retrospective review of patient notes was performed using the Botulinum Toxin clinic database of over 6,000 patients. We analysed 503 complete case notes of patients who fulfilled our criteria of having a strabismus secondary to impairment of vision. This specific subject has been discussed before by Han1 et al who reviewed 12 patients with sensory strabismus and Lawson2 et al who looked at long term review of 11 patients with sensory strabismus and 33 with consecutive exotropia. 3
RESULTS
There were 301 males and 202 females, with a mean age of treatment of 35 years. There was a very wide range of between 6 and 86 years old. Three hundred and eighty three patients (76%) had exotropia, 114 (22.5%) had esotropia and 6 (1.5%) had vertical strabismus. Reduced vision secondary to trauma accounted for 45% (227) of patients. Other causes were congenital anomalies 121 (24%), refractive error 30 (6%), retinal detachment 20 (4%), senile cataract 24 (5%), corneal problems 19 (4%), glaucoma 10 (2%) and other 52 (10%). One hundred and ninety three (38%) 53
patients were aphakic. Sixty six percent of patients had best corrected vision of between NPL and 6/60. Nineteen percent had between 6/36 and 6/18 and 15% had between 6/12 or better. One thousand four hundred and fifty seven injections were given, with a range of 1 to 50 per patient. Three hundred and eighty five patients (77%) had previous ophthalmic surgery, ranging from one to 5 operations. Ninety nine (20%) patients were managed with continued toxin treatment. Two hundred and eighteen (43%) proceeded to surgery. Forty patients (8%) required no further treatment as they regained binocularity by injection alone. Eleven percent (57) of patients had no evidence of binocular function when assessed prior to injection, but after just one injection, fusion and stereopsis were demonstrable. The best level of stereoacuity recorded was 200 seconds of arc using the Titmus test. Thirty five of these 57 patients were able to maintain alignment and binocularity and so required no further treatment. The remaining 22 of this group, required surgery to consolidate the unexpected binocular status. The duration of attendance at the clinic ranged from one day to 17 years, with a mean of 1.9 years.
4
DISCUSSION
Botulinum Toxin appears to have a role in the treatment of secondary strabismus. Only 3% (14) of patients failed to obtain any reduction in their angle. There appears no apparent reason for this. It was well tolerated, with no permanent side effects. Only 22 (4%) patients developed transient ptosis.
5
CONCLUSIONS
Many patients with secondary strabismus are under the false impression that there is no treatment for them and they have to live with the poor cosmesis of their strabismus, as well as the impaired visual acuity. Botulinum Toxin offers these patients a treatment to enable the realignment of their eyes and for the procedure to be carried out on the affected eye. There is an increased risk in patients with a residual esotropia of developing consecutive exotropia after a second surgical procedure, following an initial medial rectus recession surgery. As we are aware these patients are often extremely reluctant to undergo further surgery on their dominant eye. Tejedor3 et al further supports the use of Botulinum Toxin for the treatment of residual esotropia. He reports Botulinum Toxin is rapid and a less invasive alternative to reoperation in this group of patients. Horgan4 et al showed that in a mixed population of 95 patients, when 8 or more consecutive injections were performed, the interval between injections increased with time. We also found that the angle of deviation reduced over a period of time with repeated injections. This was hugely advantageous for the patient but also for the clinic. Due to the angle becoming smaller, the interval between injections becomes less frequent.
REFERENCES 1. Han, S.H, Lew, H, Jeong, C.W, Lee, J.B. 2001. Effects of botulinum toxin A chemodenervation in sensory strabismus. J Pediatr Ophthalmol Strabismus:Mar–April;38(2):68–71. 2. Lawson, J.M, Kousoulides, L, Lee, J.P. 1998. Long-term results of botulinum toxin in consecutive and secondary exotropia: outcome in patients initially treated with botulinum toxin. JAAPOS:Aug;2(4):195–200. 3. Tejedor, J, Rodriguez, J.M. 1999. Early retreatment of infantile esotropia: comparison of reoperaton and botulinum toxin. Br J Ophthalmol:Jul;83:783–7. 4. Horgan, S.E, Lee, J.P, Bunce, C. 1998. The long term use of botulinum toxin for adult strabismus. J Pediatr Ophthalmol Strabismus:Jan–Feb;35(1):9–16.
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Session 5: Various aspects
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Evaluation of the effect of strabismus surgery on retrobulbar blood flow with Doppler US . A. Ipek Akyüz Ünsal*, Alparslan Ünsal**, Seyhan B. Özkan* & Can Z. Karaman** Adnan Menderes University Faculty of Medicine Departments of Ophthalmology* & Radiology**, AYDIN, TURKEY
ABSTRACT: To investigate the potential alterations of ocular hemodynamics after strabismus surgery with the use of color Doppler ultrasonography. In this study 20 eyes of 18 patients and left eyes of 20 healthy age and sex matched volunteers were evaluated. Ophtalmic, central retinal, short posterior ciliary and long posterior ciliary arteries and central retinal veins of both groups were examined. With spectral analysis; peak systolic velocity, end diastolic velocity, resistivity and pulsatility indices, acceleration time and acceleration index values were calculated. There was no statistically significant difference in parameters of Doppler ultrasonography between the single and double horizontal rectus muscle surgery groups. We also could not find a significant difference between the preoperative and postoperative Doppler examinations. In contrary to some recent papers, our results suggest that the strabismus surgery involving single or two horizontal rectus muscles does not have a serious impact on retrobulbar blood flow.
1
INTRODUCTION
During conventional rectus muscle surgery, anterior ciliary arteries are not preserved, since anterior segment ischemia (ASI) does not occur in healthy subjects with routine horizontal rectus muscle surgery (Olver & Lee 1989, Lee & Olver 1990). However, some hemodynamic changes may be seen in retrobulbar circulation due to the increased blood flow need of the anterior segment circulation. Especially combined vertical and horizontal rectus muscle surgeries, have higher risk for development of ASI (Olver & Lee 1989, Lee & Olver 1990, France & Simon 1986, Olver & Lee 1992). Imaging methods may help to understand the pathophysiology of the ASI. The purpose of this study was to evaluate the effect of strabismus surgery on retrobulbar hemodynamics with Doppler ultrasonography as a non-invasive imaging method. 2
MATERIALS AND METHODS
Twenty eyes of 18 patients (Female/Male: 9/9; age range: 9–45 years, mean age: 19.15 2.86 years) with the complaint of squint who admitted to our clinic were enrolled in this prospective study. Control group included the left eyes of 20 healthy, age and sex matched volunteers. All of the patients underwent detailed ophthalmological examination – including best visual acuity, orthoptic examination, fundus and anterior segment evaluation – preoperatively and at postoperative 1st day and 1st month. Strabismus surgery was performed for exotropia (n 10), esotropia (n 4) and 4th (n 3) and 3rd nerve (n 1) palsies. Limbal conjunctival insicion was used in all of the patients. Surgery was carried out with adjustable sutures in 9 patients. Conjunctiva was recessed in adjustable suture surgery group. Operated eyes were evaluated in two subgroups. There were 7 eyes in group 1 with single rectus muscle surgery (1 patient with esotropia, 6 patients 57
with exotropia) and 13 eyes in group 2 with double rectus muscle surgery (5 patients with esotropia, 8 patients with exotropia). All surgical interventions were performed by the same surgeon (SBÖ) under general anesthesia. Ophthalmic artery, central retinal artery, short and long posterior ciliary arteries and central retinal veins of both patients and control groups were evaluated by Doppler ultrasonography. Peak systolic velocity, end diastolic velocity, resistivity and pulsatility indices, acceleration time and acceleration index values were calculated with Doppler spectral analysis. All the Doppler examinations were also done by the same radiologist (AÜ) and repeated at 1st day and 1st month of post-operative period. Mann Whitney U test was used for independent variables, Wilcoxon test was used for dependent variables. 3
RESULTS
No statistically significant difference was found between the preoperative Doppler parameters of the patients and control groups (p 0,05). There were also no significant difference between preoperative and postoperative Doppler values of the patients (p 0,05). Individual evaluation of preoperative and postoperative Doppler values of single and double rectus muscle surgery subgroups were found insignificant (p 0,05). Adjustable suture procedure had not a significant effect on retrobulbar hemodynamics (p 0,05). The results are summarized in Table 1. 4
DISCUSSION
Doppler ultrasonography is used to evaluate the orbital blood flow and the hemodynamic alterations related to certain ophthalmological and orbital diseases, since 1989 (Ericsson et al. 1989). This non-invasive imaging method was also used to demonstrate the potential hemodynamic effects of strabismus surgery on retrobulbar circulation, in recently published studies with conflicting results. Bayramlar et al. evaluated the ophthalmic arteries of 19 patients, who underwent recession or resection surgery of horizontal rectus muscles, with Doppler ultrasonography (Bayramlar et al. 2000). In that study, no statistically significant difference was found between preoperative and postoperative Doppler examinations, and they concluded that two horizontal rectus muscle surgery does not have a significant effect on ophthalmic artery circulation. Table 1.
Mean Doppler values of each evaluated arteries of the patients and control group.
Control
Patient group preoperative
Patient group postoperative 1st day
Patient group postoperative 1st month
PSV EDV RI PI
57,20 12,10 14,75 3,48 0,73 1,47
52,40 11,67 13,40 2,80 0,72 1,52
57,65 11,37 15,25 2,79 0,73 1,45
54,05 17,22 13,74 2,99 0,74 1,51
Central retinal artery
PSV EDV RI PI
21,50 4,45 7,90 1,74 0,63 1,01
21,10 4,24 7,95 1,35 0,61 0,99
21,30 4,08 7,80 1,70 0,63 1,03
23,26 3,45 9,32 2,16 0,60 0,95
Short posterior ciliary artery
PSV EDV RI PI
17,65 3,71 8,25 3,74 0,58 0,88
19,68 3,96 8,42 2,03 0,57 0,90
21,15 5,10 8,85 2,16 0,57 0,89
19,28 ± 3,95 8,16 2,01 0,57 0,88
Long posterior ciliary artery
PSV EDV RI PI
14,30 2,67 5,95 1,31 0,57 0,81
17,14 6,54 7,43 2,63 0,56 0,83
16,00 3,50 7,00 1,70 0,57 0,88
18,75 ± 4,37 8,13 1,96 0,56 0,86
Evaluated artery
Doppler parameter
Ophthalmic artery
58
Güven et al. evaluated 21 eyes of 16 patients who underwent single or double horizontal rectus muscle surgery, with color Doppler ultrasonography (Güven et al. 2000). Their results revealed a statistically significant difference between the preoperative and postoperative PSV, EDV and average velocities of both treatment groups. The difference was more prominent in double horizontal rectus muscle surgery group compared to single muscle surgery and control groups. Güven et al. stated that there were some alterations in the retrobulbar blood flow after horizontal rectus muscle surgery, probably due to increased surgical irritation and neurological stimulation. In a recent report of Pelit et al., major retrobulbar arteries of 26 patients who underwent surgical correction of strabismus were examined (Pelit et al. 2002). They reported that PSV, EDV and average velocities were increased, resistivity and pulsatility indices were decreased in ophthalmic arteries of double rectus muscle surgery group at first postoperative day, and this difference disappeared at the end of first week. Pelit et al concluded that these early postoperative alterations in ophthalmic arteries can be secondary to increased need of blood flow and can be a clue of still unknown mechanism which protects eye from anterior segment ischemia. Our results suggested that horizontal muscle surgery, whether single or double muscle surgery, does not have a significant impact on retrobulbar blood flow. We obtained similar results as Bayramlar et al., contrary to other two articles on the same topic (Bayramlar et al. 2000, Güven et al. 2000, Pelit et al. 2002). Conflicting results of the discussed articles and our study can be explained by the application of various surgical techniques, type of anesthesia and the user dependent nature of Doppler examination. The presented study, as well as the previous ones mentioned above, evaluates the retrobulbar vessels in order to detect the potential alterations in retrobulbar circulation in the absence of findings related to anterior segment ischemia. Doppler ultrasonography is an indirect way to evaluate anterior segment circulation. Orbital Doppler ultrasonography is a user dependent and time consuming imaging method in which a complete patient cooperation is essential, so all of these studies concerning orbital Doppler ultrasonography has the disadvantage of small patient groups. We believe that to assess the effects of strabismus surgery or other ophthalmological interventions on anterior segment circulation objectively, further non-invasive and direct imaging techniques are needed.
5
CONCLUSION
Our results suggested that with the conventional Doppler US equipment, there seems to be no alteration in ocular blood flow following horizontal rectus muscle surgery. REFERENCES Bayramlar H, Totan Y, Çekiç O, Yazıcıog˘lu KM, Aydın E. 2000. Evaluation of hemodynamic changes in the ophthalmic artery with color Doppler ultrasnografy after strabismus surgery. Journal of pediatric ophthalmology and strabismus 37(2): 94–100 Erickson SJ, Hendrix LE, Massaro BM, Harris GJ, Lewandowski MF, Foley WD, et al. 1989. Color Doppler flow imaging of the normal and abnormal orbit. Radiology 173: 511–6 France TD, Simon JW. 1986. Anterior segment ischemia syndrome following muscle surgery: The AAPO&S experience. J Pediatr Ophthalmol Strabismus 23: 87 . Güven D, Zıraman I, Tomaç S, Sancak D, Karaemir MA, Hasıripi H. 2000. Hemodynamic changes after strabismus surgery. Strabismus 8(1): 21–27 Lee JP, Olver JM. 1990. Anterior segment ischemia. Eye 4: 1–6 Olver JM, Lee JP. 1989. The effects of strabismus surgery on anterior segment circulation. Eye 3: 318–326 Olver JM, Lee JP. 1992. Recovery of anterior segment circulation after strabismus surgery in adult patients. Ophthalmology 99(3): 305–315 Pelit A, Barutçu Ö, Oto S, Aydın P. 2002. Investigation of hemodynamic changes after strabismus surgery using color Doppler imaging. Journal of AAPOS 6(4)
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Computer assisted parent’s vision screening in children M. Altıeri, S. Chattarjee, A. Gibson, P. Addison & A. Assaf Department of Ophthalmology, Milton Keynes NHS Trust Hospital, Milton Keynes, Bucks, UK
ABSTRACT: A total of 70 children who attended the paediatric ophthalmology clinic were entered into this prospective study. These children were aged between 3 and 10 years with a mean age of 5.86 years. The children were selected based on the parents willing to participate in the study. The children had their visual acuity tested by their parent/s using a computer with a 15 flat panel display set in a clinic room. The parents used Snellen’s E-chart with a testing distance set at 3 meters. The orthoptist also measured their visual acuity in the normal fashion. The orthoptist assessment included visual acuity assessment using linear Snellen’s chart except when indicated. Children either had their vision assessed first by the orthoptist then parents (39 children) or first by parents and then orthoptist (31 children). All the children apart from 4 (6 eyes out of 140) carried the test successfully. 81% parents found the testing process easy and 77% of the parents found the child co-operation was excellent to good. A total of 24 (17%) amblyopic eyes were detected by the orthoptist testing at the visual acuity level of 6/12 or worse. However, a total of 76 (54%) eyes had a vision of 6/12 or worse by the parents testing. Thus the false referral rate was 37%. All the 24 amblyopic eyes were detected by the parents’ testing. If the parents’ referral rate is reduced to those who had a vision of 6/18 or worse, then the over-referral rate is reduced to 18%. However, in this case the parents missed 3 amblyopic eyes. All eyes (apart from 3) had worse or similar vision on the parent testing compared to that of the orthoptist.
1
INTRODUCTION
Vision screening has been controversial in the recent ophthalmic literature. Current controversies include does it work? Is it cost effective? And who is best to do it? All are valid questions, which the profession needs to address. Recent questions raised on the validity of vision screening (Snowdon SK and Stewart-Brown SL, NHS Centre for Reviews and Dissemination, University of York, 1997). With such controversies many societies, even the affluent ones, find it difficult to justify the cost involved in setting up national screening programs. The screening process normally requires qualified personnel to conduct the testing process. The orthoptist obtained the best result. This is an expensive option for many societies. Additionally, access to the patient can be less than satisfactory, especially in remote countryside in certain countries. In a previous study Assaf and Dowaidi used Television for parents to the test the vision of their children, which was compared to that of the orthoptist. Nowadays personal computers are widespread and present in many, if not most, homes. With the advent of liquid crystal display (LCD) screens the display contrast and brightness can easily meet the national standards for vision testing devices. We present in this article a method for visual acuity screening in children using personal computer with LCD monitor. The actual testing process is carried out by the parent/s of the child. The result of the testing by the parent/s will be compared with the orthoptic assessment of the child’s visual acuity. 61
Figure 1. Computerised Snellen E-test set at 3 meters testing distance to run under MS windows environment. The display is refreshed by pressing the “Enter” key with new random letter arrangement. Fresh display was used for testing the second eye. Also there were no similar shapes “E” on the same line if the number of letters 4.
2
MATERIALS AND METHODS
A Prospective study involving 70 children who attended an orthoptic clinic over a 6 months period (September 03 to February 04) at Milton Keynes Hospital Ophthalmology Department. Before the start of the study a 2 weeks trial period involving 10 children was carried out to find out and correct any possible pitfalls of difficulties in the testing process or instructions given to the parents. These 10 children were not included in the study. Children were randomly tested first either by parent then orthoptist (31 children) or by the orthoptist then parent (39 children). Both the parent and Doctor conducting the study signed a consent form for the study. The orthoptist used the appropriate age related vision testing method, which was one of the following: LogMAR Kay pictures, linear Sheridan Gardiner or linear Snellen. Most had linear Snellen testing. The parent/s on the other hand used linear E-chart Snellen test computer software to work under Microsoft Windows (author AA) and set for a 3 meters testing distance (figure1). The software is installed on the computer placed on a side room in the clinic. The display screen was Flat 15 monitor. Instructions explaining the test were given to the parent plus E-shape for the child to point with. The parent and the child were left in the room to conduct test. The parent filled a form after carrying out the test.
3 3.1
RESULTS Children
A total of 70 children were tested. The sex ratio was 39 females to 31 males. The age range of the selected children was 3–10 years. The average age was 5.87 years.
3.2
Visual acuity
All the children apart from 4 (6 eyes out of 140) carried out the test successfully. Table 1 shows the visual acuity testing results by both parents and orthoptist. At visual acuity level of 6/12, the parents detected all the 24 amblyopic eyes as diagnosed by the orthoptist (figure 2). However, the false referral (over-referral) rate is 37% (table 2). 62
Table 1.
Amblyopia rate at 6/12 level for orthoptist and parents. Orthoptist
6/12 or worse 6/9 or better Total amblyopic eyes Not possible/not done
Parent
Right eye
Left eye
Right eye
Left eye
11 (16%) 59 (84%) 24 eyes (17%) –
13 (19%) 57 (81%) 24 eyes (17%) –
39 (56%) 29 (41%) 76 eyes (54%) 2 (3%)
37 (53%) 29 (41%) 76 eyes (54%) 4 (6%)
VA level
Amblyopic Eyes (total 24 eyes) 60 54 48 42 36 30 24 18 12 6 0 Orthoptist
Parent
Figure 2. The visual acuity level in 24 amblyopic eye as found by the orthoptist versus parent testing. Notice the parent testing is lower than the orthoptist in all cases except one. Table 2.
Over-referral at acuity levels of 6/12 (and 6/18) with parent testing. Right eye
Left eye
Amblyopic
11/70 (16%) (non missed at 6/12) (at 6/18 0 missed)
13/70 (19%) (non missed at 6/12) (at 6/18 3 missed)
Over-referral
28/70 (40%) (at 6/18 11 (16%))
24/70 (34%) (at 6/18 16 (20%))
Total
39/70 (56%)
37/70 (53%)
Among the 140 eyes, 3 eyes (2 children) had a better vision with parents testing, but was within one line of that of the orthoptist. All the remaining eyes had worse or similar vision on the parent testing compared to that of the orthoptist. Child co-operation was excellent to good in 77% of cases. In response to a questionnaire in regard to the ease of the testing process, 81% parents found the testing process easy. 4
DISCUSSION
Visual screening of children is an important topic. On the other hand, controversies exist in regard of the application of such screening program. The main objection to such an application has been the significant cost involved. This cost of universal visual screening is currently prohibiting in many developed countries, is even more so in most developing countries. Computers are becoming widespread and available increasingly in many home. The current LCD computer monitors offer excellent contrast and brightness can easily meet the national standards 63
for vision testing devices. Thus computers with LCD monitors have the potential of being an excellent home screening tool for visual acuity testing both eyes in adult and children. In our method of study we used linear Snellen E-test set at 3 meters. The 3 meters distance is appropriate to testing children as well as the dimension of most homes. The E-test was chosen for its familiarity and universal use both for English and non-English speaking adults and children as well as being available free. The old limitation of having 4 possibilities has been overcome by the ability to refresh the display with new random letter arrangements every time. This is used for testing the second eye and whenever guessing is suspected. We felt Snellen’s test format would be less confusing and more familiar to parents than LogMAR since they would have been tested with Snellen charts or seen them in their GP or optometrist practices. In this around 81% thought the child co-operation with the test was excellent or good and 77% indicated that the testing process was easy. This test is not suitable for children 3 years old or under. Most of the children completed the test (94%). If the fail level for the orthoptic testing was 6/12 and for the parents testing was 6/12 then the amblyopia detection rate was 100% (24/24). However, the false referral rate was 37%. If the parents fail rate was increased to 6/18 then the amblyopia detection rate increased to 87.5% (21/24). At this visual acuity level the false referral rate was reduced to 18%. However, in this case the parents missed 3 amblyopic eyes detected by the orthoptist testing. Among the 3 eyes missed, 2 had a vision of 6/12 by both parents and orthoptist testing and a 3rd eye had 6/60 vision but found to have 6/12 vision (in both eyes) on the parent testing. This child was examined first by the orthoptist who recorded that he attempted to cheat with on testing his amblyopic eye. Thus he appeared to have cheated with his parent testing since his vision in the amblyopic eye was 6/12, similar to that of the good eye. All the 24 amblyopic eyes had scored similar or worse vision on the parents testing compared to that of orthoptist, apart from this child who appeared to have cheated on testing his amblyopic eye (figure 2). At both levels the over-referral rate using visual acuity testing at school by community nursing revealed 43% over-referral (Yang and Dole). In another study this was 41% (Ingarm). In almost all instances (131/134 of the eyes tested) the visual acuity results obtained by the parents were similar or higher (worse vision) when compared to that of the orthoptist. Perhaps repeating the test at home could reduce the over-referral. Moreover, testing in the home environment where the child and parent are in familiar surroundings and not pressed with time might produce more accurate results.
REFERENCES Assaf A, Dowaidi M. Visual acuity screening in children using television screen. In: Ed. M Spiritus, TA of the 24th European strabismological Association 1997, Vilamoura, Portugal, pp 305–310. Ingram RM. Review of children referred from the school vision screening program in Kettering during 1976–8. BMJ 1989;298:935–6. Snowdon SK and Stewart-Brown. Preschool Vision Screening: Results of a Systemic Review. NHS Centre for Reviews & Dissemination, The University of York. CRD Report 9, 1997. Yang YF, Dole M. Visual acuity testing in schools: what needs to be done. BMJ 1996;313:1053.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Acquired neurological nystagmus: clinical and surgical approach A.C. Spielmann Ravinelle Ophthalmology Center, Nancy, France
ABSTRACT: Acquired neurological nystagmus, just like congenital nystagmus, may benefit from surgical treatment. 48 files of acquired nystagmus were reviewed. Different surgical procedures were performed in order to dampen the nystagmus, but also to treat associated disorders such as oculomotor or gaze palsies. The most common type of nystagmus was vertical nystagmus, but there were also other kinds of nystagmus, some of asymetric form. A great care was given to the torsional conditions of the eyes prior and after surgery. After surgery, oscillopsia and anomalous head posture due to nystagmus improved dramatically. However, diplopia was not always curable in cases of oculomotor palsy, especially because of poor fusional capacities and subjective torsion.
1
INTRODUCTION
Acquired nystagmus is less frequent than congenital nystagmus. Its main characteristics, as opposed to congenital nystagmus, are unbearable oscillopsia and associated neuro-ophthalmological disorders, such as oculomotor nerve palsy or gaze palsy (ref. 1). Despite many papers published by strabismologists, some of them at the occasion of passed ESA meetings (refs 2, 3, 4), acquired nystagmus is often wrongly considered as beyond surgical therapy, especially among neurologists. This study aimed at evaluating our surgical results with 48 patients, and at trying to draw some guidelines for treatment. 2
MATERIAL AND METHODS
Forty-eight usable files of neurological acquired nystagmus, from 1979 to 2003, were reviewed. Otologic nystagmus and blindness nystagmus were excluded. The follow-up was at least 6 months. Clinical features of the nystagmus and the other oculomotor disorders were studied, with the help of various documents such as coordimetric charts, photographs, videos, ENG, etc. Surgery was intended to relieve the patient from oscillopsia in primary position (straight head, looking straight) and to suppress abnormal head posture. The same techniques as used for congenital nystagmus were used, with adjustable sutures whenever possible. Surgery applying a vertical Anderson procedure (double recessions) or a vertical Kestenbaum procedure (double resect-recessions) was the most frequent (21 cases), but horizontal procedures were also common (12 cases). Horizontal and vertical Anderson-Kestenbaum procedures were also combined in some cases. A four recti recession was used in 3 cases with periodic alternant nystagmus or with no blocking position. No patient could benefit from Artificial Divergence Surgery nor retro-equatorial myopexy on medial recti. The associated paralytic oculomotor disorders were treated at the same time in 14 cases. In 15 cases, the main problem was a large and complex paralytical deviation with diplopia (often ophthalmoplegia), with no real blocking position for nystagmus. In the case of these patients, no specific surgery for the nystagmus could be performed and surgery was intended to 65
restore parallelism in primary position. Large recessions were preferred to resections with the aim to help dampening nystagmus. In some cases with cyclotorsion, a shift of the recti insertion was often performed in order to avoid surgery on too many muscles.
3
RESULTS
Acquired nystagmus was associated with a large diversity oculomotor disorders, sometimes in a context of bad general health (hemiplegia, aphasia, facial palsy, depressive syndrom…). Gaze palsy (mainly upgaze and horizontal gaze palsies, right or left) was present in 17 cases. A convergence palsy was present at least twice, whereas a convergence excess was associated in one case of upgaze palsy. An oculomotor deviation which could be caused by an oculomotor nerve palsy or paresis was present in 25 cases, either unilaterally or bilaterally. In some complex cases, an exact classification of the oculomotor disorder was impossible. Other neuro-ophthalmological disorders may have been associated, such as abnormalities of pursuit or saccades, lesions of the visual pathways, etc. An overview of our results shows that surgery has a positive effect on the intensity of nystagmus, on head posture on visual acuity and on oscillopsia, at least in primary position. It is also effective on gaze palsy and head posture due to gaze palsy. The improvement of the visual function in primary position could be assessed both objectively and subjectively in most cases, even if nystagmus did not completely disappear. The improvement of cosmesis (head posture, squint and intensity of nystagmus) was also of paramount value in terms of social rehabilitation and selfconfidence for these adult patients who were used to working. In some cases, equilibrium also improved with the disappearance of vertigo. However, the real problem was the associated oculomotor nerve palsy. Diplopia could not always be cured in the case of these patients with poor fusional capacities.
4
DISCUSSION
When a blocking position (in fact a blocking innervation necessary to stabilize fixation) is present in excentered gaze (null zone or equilibrium zone), the principles of surgery are easy. The null zone has to be transferred to the primary position. Nystagmus can then be blocked or dramatically attenuated, not only in primary position but also in any gaze position since the blocking innervation persists. The surgery of nystagmus is not only surgery of head posture: its aim is to make nystagmus disappear, even if it is not always possible. The same philosophy applies for the 4 recti recession procedure, even if the way it works is not so well understood. When nystagmus disappears, oscillopsia also disappears. Amazingly, oscillopsia may disappear even if residual nystagmus persists. Oscillopsia is probably not linked with the intensity of nystagmus. The increase of the foveation time could be enough to stabilize the perception and neutralize vision during drift or saccades. Sometimes, the effects of surgery on nystagmus may seems disappointing as regards oscillopsia, but obtaining short periods free of nystagmus and oscillopsia during which the patient can read a little may be a great help to the patient. We tried to cure all the oculomotor disorders in one operation with more or less complex procedures, frequently involving 6 muscles. In these cases, tucks were preferd to resections to preserve blood supply. Adjustable suture surgery was mandatory because of unpredictable results in paralytical and innervational deviations and because of poor fusional capacities. Adjustable sutures enabled to perform large amounts of recessions. We had no overcorrection on the head posture either due to nystagmus or to the associated gaze palsy. Ophthalmoplegia were rather undercorrected. The need for a second operation in some cases was mainly due to a residual paralytic deviation, rarely because of an insufficient result or of recurrent head posture. As a transient complication, we had 2 cases of regressive ptosis after a large vertical Kestenbaum procedure. 66
In some cases, when the primary problem was a paralytic deviation with diplopia, and no blocking position for nystagmus, we were surprised that nystagmus could be improved only by realigning the eyes. Is the restoration of the binocular single vision enough to dampen nystagmus? Should we consider some of the associated nystagmus as a kind of paralytic nystagmus? We were also surprised by the improvement of motility in gaze palsies. The shift of the eyes towards the direction of the palsy as well as neuronal reorganisation using undamaged circuit could be an explanation (ref. 5). Cyclotorsion was excessively frequent (almost half of the cases). Many factors can lead to cyclotorsion such as IVth nerve paresis or decompensated cyclophoria after rupture of fusion. Torsion is also linked to the vestibular system. According to current literature, many cases of acquired nystagmus are classified as vestibular nystagmus (ref. 7). Some patients had nausea, vertigo and walking difficulties before surgery, and were supposed to have a vestibular syndrome. With some patients, these symptoms all disappeared after surgery. They could have been explained simply by oscillopsia and the false localisation due to the paralytical deviations, without lesion of the vestibular system. The classification of nystagmus, and particularly vestibular nystagmus, should be reassessed. The existence of a specific and independent center of torsion, which could also be responsible for the cyclotorsional part of nystagmus, has not be proven so far but research on this question should be pursued. After surgery, we also found that many patients showed signs of cyclotorsion. The same reasons may apply but we can also think about the effect of large vertical procedures on the vertical recti muscles. These muscles also have an action on cyclotorsion. We showed a few years ago that large vertical kestenbaum procedures had very few effect on cyclotorsion in cases of congenital nystagmus (ref. 6). However, this may not be true with patients showing poor fusional capacities due to brain damage. A deep clinical examination with coordimetric chart is therefore mandatory before and after surgery, even in cases that may appear rather simple. We also found many cases with small angle deviation but no limitation of the motility. We may considered them as ocumotor nerve paresis that became concomittant, but some of them could be cases of decompensated phoria due to a lesion of the center of fusion. They could also be associated with the cyclotorsional problems we have just mentioned. Diplopia was in fact the main challenge when it was associated to nystagmus. There were many reasons for diplopia: lesion of the center of fusion, cyclotorsion, convergence palsy, poor vision due to a lesion of the visual pathways, abnormality of pursuit and saccades, difficulty for cervical compensation in case of hemiplegia, and sometimes maybe asymetry of nystagmus. Even large amount of surgery with adjustable sutures could not always make it disappear. Prisms were not always helpful. 5
CONCLUSION
In 48 cases of acquired nystagmus, with a diversity of associated oculomotor problems, we showed the validity of the surgical procedures used in congenital nystagmus. Surgery was efficient on nystagmus, oscillopsia in primary position and on the head posture. The main challenge was to deal with the associated palsy and diplopia when they were present. Anatomical correlation and pathophysiology may remain mysterious, but a deep clinical examination, with evaluation of fusion, convergence and cyclotorsion, will be a great help for surgery. Overall results are very gratifying, both for the patient and the surgeon. Acquired nystagmus can (and should) benefit from surgery. REFERENCES (1) Buckley SA, Elston JS. 1997. Surgical treatment of supranuclear and internuclear ocular motility disorders. Eye 11: 377–380. (2) Schiavi C, Scorolli, Campos EC. 1996. Surgical management of anomalous head posture due to supranuclear gaze palsies and acquired nystagmus. In M. Spiritus ed., Transactions of the 24th Meeting of the European Strabismological Association. Aeolus Press, Buren, The Netherlands, 229–232.
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(3) Spielmann A. 1997. Oscillopsia and nystagmus surgery. In M. Spiritus ed., Transactions of the 24th Meeting of the European Strabismological Association. Aeolus Press, Buren, The Netherlands, 300–302. (4) Spielmann A, Aflalo G, Spielmann A.C. 1998. Surgery in vertical acquired nystagmus. In Lennerstrand G. ed Advances in Strabismology. Proceedings of the 8th Meeting of the International Strabismological Association, Sept 1998. Aeolus Press, Buren The Netherlands, 369–372. (5) Spielmann A, Richter J. 1989. La chirurgie oculomotrice dans le syndrome de Parinaud. Ophtalmologie 3: 157–159. (6) Spielmann AC, Spielmann A. 1995. Bilateral vertical recti recessions for vertical abnormal head-posture in congenital nystagmus: Are they sucessful? Do they create alphabetic desequilibrium? In M. Spiritus ed., Transactions of the 22th Meeting of the European Strabismological Association. Aeolus Press, Buren, The Netherlands, 124–129. (7) Stahl JS, Averbuch-Heller L, Leigh J. 2000. Acquired nystagmus. Arch Ophthalmol April, 118: 544–549.
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Session 6: Adjustable surgery
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Strabismus surgery under topical lidocaine gel O.M. Hakim Magraby eye center, madina munwara, Saudi Arabia
Y.G. El-Hag Faculty of medicine, Zagazig University, Egypt
ABSTRACT: Objective: to evaluate the efficacy and stability of one stage adjustable suture using topical lidocaine gel 2% in combination with intravenous nalbuphine. Methods: Forty adult patients with strabismus underwent adjustable rectus muscle surgery under topical lidocaine gel 2% and an additional preoperative intravenous 10 mg nalbuphine given 10 minutes before surgery. Adjustment was done on the operating table. Analgesia was assessed using Verbal Description Scale (VDS). Changes in vital signs (blood pressure and heart rate) were recorded during surgery to evaluate the oculocardiac reflex. Results: Of the 40 patients; 35 patients expressed no pain, 3 patients complained of discomfort and 2 patients complained of distressing pain. Intraoperative cardiac monitoring did not record positive oculocardiac reflex in any of the patients. Conclusion: Topical anesthesia using Lidocaine gel in combination with intravenous nalbuphine is an effective anesthesia strategy that provides patient’s comfort and surgeon ability to control his surgical plan.
1
INTRODUCTION
Local anesthesia became preferred over general anesthesia for most ocular surgeries. The advantages of local anesthesia are well known and include avoidance of complications of general anesthesia and more rapid return to ambulation for the patient (Yepez et al. 1999). Methods of local anesthesia include retrobulbar, peribulbar, subtenon, and subconjunctival infiltration of local anesthetic solution. when these methods are used in combination with adjustable suture technique, both the patient and the surgeon have to wait at least six hours to ensure adequate dissipation of the local anesthetics’ effect on the muscles before adjustment can be performed (Velez et al. 2001; Guyton 2001). The purpose of this study is to evaluate the feasibility and stability of one stage adjustable suture using topical lidocaine hydrochloride 2% gel with intravenous analgesic agent (nalbuphine hydrochloride) as an augmented topical anesthesia combination.
2
SUBECTS AND METHODS
Forty patients (24 mens and 16 womens), who were judged to be appropriate surgical candidates for adjustable suture, were enrolled in this study. Mean patients’ age was 27 years (range 16–46 years). Ocular alignment abnormalities are shown in Table 1. All patients received intravenous 10 mg nalbuphine hydrochloride given 10 minutes before surgery. At the same time lidocaine hydrochloride B.P. 2% in an aqueous gel (xylocaine gel 2%) was applied to the eye 10 minutes before surgery. 71
Table 1.
Summary of preoperative ocular alignment abnormalities.
Deviation
Number of patients
Mean deviation ( )
Range ( )
Exotropia Esotropia Vertical
19 20 2
42.31 34.70 18
14–65 15–70 16–20
Table 2.
Summary of surgical procedures.
Procedure
Number of muscles
Lateral rectus recession Medial rectus recession Lateral rectus resection Medial rectus resection Superior rectus recession Inferior rectus recession Inferior rectus tuck
30 28 7 7 1 2 1
Conjunctival fornix incision was used for exposure of recti muscles. For muscle adjustment, the standard sliding nose adjustable technique was used for recession. When bilateral recession was planned, one muscle was recessed using the adjustable suture technique and the other muscle was recessed using hang back technique which provides less tissue manipulation than direct scleral tunnel fixation technique. When planning for resection, standard resection technique was used for all recti muscles except inferior rectus muscle which was tucked using non-absorbable suture. Changes in vital signs (blood pressure, heart rate) were recorded before and during surgery to evaluate the oculocardiac reflex. Oculocardiac reflex was defined as a decrease of 10% or more of the basal heart rate. At the end of surgery, the patient was seated upright on the operating room table and looked at a 20/200 snellen “E” on the far wall. The patient’s alignment was checked with prism and alternate cover test, and if needed, adjustments were done. Intraoperative pain was recorded, according to the type of the muscle and site of procedure, using Verbal Description Scale (VDS) with 0 score for no pain and 5 score for very severe pain. When pain was scored 3 or more then a supplementary dose of intravenous 5–10 mg nalbuphine hydrochloride was given for pain control. Patients were examined 1 day, 1 week and 3 weeks post-adjustment and ocular alignment in the primary gaze was recorded. 3
RESULTS
During this study, we had recessed 30 lateral recti muscles, 28 medial recti muscles, 2 inferior recti muscles and 1 superior rectus muscle. Also we had resected 7 lateral recti muscles, 7 medial recti muscles and 1 inferior rectus muscle was tucked (Table 2). On the first postoperative day the mean angle of deviation was 2.68 PD where 24 patients (60%) were orthophoric and 16 patients (40%) achieved deviation between 5 and 10 prism diopters (PD). After one week the mean angle of deviation was 2.38 PD where 24 (60%) patients were orthotropic and 16 patients (40%) achieved deviation between 5 and 10 PD and the mean deviation drift for all the patients was 1.68 PD (range, 10 PD exotropia to 10 PD esotropia). After three weeks the mean angle of deviation was 1.27 PD where 30 patients (75%) were orthotropic and 10 patients (25%) had deviation less than 6 PD and the mean deviation drift for all the patients was 2.45 PD (range, 10 PD exotropia to 10 PD esotropia) (Table 3). 72
Table 3.
Summary of postoperative alignment.
Orthotropia Deviation 0–5 PD Deviation 6–10 PD Mean angle of deviation Mean deviation drift
Table 4. Pain grade 0 1 2 3 4 5
After one day
After one week
After three weeks
24/40 7/40 9/40 2.68 PD
24/40 10/40 6/40 2.38 PD 1.68 PD
30/40 8/40 2/40 1.27 PD 2.45 PD
Pain score during muscle isolation. LL rec
LL res
MR rec
MR res
20 7 3
2 4 1
15 8 4 1
2 2 1 2
SR rec
IR rec
IR tuck
1 1 1
1
LL rec lateral rectus recession; LL res lateral rectus resection; MR rec medial rectus recesion; MR res medial rectus resection; SR rec superior rectus recession; IR rec inferior rectus recession; IR tuck inferior rectus tuck.
In all the procedures there was no pain recorded when an incision was made through the conjunctiva or intermuscular septum. The most recorded pain started when we hooked the muscle to isolate it and ended by muscle disinsertion. There was no pain on muscle reattachment or conjunctival closure. Pain with grade 3 was recorded for 1 patient with medial rectus recession, 2 patients with medial rectus resection, 1 patient with superior rectus recession and 1 patient with inferior rectus tuck. In these 5 cases an additional dose of 5–10 mg nalbuphine intravenous was given and pain was controlled (Table 4). Intraoperative cardiac monitoring did not record positive oculocardiac reflex in any of our patients.
4
DISCUSSION
In our study, we could achieve immediate postoperative adjustment of sutures using topical lidocaine gel 2% in combination with intravenous nalbuphine hydrochloride as an analgesic adjuvant with adequate patient convenience and comfort. Adjustable suture technique has become increasing popular over the last decade. Success with adjustable suture hinges on the adequacy of postoperative alertness and recovery of stable innervational tone in the extraocular muscles (Brown et al. 1992 &Velez et al. 2001). General and different local anesthesia techniques for strabismus operations share the disadvantage that they do not permit to evaluate the effect of the operation at the end of surgery (Walters et al. 2001). So, adjustment is usually made in the hospital or office 5 to 24 hours after surgery, when the patient has fully recovered from the anesthetic effect (Guyton 2001). Using Lidocaine gel in combination with intravenous nalbuphine enabled us to adjust the patient’s eye position on the operative table and at the same time to avoid certain hazards of general and retrobulbar anesthesia (Diamond 1989). Also, suture adjustment in the operating room provides the patient with non-painful, sterile and comfortable adjustment. Lidocaine hydrochloride 2% gel is one of topical anesthetic agents that have proven to be safe and effective for phacoemulsification, and phacotrabeculectomy cases (Assia et al. 1999, Koch 73
1999 & Lai et al. 2002). It provides better analgesia than other topical anesthetic agents even in comparison with Lidocaine 4% eye drops with better patient cooperation and less need for intraoperative supplemental anesthesia (Bardocci et al. 2003). Lidocaine diffuses readily through tissues and therefore provides a wide area of anesthesia and when used in its gel form this prolongs its residency time and effectively increases its bioavailability (Kirber 2000). This makes it superior to the aqueous form as a topical anesthetic agent with less need for intraoperative supplemental dose. Lidocaine gel provides corneal- wetting property which alleviates the need for repeated corneal irrigation and irritating patients under topical surgery (Kalyanasundaram & Hasan 2002). Also, this wetting property helps to maintain corneal clarity which is needed at the end of surgery for better fixation and adjustment. Nalbuphine hydrochloride is a new safe synthetic opioid analgesic that reduces pain without loss of consciousness. nalbuphine has an analgesic (agonist action) potency equivalent to that of morphine, and an antagonist activity (reversal of major effects of opioid drugs) (Stene et al. 1988). In our study, it was used to augment the anesthetic effect of topical Lidocaine gel without affecting patient conscious level at the end of surgery. The trigemino-vagal bradycardia elicited by tension on an extraocular muscle (Oculocardiac reflex; OCR) is uncommon but potentially fatal complication of strabismus surgery. It can cause severe bradycardiac arrhythmias during surgical manipulation of extraocular muscles. Prolonged oculocardiac reflex for strabismus surgery under topical anesthesia was reported by Arnold RW (Arnold et al. 1997). In their study patients received midazolam 1 mg and fentanyl 100 mg intravenously before surgery and used tetracaine 0.5% topically. In recent studies, it is proven that rapidly acting narcotics (like fentanyl and midazolam) enhance the degree of bradycardia due to the oculocardiac reflex. (Paciuc et al. 1999) In our study we did not record unfavorable oculocardiac reflex this is because we did not use rapidly acting narcotics and using Lidocaine reduces the incidence of oculocardiac reflex by limiting afferent transmission. (Ruta et al. 1996 & Ruta et al. 1997) Also doing surgery under topical anesthesia requires gentle manipulation for extraocular muscles with minimal traction which is the main stimulant for OCR. In conclusion we feel that topical anesthesia is not just an alternative to general anesthesia but can be used as an effective tool on planning for adult strabismus surgery. Using Lidocaine gel 2% in combination with intravenous nalbuphine offers a safe and potent topical anesthetic combination with many practical benefits for both the surgeon and the patient.
REFERENCES Arnold RW, Ellis FD, Wolfe TM. 1997. Prolonged oculocardiac reflex during strabismus surgery under topical anesthesia. Journal of Pediatric Ophthalmology & Strabismus 34(4): 252–4 Assia EI, Pras E, Yehezkel M, Rotenstreich Y, Jager-Roshu S. 1999. Topical anesthesia using lidocaine gel for cataract surgery. Journal of Cataract and Refractive Surgery 25(5): 635–9 Bardocci A, Lofoco G, Perdicaro S, Ciucci F, Manna L. 2003. Lidocaine 2% gel versus lidocaine 4% unpreserved drops for topical anesthesia in cataract surgery: a randomized controlled trial. Ophthalmology 110(1): 144–9 Brown DR, Pacheco EM, Repka MX. 1992. Recovery of Extraocular-Muscle Function After Adjustable Suture Strabismus Surgery Under Local-Anesthesia. Journal of Pediatric Ophthalmology & Strabismus 29(1): 16–20 Diamond GR. 1989. Topical anesthesia for strabismus surgery. Journal of Pediatric Ophthalmology & Strabismus 26(2): 86–90 Guyton DL. 2001. A testimony for Postop’ adjustable sutures in strabismus surgery, on the 25th (Silver) anniversary of Arthur Jampolsky’s original description. Binocul. Vis. Strabismus Q. 16(4): 241–2 Kalyanasundaram TS, Hasan M. 2002. Corneal-wetting property of lignocaine 2% jelly. Journal of Cataract and Refractive Surgery 28(8): 1444–5 Kirber WM. 2000. Lidocaine gel for topical anesthesia. J. Cataract Refract. Surg. 26(2): 163 Koch PS. 1999. Efficacy of lidocaine 2% jelly as a topical agent in cataract surgery. Journal of Cataract and Refractive Surgery 25(5): 632–4
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Lai JSM, Tham CCY, Lam DSC. 2002. Topical anesthesia in phacotrabeculectomy. Journal of Glaucoma 11(3): 271–4 Paciuc M, Mendieta G, Naranjo R, Angel E, Reyes E. 1999. Oculocardiac reflex in sedated patients having laser in situ keratomileusis. Journal of Cataract and Refractive Surgery 25(10): 1341–3 Ruta U, Gerding H, Mollhoff T. 1997. [Effect of locally applied lidocaine on expression of the oculocardiac reflex]. Ophthalmologe 94(5): 354–9 Ruta U, Mollhoff T, Markodimitrakis H, Brodner G. 1996. Attenuation of the oculocardiac reflex after topically applied lignocaine during surgery for strabismus in children. Eur. J. Anaesthesiol. 13(1): 11–5 Stene JK, Stofberg L, MacDonald G, Myers RA, Ramzy A, Burns B. 1988. Nalbuphine analgesia in the prehospital setting. Am. J. Emerg. Med. 6(6): 634–9 Velez FG, Chan TK, Vives T, Chou T, Clark RA, Keyes M, Rosenbaum AL, Isenberg SJ. 2001. Timing of postoperative adjustment in adjustable suture strabismus surgery. Journal of Aapos 5(3): 178–83 Walters G, Stewart OG, Bradbury JA. 2001. The use of subtenon ropivacaine in managing strabismus with adjustable sutures. Journal of Aapos 5(2): 95–7 Yepez J, De Yepez JC, Arevalo JF. 1999. Topical anesthesia for phacoemulsification, intraocular lens implantation, and posterior vitrectomy. Journal of Cataract and Refractive Surgery 25(8): 1161–4
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
When should the amount of surgery be adjusted during conventional muscle surgery? A. Roth Medical School, University of Geneva, Switzerland
C. Speeg-Schatz Eye Department, Medical School, University of Strasbourg, France
ABSTRACT: In which cases of concomitant strabismus is intra-operative adjustment of the amount of surgery justified? Patients and method: The study involved 80 consecutive cases of infantile esotropia and 44 of intermittent exotropia (124 cases). The angle to be corrected was measured in the awake state. Intra-operative data were recorded during surgery. Results: Results are presented for 86 patients having follow-up of at least two and one years respectively. In 42 patients, surgery was carried out with no allowance for intra-operative data. In 44 patients it was adjusted, or not, according to these latter. Discussion: Our results suggest that the variance of the results is reduced by intraoperative adjustment if the angle under anaesthesia and the extensibility differential in an antagonistic muscle pair indicate a significant imbalance between the passive muscle forces. Conclusion: Drawn from our results, guide lines for intra-operative adjustment are proposed.
The present study is the continuation of a previous one on the parameters to calculate the amount of conventional eye muscle surgery (ESA, 2003 [3]). We concluded that intra-operative data are useful additional parameters that, when taken into account, significantly reduce the variance of results. The aim of the new study is to demonstrate which cases of concomitant strabismus require intra-operative adjustment and by how much. The squint angle is variable in concomitant strabismus. The horizontal angle A, at a given moment i, can be given according to the following general descriptive formula [4], which sums up the implied factors: (1) Dv excess or insufficiency of tonic vergence; Dan anatomized part of the deviation, resulting from lasting Dv; Σi sum of the variability factors; Mc compensatory movements according to Bielschowsky, reducing the angle; Mh and Mac convergence excess independent and dependent of accommodation, increasing the angle. Dv and Dan represent the components of the basic angle, Mc, Mh and Mac the factors responsible for the variability. The aim of conventional surgery is to correct the basic angle of deviation [1, 2]. This angle, however, differs according to the type of concomitant strabismus. This can be illustrated with the formula (1) as shown by the two opposite types of strabismus set out in this study, infantile esotropia and normosensorial intermittent exotropia with normal AC/A ratio. 1
METHOD AND PATIENTS
In infantile esotropia compensatory movements are insignificant: the basic angle corresponds to the minimum angle and any variability results only from convergence excess, whether 77
accommodation-dependent or not. Thus the formula (1) can be simplified to: (2) The series of 80 children who underwent surgery for infantile esotropia from 1994 to 1998, with ages ranging from 11 to 100 months (median 44 months) and studied a year ago [3] are reconsidered here. Bilateral medial rectus posterior fixation sutures combined with uni or bilateral recession were carried out in all cases. The global amount of recession was calculated on the basis of the minimum angle in the waking state. 51 of the 80 children have been followed for over two to seven years. In normosensorial intermittent exotropia with normal AC/A ratio the compensatory movements according to Bielschowsky are powerful enough to compensate intermittently for the deviation. The amount of convergence excess, however, is insignificant. The basic angle corresponds to the maximum angle or, more precisely, to the prism power allowing optimal compensation of the deviation at distance. The variability results only from compensatory movements. The formula (1) can therefore be simplified to: (3) A series of 44 children who, during the same period, underwent a first surgery for normosensorial intermittent exotropia, with ages ranging from 3 to 12 years (median 5 years) is compared with the previous series. Intra-operative data were recorded routinely in the same way as for infantile esotropia. Combined unilateral surgery, i.e. recession of the lateral rectus and plication of the medial rectus, was carried out in all cases. The global amount of surgery was calculated on the basis of the optimal prismatic correction of the deviation. 35 of the 44 children have been followed over one to nine years. Of the total 86 patients from both series, in 44 cases (28 infantile esotropia and 16 intermittent exotropia) the amount of surgery was carried out making allowance for the imbalance between passive muscle forces as assessed by the position of the eye under anaesthesia and the extensibility differential in the lateral and medial antagonistic muscle pair; adjustment was made whenever these data indicated a significant imbalance between the passive muscle forces.
2 2.1
RESULTS Intra-operative data
In the previous study on infantile esotropia we noted a significant correlation between the angle under anaesthesia and the sum of the extensibility differential of the two eyes. Here, we consider the position under anaesthesia and the extensibility differential of each eye separately. The correlation is similar to the previous one with r2 0.32 (2 outlayers – 4 eyes – being deleted) [3]. In the series with normosensorial intermittent exotropia, data were recorded on the operated eye only. The correlation between the position under anaesthesia and the extensibility differential was r 2 0.23 (2 outlayers being deleted). The plot of the two series on a same graph shows that their distributions are in continuity and both regression lines (polynomial quadratic order) in extension. The regression of both series considered together is r2 0.45 (Fig. 1). This correlation demonstrates that the principle of intraoperative adjustment is valid for all types of concomitant strabismus. 2.2 From application to postoperative results We consider stable microtropia (between –4° and 4°) in infantile esotropia and a controlled exophoria or esophoria in intermittent exotropia to be a good result (it being well known that 50% of intermittent exotropia require a second surgery one or more years later). 78
LR MR extensibility differential vs eye position under anaesthesia 10
LR – MR extensibility differential
8 6 4 2 0 -2 -4 -6 -15
-10 -5 0 5 10 Eye position under anaesthesia (filled circles : infantile esotropia, open circles : intermittent exotropia)
15
Figure 1. Correlation between the differential of extensibility between lateral and medial rectus (LR – MR) and the position under anaesthesia of each eye (polynomial 2nd order regression) (a) infantile estropia (filled circles), N 156 eyes (4 out-layers being deleted): r2 0.32 (b) normosensorial intermitent exotropia (open circles), N 42 eyes (2 outlayers being deleted): r2 0.23 (c) all data: r 2 0.45.
Table I. Comparison of the results obtained in infantile esotropia depending on whether the adjustment or absence of adjustment was appropriate or not to the (im)balance of the passive muscle forces as shown by the intra-operative data: (a) in infantile esotropia; (b) in intermittent exotropia. Appropriate
Inappropriate
(a) Infantile esotropia (N 51) adjustment/no adjustment At least 2 years follow-up Adjustment No adjustment
4° to 4°
4° to 4°
12 12
7° to –18° 5° to 10° 2 2
9 7
7° to –18° 5° to 10° 4 3
Total
24 (86%)
4
16 (70%)
7
(b) Normosensorial intermittent exotropia (N 35) adjustment/no adjustment At least 1 year follow-up Adjustment No adjustment
Phoria 10 0
Residual X(T)/T or E(T) 1 5
Total
Phoria 3 2
Residual X(T)/T or E(T) 6 8
10 (63%)
6
5 (26%)
14
The results varied according to whether or not the adjustment, or absence of adjustment, was appropriate to the intra-operative data. Both series showed proportionally better results when adjustment or no adjustment was appropriate compared to when it was not (Table Ia and Ib): 86% versus 70% in infantile esotropia and 63% versus 26% in intermittent exotropia. 79
Table II. Guidelines for intra-operative adjustment of the amount of surgery in conventional surgery. MED: Muscle extensibility differential (lateral rectus extensibility minus medial rectus extensibility). Esotropia MED
Exotropia MED
Adjustment on the most abnormal muscle
Angle under Anaesthesia Basic angle 3°
Normal (0 to 1) Convergence (1) Divergence (0)
Normal (0 to 1) Divergence (0) Convergence ( 1.0)
No adjustment 0.5 to 1 mm; 0.5 to 1 mm
Angle under Anaesthesia 3° Basic angle
Normal (0 to 1) Convergence (1) Divergence (0)
Normal (0 to 1) Divergence (0) Convergence 1.0)
Idem, plus 0.5 to 2 mm no adjustment
Angle under Anaesthesia 3° Basic angle
Normal (0 to 1) Convergence (1) Divergence (0)
Normal (0 to 1) Divergence (0) Convergence ( 1.0)
Idem, minus 0.5 to 2 mm no adjustment
3
DISCUSSION
Conventional muscle surgery pertains to parametric calculation for which the angle measured in the awake state represents the parameter, the amount of surgery the variable and the result the probability of effect [2]. The angle under anaesthesia and the differential of extensibility in an antagonistic muscle pair represent valuable additional, partially independent, parameters, provided their assessment was precise [3]. Our results show that the variance is reduced by an intraoperative adjustment in the cases in which intra-operative data indicate a significant imbalance between the passive forces. The number of cases of our series, however, is too small and the confidence interval remains too large to be certain that the differences between the two subgroups, with or without an appropriate adjustment, are significant or not. This cannot, however, be rejected out of hand. The fact that a similar difference was found in both series is an additional argument in favor of the significance of our results. Guidelines for the amount of adjustment to be carried out according to intra-operative data are drawn from our results and summed up in Table II.
4
CONCLUSION
Our present study provides further supportive evidence to intra-operative adjustment in conventional surgery, this combined or not with posterior fixation sutures. An adjustment is justified whenever a significant imbalance between the passive muscle forces is assessed.
REFERENCES 1. KAUFMANN H. 2004. – Strabismus. Thieme, Stuttgart, 3rd ed. 2. ROTH A. 2004. – Which angle for which surgical strategy in comitant strabismus. The Pratt-Johnson annual Lecture. Amer. Orthop. J., 53: 75–87. 3. ROTH A. 2004 – Parameters to calculate the amount of conventional eye muscle surgery. In: de FABER J.- T. (ed.): Trans. 28th ESA Meeting 2003, Taylor & Francis, London, pp.179–183. 4. ROTH A., SPEEG-SCHATZ C. 2001. – Eye muscle surgery. Swets & Zeitlinger, publ., Lisse, NL.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Non-absorbable suture should be used for adjustable inferior rectus muscle recessions C.F. Parsa, M. Soltan-Sanjari & D.L. Guyton Johns Hopkins University School of Medicine, Wilmer Ophthalmological Institute, Baltimore, Maryland
ABSTRACT: Purpose: To compare the incidence of delayed overcorrection after adjustable inferior rectus muscle recession when using polyglactin versus polyester sutures. Methods: Inferior rectus muscle recessions performed over 23 years were reviewed. Patients were separated into two categories: recession using polyester suture versus polyglactin suture. Surgical results were evaluated by student t-test and Fisher exact test. Results: One hundred and twenty patients underwent inferior rectus muscle recession: 64 patients using polyester suture and 56 using polyglactin suture. By the two-month post-operative exam, 5 overcorrections (hyperdeviation 3 PD) had developed in the polyglactin group, but none in the polyester group (p 0.02). At the final follow-up exam, in addition to the five already present in the polyglactin group, only one small overcorrection had occurred in the polyester group, (p 0.096). Conclusion: The use of non-absorbable suture substantially decreases the possibility of delayed overcorrection in adjustable inferior rectus muscle recession surgery.
1
INTRODUCTION
Adjustable suture surgery on the extraocular muscles is increasingly common for horizontal and vertical strabismus. This technique is especially useful for vertical strabismus since the demand for surgical accuracy is greater than with horizontal strabismus. One of the complications of extraocular muscle recession is delayed overcorrection. This seems to occur more commonly with the inferior rectus and medial rectus muscles (Kushner 1990). Recent reports have described delayed overcorrection four to six weeks after inferior rectus recession (Wright 1996), particularly in those with thyroid eye disease, and in those with adjustable suture surgery (Helveston 1987, Kushner 1990, Hudson & Feldon 1992, Sprunger & Helveston 1993, Ruttum 1995, Vazquez & Muñoz 1999). While most delayed overcorrections develop four to six weeks after surgery, after absorbable sutures lose their strength, some authors (Hudson & Feldon 1992, Wright 1996), have attributed this phenomenon to factors unrelated to suture type or surgical technique. After experiencing several progressive overcorrections following inferior rectus muscle recessions using absorbable sutures, the senior author (DLG) initiated the use of non-absorbable suture material in 1983 in a proportion of cases, notably those where larger recessions were needed. The purpose of this study was to determine whether the rate of overcorrection after inferior rectus muscle recession decreased with the use of non-absorbable sutures.
2
MATERIAL AND METHODS
This study was a retrospective review. The records of all patients who underwent inferior rectus muscle recession by the senior author (DLG) at the Wilmer Ophthalmological Institute between 81
1978 and 2001 were reviewed. All patients with follow-up of less than 6 weeks, or simultaneous surgery on another cyclovertical muscle in the same or fellow eye were excluded. Pre-operative data collected included age, sex, pre-operative diagnosis, and pre-operative deviation, which was measured with prism and alternate cover test in primary position at distance. The initial amount of recession performed was based on the size of the hypodeviation, with approximately one millimeter of recession performed per 3 PD of hypodeviation. The surgical technique was described previously for hang-back recession on an adjustable suture with the variable substitution of polyester for polyglactin sutures (Guyton 1999). In cases where the inferior rectus muscle was recessed 4 mm or more, a separate adjustable 6-0 polyglactin suture was placed into the capsulopalpebral fascia, which had been dissected from the orbital face of the muscle, and was attached to the original muscle insertion site, just temporal to the site of muscle suture re-attachment, as previously described (Pacheco et al. 1992). Moreover, since 1991, four to six millimeters of Tenon’s tissue have also been excised between the muscle and the sclera to aid in the apposition and fusion of the recessed tendon to the sclera. Since 1999, radial, rather than circumferential conjunctival incisions have been preferred. To minimize irritation from cut polyester suture ends abutting the conjunctiva, approximately four millimeters of suture material is left beyond the knot, allowing the suture “tail” to flex and be positioned facing posteriorly, away from firmly adherent limbal conjunctiva. Moreover, as of 2001, the suture insertion site has been recessed two millimeters posterior from the original insertion site to further minimize suture material abutting limbal conjunctiva. Sutures were adjusted 6 to 8 hours following surgery, with the endpoint of adjustment being “no shift,” or an estimated 2–3 PD of undercorrection by alternate cover test. Lid sutures, if present, were adjusted at the same time. The first post-adjustment visit was usually 6 weeks after the surgery, and deviations were measured with the prism and alternate cover test. Surgical outcomes were analyzed for all patients, and separately for the two groups with polyglactin and polyester sutures respectively. Results were assessed using a consecutive hyperdeviation equal to 3 PD or more in the primary position as indication of overcorrection (failure). Failure rates for each type of surgery were analyzed statistically.
3
RESULTS
One hundred and twenty patients were identified who underwent adjustable inferior rectus muscle recession. Fifty-three (43.7%) were male and 67 (56.3%) were female. The mean age was 52.3 years. Fifty-six patients were operated on using polyglactin sutures, and 64 using polyester sutures. The mean pre-operative hypodeviation in the polyester suture group was significantly greater than in the polyglactin group. In addition, the polyester suture group had a mean undercorrection significantly greater than the polyglactin suture group, assessed by the student’s t-test. The overall failure rates (overcorrection) in the polyester and polyglactin suture groups were analyzed by Fisher’s exact test. There was no overcorrection six weeks after surgery in the polyester suture group, but overcorrection was present in 5 cases (8.9%) in the polyglactin suture group. This difference was statistically significant (p 0.020). By the time of the last follow-up exam, however, one overcorrection did develop in the polyester group. With this one late overcorrection in the polyester group, the difference between the two groups at the time of the last follow-up exam did not achieve statistical significance at the traditional p 0.05 level, but p 0.096 instead. Table 1 depicts the data of the patients with overcorrection. The amounts of overcorrection were greater in the patients with polyglactin rather than polyester suture. In 105 of the 120 patients, Tenon’s tissue between the muscle and sclera had been excised. Overcorrection at the sixth week after surgery developed in three of these 105 cases (2.9%), and by the last follow-up exam in a total of four cases (3.8%), with the final addition in the polyester group. Overcorrection had developed in two of the cases operated on without excision of Tenon’s tissue (13.3%) six weeks after surgery; this number did not change by the time of the last follow-up exam. The difference between the groups with and without Tenon’s excision at the six-week and at the final follow-up exam did not achieve statistical significance (p 0.117 and p 0.163 respectively). 82
Table 1.
Overcorrected cases.
Pre-Op Diagnosis (PD)
Pre-Op deviation (PD)
Suture material
Amount of recession (mm)
6th week deviation (PD)
Last follow-up deviation (PD)
Superior oblique palsy Superior oblique palsy Thyroid ophthalmopathy Multiple operations Post scleral buckling Post orbital floor fracture
10 13.5 30 6 13 18
Polyester Polyglactin Polyglactin Polyglactin Polyglactin Polyglactin
5 4.5 8 2 10 8
0 5 3 8 9 14
4 4 8 8 9 14
Minus hypotropia in operated eye; Plus hypertropia in operated eye.
4
DISCUSSION
Over- and undercorrections are poorly tolerated in vertical strabismus due to limited motor and sensorial fusional amplitudes. Hang-back adjustable suture surgery enables the surgeon to improve the immediate result of strabismus surgery, but does not guarantee long-term alignment. Some authors have attributed delayed overcorrection following inferior rectus recession to the anatomic relationship of the inferior rectus muscle with the inferior oblique muscle and linking connective tissue (Jampolsky 1978, Kushner 1990, Sprunger & Helveston 1993, Chatzistefanou et al. 2000) although alternative hypotheses have also been put forward (Hudson & Feldon 1992, Wright 1996). The supposition has been that continuing movement of this tissue complex during the healing phase may interfere with the anticipated fusion and reattachment of the inferior rectus muscle to the sclera. A recent multipositional MRI study of the extraocular muscles in different positions of gaze also confirms that of all the extraocular muscles, the inferior rectus muscle has the shortest arc of contact with the globe (Chatzistefanou et al. 2000). Thus, when the inferior rectus is suspended backward on a hang-back suture, the tendon may not be sufficiently apposed to the sclera for proper reattachment, especially when the eye is in downgaze and the desired new insertion may then be posterior to the point of tangency between muscle and globe. Poor adhesion of the recessed inferior rectus muscle to the globe may explain the higher prevalence of delayed post-operative slippage or “underaction” of this muscle after recession. Most delayed overcorrections develop four to six weeks after surgery, the same time period when absorbable sutures lose their strength. By 1983, we had begun using polyester suture in most cases of inferior rectus muscle recession, especially those with larger vertical deviations. For similar reasons, in 1990 Kushner also had suggested the use of non-absorbable sutures (Kushner 1990). In our study, overcorrection equal to or greater than three PD developed in six of 120 patients (5%) undergoing unilateral inferior rectus recession as the only cyclovertical surgery. Four of these six patients had restrictive strabismus pre-operatively (Table 1). Six weeks post-operatively, overcorrection developed in 5 of the 56 (8.9%) operated using polyglactin suture. In contrast, at the six-week post-op visit, no patient in the polyester suture group was overcorrected. This difference is statistically significant (p 0.02). The mean duration of follow-up in both groups was over seven months, with a median duration of 3.5 months. By the last follow-up exam, overcorrection developed in a single patient (1.5%) in the polyester suture group, with a small 4 PD of vertical deviation. This contrasts with five patients (8.9%) in the polyglactin suture group with a mean overcorrection of 9 PD. Although the difference between the two groups at the last follow-up exam no longer achieved statistical significance (p 0.09), we shall continue to use polyester sutures. We believe the explanation for this single case of delayed overcorrection, despite the use of non-absorbable suture, lies in the fact that the adjustable noose used to determine the amount of recession is still made of absorbable polyglactin 83
suture. While the polyester suture is tied in apposition to this polyglactin noose following the postoperative adjustments, the noose itself occupies a certain “volume” that, once fully dissolved, could account a further recession of up to one millimeter. Perhaps more importantly, should the permanent polyester suture knot not be carefully tied flush against the polyglactin noose due to intervening fascial and connective tissue at the moment of adjustment, even greater recession could occur once the noose material dissolves. We believe either or both of these mechanisms to be accountable for our single, mild (4 PD), delayed overcorrection with polyester suture. Even with our liberal criterion for overcorrection of any deviation equal to or greater than 3 PD, the overcorrection rate for the absorbable polyglactin suture group was only 8.9%. This rate is lower than some other studies using adjustable suture techniques with traditional absorbable sutures (Sprunger & Helveston 1993, Vazquez & Muñoz 1999). This may possibly be explained by our supplementary excision of Tenon’s tissue between muscle and sclera, which we believe increases the likelihood of tendon fusion to sclera. Although the difference in the overcorrection rates between Tenon excision versus non-excision cases in the polyglactin group did not reach traditional statistical significance, the number of non-excision cases was perhaps too small for a meaningful comparison. We believe this study demonstrates shows the most important factor for the prevention of delayed overcorrection after adjustable inferior rectus muscle recession is the use of nonabsorbable suture. We recommend the use of such sutures for all inferior rectus muscle recessions.
REFERENCES Chatzistefanou, K.I., Kushner, B.J., Gentry, L.R. 2000. Magnetic resonance imaging of the arc of contact of extraocular muscles: implications regarding the incidence of slipped muscles. J AAPOS 2:84–93. Guyton, D.L. 1999. Strabismus surgery. In: Gottsch, J.D., Stark, W.J., Goldberg, M.F. (eds). Ophthalmic Surgery, 5th edition:85–91. New York: Oxford Press Inc. Helveston, E.M.1987. Slipped inferior rectus after adjustable suture: Orthoptic horizons. In: Lenk-Schaffer, M (ed.) Transactions of VI International Orthoptic Congress: 421–425. Harrogate: Great Britain. Hudson, H.L. & Feldon, S.E. 1992. Late overcorrection of hypotropia in Graves ophthalmopathy. Predictive factors. Ophthalmology 99:356–60. Jampolsky, A. 1978. Surgical leashes and reverse leashes in strabismus surgical management. Trans New Orleans Acad Ophthalmol. St. Louis: Mosby, p. 251. Kushner, B.J. 1990. Pearls and pointers in adjustable sutures for strabismus surgery. In: Haik, B. (ed) Transactions of Symposium on Oculoplastic Surgery, Strabismus and Pediatric Ophthalmology:215–25. Thorofare (New Jersey): SLACK, p. 215–25. Pacheco, E.M., Guyton, D.L., Repka, M.X. 1992. Changes in eyelid position accompanying vertical rectus muscle surgery and prevention of lower lid retraction with adjustable surgery. J Pediatr Ophthalmol Strabismus 29:265–72. Ruttum, M.S. 1995. Adjustable versus nonadjustable sutures in recession of the inferior rectus muscle for thyroid ophthalmopathy. Binocular Vis Eye Muscle Surgery Q 10:105–112. Sprunger, D.T. & Helveston, E.M. 1993. Progressive overcorrection after inferior rectus recession. J Pediatr Ophthalmol Strabismus 30:145–148. Vazquez, C.W. & Muñoz, M. 1999. Overcorrection after adjustable suture suspension-recession of the inferior rectus muscle in non-thyroid eye disease. Binocular Vis & Strabismus Q 14:103–106. Wright, K.W. 1996. Late overcorrection after inferior rectus recession. Ophthalmology 103:1503–7.
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Session 7: Physiology and refractive surgery
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Metabolic changes in brain related to strabismus registered by brain SPECT S. Moguel & L. Orozco “20 de Noviembre” Hospital. México city, D.F. México.
ABSTRACT: Objective: To demonstrate metabolic changes happening in brain cortex in strabismus. Methods: Single photon emission computed tomography (SPECT) of brain was made in congenital esotropia, previous and after treatment. Results: Case 1: SPECT showed hypo-perfusion in left frontal lobe (7.38). Strabismus was corrected with botulinum toxin obtaining binocularity. Control SPECT showed correction of lobe (1.19). Case 2: had hypoactivity in left parietal area (8.59), strabismus was corrected with botulinum and binocularity was demonstrated, control SPECT showed increase of hypoactivity levels (5.95). Case 3: strabismus was corrected under surgery obtaining binocularity. SPECT had hypoactivity in right hemisphere (3, 4, 5 areas 0.7, 3.71, 11.09), positive changes after treatment was demonstrated (9.78, 6.44, 3.22). Conclusions: Metabolic changes in brain happened in congenital esotropia. In all cases Brain SPECT could demonstrate improvement after treatment, related to good response of motor and sensorial state. This is the first report of metabolic changes of brain in strabismus.
1
INTRODUCTION
Many areas of brain cortex participate in visual functions. The V1 cortex is now considered as the principal center of vision in human, and the associated cortex in fusiform gyrum and lingual gyrum for color. By Photon emission computed tomography of brain has been studied the synergistic activity of V1, V2, V4 and V5 of striatum and extra striatum areas, showing the V1–V2 as a segregators of functions. Integrity and perfect functions of all cortex are important to have a healthy visual and movements functions. But at this moment identify the brain alterations in strabismus has been difficult. The objective of this paper is to identify the metabolic alterations in brain cortex related to patients with strabismus and changes after treatment by Single photon emission computed tomography of brain (Brain Spect). (Milner 1998, Zeki 1991, Marg 1998, Pigassou 1967) 2
METHODS
This is a prospective, longitudinal, descriptive and observational study, from June 2003 to December 2003, including children with congenital and variable esotropia, without any brain damage demonstrated. SPECT was made under brain centellography 45 minutes after intravenous 99 Technetium (ECD-Tc99m), without any light stimulus and keeping open eyes. SPECT was made previous and 4 months after treatment. Levels of activity was always registered in base of right hemisphere, normality and pathology levels were analyzed by Nuclear Medicine Department and comparing the basal (previous SPECT) and control levels (after treatment SPECT). Strabismus treatment was made with botulinum direct technique injecting through conjunctiva to localize the medial rectus muscles and using a 27 g insulin syringe, doses of botulinum was 5 UI. When surgery was necessary 87
1a
1b
2a Figure 1a–1b.
Case 1 pre and post treatment. 2a, 2b.
2b
previous and control SPECT.
3a
3b
4a Figure 3a–3b.
Case 2 pre and post treatment. 4a, 4b.
4b
previous and control SPECT.
classical technique was planed. (Moguel 2003). Follow up was completed until one year posterior to treatment. Worth and Titmus test were used to demonstrate fusion and stereovision.
3
RESULTS
We have studied three cases with congenital and variable esotropia. Brain Spect was made demonstrating a regular concentration of technetium with physiological images of brain hemispheres, basal ganglia and cerebellum. Case 1: 5 years age female. RE (Right eye): 20/25, LE (Left eye): 20/50. Right fixation, suppression of left eye, 10 to 35 diopters esotropia, latent nystagmus, dissociated vertical deviation (DVD) and negative Worth test. Strabismus was corrected with botulinum 5UI in medial rectus, obtaining binocularity three months after. Figure 1a, 1b. Basal brain SPECT showed an hypo-perfusion in left frontal lobe (7 area), of 7.38, and hyper perfusion in right parietal and temporal area (3,4 areas). Control brain SPECT after treatment showed a better levels of frontal area 1.19. Figure 2a, 2b. Case 2: 6 years age female with recurrent strabismus. 20/20 both eyes. Right fixation, suppression of left eye, 10 to 20 diopters esotropia, latent nystagmus and DVD. Negative Worth test. Strabismus was corrected injecting 7.5 UI botulinum in left medial rectus, obtaining binocularity. Basal SPECT showed an evident hypo-activity in left parietal area (8.59), and control SPECT showed a better function in this area (5.95). Figures 3a, 3b, 4a, 4b. Case 3: 6 years age female with 45–60 variable esotropia, with recurrent esotropia, DVD and “V” pattern. 20/20 both eyes. Right fixation, suppression of left eye, negative Worth test. We made a 88
5a
5b
6a Figure 5a–5b.
Case 3 pre and post treatment. 6a, 6b.
6b
previous and control SPECT.
recession and faden operation in both medial rectus, and inferior oblique transposition in both eyes, obtaining binocularity. Basal SPECT had hypo-activity of right hemisphere in 3, 4 and 5 areas, (0.7, 3.71, 11.09 respectively) and getting better after treatment (9.78, 6.44, 3.22). Figures 5a, 5b, 6a, 6b.
4
DISCUSSION
We are demonstrating changes in brain cortex of patients with strabismus under treatment and relating to clinical improvement by SPECT. This could show the participation of brain in recurrence of strabismus. The extension of visual cortex in many areas of brain could have different alterations as we have demonstrated. Our criteria to study the metabolism in congenital esotropias with characteristics of variability, DVD and nystagmus was based in previous studies demonstrating alterations of horizontal conjugated movements with bad coordination in both eyes, explaining the changes of angle of deviation because of retardation to begin the movement in the eye going to outside (abduction movement) happening in this esotropic patients. Authors have related this retardation of abduction to electric alterations registered by brain Map (electroencephalography) (Sánchez & Shokida 2000, Ciancia 1998, Gallegos & Moguel 2003). In this paper we could relate the improvement of brain with the clinical changes of vision obtaining binocularity in all cases. The early treatment of strabismus doesn’t impede the recurrence, but we have considered that treatment made in 5–6 years old could obtain a more stable response because of better maturity of brain. Following this, treatment of strabismus have to be early to avoid monocular deterioration, amblyopic phenomenon, and to keep the fusion until a more stable brain age. Efficacy of botulinum toxin for treatment of esotropia has been already demonstrated. (Moguel 2003). We showed in this study the effectiveness of botulinum, not only a good response for angle of strabismus, but also a better horizontal conjugated movement, with regulation of the eye going to abduction. We consider that this improvement on the brain could be secondary to a regulative effect of botulinum, or by the other side because of a better capacity of the brain to maintain the good response to treatment in older children.
5
CONCLUSIONS
Improvement of metabolism alterations of brain cortex was demonstrated by SPECT in patients with strabismus under treatment, obtaining a better sensorial and motor states. This is a paper to promote the study of metabolism of brain cortex in patients with strabismus to get a better knowledge of participation of brain in the genesis of strabismus. 89
BIBLIOGRAPHY Ciancia, A.O. 1998. La esotropia del lactante. In CLADE (eds). Actualidades del Estrabismo Latinoamericano: 47–52. México: Lithoimpresora Portales. Gallegos-Duarte, M. & Moguel, S. et al. 2003. Pathogenesis of lateral nystagmus in congenital esotropia. An Inst Barraquer 32: 21–27. Marg, E. 1988. Imaging visual function of the human brain. Am J Optom & Physiol Optics 65(10): 828–851. Milner, A.D. & Goodale, M.A. 1998. The visual brain in action. Psyche 4 (12): 1–11. Moguel-Ancheita, S. 2003. Botulinum toxin as a treatment for strabismus in systemic diseases. Arch Soc Esp Oftalmol 78: 9–14. Pigassou, R. 1967. L’integration visuelle. Acta Neurol Psych Belg 67: 198–213. Sánchez, C. & Shokida, F. et al. 2000. Alteraciones de los movimientos de seguimiento en la esotropia de comienzo tardío. In Souza-Días, C. & Goldchmit, M. (eds). XIV Congreso del Consejo Latinoamericano de Estrabismo: 387–389. Sao Paulo: CLADE. Ten Tusscher, M.P.M. & Backes, W. 2000. Neuronal correlates of binocularity. In Souza-Dias, C. & Goldchmit, M. (eds). XIV Congreso del Consejo Latinoamericano de Estrabismo: 295–298. Sao Paulo: CLADE. Zeki, S. & Watson, J.D.G. et al. 1991. A direct demonstration of functional specialization in human visual cortex. J Neurosc 11(3): 641–649.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Histological analysis of the efferent innervation of human extraocular muscle fibres I-B. Kjellevold Haugen & J.R. Bruenech Biomedical research unit, Department of Optometry and Visual Science, Buskerud University College, Kongsberg, Norway
ABSTRACT: Although motor units are considered to be vital indicators of muscle physiology, information regarding such units is limited for the different muscle fibres in human extraocular muscles. Seven inferior oblique muscles and corresponding nerves were therefore examined to determine the size of the motor units associated with Felderstruktur and Fibrillenstruktur fibres. Neuromuscular analysis and motor unit estimations were undertaken through light and electron microscopy, later verified by computer-based image analysis. The spectrum of nerve fibre diameters displayed a tri-modal distribution. The motor unit size varied from 1.1 to 6.7, depending on the morphology of the associated muscle fibres. These units are smaller than those previously reported, even when the complement of sympathetic and sensory nerve fibres are taken into account. The functional implications of these findings are discussed.
1
INTRODUCTION
The existence of two morphologically distinct muscle fibre types in extraocular muscles has lead to the notion that they may serve different functions in oculomotor control. The nature of the slow fibre system, comprising the Felderstruktur fibres, has been subjected to most speculation. The supply of strong tonic activity in eye fixation has been suggested as one plausible function (Scott 1971, 1973). The presence of sensory receptors exclusively associated with Felderstruktur fibres (Bruenech & Ruskell 2000) has added credence to this view, but does not preclude that these fibres also may serve other functions. More recent studies have shown that the orbital muscle fibre layer, where also Felderstruktur fibres reside, contributes to a fibromuscular system, suggested to influence ocular kinematics (Demer et al. 1995). Felderstruktur fibres must have the capacity of performing very minute and fine tuned contractions in order to fulfil many of the proposed functions. Yet, information regarding the size of the motor units of these muscle fibres is limited. The purpose of this study was therefore to analyze the efferent innervation of the two main fibre types found in human extraocular muscles to see if the theoretical neuromuscular basis is present to fulfil the anticipated tasks of the two muscle fibre groups.
2
MATERIAL AND METHODS
The inferior oblique muscle and corresponding nerve were obtained from 7 subjects, aged 30 to 90 years. Transverse semi-thin sections were cut with a standard ultra-microtome and prepared for light and electron microscopy. Complete serial transverse sections of 7 nerves were kept for tracing and axon counts. Comparable sections were collected from the largest cross sectional portion of 4 corresponding muscles. The three remaining muscles were incomplete after surgery and subsequently 91
Figure 1.
Electron micrograph showing a single Felderstruktur fibre surrounded by Fibrillenstruktur fibres.
excluded from the motor unit analysis. None of the subjects had any history of binocular vision abnormality or neuromuscular disease. A photomontage was made of all muscles and nerves to ensure proper orientation during analysis and counting of fibres. These results were later confirmed by a purpose built image analysis system. The same system was also used for tracing axons, where images from serial sections were superimposed by the computer to produce three-dimensional representations of the motor units. The complement of sensory receptors and autonomic nerve fibres, necessary for the calculation of motor units, were estimated based on previous studies (Bruenech & Ruskell 2000, 2001, Ruskell 1983).
3
RESULTS
Light microscopic observations confirmed many of the distinct structural diversities of human extraocular muscles previously reported by others (Locket 1968, Peachey 1971, Nunomura et al. 1984). Densely stained muscle fibres, frequently encountered in the orbital layer, had sparse amounts of sarcoplasmic reticulum and were found to be innervated by small diameter efferents (1–4 m). Lesser stained fibres had larger diameters, fine stippled appearances and well delineated myofibrils. Large myelinated axons (5–17 m) terminated on the latter muscle fibres, displaying motor end plates with terminal boutons clearly indenting the sarcolemma. The two distinct muscle fibre types (Fig. 1) were found to have features consistent with fibres previously described as Felderstruktur and Fibrillenstruktur. The total number of muscle fibres in the various inferior oblique muscles ranged from 5875 to 16,152 (mean 10966). The complement of Felderstruktur fibres constituted between 18 and 23%. Electron microscopy exposed unmyelinated nerve fibres to be randomly scattered in small bundles throughout the cross-sectional area of the nerve (Fig. 2). The number of unmyelinated axons ranged from 368 to 658, with a mean value of 465. They constituted 10.2% to 19.3 % of the nerve fibres (mean 16.1%). The ratio between myelinated and unmyelinated fibres was fairly uniform, seemingly unaffected by total nerve fibre quantity. Analysis of the spectrum of myelinated fibres (1–17 m) revealed a bimodal distribution. As illustrated in the histogram (Fig. 3), the first peak occurred between 2 and 3 , while the second 92
Figure 2. Electron micrograph showing bundles of small unmyelinated nerve fibres amongst larger myelinated nerve fibres. 600 550 500 450 400 350 300 250 200 150 100 50 0 1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17
Figure 3. Histogram illustrating the mean value of all nerve fibre diameter spectrums. The trimodal distribution was apparent in all specimens.
peak spanned from 6 to 10 m. Electron microscopy uncovered a third peak, encompassing all unmyelinated nerve fibres (1 m). The trimodal pattern, illustrated in Figure 3, was consistent in all nerves with only small individual variations. 4
CONCLUSION
In the current study, nerve fibres with small diameters ( 4 m) were found to innervate Felderstruktur fibres, while larger myelinated nerve fibres (5–17 m) terminated on Fibrillenstruktur 93
fibres. Similar findings have been reported by others (Mühlendyck & Ali 1978). The average number of nerve fibres serving the inferior oblique muscles was found to be 3351, with only small individual variations. Out of these, 1428 fibres had diameters of 4 m or less, indicating that 42% of the total nerve fibre population terminate on Felderstruktur fibres. In agreement with the literature (Mühlendyck & Ali 1978, Ringel et al. 1978), the quantity of Felderstruktur fibres found in the current study constituted approximately 20% of the muscle fibre population. Assuming that polyneural innervation is absent, the muscle/nerve fibre ratio for this fibre type is hence very small (0.82 to 1.7). The complement of afferent nerve fibres from sensory receptors is found to be modest (Bruenech & Ruskell 2000, 2001) and could hence be ignored when calculating the motor unit size. The number of sympathetic fibres, however, had to be taken into account. Superior cervical ganglionectomy in monkeys has shown that sympathetic nerves constitute up to 30% of the unmyelinated nerve supply to the IOM (Ruskell 1983). Presuming that similar figures also apply for man, the recalculated unit range (1.1 to 3.2) was still significantly smaller than those reported in the literature. Previous studies, applying low-resolution techniques, have seemingly failed to include the full range of nerve fibre diameters. The current study therefore reveals that Felderstruktur fibres, known to be served by such small diameter efferents, arguably have a significantly smaller motor unit than previously assumed. In contrast to the Fibrillenstruktur system that holds larger motor units, recruitment of single Felderstruktur fibres could hence theoretically occur, resulting in very small additional forces that give the basis for fine gradations in muscle contraction. This demonstrates that the necessary neuromuscular basis for some of the proposed roles of Felderstruktur fibres is present and, furthermore, supports the notion that the Felderstruktur fibre system may be responsible for delicate movements and their tuning.
REFERENCES Bruenech, J.R. & Ruskell, G.L. 2000. Myotendinous nerve endings in human infant and adult extraocular muscles. The Anatomical Record 260: 132–140. Bruenech, J.R. & Ruskell, G.L. 2001.Muscle spindles in extraocular muscles of human infants. Cells Tissues Organs 169: 388–394. Demer, J.L., Miller, J.M., Poukens, V., Vinters, H.V. & Glasgow, B.J. 1995. Evidence for fibromuscular pulleys of the recti extraocular muscles. Invest Ophthalmology Vis Sci 36: 1125–1136. Locket, N. A. 1968. The dual nature of human extraocular muscles. British Orthoptic Journal 25: 2–11. Mühlendyck, H. & Ali, S.S. 1978. Histological and ultrastructural studies on the ringbands in human extraocular muscles. Graefes Archiv Ophthalmologie 208: 177–191. Nunomura, S., Hizawa, K., Ii, K. & Sano, T. 1984. A histochemical study on fibre types in human extraocular muscles. Biomedical Research 5: 295–302. Peachey, L. 1971. The structure of the extraocular muscle fibres in mammals. In Bach-y-Rita, P., Collins, C.C. & Hyde, J.E. (eds), The Control of Eye Movements: 47–66. New York: Academic press. Ringel, S.R., Wilson, B., Barden, M.T. & Kaiser, K.K. 1978. Histochemistry of human extraocular muscle. Archives of Ophthalmology 96: 1067–1072. Ruskell, G.L. 1983. Fibre analysis of the nerve to the inferior oblique muscle in monkeys. Journal of Anatomy 137: 445–455. Scott, A.B. 1971. Active force test in lateral rectus paralysis. Archives of Ophthalmology 90: 319–322. Scott, A.B. & Collins, C.C. 1973. Division of labour in human extraocular muscles. Archives of Ophthalmology 90: 319–322.
94
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Effect of refractive surgery on ocular alignment and binocular vision in patients with manifest or intermittent strabismus D.J.M. Godts, J. Claeys, P. Schraepen & M.J. Tassignon Department of Ophthalmology, University Hospital Antwerp, Edegem, Belgium
ABSTRACT: We evaluated the effect of refractive surgery on ocular alignment and binocular vision in patients with intermittent and manifest strabismus. Seventeen eyes of 10 strabismic patients underwent refractive surgery. Five patients were myopic, 2 hyperopic and 3 anisometropic. Two patients had an esotropia and 5 had a manifest exotropia, 3 of them with a vertical deviation. Two patients had an intermittent exotropia with good binocular vision. One patient had a pure vertical deviation with DVD. The dominant eye was operated first in all patients of whom both eyes underwent surgery. In all ametropic patients the ocular alignment and binocular functions remained unchanged. Only in the two high anisometropic patients the manifest deviation became intermittent or latent and fusion and stereopsis restored.
1
INTRODUCTION
Refractive surgery has become a common procedure for correcting myopia, hyperopia, astigmatism and anisometropia. Lately even accommodative strabismus has been proposed to be treated with refractive surgery (Stidham et al 2002, Nemet et al 2002, Nucci et al 2002). Diplopia and strabismus are reported as an uncommon complication after refracive surgery (Marmer 1987, Mandava et al 1996, Schuler et al 1999, Holland et al 2000, Yap & Kowal 2001, Kushet & Kowal 2003, Godts et al 2004) making orthoptic examination obligatory prior to surgery especially in risk patients (Kowal 2000, De Faber & Tjon-Fo-Sang 2001). The purpose of this prospective study was to evaluate the effect and/or the benefit of refractive surgery on ocular alignment and binocular functions in patients with intermittent and manifest strabismus.
2
MATERIAL AND METHODS
Seventeen eyes of ten strabismic patients were operated between January 2000 and December 2003, five patients were male, five female. The age ranged between 24 and 68 years (mean 44.6 years). A complete ophthalmological examination including uncorrected visual acuity (UCVA), bestcorrected visual acuity (BCVA), manifest and cycloplegic refraction, anterior and posterior segment evaluation, intraocular pressure (IOP), corneal topography, ultrasonic pachymetry, pupillometry and macular cyclotorsion examination, was performed. Refractive error, BCVA, surgical procedure and macular cyclotorsion are summarized in Table 1. A complete orthoptic examination was performed before surgery and at 2 weeks, 6 weeks and 3 months after surgery. The ocular alignment was measured with the alternate prism cover test (APCT) at 6 m and 33 cm and in the synoptophore. The ocular motility was evaluated with the alternate cover test in the nine directions of gaze. Binocular vision was measured with the 15 prism diopter (PD) and/or 4 PD test. Fusion or suppression range was measured at distance and at 95
Table 1.
Patient
Age/ sex
NVDP FV WV AD BH MD MH CS MVG HJ
24/M 55/M 33/M 43/M 39/F 37/F 68/F 57/M 46/F 44/F
Preoperative refractive error
Preoperative BCVA
Surgery
RE
LE
RE
LE
Macular torsion
PRK BE Lasek BE Lasik BE Iris Claw BE Iris Claw BE Iris Claw BE DTK BE DTK LE Iris Claw LE Iris Claw RE
0,25 3,50 20 2,50 0,75 10 4,75 1,25 165 9,50 1,00 175 14,00 6,00 1,25 110 2,00 1,00 90 2,50 0,50 125 1,75 0,50 40 9,00 1,25 160
1,50 2,50 160 3,50 0,75 0 4,25 1,25 0 9,00 1,00 0 13,50 6,00 0,75 50 2,50 0,75 110 1,25 0,50 0 7,50 1,50 0 0,75 0
20/60 20/40 20/20 20/30 20/25 20/30 20/20 20/20 20/20 20/40
20/25 20/20 20/20 20/30 20/25 20/25 20/20 20/20 20/40 20/20
excyclotorsion LE none none excyclotorsion BE excyclotorsion BE excyclotorsion BE none none excyclotorsion LE excyclotorsion RE
Table 2. Preoperative ocular alignment
Binocular vision
Ocular motility
Patient
Distance
Near
Fusion
Stereopsis
Pattern
Inferior oblique
NVDP
sc: RE: 20^LHT LE: 5^LHT cc: RE: 20^LHT LE: 5^LHT sc: 20^XT cc: 16^XT sc: 25^ET cc: 25^ET sc: 4^XT 4^LHT cc: 4^XT 4^LHT sc: 2^XT’ 2^RHT cc: 2^XT’ 2^RHT sc: 6^ET 4^RHT cc: 6^ET 4^RHT sc: 4^XT cc: 4^XT sc: 35^XT cc: 35^XT sc: 10^XT cc: 10^XT sc: 8^XT 6^RHT cc: 8^XT 6^RHT
sc: RE: 20^LHT LE: 5^LHT cc: RE: 20^LHT LE: 5^LHT sc: 30^XT cc: 25^XT sc: 30^ET cc: 25^ET sc: 12^XT 4^LHT cc: 12^XT 4^LHT sc: 8^XT 2^RHT cc: 8^XT 2^RHT sc: 25^ET 4^RHT cc: 12^ET 4^RHT sc: 14^XT cc: 14^XT sc: 40^XT cc: 40^XT sc: 14^XT cc: 14^XT sc: 6^XT 5^RHT cc: 6^XT 5^RHT
d: no n: no
no
V exo
Overaction LE
d: no n: no d: no n: no d: no n: no d: 16° n: 30° d: no n: no d: 5° n: 21° d: no n: no d:7° n: no d: no n: no
no
normal
no
no
normal
no
no
V exo
Overaction LE
120
V exo
Overaction RE
no
V exo
Overaction RE
60
V exo
no
no
normal
no
no
normal
no
no
normal
no
FV WV AD BH MD MH CS MVG HJ
near with the prism bar and in the synoptophore. Suppression depth was measured with the Bagolini red filter bar. Stereoacuity was measured with the Titmus and Lang test and retinal correspondence was evaluated in the synoptophore. Orthoptic measurements are summarized in Table 2. The follow-up ranged from 6 months to 53 months (mean 17.3 months). The dominant eye was operated first in all patients of whom both eyes were operated (7 patients). The time between the two surgeries ranged from 1 week (2 patients) to 4 weeks (4 patients), only in one patient the time interval was one year because of interfering medical reasons. All patients were high-risk patients as defined by Kowal (Kowal 2000). After orthoptic evaluation and positive trial with contact lenses all patients were considered «save» to undergo refractive surgery. However all patients were still warned about the risk of possible post-operative diplopia. 96
Table 3. Preoperative refractive error
Postoperative refractive error
Preoperative BCVA
Postoperative BCVA
Patient
RE
LE
RE
LE
RE
LE
RE
LE
NVDP FV WV AD BH MD MH CS MVG HJ
0,25 3,50 20 2,50 0,75 10 4,75 1,25 165 9,50 1,00 175 14,00 6,00 1,25 110 2,00 1,00 90 2,50 0,50 125 1,75 0,50 40 9,00 1,25 160
1,50 2,50 160 3,50 0,75 0 4,25 1,25 0 9,00 1,00 0 13,50 6,00 0,75 50 2,50 0,75 110 1,25 0,50 0 7,50 1,50 0 0,75 0
0,25 115 1,00 1,75 80 0,00 1,00 1,00 5 1,25 0,50 100 1,00 1,75 115 1,25 1,75 100 2,50 0,50 125 1,50 0,50 40 0,50 1,00 130
0,50 145 0,75 0 0,25 0,50 1,25 175 1,50 0,75 60 1,00 50 1,25 1,00 115 0,50 0,50 1,5 60 0,75 0
20/60 20/40 20/20 20/30 20/25 20/30 20/20 20/20 20/20 20/40
20/25 20/20 20/20 20/30 20/25 20/25 20/20 20/20 20/40 20/20
20/30 20/40 20/20 20/30 20/20 20/25 20/20 20/20 20/20 20/40
20/20 20/20 20/20 20/30 20/20 20/20 20/20 20/20 20/30 20/20
Table 4. Preoperative ocular alignment
Postoperative ocular alignment
Preoperative
Postoperative
Patient
Distance
Near
Distance
Near
Fusion
Stereo
Fusion
Stereo
NVDP
sc: RE: 20^LHT LE: 5^LHT cc: RE: 20^LHT LE: 5^LHT sc: 20^XT cc: 16^XT sc: 25^ET cc: 25^ET sc: 4^XT 4^LHT cc: 4^XT 4^LHT sc: 6^X(T)2^RH(T) cc: 6^X(T)2^RH(T) sc: 6^ET 4^RHT cc: 6^ET 4^RHT sc: 4^X cc: 4^X sc: 35^XT cc: 35^XT sc: 10^X(T) cc: 10^X(T) sc: 8^XT 6^RHT cc: 8^XT 6^RHT
sc: RE: 20^LHT LE: 5^LHT cc: RE: 20^LHT LE: 5^LHT sc: 30^XT cc: 25^XT sc: 30^ET cc: 30^ET sc: 12^XT 4^LHT cc: 12^XT 4^LHT sc: 8^X(T)2^RH(T) cc: 8^X(T)2^RH(T) sc: 25^ET 4^RHT cc: 12^ET 4^RHT sc: 14^X(T) cc: 14^X(T) sc: 40^XT cc: 40^XT sc: 14^XT cc: 14^XT sc: 6^XT 5^RHT cc: 6^XT 5^RHT
RE: 20^LHT LE: 8^LHT
RE: 20^LHT LE: 8^LHT
d: no n: no
no
d: no n: no
no
18^XT
25^XT
no
d: no n: no d: no n: no d: no n: no d: 17° n: 30° d: no n: no d: 6° n: 20° d: no n: no d: 14° n: 21° d: 12° n: 20°
no
FV WV AD BH MD MH CS MVG HJ
3
d: no n: no 14^ET 25^ET d: no n: no 4^XT 3^LHT 14^XT 3^LHT d: no n: no 2^X 2^RH 8^X 2^RH d: 16° n: 30° 6^ET 3^RHT 8^ET 3^RHT d: no n: no 2^X 20^X(T) d: 5° n: 21° 30^XT 30^XT d: no n: no 8^X 12^X(T) d: 7° n: no 2^XT 2^RHT 2^XT 2^RHT d: no n: no
no no 120 no 60 no no no
no no 40 no 60 no 60 400
RESULTS
The refractive error improved in all patients. Some patients needed additional surgery. None of the patients lost visual acuity and in some patients the visual acuity improved (Table 3). Little change in ocular alignment was seen after surgery. In some patients the deviation improved some degrees in others it decreased by the same amount. Only in the two high anisometropic patients (patient 9 and 10) the deviation became intermittent to latent resulting in an improvement of binocular vision. Patient 9 who had minimal peripheral fusion at distance preoperatively, developed postoperatively good peripheral and central fusion with stereopsis of 60 seconds of arc. Patient 10 who had no binocular vision, developed peripheral fusion with stereopsis of 400 seconds of arc. Postoperative orthoptic results are summarized in Table 4. 97
4
CONCLUSION
Refractive surgery did not change the ocular alignment. Binocular functions were only improved in the high anisometropic patients. None of our patients had post-operative diplopia, binocular vision problems or dominance problems. Extended orthoptic examination prior to refractive surgery is mandatory in at risk patients to prevent diplopia, binocular vision problems or dominance problems. Patients should be warned before refractive surgery about these risks. The dominant eye should always be operated first to avoid a switch of dominance.
REFERENCES De Faber, J.T.H.N. & Tjon-Fo-Sang, M. 2001. Strabismologic advice for the refractive surgeon. In de Faber, J.T.H.N. (ed.) Transactions, 26th meeting European Strabismological Association: 41–43. Lisse: Swets Zeitlinger. Godts, D., Tassignon, M.J., Gobin, L. 2004. Binocular vision impairment after refractive surgery. J. Cataract Refract. Surg. 30, 101–109. Holland, D., Amm, M., de Decker, W. 2000. Persisting diplopia after bilateral laser in situ keratomileusis. J. Cataract Refract. Surg. 26: 1556–1557. Kowal, L. 2000. Refractive surgery and diplopia. Clinical and experimental Ophthalmology 28: 344–346. Kushner, B.J. & Kowal, L. 2003. Diplopia after refractive surgery. Arch ophthalmol 121: 315–321. Mandava, N., Donnenfeld, D.E., Owens, P.L., Kelly, S.E., Haight, D.H. 1996. Ocular deviation following excimer laser photorefractive keratectomy. J. Catararct Refract. Surg. 22: 504–505. Marmer, R.H. 1987. Ocular deviation induced by radial keratotomy. Ann.Ophthalmol: 451–452. Nemet, P., Levinger, S., Nemet, A., 2002. Refractive surgery for refractive errors which cause strabismus. Binocular Vision & Strabismus Quarterly. 17 (3): 187–190. Nucci, P., Serafino, M., Hutchinson, A.K. 2003. Photorefractive keratectomy for the treatment of purely refractive accommodattive esotropia. J Cataract Refract. Surg. 29; 889–894. Schuler, E., Silverberg, M., Beade, P., Madel, K. 1999. Decompensated strabismus after laser in situ keratomileusis. J. Cataract Refract. Surg. 25: 1552–1553. Stidham, D.B., Borissova, O., Borrissov, V., Prager, T.C. 2002. Effect of hyperopic laser in situ keratomileusis on ocular alignment and stereopsis in patients with accommodative esotropia. Ophthalmology 109 (6): 1148–1153. Yap, E.Y. & Kowal, L. 2001. Diplopia as a complication of laser in situ keratomileusis surgery. Clinical and Experimental Ophthalmology 29: 268–271.
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Diplopia and strabismus after refractive surgery R. Gomez de Liaño, G. Franco Iglesias & P. Gomez de Liaño Hospital Clínico San Carlos, Universidad Complutense de Madrid, Spain
ABSTRACT: Objective: To evaluate factors that may conduce to diplopia or decompensate a strabismus after refractive surgery. Methods: Retrospective study of 17 patients who, presented diplopia or strabismus after refractive surgery. Twelve patients were myopic, five hyperopic and 4 of them had a marked anisometropia. Average age at surgery was x 36,88 SD 8,45 (27–51) years. PRK was the refractive procedure in 3 cases, LASIK in 13 and PC IOL LASIK. Results: We could observe that all of our patients had a binocular pathology previous to the refractive surgery. After surgery 11 patients had an esophoria or esotropia, 3 exophoria or exotropia and 3 decompensated vertical deviations. Frequently, several factors worked simultaneously in the same patient as: Hypercorrected myopia, residual hyperopia, postoperative visual instability, dominance change, a marked flap decentration, and a presbiopic age. Conclusions: The most important factor to develop a diplopia or strabismus after refractive surgery is the presence of a previous binocular pathology, above all in patients close or in presbiopic age. This situation may decompensate by several factors but mostly by myopic hypercorrection, accommodative and visual factors.
1
INTRODUCTION
The appearance of a diplopia or the decompensation of a strabismus after a refractive surgery is an unusual complication. The first case of an accommodative esotropia after a radial keratotomy was submitted in 19961. Afterwards, there were published cases of diplopia or decompensation of the ocular motility in patients with myopic anisometropia, a decompensation of an IV nerve palsy or a vertical strabismus in a patient who presented a marked flap decentralization2–5. Later On Kowal et al.5 graded the risk of motility complications after refractive surgery among general population. In previous studies we have analyzed binocular vision after refractive surgery in myopic6 and hyperopic7 patients. The aim of the study is to analyze the factors taking part in the binocular decompensation in a wider range of patients. 2
METHODS
This is a retrospective study of 17 patients who attend our ocular motility service because they report strabismus or diplopia after a refractive surgery. Five patients were treated with refractive surgery in our center and twelve were referred from other centers. The average age at the moment of the refractive surgery was 36.88 DS 8.45 years old (27–51); eight patients were over 40 years old. Twelve patients were myopic and five hyperopic. Refraction in myopic patients (spherical equivalent) was of (10.52 DS 8.26 DP (2 to 28 DP) in the most myopic eye and 6.06 DS 6.40 (0,50 to 20 DP) in the less myopic eye. Refraction in hyperopic patients was of 4,70DS 1,61 DP (3,50 to 7,50) in the most hyperopic eye and 4.05 DS 1.12 DP (3,25 to 6) in the eye with less refraction. In four of them anisometropia was severe (8DP). 99
The refractive surgery procedure practiced was PRK type in three patients (unilateral in one of them), the LASIK technique in thirteen patients (unilateral in three of them) and the lens surgery with posterior IOL and a LASIK surgery at the postoperative period in one patient. Five patients required secondary intervention with PRK (one patient) or LASIK (4). One patient had an important corneal “haze” postoperatively. RESULTS AND DISCUSSION The appearance of a diplopia or strabismus after a refractive surgery is not a frequent pathology. And according to our range results, it has appeared in patients with a previous binocular pathology. In order to evaluate the frequency of a binocular decompensation we based our study on the patients who had a motility decompensation and who were intervened of refractive surgery in our center (5), compared with the total range of patients intervened (4,135) which stands for 0,12%. But it is likely that frequency of binocular complications, if we take into account of as non referred, asthenopias, longer term decompensation when accommodation decreases, will increase this percentage 6,7. The kind of binocular alteration that made them go to consultation was strabismus (8 cases), diplopia (2 cases) or strabismus and diplopia (7 cases). The kind of strabismus the patients most evidently presented was an Esophoria or esotropia (11/17 cases) (Figure 1,3). Three patients had exophoria (1) or exophoria-tropia (1) and three patients had a vertical strabismus. Figure 1 shows the type of strabismus of the range of patients we present. We have been able to record that all patients had previous binocular pathology to the refractive surgery. Before refractive surgery, they had strabismus or microstrabismus (12/17), a phoria (8/17), an amblyopia (11/17) or an asthenopia (2/17). Four patients of this series had an important anisometropia, which has been considered a risk factor of decompensation after refractive surgery5,8,10. Another group of risk is composed of those with a high degree of myopia5 (7/11 myopic patients has over 6D) (Figure 3), as those patients frequently have binocular problems. Although we have not been able to state it with certainty, the reason which precipitate the decompensation in each case, the causes has been variable and frequently several factors were responsible simultaneously. (Figure 2). We point out that 8/17 of our patients were over 40 years old and relaxation of the accommodative power at that period could also have plaid an important role into decompensation. 4/17 patients were operated only on one eye. Unilateral surgeries may conduce to different quality of image in terms of contrast sensitivity and other factors. One of our patients (patient no. 14) was operated of hyperopia only in his non-dominant eye, and switched the dominance; another patient (patient 17) was operated only of one eye to be in monovisión and decompensate his Phoria. This has to be considered in patients who are operated to obtain monovision and have binocular pathology.
Figure 1.
Type of strabismus after refractive surgery.
100
The onset of the symptoms appeared in some cases in the early postoperative period, and other cases along the following weeks/months. Sometimes the initial distortion is mistaken by a vertical diplopia. Between 6/17 patients reported the symptoms in a progressive way; in particular, one patient 8 months after the refractive surgery. We believe that some patients without symptoms will be more symptomatic as they go in to presbiopic ages. Strabismus or residual diplopia treatment was different in each case depending on the degree of strabismus and the symptomatology it caused, as well as on personal aspects. Six patients were corrected with glasses; Four by a secondary refractive intervention; Three patients required prisms although they refused to use them; and four patients needed the treatment of botulinum toxin or strabismus surgery. Therefore, and also based studies that evaluate the binocular vision after the refractive surgery 6,7, we have to conclude that it is important to carry out a complete study of the binocular status preoperatively. These data should consider the possible risk of diplopia in patients treated in intended monovision if they have a previous binocular pathology 4,9.
Figure 2.
Factors that affected in the binocular decompensation.
Figure 3.
Characteristics of the series.
101
CONCLUSIONS 1. Diplopia or strabismus after refractive surgery has generally appeared in patients with under lying binocular pathology. 2. Several factors may affect the decompensation; among them we emphasize the myopic hypercorrection, the residual hyperopia as well as the visual instability and the change of dominance. 3. The most frequent deviation is the esophoria or esotropia. Less frequent are vertical strabismus and exotropias. 4. The treatment of strabismus or diplopia varies and includes the correction of the residual refractive defect by glasses or by a refractive re-intervention, the prescription of prisms, and the injection of botulinum toxin or strabismus surgery.
REFERENCES 1. Zwaan J. Strabismus induced by radial keratotomy. Mil Med 1996 Oct;161(10):630 2. Mandava N, Donnenfeld ED, Owens PL, Kelly SE, Haight DH. Ocular deviation following excimer laser photorefractive keratectomy. J Cataract Refract Surg 1996 May;22(4):504–5. 3. Kim SK, Lee JB, Han SH, Kim EK.Ocular deviation after unilateral laser in situ keratomileusis. Yonsei Med J 2000 Jun;41(3):404–6. 4. Schuler E, Silverberg M, Beade P, Moadel Decompensated strabismus after laser in situ keratomileusis. K. J Cataract Refract Surg 1999 Nov;25(11):1552–3 5. Kowal L. Refractive surgery and diplopia. Clin Experiment Ophthalmol 2000 Oct;28(5):344–6. 6. Gomez de Liaño R. Arias A, Ragai N et al. Visión Binocular tras la cirugía fotorrefractiva. Acta Estrabológica. 1996. 25: 185–188. 7. 7. Gomez de Liaño R, Piedrahita E, Arias A. Modificación de la cirugía visión binocular con técnica lasik en hipermétropes. Acta del Congreso del CLADE año 2003 8. Maden A, et al. Unilateral refractive keratotomy for anisometropia. J Refract Surg. 1998 MayJun;14(3):325–30. 9. Wright KW. Guemes A, Kapadia MS, Wilson SE et al. Binocular function and patient satisfaction after monovision induced by myopic photorefractive keratectomy. J Cataract Refract Surg. 1999 Feb;25(2):177–82. 10. Holland D, et al. Persisting diplopia after bilateral laser in situ keratomileusis. J Cataract Refract Surg. 2000 Oct;26(10):1555–7. 11. Bilgihan K, Ozdek SC, et al. Photorefractive keratectomy for visual rehabilitation of anisometropia induced by retinal detachment surgery. J Refract Surg. 2000;16:75–78.
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Session 8: Various surgical methods
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Does the bilateral inferior obliques anterior transposition influences the amount of surgery on the horizontal muscles? D. Cioplean & L. Teodorescu Oftapro, Ophthalmology Clinic, Bucharest, Romania
ABSTRACT: Dissociated Strabismus Complex (DVD) is one of the most frequent conditions associated to infantile esotropia and very often to the primary over action of the inferior obliques. The aim of this presentation is to reveal an observation made on 25 cases operated for this condition using the surgery on the horizontal muscles combined with the bilateral anterior transposition (BAT) of the inferior oblique (IO). The procedure for the AT was the insertion of full IO tendon quite parallel to the inferior rectus insertion. It seems that this technique produce an augmentation of the surgery on the horizontal muscles. We observed 25 children, between 18 months and 8 years of age, in the first year after surgery, using the same amount of the surgery on the horizontals related to the same amount of deviation and BAT of IO, with identical surgical procedures. The follow-up was made every two months after surgery. In the same period, other 27 cases, operated for esotropia and IO OA (2+ and 3+) without DVD, using the same surgery for the horizontals but IO Recession for the treatment of the IO dysfunction where observed. In the first group, a consecutive exodeviation, more or less permanent was present, between 1 and 10 months after surgery, in 15 cases. In two cases the surgery was needed. The parallel versions were obtained in 20 cases and in 7 cases residual DVD was present. In the second group, only 3 cases developed a consecutive exodeviation, and the parallel versions were obtained in 19 cases. They are many factors which influence the postoperative behavior in combined surgery, but prob ably because of its anatomical particularities IO remains the less quantifiable muscle. Considering that DVD means excyclotorsion is probably indicated to use another AT technique and/or to reduce the amount of the surgery on the horizontals to obtain a better result.
1
INTRODUCTION
Dissociated Strabismus Complex (DVD) is one of the most frequent conditions associated to infantile esotropia (46–90 %) and often to the primary over action of the inferior obliques. DVD usually occurs bilaterally but may be asymmetric because of unequal inferior oblique (IO) over action (IOOA). The surgery for this condition can be done in one or more steps depending of the amount of horizontal deviation and the clinical manifestations. As general rule, we prefer to do as a first surgery a bilateral MR recession in angles larger than 45 PD and, as a second step, a combined surgery for the residual angle on the LRecti and for the vertical deviation. When bilateral IOOA is associated to bilateral DVD and V-pattern our choice is bilateral anterior transposition of the inferior obliques (BATIO). The IO functions in primary position are: abduction, elevation and excyclotorsion. 105
2
PURPOSE
The purpose of this work-paper is to show that the BATIO influences the horizontal deviation in combined or unique surgery comparatively with the bilateral IO recession which does not.
3
MATERIAL AND METHODS
The observation was made in 52 patients operated in our clinic in a period of three years, divided in two groups.The patients were children, aged 18 months-8 years. The surgery was done for esotropia (ET) or residual esotropia combined with bilateral IOOA. In most cases the IOOA was asymmetric from 2 to 4. The VA was better than 20/40 on each eye in all cases. The follow-up was done at least one year after surgery every two months. The surgical technique for each procedure was the same and executed by the same surgeon. In the first group we studied 22 cases with primary or residual ET (more than 10 PD) bilateral OAIO bilateral DVD and three cases where the ET was solved in a previous surgery, having only bilateral IOOA and DVD (ET les than 10 PD or absent). In all cases a V-pattern was present. In primary ET a bilateral MR recession and bilateral IO anterior transposition (BATIO) was done and in residual ET a uni- or bilateral LR resection and BIOAT was the choice. In three cases the surgery was only bilateral IO anterior transposition. We used the same algorithm for the ET surgery according to the amount of deviation. The symmetrical procedure that we used for the IO anterior transposition was the technique described as a “spreading-out” procedure by the reinsertion in two stitches of the IO, quite parallel with the inferior rectus insertion. (Slide 8) In the second group, 27 cases with primary or residual ET and bilateral IOOA, more or less symmetric, were operated in the same manner regarding the ET but IO recession, symmetrical or asymmetrical, was used as a weakening procedure for the IO dysfunction. In this group DVD was absent.
4
RESULTS
In the first group the surprise was a consecutive exotropia, exoforia or DHD which followed the surgery, mainly in the first three-four months, in 15 cases. In two cases where less than 10 PD ET was present before surgery, the esodeviation disappeared without surgery on the horizontal muscles. In one case, with no horizontal deviation before surgery, an exoforia of 8 PD was observed after surgery. Residual DVD was observed in 7 cases and residual IOOA in one or both eyes, 1+ or 2+, in 5 cases. Also a mild limitation in elevation was present in 8 cases. In two cases the surgery was need it for consecutive exotropia more than 12 PD. In four cases additional surgery for residual DVD on one superior rectus was necessary. In the second group, just three cases of transitory exoforia were observed. In 8 cases the parallel versions were not obtained.
5
DISCUSSIONS
The results in the first group looking the horizontal deviation made us to reconsider the amount of surgery on MR and/or LR, corresponding to a smaller deviation with 5–10 PD and to study more deeply how the main functions of IO are changed with this “spreading-out” technique. It is difficult to explain why the DVD becomes DHD. It seems that the new insertion of the IO amplifies its abducting function and this effect is doubled by bilateral surgery. The IO is not a Rectus muscle, it has a long tendon and its physiological insertion is “bunched, so, it should not be treated like a rectus. A new insertion in two switches, is followed by exo rotation and excyclotorsion due, probably, to the posterior fibers of the IO and to the parallel position with the 106
IR insertion (its second function is also excyclotorsion).Our last ten cases (which are not included in this study) we changed the procedure in a “bunched-up” procedure.
6
CONCLUSIONS
We think the BATIO can be a successful surgery in cases with ET IOOA DVD if we use the right surgical procedure for each case depending of the amount of the ET, and also we think that better result regarding the versions and DVD can be accomplished using different degrees of IO anteriorisation / resection connected with the IOOA degree and DVD quantity, so an asymmetrical surgery should be done in asymmetrical cases.
REFERENCES Esswein, M.B, Van Noorden, G.K., Coburn, A.1992: Comparison of surgical methods in the treatment of dissociated vertical deviation, Am J Ophtalmol, 113: 287–290. Gonzales C., Klein B. 1993: Myectomy and anterior transpositions of inferior oblique muscle: A new surgical procedure and its results in 49 operations, Binocular vision. Eye muscle surgery, 8: 249–258. Guemes A., Wright K.W. 1998: Effect of graded anterior transpositions of the inferior oblique muscle on versions and vertical deviation in primary position, JAAPOS, 2:201–206. Helveston, E.M. 1992: Surgical management of strabismus: An atlas of strabismus surgery, Mosby – Year Book. Mims, J.L. 1999: Antielevation syndrome after bilateral transpositions of the inferior oblique muscle: incidence and prevention, JAAPOS, 333–336. Seawright, A.A, Gole G.A. 1996: Results of anterior transposition of inferior oblique muscle, J. Australian and New Zeeland Ophthalmology, 24:339–344. Snir, M., Siegel R.A., Cotlear, D., Sherf, I., Yassur,Y. 1999: Combined resection and anterior transposition of the inferior oblique muscle for asymmetric double, dissociated vertical deviation, Ophthalmology, 106, 2372–2376. Rosenbaum, S.1999: Clinical Strabismus Management: Principles and Surgical Techniques, W.B. Saunders Company.
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Efficacy of the anterior transposition of the inferior oblique as a secondary procedure in cases of recurrent DVD V. Paris Liège University, Belgium
ABSTRACT: Twenty one patients, presenting a residual manifest DVD, after one to three procedures to control it, were retrospectively studied. They were treated by anterior transposition of the inferior oblique muscle (ATPIO) at zero, 1 or 2, in association with a resection of the proximal part of the IO tendon in three cases and with a re-recession of the superior rectus (SR) in three other cases. The mean age at surgery was 8.4 years (1.5–42). No patient had any ATIO before and they were all operated by the same surgeon (VP). Preoperatively, a residual vertical lateral incomitance was present in 24% of the cases and a V pattern in 19%. A latent DVD was finally obtained in all cases but two. One of these two cases was reoperated 3 years later in the same manner on the other eye and led to a stable good result. The mean follow up is 4 years (0.6–7). No significant side effect was observed. However, a residual upgaze limitation was small in three cases and mild in one case without provoking any chinup head posturing.
1
INTRODUCTION
DVD remains one of our most difficult challenge because of its various clinical aspects: latent or manifest, variable, recurrent, pseudo or really asymmetric, sometimes even unilateral. ATIO is an old method which proved its efficacy for treating DVD (Mims 1989, Krats 1989,) but less stable to control the largest ones ( 15 PD) (Burke 1993). These authors performed this technique bilaterally, always for incomitant DVD and never combined with SR recessions (SRR). In 1997, Varn (Varn 1997) demonstrated the efficacy of a combined procedure in “pure” DVD but, again, proposed bilaterally in all cases but one. This study wants to demonstrate the efficacy of a graded, almost unilateral (77%), ATIO as a combined and “staged” procedure in a population presenting recurrent DVD, almost operated bilaterally (86%) before. 2
METHOD
We have retrospectively studied twenty one consecutive patients aged from 1.5 to 42 years (mean: 8.4) presenting a recurrent manifest DVD operated once (66%), twice (29%) or three times (5%) before, by the same surgeon (VP). In 24% of the cases, an additional vertical lateral incomitance (termed incomitant DVD) was present. A V pattern was measured in 90% of the cases but no A pattern was noticed. All patients were esotropic with the clinical signs of early onset strabismus. A SRR was initially performed in 14 patients (66%), combined with an IO recession ( IOR ) in 6 patients (29%). One patient underwent a simple bilateral IOR. As already mentioned, the majority of the cases was initially operated on both eyes. In all cases but one, our previous surgery was based on a classical, graded, almost asymmetric recession of the SR without using “hang back” technique to avoid any forward postoperative gliding. The amount of SRR was limited to 8 mm in order to eliminate any risk of lid retraction or limitation of elevation. According to the size of the DVD, we have 109
Table 1.
Quantification of the DVD. Symmetric
Asymmetric
Not available
Initial DVD
17.5 PD (10–20) N6
23 PD (12–40)/8.6 PD (0–18) N 12 3 unilat
N3
Preoperative DVD
12 PD N1
15.4 PD (10–20)/5.8 (5–7) N 20 16 unilat
N0
Table 2.
Quantification of the technique (* recession of the contral at IO).
ATIO 0 ATIO 0 Resec ATIO 0 RRSR ATIO 1 ATIO 2 ATIO 2 Resec ATIO 2 RRSR
Unilat (nb of patients)
Bilat (nb of patients)
4 1 2 2 6 1 1
1 1* 0 0 0 2* 1 0
planed a simple SRR or a combined surgery ( SRR IOR ) as a single or a staged procedure. The amount of IOR was 8 to 10 mm. As described in table 1, the initial DVD was large and asymmetric in most of the cases. It is interesting to notice that only one of the three cases presumed unilateral at first remained like that during the follow up. At the time of the ATIO, all patients but one had an asymmetric deviation. Most of them were considered as unilateral (80%) and remained unilateral after the follow up, except for one single case. We have used a graded technique of AT. The IO was attached to the globe at the temporal edge of the insertion of the inferior rectus (IR) muscle (AT at zero), 1 or 2 mm anteriorly (AT 1, 2), never more. Using the Gobin’s technique for many years, we are used to bunch the new insertion of the IO so that we have never taken any risk of upgaze restriction due to the spread of this insertion (Mims 1999). Nevertheless, some cases underwent a small additional anterior displacement of the posterior part of the IO tendon in order to reinforce the mechanical action of the global anteriorization, as proposed by Kratz (Kratz 1989). For the same reason, as described in table 2, we also performed a resection of the proximal part of the IO tendon (limited to 4 mm) in three cases. One case for a hyperelasticity of the IO muscle, one for a persisting unilateral DVD after a maximal combined procedure. The last case presented a residual incomitant DVD with a large V pattern and so, underwent a bilateral resection associated with an ATIO 2. Finally, we performed in some cases a re-recession of the SR (RRSR), respecting the limit of a total amount of 8 mm. 3
RESULTS
The result was considered as good when manifest DVD became latent or 4 PD, either eye fixing. This result was obtained in all cases but two. A moderate lateral incomitance was persisting in 2 cases (symmetric 1) and a significant V pattern in 1 case. This latter patient can be considered as a bad result in term of horizontal incomitance but the DVD was latent and 5 PD. The 2 patients with a small incomitant DVD had only a latent vertical deviation 5 PD in primary position. Finally, a residual manifest DVD was only present in 2 cases as summarized in table 3. 110
Table 3.
Results.
Incomitant DVD V pattern Manifest DVD
Patients: pre op
Patients: post op
5 4 11
2 (small 1) 1 2
Our graded technique of anteriorization of the IO was then efficient enough to control the residual DVD in 95% of the cases. One of the 2 failures was considered as good during a period of 3 years….. then he started to present a manifest DVD on the contralateral eye. He was treated with an unilateral ATIO 2 with success (follow up: 3 years). This patient was the only “false unilateral” case out of the 16 patients diagnosed preoperatively as unilateral in this study (see table 1). We proposed a fourth step of surgery to the other patient. His parents refused because they were satisfied of the cosmetic aspect. However, the residual DVD (10 PD) was not compatible with a good binocular sensorial result, which is much more important than the cosmetic appearance. The mean follow up is 4 years (0.6–7). We didn’t measure any significant side effect. However, an upgaze limitation was found in 4 patients: small in 3 patients and mild in 1 patient. This latter patient was the only one who underwent a bilateral resection of the IO associated with an anteriorization of 2. He didn’t adopt any chinup posturing anyway. We observed no lid retraction, no A pattern and no postoperative overcorrection. 4
DISCUSSION
According to the fact that spontaneous evolution of the DVD is not easily predictable, the duration of the follow up takes a great importance. To our knowledge, it is the first time that ATIO is proposed, almost unilaterally, as a combined procedure. The main problem of using an unilateral or an asymmetric surgery of the DVD is to increase the DVD on the non operated eye and to provoke a hypotropia on the operated eye. This overcorrection has no correlation with the amount of SRR (Schwartz & Wilson 1991) but is related to the presence of an increasing DVD on the less operated eye (Can et al 1997). One of the most plausible explanation of these frequent clinical facts is to accept the following hypothesis: DVD doesn’t violate Hering’s law all the time as already mentioned by Guyton’s findings (Guyton et al 1998). Guyton described a supraversion impulse coming from the SR of the fixing eye, succeeding to an initial vertical vergence phase, to elucidate the mechanism of DVD. We propose that, in some asymmetric cases, the persistence of SR contracture on the fixing eye can provoque an infraversion impulse on the non fixing eye as already assessed by the persistence of hypotropia under general anesthesia in highly asymmetric DVD (Paris 1998). This hypothesis is clinically correlated by the efficacy of an unilateral procedure in large bilateral DVD and the efficacy of bilateral symmetric SRR in cases of apparent asymmetric DVD. This «hypotropic» effect represents the principle trap of the surgical management of the DVD. Taking this observation into account we think that the hypotropic effect of the IO on the contralateral eye in abduction is not systematically valid to differentiate DVD and IOOA. We have enough clinical clues such as; presence of V pattern, lateral incomitance, to do that. Based on the hypothesis that oblique muscles were primary concerned by the DVD process, it would be attractive to propose a “magic formula” to control it, which could be a bilateral recession of the four oblique muscles. Guyton was disappointed by this procedure but Gamio’s results are encouraging (Gamio 2002). 5
CONCLUSIONS
Because ATIO causes an anti-elevating force vector resulting from the fibrous nature of the neurovascular bundle of the IO (Stager 1997), it is very efficient to control vertical deviations. 111
Waiting for more clinical experiences about the use of a standard formula in all kind of DVD, we can perform a combined procedure, single or staged, symmetric or not, but always graded proportionally to the estimate of the DVD deviation. Respecting some surgical limitations and technical details we can obtain good stable results in most of the difficult cases without provoking any significant side effects.
REFERENCES 1. Burke J., Scott W., Kutschke P. 1993. Anterior Transposition of the Inferior Oblique Muscle for Dissociated Vertical Deviation. Ophtalmology. 100(2): 245–250. 2. Can D., Özkan S.B., Kasim R., Duman S. 1997. Surgical results in highly asymmetric dissociated vertical deviations. Strabismus. 5(1): 21–26. 3. Gamio S. 2002. A Surgical Alternative for Dissociated Vertical Deviation Based on New Pathologic Concepts: Weakening All Four Oblique Eye Muscles. Outcome and Results in 9 Cases. Binocular Vision & Strabismus. 17(1): 15–23. 4. Guyton D.L., Cheesman E.W., Ellis F.J., Starutmann D., Zee D. 1998. DVD: An exaggerated normal eye movement used to damp cyclovertical latent nystagmus. Trans Am Ophtalm Soc. 96: 390–429. 5. Kratz R.E., Rogers G.L., Bremer D.L., Leguire L.E. 1989. Anterior tendon displacement of the inferior oblique for D.V.D. JPOS: 212–217. 6. Mims J.L., Wood R.C. 1989. Bilateral anterior transposition of the inferior oblique. Arch. Ophthalm.1 (107): 41–44. 7. Mims J.M., Wood R.C. 1999. Antielevation Syndrome After Bilateral Anterior Transposition of the Inferior Oblique Muscles: Incidence and Prevention. J. AAPOS. 3(6): 333–336. 8. Paris V. 1998. Reality of vertical deviation asymmetry in early onset strabismus: observation during general anesthesia as a predictive sign. Proceedings of the VIIth Meeting of the ISA. Maastricht, 10–12 September, The Nederland. : 357–360. 9. Schwartz T., Scott W. 1991. Unilateral Superior Rectus Recession for the Treatment of Dissociated Vertical Deviation. JPOS. 28(4): 219–222. 10. Stager D.R. 1997. The Neurofibrovascular Bundle of the Inferior Oblique Muscle as the Ancillary Origin of that Muscle. J AAPOS. 1(4): 216–225. 11. Varn M.M., Saunders R.A., Wilson M.R. 1997. Combined Bilateral Superior Rectus Muscle Recession and Inferior Oblique Muscle Weakening for D.V.D. J. AAPOS 1(3): 134–137.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Mechanical and histopathological effects of ADCON – L, conventional and polymer coated liposomes in an experimental strabismus surgery model B. Sönmez Department of Ophthalmology, Military Hospital, Malatya, Turkey
S¸. Gedik Department of Ophthalmology, Bas¸ kent University, Ankara, Turkey
Ç. Karaca, E.C. S¸ener & A.S¸. S¸anaç Department of Ophthalmology, Hacettepe University, Ankara, Turkey
T. Eldem Department of Pharmaceutical Biotechnology, Hacettepe University, Ankara, Turkey
ABSTRACT: Aim: To investigate the effect of ADCON – L, conventional and polymer coated liposomes on the formation of scar tissue following strabismus surgery. Methods: Thirty-six eyes of 18 rabbits underwent 5 mm superior rectus recessions. One eye of each rabbit was used as control. ADCON – L, conventional and polymer coated liposomes were applied to five, six, seven eyes respectively. For all eyes, preoperative, early postoperative late postoperative quantitative forced duction measurements were carried out. At the postoperative 6th week surgical region was explored and histopathological specimens for light and electron microscopy were prepared. Results: The administration of ADCON – L was associated with less adhesion formation. Both liposome groups showed less restriction in quantitative forced duction compared to the control group. Conclusion: ADCON – L is an effective anti-adhesive barrier gel which can be used in prevention of adhesions caused by strabismus surgery.
Adhesions arising between sclera, conjunctiva and extra ocular muscles have a negative impact on the success of strabismus surgery. Avoiding traumatic surgical techniques, control of excessive hemorrhage, suppression of postoperative infection and inflammation and avoiding multiple surgical interventions are frequently employed to prevent adhesion formation following strabismus surgery. Wagner & Nelson (1985). Many kinds of synthetic and biological membranes and implants were used experimentally to prevent the development and spread of fibrotic scar tissue. Synthetic and biological implants act as mechanical barriers whereas antifibrotic drugs act on several steps of wound healing pharmacologically. Among these materials are tissue implants such as Tenon’s capsule, Amnioplastin, egg membrane and peritoneum Berens (1943); and plastic implants such as pig gelatin, polyester film and silicon. Polyglactin mesh sleeves placed over extraocular muscles also have been tried Dunlap (1976). In our study, ADCON – L, which is a bioabsorbable barrier gel shown to be effective experimentally in preventing postlaminectomy peridural fibrosis in rabbits and conventional and polymer coated liposomes were used in an experimental model of strabismus surgery to observe their mechanical and histopathological effects on the development of fibrosis. 113
1
METHODS
The study was conducted at Hacettepe University School of Medicine and School of Pharmacy. Thirty-six eyes of 18 rabbits were included in the study. One eye of each rabbit was used as control. After intramuscular anesthesia with Ketalar (Ketamine Hydrochloride 40 mg/kg, Parke Davis) and Rompun (Xylazine Hydrochloride 4 mg/kg, Bayer) quantitative forced duction (QFD) measurements were done via a traction suture piercing sclera partially at 12 o’clock quadrant with a Pesola dynamometer. Passive traction forces against the superior rectus muscle were recorded for each 1 mm movement as grams. The superior rectus muscles were recessed 5.0 mm in all eyes. In control group surgical field was washed with 0.9% NaCl. 1 ml of ADCON – L was applied to the surface of the superior rectus muscle and the surgical field after recession in 5 eyes. ADCON – L is a polyglycan formed by repeat sequences of poly-sulpho-alpha(1→6)–D-glucan Fredericson (1996). Two types of liposomes were prepared at the department of pharmacy namely conventional and polymer coated liposomes Table 1. 0.1 ml of conventional liposomes were used in 6 eyes and polymer coated liposomes in 7 eyes. Liposomes were injected into the superior rectus muscle with a 26 gauge needle and the surgical field was washed with the rest. After closure of the conjunctiva with 7/0 vicryl sutures the QFD test was repeated. No other topical medications were used postoperatively. After a six week period the rabbits were anesthetized again and QFD test repeated by the same examiner. The surgical field was explored and adhesions between conjunctiva, superior rectus muscle and the sclera were evaluated and graded Table 2. Thereafter 5.0 mm muscle tissue specimens with adjacent conjunctiva and sclera were prepared and the rabbits were sacrificed with intravenous pentobarbital. All of the surgeries and the quantitative forced duction measurements were done by the same examiner. Tissue specimens were fixated with 2.5% gluteraldehyde solution and treated with Sorensen’s phosphate buffer and 1% osmium tetroxide solution. After dehydration with alcohol and treatment with propylene oxide specimens were embedded in epoxy-resin material and 2 thick sections were cut with ultramicrotome (LKB – Nova Ultratome). Sections were stained with methylene blue for 200 magnification observation with light microscopy. For electrone microscopy 60 nm thick sections were cut and evaluated with 10000 and 120000 magnification after staining with uranyl acetate and lead citrate. The sections were analyzed by the same anatomo-pathologist.
Table 1.
Materials used for the preparation of the liposomes.
DSPG (Distearoyl phosphatidyl glycerol) (Genzyme Corporation) MPEG-DSPE (2000) (Distearoyl-N-monomethoxypolyethileneglycol phosphatidyl ethanolamine) (Molecular Weight 2000) (Genzyme Corporation) CHOL (Cholesterol) (Sigma) HSPC (Semi-hydrogenised phosphatidylcholine) (Lipoid AG) HEPES (n-2-hydroxypiperazine-N-2-ethanesulphonic acid) CHCl3 (Chloroform) (Sigma) MeOH (Methanol) (Sigma) NaCl (Sodium chloride) Deionized water
Table 2. Grade 0 Grade 1 Grade 2 Grade 3
Grading of the adhesions after surgical exploration. No adhesions Mild adhesions Moderate adhesions Severe adhesions
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Data obtained from the quantitative forced duction tests at preoperative, early postoperative and late postoperative measurements are evaluated with Mann-Whitney U test statistically and ingroup and intergroup comparisons were used. Findings from the surgical exploration at the sixth week which were evaluated as gradings are analyzed as percentages in groups.
2
RESULTS
At the postoperative 6th week surgical field was explored and adhesions between conjunctivamuscle and adhesions between muscle-sclera were evaluated and graded. In the control group; 94.5% of adhesions between conjunctiva and the superior rectus muscle were grade 1 (55.6%) and grade 2 (38.9%). 100% of adhesions between muscle and sclera were in grade 1 (44.4%) and grade 2 (55.6%). In the ADCON – L group; 100% of adhesions between conjunctiva and muscle were in grade 0 (60%) and grade 1 (40%). Also 100% of the adhesions between the muscle and the sclera were grade 0 (20%) and grade 1 (80%). In conventional liposome group 100% of adhesions between the conjunctiva and the muscle were in grade 0 (16.7%) and grade 1 (83.3%); also 100% of adhesions between the muscle and the sclera were grade 1 (16.7%) and grade 2 (83.3%). In polymer coated liposome group 100% of adhesions between conjunctiva and muscle were grade1, and 100% of adhesions between the muscle and the sclera were in grade 1 (42.9%) and grade 2 (51.7%). When compared to the control group and both liposome groups both conjunctiva-muscle adhesions and muscle-sclera adhesions were less severe in the ADCON – L group. There were no significant differences in terms of surgical findings between the control and both liposome groups. Mean values for QFD measurements were 6.12 gr for 1 mm and 19.22 gr for 6 mm in control group preoperatively. Early postoperative values were 5.42 gr for 1 mm and 17.97 gr for 6 mm, late postoperative values 6.33 gr and 19.22 gr for 1 and 6 mm respectively. The differences were not statistically significant. In the ADCON – L group preoperative QFD measurements were 6.36 gr for 1 mm and 18.8 gr for 6 mm. The mean early postoperative values were 5.76 and 18.0 gr and late postoperative values were 6.32 gr and 18.64 gr for 1 and 6 mm respectively. When we compared the QFD values of the ADCON – L group with the control group, no statistically significant difference was found. The QFD measurements of the conventional liposome group showed statistically significant differences compared to the control group at the early postoperative 2,4 and 6 mm measurements and at all values of the late postoperative measurements. Also in the polymer coated liposome group there were statistically significant differences at early postoperative 2 mm and late postoperative all measurements compared to the control group.
(a)
(b)
Figure 1a and 1b. Fibroblastic proliferation and collagen deposition was more pronounced in the control group (1a). The muscle fibers were more preserved in the ADCON – L group (1b).
115
On histopathological sections less amount of fibrotic tissue were observed between the muscle fibers in ADCON – L group compared to the control group. Also the bulk of muscle tissue was better preserved compared to the control group (Figure1a, 1b). In both of the liposome groups the muscle tissue was not well preserved as in the ADCON – L group. Also in the electron microscopic sections of the liposome groups intracytoplasmic and mitochondrial edema was noticed which was not seen both in the control and the ADCON – L groups.
3
DISCUSSION
ADCON – L is a drug of polyglycan formed by repeat sequences of poly-sulpho-alpha(1 → 6) – D-glucan Fredericson (1996). It is a clinically safe drug with bioabsorbtion and antiadhesive barrier gel properties. First use of ADCON – L was in experimental neurosurgical laminectomy procedures for the prevention of postoperative peridural adhesions after laminectomy procedures Robertson 1993. Later on it was also shown to be effective in adjustable suture surgery for the prevention of adhesions histopathologically Choi 2001. Our results on the effects of ADCON – L were similar to the findings of Choi and friends. On histopathological sections with light microscopy less amount of fibroblastic tissue were observed between the muscle fibers in ADCON – L group compared to the control group, also the bulk of muscle tissue appeared to be well preserved. On electron microscopy, less amount of collagen bundles were appearent between the muscle fibers compared to the control group. These histopathological findings were not supported with the quantitative forced duction measurements in our study. There were no statistically significant differences between the ADCON – L and control groups in the preoperative, early and late postoperative quantitative forced duction test results. Liposomes are global structures formed by a liquid phase in the middle covered by one or more lipid bilayers mainly formed by cell membrane components, phospholipids and cholesterol. They are usually used as adjuvants or carriers for drugs in chemotherapy, immunization or diagnostic imaging. To the best of our knowledge, liposomes have not been used in strabismus surgeries, neither alone nor combined to any antifibrotic drug. In our study, quantitative forced duction measurements showed less restriction in both of the liposome groups compared to the control group especially in the late postoperative values. Whereas these findings were not supported by the histopathological data. The sections for light microscopy showed increased amount of fibrotic tissue and decreased amount of muscle tissue compared to the control group. In the electron microscopic sections intracytoplasmic and intramitochondrial edema was observed, especially in the polymer coated liposome group. As a result ADCON – L decreased postoperative fibrosis and adhesions in our experimental strabismus surgery model. Neither conventional nor polymer coated liposomes decreased postoperative fibrosis but they seemed to be safe for the future combinations with antifibrotic drugs. REFERENCES Berens C & Romina HH. 1943. Postoperative cicatricial strabismus, results of the transplantation of the Tenon’s capsule. Transactions of the American Academy of Ophthalmology 47:183–205 Choi MY. 2001. Effect of ADCON – L on adjustable strabismus surgery in rabbits. Br J Ophthalmol 2001. 85:80–84 Dunlap EA. 1976. Plastic implants. Int Ophthalmol Clin 16:221–227 Frederickson RC. 1996. ADCON – L: a review of its development, mechanism of action, and preclinical data. Eur Spine J 5:7–9 Robertson JT. 1993. The reduction of postlaminectomy peridural fibrosis in rabbits by a carbohydrate polymer. J Neurosurgery 75:89–95 Wagner RS & Nelson LB. 1985. Complications following strabismus surgery. Int Ophthalmol Clin 25:171
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Outcomes of surgery for vertical strabismus in thyroid-associated ophthalmopathy A.C. Bates, G.G.W. Adams, J.F. Acheson & J.P. Lee Moorfields Eye Hospital, London, UK
ABSTRACT: At our institution the preferred surgical management of large-angle vertical strabismus secondary to thyroid-associated ophthalmopathy is inferior rectus recession combined with contralateral superior rectus recession. We report the results of surgery on 31 patients. 16 patients had a good result with this one procedure. 8 patients had an over-correction requiring further rectus muscle surgery or botulinum toxin treatment.
1
INTRODUCTION
Restrictive strabismus secondary to thyroid-associated ophthalmopathy is commonly managed by recession of the muscles most affected by fibrosis and contracture. The inferior rectus muscle is the most frequently affected extraocular muscle and in asymmetrically affected cases a large vertical deviation can result (Flanders & Hastings 1997). Although unilateral inferior rectus recession using adjustable sutures has been advocated in vertical strabismus, a tendency to overcorrection in downgaze has been reported (Lueder et al. 1992); in another series 9 out of 14 patients undergoing unilateral adjustable surgery suffered a progressive overcorrection in the primary position (Sprunger & Helveston 1993). Other authors have suggested performing inferior rectus recession combined with contralateral superior rectus recession to avoid these consequences (Weir & Ansons 2004). The four consultant strabismologists at our institution utilise the latter procedure with adjustable sutures in large-angle vertical strabismus, performing bilateral inferior rectus recession in more symmetrically affected cases, or unilateral inferior rectus recession in vertical strabismus of a smaller magnitude. We reviewed the results of inferior rectus recession combined with contralateral superior rectus recession. 2
METHODS
37 patients operated on over a ten-year period by four consultant teams were retrospectively identified from the surgical diaries kept at Moorfields Eye Hospital. Five case notes were unavailable and one patient was excluded as 3-month post-operative data were unavailable. 21 patients were female, 10 were male. The mean age at surgery was 56.6 years, with a range from 34 to 81 years. Four patients had previously undergone bilateral orbital decompression surgery; four had undergone decompression surgery ipsilateral to the hypotropic eye preceding strabismus surgery. No patients had undergone any strabismus surgery previously, or had been diagnosed with any co-existing ocular motility disorder. The mean pre-operative prism cover test angle in the distance was 32 prism dioptres (SD 9.4 prism dioptres, range 16–56 prism dioptres). 13 patients were operated on with both muscles on adjustable sutures, 10 patients only had the inferior rectus recession on an adjustable suture, and 8 patients only had the superior rectus recession on an adjustable suture. The mean amount of inferior rectus recession was 4.3 mm (range 2–6 mm), the mean amount of superior rectus recession was 4.4 mm (range 2–6 mm). All patients had orthoptic measurements at 3 months postoperatively, 30 patients had orthoptic measurements at 2 weeks post-operatively, and 13 patients had orthoptic measurements immediately after post-operative adjustment. 117
3
RESULTS
All 13 patients for which orthoptic measurements immediately post-adjustment were available were left under-corrected with a mean prism cover test angle in the distance of 8.8 prism dioptres (range 3–16 prism dioptres). At 3 months post-operatively the mean vertical deviation was 8.5 prism dioptres (n 31, SD 9.6 prism dioptres, range 0–30 prism dioptres). There was a tendency to further correction from 2 weeks to 3 months post-operatively with a mean shift of 6.6 prism dioptres (n 30). 16 patients (52%) had just this one procedure, of which 9 were phoric and free of diplopia in primary position and down-gaze, 2 were phoric and free of diplopia in the primary position and ignored diplopia in down-gaze, 2 patients were suppressing and cosmetically happy, and 3 patients had a small incorporated prism. 6 patients (19%) went on to further surgery on the vertical rectus muscles for an over-correction, 2 patients had botulinum toxin treatment to the contralateral inferior rectus for over-correction, 3 patients had oblique surgery for incomitant strabismus out of the primary position, 2 patients went on to have esotropia surgery, one patient had surgery for an under-correction, and one patient underwent further orbital decompression surgery. Excluding the latter patient, of the 14 patients who had further strabismus procedures 9 were phoric in the primary position after one procedure, and 3 were phoric after two procedures. One patient continues with regular botulinum toxin treatment and one continues to wear a fresnel prism.
4
DISCUSSION
Our study shows that this procedure was effective in about half of the patients as a single operation. A quarter of patients went on to have either surgery or botulinum toxin treatment for an overcorrection. These patients had a similar mean pre-op deviation and similar amounts of recession surgery compared to the group as a whole. In the literature various factors have been implicated in the tendency to overcorrection following inferior rectus recession in thyroid-associated ophthalmopathy. A “masked” restriction of the ipsilateral superior rectus or contralateral inferior rectus that is uncovered by recession of the more restricted inferior rectus has been suggested. It has also been suggested that the association of the inferior rectus muscle with the inferior oblique and Lockwood’s ligament can cause delayed attachment of the inferior rectus to the globe. More recently, the use of non-absorbable sutures has been advocated to prevent this complication (Parsa, C., Soltan-Sanjari, M. & Guyton, D., in press). In order to try and prevent over-correction, one consultant changed from only putting the inferior rectus on an adjustable suture to only putting the superior rectus on an adjustable suture during the time period covered in this study. The management of strabismus secondary to thyroid-associated ophthalmopathy is not always straight-forward. Patients should be counselled that the first operation for large-angle vertical strabismus only succeeds in around half of cases, but that all but a small minority of cases achieve a good result within three procedures.
REFERENCES Flanders, M. & Hastings, M. 1997. Diagnosis and surgical management of strabismus associated with thyroidrelated orbitopathy. J Pediatr Opthalmol Strabismus 34: 333–340. Lueder, G.T., Scott, W.E., Kutschke, P.J. & Keech, R.V. 1992. Long-term results of adjustable suture surgery for strabismus secondary to thyroid ophthalmopathy. Ophthalmology 99(6): 993–997. Sprunger, D.T. & Helveston, E.M. 1993. Progressive overcorrection after inferior rectus recession. J Pediatr Opthalmol Strabismus 30: 145–148 Weir, C. & Ansons, A.M. 2004. Management of large vertical deviations in thyroid eye disease. In de Faber, J.H.N. (ed.), Trans 28th Meeting Europ Strabismolog Assoc: 261–263. London: Taylor & Francis.
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Session 9: Brown’s syndrome and congenital fibrosis syndrome
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Surgical findings in Brown’s syndrome Serpil Akar, Birsen Gökyig˘it, Kemran Gök . & Ömer Faruk Yılmaz Beyog˘ lu Eye Education and Research Hospital, Istanbul, Turkey
ABSTRACT: Purpose: Investigation of the results of the surgery applied to patients with Brown’s syndrome. Material and Methods: The files of 51 patients with Brown’s Syndrome, who were examined between 1991–2003 at the Pediatric Ophthalmology and Strabismus Department of our hospital, were retrospectively studied. This study was conducted on 18 patients who had been operated. The subjects consisted of 10 female and 8 male patients with mean follow up being 28 months. Findings: 19 eyes of 18 patients were operated. In 5 cases superior oblique tenotomy, in 4 cases elongation with superior oblique silicon expander, in 9 cases inter capsular tenotomy and elongation with non-absorbable suture were performed. When 1–10 scale was used for operation results, 17 of 19 eyes (89.5%) had successful results with 7 and above score. Results: Operation techniques used, gave successful results. Elongation with suture had both stable successful results in controls and was simple and may be preferred.
1
INTRODUCTION
In 1950, Harold Brown described superior oblique tendon sheath syndrome with a series of 8 cases which had positive traction test together with adduction elevation restraint. It was pointed out that the cause of this syndrome was the shortening of superior oblique tendon sheath (Crawford 1980). In literature, in the surgical treatment of Brown’s syndrome, different procedures with different results are given (Dyer 1970, Parks 1987, Wright 2000). In this study, our purpose was the treatment of Brown’s syndrome with different surgical techniques, examination of the results and to determine which technique was the most effective.
2
MATERIAL AND METHODS
The files of 51 patients with Brown’s syndrome, who were examined between 1991–2003 at the Pediatric Ophthalmology and Strabismus Department of our hospital, were retrospectively studied. This study covers 18 patients who had surgical treatment due to manifested head position or hypotropia (Wright 2000). One eye of the 17 patients and two eyes of the 1 patient were operated. Prior to surgeries, all patients underwent full ophthalmologic and orthoptic examination. In 5 patients (Group I) superior oblique tenotomy, in 4 patients (Group II), elongation of superior oblique with silicone expander , in 10 eyes of 9 patients (Group III) elongation with non-absorbable suture bridge and inter capsular tenotomy were performed. Suitable horizontal surgery was done on patients with horizontal deviations before, during or after superior oblique surgery. Results were evaluated according to these groups. Surgical results were graded according to 1–10 scale (Wright 2000). Post-operative findings in their last examinations were the basis for this grading. The mean follow-up was 28 (10–97) months. Mean follow-up for the Group III who had inter capsular tenotomy and elongation with non-absorbable suture was 9,33 (6–15) months. We used Wilcoxon Signed Ranks tests for statistical evaluations. 121
Table I.
Clinical findings Group I (Superior oblique tenotomy).
Surg No. Ind
Pre Pre El Pre Dev Ad Fd (pd)
Pos El Ad
Pos Pos Dev Fd (pd)
Pos Abp
Pos Sop
Pos Bin Add (sec) Surg
1 2 3 4 5
4 4 4 3 4
3/0 0 2 1 1
0 0 0 0 0
No Small Yes Small No
Mod Small No No No
No – 40 40 No
Face turn Face turn Chin elev Chin elev Face turn
4 4 4 4 4
Lho4E6 E40 Lho2E4 Rho4E10 Ortho
16H/4H 5H ortho E10 ortho
Fp Fs
IO SR Rec. No No No No
96 19 6 24 48
7 7 3 7 8
Sur Ind: Surgical Indication, Pre:Preoperative, Pos:Postoperative, El ad: Elevation adduction, Fd: Forced Duction, Dev: Deviation in primary position, ho: hypotropia, E: Esotropia, X:Exotropia, Abp: Abnormal head Position, Sop; Superior Oblique palsy, Bin; Postoperative Binocularity, Add surg; Re-operation, Fp; Follow period, Fs: success score (1–10) Table II.
Clinical findings in Group II (Superior oblique tendon expander procedure).
Surg No. Ind
Pre El Ad
Pre Fs
Pre Dev (pd)
1 2 3 4
4 4 4 4
4 4 4 4
Lho6E45 1 Ortho 0 Lho4 0 Rho7 0
Chin elev Chin elev Face turn Chin elev
Pos El Pos Ad Fs 0 0 0 0
Pos Dev (pd)
Pos Abp
Pos Pos Bin Add Sop (sec) Surg
FP
FS
3Ho Ortho Ortho Ortho
No No No No
No No No No
15 17 12 15
8 10 1 10
No 600 No 1200
No No *SO sut.el. No
*Superior Oblique suture elongation procedures*.
2.1.1
Surgical Techniques
Superior oblique tenotomy was done to superior rectus from nasal, as Parks has explained (Parks1987). Superior oblique tendon expander procedure was done as Wright (1991) has explained. between the tips of the tendon cut from the 2–3 mm superior rectus nasally, 5.5–6 mm segment of No. 40 medical grade silicone retinal band is attached. In intercapsular tenotomy and elongation with non-absorbable suture technique, following temporal conjunctiva incision, superior oblique tenotomy was done to superior rectus from nasal, as Parks (1987) has explained . During this procedure the base of the superior oblique capsule was protected. Between the tips of the tendon cut from the 2–3 mm superior rectus nasally, 5.5–7 mm segment was attached. This elongation procedure was done like braiding with 5–0 Dacron nonabsorbable suture. Tendon capsule and conjunctiva was stitched with 8–0 vicryl. 3
FINDINGS
Surgical treatment was done on one eye of the 17 patients and two eyes of the 1 patient with the Brown’s syndrome. 12 of the 18 cases were congenital and 6 cases were acquired as patient’s story (cause of 2 case was trauma, cause of four cases was inflammation). Surgeries in these cases were done after at least a year’s follow-up. The subjects consisted of 10 female and 8 male patients with mean age being 7.96 (4–21) years. It can be seen preoperative and postoperative clinical findings in Group I, Group II, Group III (Table I)(Table II)(Table III). There are statistically significant difference between preoperative and postoperative restriction elevation adduction and maximum hypotropia angle for Group I, Group II, Group III (p0.04, p 0.05), (p 0.05, p 0.04), (p 0.004, p 0.001). 122
Table III. Clinical findings in Group III (Superior oblique tenotomy and elongation with non absorbable suture bridge procedure). Pre Ad El
Pre Pre Dev Fd (pd)
4 4
4 Ortho 2 4 Rho12X30 4/0
3 4
Chin Elev Face turn Hypo Face Turn Chin Elev
4 3
4 Lho4 4 Ortho
3/0 3/2
5 6 7 8 9
Face Turn Chin Elev Face Turn Hypo Chin Elev
4 3 4 4 4 4
4 3 4 4 4 4
1 0 0 0 0 0
No. 1 2
Surg Ind
Rho4E25 E10 Lho2X10 Lho10E40 E18
Pos Ad El
Pos Sop
Pos Bin (sec)
0 Ortho Small 4/0 X2 No
No No
No 120
3/0 LH4 No 3/0 Ortho No
No No
200 600
No No No No No No
No – – 3000 600
Pos Fd
0 0 0 0 0 0
Pos Dev (pd)
E4 Ortho Ortho Ortho Ortho
Pos Ahp
No No No No No
Add Surg
Fp
Fs
No 7 *Exp 6 Adh.Liz No 12 *Expl. 8 Adh Liz No 15 No 6 No 6 No 6 **Acc. 14 So releas.
7 8 7 7 9 10 10 10 10 10
* Exploration and adhesion lizis, **Accessory superior oblique realesed.
When superior oblique tenotomy surgery final results in 5 patients based on 1 to 10 scale (10 being best); 4 of the 5 patients (80%) had 7 and above scores. In 3 of these 5 patients (60%) had 7 and above score with one surgery and 1 patient needed a second operation for secondary superior oblique paralysis (Table I). When superior oblique tendon expander surgery final results in 4 patients based on 1 to 10 scale (10 being best); 3 of the 4 patients (75%) had 7 and above scores. With this surgery, results in 1 patient were unsuccessful and needed a second operation for secondary superior oblique. Silicon was removed and superior oblique tendon was elongated by non-absorbable suture bridge. (Table II). When elongation with non-absorbable suture bridge surgery final results in 9 patients based on 1 to 10 scale (10 being best); all of the 10 eyes (100%) had 7 and above scores. In 7 of these 10 eyes (70%) had 7 and above score with one surgery and 3 patients needed a second operation. Under correction was due to adhesion in 2 cases and surgically their lizis was necessary. In case 9 which was bilateral an accessory superior oblique tendon was found in both eyes. These accessory tendons were realesed (Table III).
4
DISCUSSION
Brown, in 1950, defined superior oblique tendon sheath (Brown) syndrome and since than the surgical treatment of the syndrome had many modifications and changes (Dyer 1970, Parks 1987, Wright 2000). In early reports, in surgical treatment of Brown’s syndrome, the most preferred method was tenotomy and tenectomy. Sprunger and von Noorden(1991) defend SO tenectomy as a most effective starting procedure. Some other authors state that tenotomy and tenectomy results were successful in 44–50% ratio and additional surgery is required in 50–56% cases (Parks 1987, Sprunger 1991, von Noorden 1982, Wright 1992). In our series, we obtained 60% success after SO tenotomy with one operation. In 1 (20%) case additional surgery was needed. Uncontrolled separation of tendon tips is the major problem of tenotomy and tenectomy and cause consecutive UO paralysis. In different publications, ratio of development of post-operative consecutive superior oblique paralysis after these operations is given as 30–85% (Crawford 1980, Parks 1987, Sprunger 1991,von Noorden 1982, Wright1992). In our series ratio of development of superior oblique paralysis was 40%. 123
Another method suggested in the treatment of Brown’s syndrome is superior oblique tendon elongation reported by Wright in 1991. This procedure provides controlled elongation of superior oblique tendon thus reducing the incidence of post-operative paralysis and residual over reaction (Wright 1992). By applying this procedure to his 15 Brown’s syndrome cases and follow-up 1–134 months, Wright has stated that success rate was 87% with one surgery (success result scores were 7–10 based on 1–10 grading scale). 39 pediatric ophthalmologists, members of AAPOS, reported same success based on same scoring system, on 65% of 140 Brown’s syndrome patients who had superior oblique tendon procedure (Wright 2000). We also obtained successful results with one surgery on 75% of the 4 cases using the same procedure. Clarke(1995) and Stager(1999) have obtained very successful results in their cases with silicon tendon expander procedure. Other method suggested in the treatment of Brown’s syndrome is to place a suture bridge between the cut tips of tendon after the superior oblique tenotomy. Thus, superior oblique tendon can be loosened without causing an important superior oblique paralysis (Wilson 1995). Dyer(1970) has reported that by using suture bridge tips of the cut tendon can be held apart and the surgery results are successful. On the other hand Wright(2000) stated that suture bridge is not rigid enough to keep the cut tips apart, sutures can have scaffolding effect for fibrosis, cut tips will again come together and it would result in under correction. We have applied superior oblique tenotomy and elongation with nonabsorbable suture technique to 10 eyes of 9 patients in our series. It was successful with one surgery with 70% of patients (scored 7–10). There was under correction in 30% and re-operation was necessary. Under correction was due to adhesion in 2 cases and surgically their lizis was necessary. In case 9 which was bilateral an accessory superior oblique tendon was found in both eyes. These accessory tendons were realesed. Following re-operation their post-operative versions became normal and 7–10 success scores are obtained in all cases. In our study, we have followed our patients 9,33 (6–15) months. We think that there is need for a longer period to evaluate the stability of the results. 5
CONCLUSION
All our results were successful with the surgical techniques we have applied. We suggest the use of elongation with suture technique, because of its results being favorable and also it being simple. REFERENCES 1. Clarke MP, Bray LC, Manners T. 1995. Superior oblique tendon expansion in the management of superior oblique dysfunction. Br J Ophthalmol 79:661–3. 2. Crawford JS, Orton RB, Labow- Daily L. 1980. Late resuls of superior oblique muscle tenotomy in true Brown’s syndrome. Am J Ophthalmol 89: 824–9 3. Dyer JA. 1970. Superior oblique tendon sheath syndrome. Ann Ophthalmol 2:790–2. 4. Parks MM, Eustis HS. 1987. Simultaneous superior oblique tenotomy and inferior oblique recession in Brown’s syndrome.Ophthalmology 94:1043–8. 5. Sprunger DT, von Noorden GK, Helveston EM. 1991. Surgical results in Brown syndrome. J. Pediatr Ophthalmol Strabismus 28:164–7. 6. Stager Jr DR, Parks MM, Stager Sr DR, et al. 1999. Long-term results of silicone expander for moderate and severe Brown syndrome (Brown syndrome “plus”). JAAPOS 3:328–32. 7. Von Noorden GK, Olivier P. 1982. Superior oblique tenectomy in Brown’s syndrome. Ophthalmology 89:303–8. 8. Wilson ME, Sinatra RB, Saunders RA. 1995. Downgaze restriction after placement of superior oblique tendon spacer for Brown’s syndrome. J Pediatr Ophthalmol Strabismus 32:29–34. 9. Wright KW.1991. Superior oblique silicone expander for Brown’s syndrome and superior oblique overaction. J Pediatr Ophthalmol Strabismus 28:101–7. 10. Wright KW, Min BM, Park C. 1992. Comparison of superior oblique tendon expander to superior oblique tenotomy for the management of superior oblique overaction and Brown syndrome J Pediatr Ophthalmol Strabismus 29:92–9. 11. Wright KW. 2000. Results of the superior oblique tendon elongation procedüre for severe Brown’s syndrome. Tr Am Ophth Soc 98:41–50.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
A new surgery technique in Brown’s syndrome B. Gökyig˘ it, S. Akar & O.F. Yilmaz Istanbul Beyoglu Education and Research Eye Hospital, Istanbul,Turkey
ABSTRACT: Purpose: To introduce a new modified technique. Materials & Method: The affected superior oblique muscle tendon complex is found by conventional technique. The tendon is freed from the capsula. A 5/0 non-absorbable suture is made and tied to the tendon. With a special binding technique, the suture, is stretched out 5–8 mm and is passed through the tendon approximately 1 mm beyond the first pass and the tendon is cut between the two passes. The tendon then moves freely in the capsule. Findings: Surgery was applied to 12 eyes of 11 patients. The patients were 3–17 years (med. 6.6 years). The results were successful except for 3 patients. After the second operation, the first two cases were partially corrected and the third case was fully corrected. Result & Conclusion: This technique, without the need for any special equipment besides the operation microscope, is found to be an easy and effective method.
1
INTRODUCTION
In 1950, Harold Brown described superior oblique tendon sheath syndrome with a series of 8 cases which had positive traction test together with elevation restriction in adduction. Brown has in 1973 classified this syndrome in two groups as real and pseudo superior oblique tendon sheath syndrome (Brown 1973). It was pointed out that the cause of this syndrome was the shortening of superior oblique tendon sheath (von Noorden 2002, Parks 1975,Crawford 1980). It was stated that many mechanic factors including short tendon, wrongly placed tendon, iatrogenic or acquired factors may cause this condition (Clarke1995). The first operation applied to Brown Syndrome is peeling or extraction of superior oblique tendon sheath and generally this procedure is ineffective (Wright 2000, Scott 1972, Parks 1977). Parks (1975), Crawford (1980) and Von Noorden (1982) have stated that in Brown Syndrome there is no abnormality in tendon sheath, superior oblique muscle tendon complex is tight and firm and this tightness would be relieved by tenotomy and tenectomy. Another method, after tenotomy, is to place a suture bridge between two cut tips of tendon (Chicken suture). In this way, consecutive superior oblique paresis is avoided (Dyer 1970, Suh 2001). Parks and Wilson have stated that with split tendon elongation procedure, both the superior oblique paresis would be avoided and the superior oblique tendon wholeness is preserved (Parks 1978, von Noorden 1982). Recession of superior oblique muscle is defined as a procedure that produces gradual relaxation of tendon (Romano 1983, von Noorden 1982, Drummond 1990). The other surgical procedure developed in Brown Syndrome cases is to elongate the superior oblique tendon with silicon expander (Wright 1989, Stager 1999). Also, Mombaerts suggests the luxasion of superior oblique and trochlea as a new surgery procedure to treat acquired Brown Syndrome (Mombarets 1995). Our purpose with this study was to identify a new modified technique we used in the treatment of Brown Syndrome and to evaluate the results obtained in 12 eyes of 11 patients operated with this technique. With this modified technique, we aimed to gain certain amount of elastisity besides avoiding superior oblique under action. Intra operative adjustment can be possible with this technique. 125
2
MATERIALS AND METHOD
The patients with Brown’s syndrome who were examined and operated between 2002 April and 2003 October at the Pediatric Ophthalmology and Strabismus Department of our hospital, were prospectively studied. This study covers 12 eyes of 11 patients – 5 male and 6 female – who had surgical treatment due to manifested head position or hypotropia (von Noorden 2002). The patients were 3–17 years old (med. 6.6 years) and were followed up 6–20 months (med.9.1 months) after the procedure. Neither of the patients had neurological problem, head trauma, arthritis or had not undergone surgery. One eye of 10 patients and two eyes of one patient were operated. Prior to surgeries, all patients underwent full ophthalmologic and orthoptic examination. Distant vision was checked with Snellen scale. Anterior segment with biomicroscope, posterior segment with indirect ophthalmoscope was evaluated. Deviation amounts, with or without glasses, at distant and near fixation and at cardinal gaze positions were evaluated with cover and uncover, alternant cover, prism cover tests and sinoptofor. Ocular ductions and versions were examined in all cardinal gaze positions. Function of the muscle, from center to muscle’s influence area, was graded between 0 4. Binocularity was evaluated with Worth 4 point, TNO, Titmus, Lang tests and Bagolini glasses. Before to the surgery, restriction in eye movements were evaluated by “passive force duction test” in all gaze positions. Inter capsular tenotomy and tendon elongation with non-absorbable suture bridge were applied to 12 eyes of the 11 patients. Suitable horizontal surgery was done on patients with horizontal deviations before, during or after superior oblique surgery. Surgical results were graded according to 1–10 scale (Wright 2000). Post-operative findings in their last examinations were the basis for this grading.
3
SURGICAL TECHNIQUES
The affected superior oblique muscle tendon is approached from the nasal superior rectus with a fornix incision, made at a distance of 7–8 mm from the cornea. Surgery is performed under the operation microscope, where the superior oblique tendon complex is found. An incision is made at the capsule parallel to the tendon and the tendon is freed from capsule very carefully and a fine dissection. When the tendon is held with a small hook, a 5/0 non-absorbable suture (Dacron, Ethibond) is passed through and tied to the tendon from approximately at a 3 mm distance from the superior rectus medial edge. With a special binding technique (knots, reversing ties alternatively, are done several times by using one of the suture lines as doubled.), the suture, depending on the restrictions of the case, is stretched out 5–8 mm. It is than passed through the tendon approximately 1 mm beyond the first pass and made a knot once and the tendon is cut between the two passes. At these stage, passive force duction is applied to determine if adjustment is needed. If adjustment is not required, second and third knots are made than tendon and bridge move freely in the capsule. After securing the eye’s free movement in the force duction, tendon is put back in the capsule. During this procedure, the base of the superior oblique capsule was protected. At the end of the surgery, tenon and conjunctiva is closed with an 8/0 vicryl suture. After injecting sub cojunctival antibiotic and steroid, 5/0 silk suture is put through the sclera at the limbus infratemporally as traction suture. Traction suture is removed after 24–48 hours.
4
FINDINGS
Pre-operatively, there was ocular restriction elevation in adduction in 12 eyes of 11 patients. This restriction was 4 in 10 eyes and 3 in 2. Vertical deviations in pre-operative primary position changed between orthotropic and 12 prism diopter (PD). After the procedure, in 6 of the 12 eyes were moved freely and restriction was corrected. In 6 eyes restriction was (3)–(4) after the surgery. After the second surgery, ocular motility was normalized on all of the eyes. 126
Table I.
Clinical findings
Surgery Indication 1 2
Chin elev Face turn Hypotrophy 3 Face turn 4 Chin elev 5 Face turn 6 Chin elev 7 Face turn 8 Hypotrophy 9 Face turn 10 Hypotrophy 11 Chin elev
PRE-OPERATIVE VA El Primary R/L ad F.D. Position
El add.
0.5/0.4 1.0/1.0
4 4
4 4
Ortho 2 RHo 12 30 4/0
1.0/1.0 1.0/1.0 0.5/0.6 0.7/0.4 – 1.0/0.3 1.0/1.0 1.0/0.4 1.0/1.0
4 3 4 3 4 4 4 4 4 4
4 4 4 3 4 4 4 4 4 4
LHo4 Ortho RHo4E25 E10 LHo2 10 LHo10E40 RHo 6 LHo8E8 E18
3/0 3/2 1 0 0 0 1 1 3 3
POST-OPERATIVE Dev. SO F.D. (PD) AHP u/a
Bin (sec)
S.S
0 4/0
Ortho Tilt X2 No
No No
– 1200
7 8
3/0 3/0 0 0 0 0 0 0 3/0 3/0
LH4 Ortho E4 Ortho Ortho Ortho Ortho Ortho Ortho
No No No No No No No No No No
200 600 No – – No 600 No 600
7 7 9 10 10 10 9 7 10 10
No No No No No No No No No
VA:Visual acuity, R:Right, L:Left, El Add:Elevation in adduction, FD:Forced Duction, Dev.:Deviation, AHP:Abnormal head position, SO u/a:Superior oblique under action, Bin:Binocularity, S.S:Success score
After the surgery, motility was corrected in 3 eyes. In 3 eyes 1 normal version was obtained. In 6 eyes more than 1 under correction happened. Case 1 had a light under correction. In order to find out what caused the under correction in these 5 eyes, an exploration surgery was done in 2nd month post-operatively. After the second surgery, normal versions were obtained in Case 3. Adhesions were found in exploration surgery in Case 2 and 4 and were separated. In Case 3, the length of suture bridge made between tendon tips was extended. In case 11 aberrant tendon was found and released in both eyes. Versions in these cases were corrected after the second surgery. Pre-operatively, face turn and/or chin elevation existed in patients. Abnormal head posturing has improved in all of them. With this binding technique, besides improvement of motility, eyes also gained elasticity like silicon band. In any of the patients in our group, post-operatively, we did not find under correction in versions in early period and spontaneous correction in later periods. Final results of this surgery based on 1 to 10 scale (10 being best) is shown in Table I.
5
DISCUSSION
Brown, in 1950, defined superior oblique tendon sheath syndrome and since than the surgical treatment of the syndrome had many modifications and changes (Astle 1993,Wright 1992). Treatment of the Brown’s syndrome is extremely difficult (von Noorden 1982). In early reports, in surgical treatment of Brown syndrome, the most preferred method was tenotomy and tenectomy. Uncontrolled separation of tendon tips is the major problem of these procedure. In some cases these tendon tips are widely separated and cause consecutive UO paralysis and in others scars in cut edges cause under correction. In different publications, ratio of development of post-operative consecutive superior oblique paralysis after these operations is given as 30–85% (Buckley 1983, Mombaerts 1995, Parks 1975, von Noorden 1982 and Wright 1992). For this reason patients needed additional surgery (Troutman 1990) Other method suggested in the treatment is to place a suture bridge between the cut tips of tendon after the superior oblique tenotomy (Dyer 1970, Suh 2001). Thus, superior oblique tendon can be loosened without causing an important superior oblique paralysis (von Noorden 2002, Wilson 1995). Wright stated that a suture bridge is not rigid enough to keep the cut tips apart, sutures can have scaffolding effect for fibrosis, cut tips 127
will again come together and it would result in under correction (Wright 2000). Another method suggested in the treatment of Brown syndrome is superior oblique tendon elongation reported by Wright (Wright 1991). Theoretically, putting a spacer between the cut tips of superior oblique tendon provides for controlled elongation of tendon thus reducing the incidence of post-operative paralysis and residual over reaction (Wright 1989, 1991, 1992). It is important to have long followup, to evaluate the extrusion of implant or presence of inflammation and the stability of results. Tendon sheath, which does a barrier role against orbital fat tissue, should be protected during the surgery. After the operation, fat adherence syndrome may happen as soon as the exposure of orbital fat and this condition often may give post-operative result worse than pre-operative strabismus. Successful results with all of the suggested treatments of Brown syndrome depend on careful dissection. After doing tenotomy of all tendons by protecting nasal intramuscular septum, it is necessary to ratify complete tenotomy by doing forced duction of superior oblique. If the case who had aberrant tendon in both eyes was kept out of the results, the procedure was successful with one surgery with 70% of the patients (scored 7–10). There was under correction in 30% and re-operation was necessary. Under correction was due to adhesion in only two cases and surgical lyses were successful. Following re-operation, their post-operative versions became normal and 7–10 success scores are obtained in all cases. Superior oblique paralysis did not form in any of the patients and there were no other complications. There was no under correction in any of the patients during follow up. We think that our success depended on the binding suture having enough rigidity and elasticity but, there is a need for a longer period to evaluate the stability of the results. In concluding, because of its results being excellent and also it being economic, we suggest the use of elongation with special binding suture technique.
REFERENCES Astle WF, Cornock E, Drummond GT. (1993): “Recession of the superior oblique tendon for inferior oblique palsy and Browns syndrome.” Can J Ophthalmol 28:207–12. Brown HW. (1973): “True and simulated superior oblique tendon sheath syndromes”. Doc Ophthalmol 34:123–136. Buckley EG, Flynn JT.(1983): “Superior oblique recession versus tenotomy: A comparison of surgical results.” J Pediatr Ophthalmol Strabismus 20:112–117. Clarke MP, Bray LC, Manners T.(1995): “Superior oblique tendon expansion in the management of superior oblique dysfunction.” Br J Ophthalmol 79:661–663. Crawford JS, Orton RB, Labow- Daily L.(1980): “Late resuls of superior oblique muscle tenotomy in true Brown’s syndrome.” Am J Ophthalmol 89: 824–29. Drummond GT, Pearce WG, Astle WF.(1990): “Recession of the superior oblique tendon in A-pattern strabismus.” Can J Ophthalmol 25:301–305 Dyer JA. (1970): “Superior oblique tendon sheath syndrome.” Ann Ophthalmol 2:790–2. Mombaerts I. et al.(1995): “Superior oblique luxation and trochlear luxation as new concepts in superior oblique muscle weakening surgery.” Am J Ophthalmol 120:83–91. Parks MM, Brown M.(1975): “Superior oblique tendon sheath syndrome of Brown.” Am J Ophthalmol 79:82–86. Parks MM.(1977): “The superior oblique tendon.” Trans Ophthalmol Soc UK 97:288–304.* Parks MM, Eustis HS.(1987): “Simultaneous superior oblique tenotomy and inferior oblique recession in Brown’s syndrome.” Ophthalmology 94:1043–48. Parks MM,(1978): “Surgery for Brown’s syndrome. In: Symposium on Strabismus” Transactions of the New Orleans Academy of Ophthalmology. St Louis:CV Mosby; 157–177. Parks MM. (1975): Ocular Motility and Strabismus. Hagerstown, Md: Harper & Row; 147. Prietz-Diaz J.(1988): “Management of superior oblique overaction in A pattern deviations”. Graefes Arch Clin Exp Ophthalmol 226:126–131. Romano P, Roholt P.(1983): “Measured graduated recession of the superior oblique muscle.” J Pediatr Ophthalmol Strabismus 20:134–140. Scott AB, Knapp P.(1972): “Surgical treatment of the superior oblique tendon syndrome.” Arch ophthalmol 88:282–86.
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Stager Jr DR, Parks MM, Stager Sr DR, et al. (1999): “Long-term results of silicone expander for moderate and severe Brown syndrome (Brown syndrome “plus”).” JAAPOS 3:328–32. Suh DW, Guyton DL, Hunter DG.(2001): “An adjustable superior oblique tendon spacer with the use of non absorbable suture.” JAAPOS 5(3):167–71 Troutman AV.(1990): “Simultaneous superior oblique sheathectomy and inferior oblique tuck in congenital Brown’s syndrome.” Ann Ophthalmol 22:406–413.* von Noorden GK, Campos EC.(2002): “Binocular Vision and Ocular Motility: Theory and Management of Strabismus.” 6th ed. St Louis, Mo CV Mosby; 470–71. von Noorden GK, Olivier P.(1982): “Superior oblique tenectomy in Brown’s syndrome.” Ophthalmology 89:303–8. Wilson ME, Sinatra RB, Saunders RA. (1995): Downgaze restriction after placement of superior oblique tendon spacer for Brown’s syndrome. J Pediatr Ophthalmol Strabismus 32:29–34. Wright KW. (2000): “Results of the superior oblique tendon elongation procedüre for severe Brown’s syndrome.” Tr Am Ophth Soc 98:41–50. . Wright KW,(1989): “Surgical procedure for lengthening the superior oblique tendon.” Invest Ophthalmol Vis Sci 30(supple):377. Wright KW.(1991): “Superior oblique silicone expander for Brown’s syndrome and superior oblique overaction.” J Pediatr Ophthalmol Strabismus 28:101–107 Wright KW, Min BM, Park C.(1992): “Comparison of superior oblique tendon expander to superior oblique tenotomy for the management of superior oblique overaction and Brown syndrome.” J Pediatr Ophthalmol Strabismus 29:92–9.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Long term outcome of silicone expander for Brown’s syndrome H. Kadircan Keskinbora* & Nuray Karakus¸çu Pulur Bakirköy Dr. Sadi Konuk Education and Research Hospital, Clinic of Ophthalmology*, Istanbul, Turkey
ABSTRACT: To evaluate the long term outcome of silicone tendon expander for Brown’s syndrome. Records of 22 eyes of 16 patients with diagnosis of Brown’s syndrome reviewed. The mean followup period was 54,7 months. The expander, which varies 5 to 7 mm.in length was placed in all patients in the tenotomized superior oblique muscle tendon 5 mm. nasal border of the superior rektus muscle using 6–0 nonabsorbable suture. Elevation in adduction obtained in all operated eyes. Two eyes had undercorrection and 3 eyes had overcorrection postoperatively. Four eyes has a severe postoperative inflammatory reaction. Two eyes developed granuloma and 6 eyes had foreign body sensation. One eye reoperated for extrusion. The silicone bands extirped from 3 eyes. Two eyes developed consecutive SO palsy. The silicone expander surgery is successful in treating overacting superior oblique muscle. No cyclotorsion symptom occurred after this surgery. This procedure is reversible and can repeat.
1
INTRODUCTION
Brown syndrome is characterized by limited elevation in adduction. It is described as superior oblique (SO) muscle tendon sheath first by Dr. H. Whaley (Brown 1950). Later, Brown stated this theory does not explain the etiology sufficiently (Brown 1973). In 1977, Parks expressed SO muscle tendon does not have a sheath; so it is clarified that the syndrome defined by Brown is not a sheath syndrome (Parks 1977). The syndrome may present in a congenital, acquired, constant or intermittent form. The silicone tendon expander technique as a weakening procedure can be succesfully used in the surgical treatment of SOOA on Brown syndrome in addition to various other surgical procedures (Wright 1991, Wright et al. 1992). We investigate the results of SO silicone tendon-expander procedure in a series of patients with SOOA for surgical treatment of Brown’s syndrome.
2
MATERIALS AND METHODS
Records of 22 eyes of 16 patients with diagnosis of Brown’s syndrome have been reviewed between January 1995 and January 2002. Nine of the patients were female and 7 were male. Criteria for exclusion included previous SO muscle surgery, previous or concurrent other rectus muscle surgery. We aimed to observe only the results of the patients on whose SO muscles expander was applied. As a summary, silicon expander was applied to only single or both of the SO muscles tendons according to unilateral or bilateral presence of the disease. Preoperative patient measurements included detailed ocular examination, versions and ductions in the diagnostic positions of gaze, primary position deviation at distance and at near and with head tilt. 131
The operation criteria were as follows: 1. Evident hypotropia on affected eye in primary position. 2. The presence of compensatory head tilt. 3. The presence of limited elevation which cannot be accepted aesthetically in adduction. The aims of the surgery were to provide binocularity of vision and prevention of the available physical abnormalities after a long lasting head position. Forced duction test was performed to SO muscle before the operation under general anesthezia, thus the diagnosis of Brown’s syndrome was confirmed. The conjunctiva and Tenon’s capsule were incised nasally on the superior quadrant. SO tendon was brought out with a hook from nasal side of insertion of SR muscle. SO tendon was pulled out gently with a hook. It is essential to be careful to avoid traumatisation of SO tendon sheath and intermuscular septum in this step. After dissection of SO tendon sheath, the tendon was clearly seen. The part of the sheath which touches the sclera was not dissected. Two non-absorbable sutures were applied to tendon separetely with a distance of 1–1,5 mm. from each other. The expander was prepared with proper length with silicone band No. 240. The silicone band was sutured with mentioned two sutures to the tendon. After that, the SO tendon was cut between the sutures, silicone band was brought close to the tendon and the sutures were tied. The elongated tendon was pushed into its sheath. Tenon capsule and conjunctiva were closed separetely. The forced duction test was repeated at the end of the operation to assure whether the tendon was cut completely.
3
RESULTS
The Brown’s syndrome was congenital in 11 patients and acquired in 5 patients. Bilateral SO tendon-expander procedure was performed on six patients out of the mentioned sixteen. The mean age of patients at surgery was 9.7 years (range: 3.4 years to 49.1 years). The silicone expander was applied for 5 mm in 8 eyes, for 6 mm in 10 eyes, and for 7 mm in 4 eyes. The average figure of SOOA was 3.0 preoperatively while 0.3 postoperatively. The preoperative average for “A-pattern” was 23.15 prism diopter while it became 3.56 prism diopter postoperatively. The postoperative temporary complications included: inflammation in 4 eyes (18.1%), granuloma in 2 eyes (9.0%) and irritation in 6 eyes (27.2%). The inflammation was succesfully treated with local corticosteroids and oral NSAI drugs. The complications which required surgical intervention were extrusion in 1 eye (4.5%) and SO palsy in 2 eyes (9.0%). In addition, the implanted silicone band had to be removed in 2 cases (9.1%). However, a complete improvement occurred 2 and 4 months after removal of silicone band. An overcorrection appeared in 3 cases. Paretic hypercorrection developed in 2 cases in postoperative period although a diplopia or restriction in down gaze was not present. While an anterior transposition was performed on inferior oblique muscle in one of these patients, silicone band was removed on the other one. A complete recovery was observed in 3 cases 2 to 4 months after explantation of silicone band. No cyclotortion symptom occurred after surgery. A slight esotropia in one case and an exotropia in 3 cases developed in postoperative period. The exotropia recovered in one of them later whereas in 2 patients it continued. Diplopia, phoria or even no aesthetic problem has been observed neither in exotropic nor esotropic cases. All other patients were ortophoric in primary position. The head tilt improved in all cases. Downgaze restriction was not seen in any cases.
4
DISCUSSION
The etiology of Brown’s syndrome is multifactorial: 1) Anomalies of tendon or trochlea, 2) Tendon tightness, 3) The reasons which lead to dyskinesia of SO tendon on trochlea, 4) Dysgenesis of SO 132
muscle, 5) Secondary defects on trochlea and SO tendon because of infection or trauma, 6) SO anomalies, developed secondary as a result of anomalies of inferior oblique (IO) itself or its neighbourhood, 7) After surgery of SO tendon, 8) Paradoxical innervation, 9) Secondary development of Brown’s syndrome because of IO muscle palsy (Von Nooerden 1996).Considering the theories describing Brown syndrome, many operation techniques have been proposed to treat the disease. SO tendon silicon expander technique is a recently described technique for the treatment of Brown syndrome, which provides a quantitative expansion in the SO tendon (Wright 1992). This techique is superior to the other techniques because it causes a quantitative relaxation in the functions of the SO tendon without impairing its functions. This is due to the broad insertion of the muscle that enables it to run three functions which are: The tendon fibrils in front of the equator are responsible for the incyclotorsion and the posterior fibrils are responsible for the depression and adduction. Stager et al. reported that placement of a 5 to 8 mm. silicone expander in the tenotomized SO muscle tendon is an effective means of correcting Brown syndrome with a low rate of reoperation. Initial undercorrection should not discourage the surgeon because improvement may continue for up to 3 years. This technique reduces the need for either simultaneous or subsequent inferior oblique muscle weakening and represents an advance in the treatment of Brown syndrome (Stager et al. 1999). In our study, the SOOA reduced to 0.3 after surgery while it was 3.0 on the average preoperatively. The average amount of “A-pattern” reduced to 3.56 from 23.12 as prism diopter. The average improvement of “A-pattern” was 19.56 prism diopter. It was observed that 5 years’ post operative results have improved compared to the 6 months’ post operative results. Our study supports the improvement in the long term. Awad et al. performed a SO tendon lengthening procedure, using a 10 to 12 mm. long silicone band on each patient. All patients had a hypotropia equal or higher than 20 prism diopter in primary position. All patients experienced an improvement in their severe Brown syndrome. Hypotropia in postoperative primary-position was less than 8 prism diopter in all patients. No patient required further surgery, and no extrusions of the implants were noted (Awad et al. 2003). In our study, even if the “A-pattern” was very severe, we did not implant expanders as long as the expanders used by Awad et al. In spite of this fact, may be not in short term but in long term, satisfactory results have been achieved. Regarding further surgery and extrusion, we were not as lucky as Awad et al. One patient had extrusion. On the other hand, band extraction had to be applied for 3 patients. The silicon band, by keeping the tendon ends apart, prevents postoperative scar contractures that may develop following suture expansions. This technique is superior to SO retraction operations because the localization of the tendon insertion and the functional characteristics are left unchanged. In addition, the length of the expander silicon band may vary according to the clinical situation. Besides, retraction of ipsilateral inferior oblique muscle retraction which is performed frequently after SO tenotomy operations is not necessary in this technique.
REFERENCES Awad AH, Digout LG, Al-Turkmani S, Khan AO, Fallata A. 2003. Large-segment superior oblique tendon expanders in the management of severe congenital Brown syndrome. J AAPOS Aug;7(4):274–278. Brown HW. 1950. Congenital stuructural muscle anomalies. In Allen JH., editor: Strabismus ophthalmic symposium. St.Louis Mosby Co, s.205–206. Brown HW. 1973. True and simulated superior oblique tendon sheath syndromes. Doc Ophthalmol. 34:123–136. Parks MM. 1977. The superior oblique tendon. 33rd Doyne Memorial Lecture. Trans Ophthalmol Soc UK. 97:288–304. Stager DR Jr, Parks MM, Stager DR Sr, Pesheva M. 1999. Long term results of silicone expander for moderate and severe Brown syndrome (Brown syndrome “plus”). J AAPOS Dec;3(6):328–332. Von Noorden GK. 1996. Binocular vision and ocular motility, theory and management of strabismus. St. Louis. CV Mosby Co s:437–442.
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Wright KW. 1991. Superior oblique silicone expander for Brown syndrome and superior oblique overaction. J Pediatr Ophthalmol Strabismus. 28:101–107. Wright KW. 1992. Surgical management of superior oblik overaction and Brown’s syndrome. Ophthalmology Clinics of North America. 5:67–78. Wright KW, Min B, Park C. 1992. Comparison of superior oblique tendon expander to superior oblique tenotomy for the management of superior oblique overaction and Brown syndrome. J Pediatr Ophthalmol Strabismus. 29:92–97.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Outcome of strabismus surgery in Congenital Fibrosis of Extraocular Muscles (CFEOM) E.C. S¸ ener, B.T. Öztürk*& A.S¸ . S¸anaç Hacettepe University, Faculty of Medicine, Department of Ophthalmology *Currently assigned at the Ankara Güven Hospital
ABSTRACT: CFEOM is one of the challenging topics in strabismus surgery. The data of 14 CFEOM patients who agreed to undergo strabismus surgery was retrospectively analysed. Twentythree operations on 19 eyes were evaluated in the study. All of the patients had significant restricted motility, nine had exotropia and hypotropia, 2 had esotropia and hypotropia, 1 had alternating esotropia, and 2 had hypertropia, one of them associated with exotropia. Recession of the horizontal or vertical recti were performed in all, together with resection in 5, transposition in 9 and conjunctival recession in one operation. Along the course of the follow-up of our patients, more common surgical doses were augmented because of the unsatisfactory outcome, in addition to the application of stay sutures in 6 patients. Large deviations of CFEOM patients with extreme restriction are difficult to overcome with even augmented surgery. Stay sutures can improve the results of augmented surgery in these cases.
1
INTRODUCTION
CFEOM is one of the challenging topics in strabismus surgery. Functional recovery and cosmetic improvement are hard to achieve and multiple operations are usually needed. We herein report surgical results of our CFEOM patients.
2
MATERIALS AND METHODS
Fiftysix CFEOM patients followed at one university hospital setting were included in the study. The data of 14 patients who agreed to undergo strabismus surgery was retrospectively analysed.
3
RESULTS
At the time of the surgery the age of the patients ranged between 3–44 years. Two patients underwent 2 and one patient had 3 operations. Twenty-three operations on 19 eyes were evaluated in the study. All of the patients had significant restricted motility, nine had exotropia and hypotropia, 2 had esotropia and hypotropia, 1 had alternating esotropia, and 2 had hypertropia, one of them associated with exotropia. Recession of the horizontal or vertical recti were performed in all, together with resection in 5, transposition in 9 and conjunctival recession in one operation. Along the course of the follow-up of our patients, more common surgical doses were augmented because of the unsatisfactory outcome, in addition to the application of stay sutures in 6 patients. 135
4
CONCLUSIONS
Smaller deviations of CFEOM patients can be corrected by common recess-resect and transposition procedures, however larger deviations with extreme restriction are difficult to overcome with even augmented surgery, and reoperations are not rare. Stay sutures can improve the results of augmented surgery in these cases.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Surgical management in a newly identified CFEOM/postaxial oligo-syndactyly syndrome Acun Gezer1 & Turgut Tükel2,3,4 1
Istanbul University, Medical Faculty of Istanbul, Department of Ophthalmology, Itanbul, Turkey Departments of Human Genetics, Mount Sinai School of Medicine of New York University, New York, USA 3 Istanbul University, Child Health Institute, Division of Medical Genetics, Istanbul, Turkey 4 Istanbul University, Institute for Experimental Medicine, Department of Genetics, Istanbul, Turkey 2
ABSTRACT: Objective: Surgical management of a newly identified syndrome consisting various forms of developmental anomalies of extraocular muscles innervated by the III. cranial nerve resembling CFEOM and oligodactyly is described. Materials and Methods: Strabismus surgery is performed in four of the six members of the family. Two of the patients had clinical findings of double elevator palsy. On one of these patients an inferior rectus recession combined with superior rectus resection is performed, while the other patient underwent an inferior rectus recession. Superior oblique tenotomy and inferior rectus recession is performed in the third patient with clinical characteristics of Brown syndrome. Moderately affected fourth patient had the clinical presentation of a pseudo-Brown syndrome and exotropia and underwent merely a lateral rectus recession. Results: All of the patients yielded satisfactory clinical results with reduction of the significant misalignment of their eyes. Conclusions: The choice of procedure in CFEOM patients must be individualized according the pre- and peroperative findings.
1
BACKGROUND
The combination of congenital blepharoptosis and restricted eye movements was first reported in 1879 by Heuk. In 1950, Brown described this group of ocular disorders in detail and subcategorized them into five distinct phenotypes: 1) horizontal retraction syndromes, 2) strabismus fixus, 3) vertical retraction syndromes, 4) superior oblique tendon sheath syndromes, and 5) a general fibrosis syndrome. Currently, the horizontal retraction syndromes are referred to as Duane syndrome, the superior oblique tendon sheath syndromes as Brown syndrome, and the remaining syndromes as congenital fibrosis of extraocular muscles (CFEOM)1. Initially, these disorders were considered primarily due to fibrosis of the extraocular muscles (EOM). However, recent neuropathological studies revealed that some of the fibrosis syndromes resulted from defects in the development of particular brainstem alpha motor neurons and their corresponding axons2,3. To date, three inherited CFEOM syndromes have been mapped to different genetic loci. CFEOM1 (OMIM #135700), an autosomal dominant disorder, was mapped to 12q124, and the disease-causing gene was recently identified as KIF21A5. Affected individuals have bilateral ptosis and restrictive ophthalmoplegia, and their eyes are fixed below the horizontally neutral position with or without secondary esotropia or exotropia. Phenotypically, this syndrome is variable with some affected individuals having a milder phenotype, which resembles CFEOM3, but have been linked to CFEOM1 locus, and are referred to as CFEOM3A (OMIM %607034)6. The CFEOM2 locus (OMIM #602078), an autosomal recessive disorder, was mapped to chromosome 137
11q13.3 in three consanguineous Saudi Arabian families7, and subsequently, mutations in ARIX gene were described8. Affected individuals with CFEOM2 have bilateral ptosis with the eyes fixed in abduction which virtually prevents voluntary eye movements. CFEOM3 (OMIM %600638, formerly #604361), an autosomal dominant disorder originally descibed in a large Canadian family was mapped to a 5.6 cM region on chromosome 16q24.29. The CFEOM3 phenotype of affected individuals was variable and ranged from bilateral ptosis with fixed eyes in an infraducted and exotropic position to normally positioned eyes with minimal limitation of vertical gaze and unilateral or absent ptosis. To date, the gene causing CFEOM3 has not been identified. Here, we describe a new syndrome of CFEOM and ulnar abnormalities in a large consanguineous Turkish family and their surgical management.
2
SUBJECTS AND METHODS
In five of the cases ocular studies and in four of them surgical treatment was performed. Histochemistry and electron microscopy of EOM, were performed in one patient, and genome-wide linkage analysis was made using DNA samples obtained from 13 individuals of the family.
3
RESULTS
Six affected individuals spanning three generations, had mainly presented with right eye involvement and bilateral postaxial oligodactyly/oligosyndactyly of varying severity of the hands, with the right hand more severely affected. Case #1 (II-7): 29 year old male. Bilaterally visual acuity was 10/10 and no remarkable refractive error was found. Slight chin up anomalous head posture was present. Right 14 pd exotropia and 25 pd hypotropia was found. The right eye had restricted elevation in both adduction and abduction. A slight pseudoptosis on the right eye existed. Forced duction test was found negative. MRI revealed a volume loss of the right SR and hypertrophy of the IR muscle. Patient had oligodactyly. His IR was recessed 5 mm and after 1 year of follow up his head posture were corrected with eyes rendered straight on the primary position. Case #2 (II-12): 26 year old male with 1/10 OD and 10/10 OS visual acuity and a chin up head posture. Elevation of the right eye was restricted which was more significant on abduction. Right eye had a 12 pd exotropia and a 25 pd of hypotropia. Hemiptosis with no levator function and a poor Bell phenomenon was present. Forced duction test was negative. MRI showed light volume loss of the right SR and hypertrophy of IR. Oligodactyly was present. He firstly underwent a right IR recession and a SR resection 4 mm each. Three months later a frontalis suspension procedure performed which helped to correct ptosis with pupils free of lid intervention. After one year follow up patient is free of anomalous head posture with a 12 pd exotropia. Case #3 (III-10): 4 year old female with 10/10 visual acuity bilaterally. She had restricted elevation on adduction in both eyes and a 16 pd right exotropia. A slight head tilt to the right shoulder occurred occasionally. MRI was normal and oligodactyly was present. Forced duction test was negative and 3-step test indicated a right IO dysfunction. This patient underwent a 5 mm LR recession and after one year she has a 10 pd exophoria. Case #4 (III-11): 3 years old male with 1/10 OD and 10/10 OS visual acuity and no significant refractive errors. This patient had a 30 pd exotropia with 10 pd hypotropia on the right eye. Elevation was restricted and this was more marked in adduction than in abduction. A positive forced duction test showing a markedly restricted elevation in adduction resembling a Brown syndrome. He had a slight (pseudo)ptosis of the right eye and a slight head tilt towards the right side occurred intermittently. Three step test revealed a right IO defect. MRI was normal and oligodactyly also present. Firstly he underwent a right IR recession (4 mm) combined with SO tenotomy which resulted in A pattern exotropia, persistence of restricted elevation in adduction and 138
restricted depression. Six months later a right SR resection performed which left the patient with a 25 pd exophoria and straight eyes in primary position, which helped his amblyopia to improve and occlusion therapy resulted in a visual acuity increase from 1/10 to 6/10. Case #5 (IV-1): 2.5 years old female. She was the most severely affected member of the family. Total ptosis, enophthalmia, microcornea and tilted disc anomaly on the right side was found. Right eye movements were restricted in all directions, while they were normal on the left. The MRI confirmed enophthalmia but did not reveal any additional abnormalities. Oligodactyly was also present. Her follow up and surgical management were done at another institution and we had no opportunity to obtain further data. On light microscopic examination right superior rectus muscle revealed primarily fibrous tissue and no muscle cells. In contrast, the inferior oblique muscle showed skeletal muscle with mild, non-specific variation in fiber size by routine light microscopy. No abnormalities were observed by histochemical analysis or electron microscopy With the genomic scan of the family, the disease locus was mapped to 21q with a critical region of 1.5 cM between D21S1897 and the telomere of the long arm. A multipoint LOD score of 4.525 was obtained.
5
CONCLUSION
The patients in this Turkish consanguineous pedigree define a new autosomal recessive syndrome of CFEOM with ulnar hand abnormalities. The five examined patients had CFEOM of varying severity, mainly confined to the right eye and postaxial oligodactyly/oligosyndactyly of both hands, more severly affecting the right hand . Although, clinical findings were variable between affected individuals, the penetrance was complete. Clinically, two adult patients (#1, #2) had a double elevator palsy and ptosis of varying degree, most likely due to a N.III superior division defect. Younger patients (#3, #4) had more marked restriction of elevation in adduction. Patient #3 had a negative forced duction test, hence she is interpreted as a pseudo-Brown syndrome. Patient #4 was distinctive in having a more marked mechanical restriction to elevation in adduction resulting in a positive forced duction test, resembling a Brown syndrome. Histopathologically SR of Patient #4 was found fibrotic and IO was normal, raising the question if simply a secondary IO and/or IR contracture or a primary involvement may be the cause of restriction to elevation in adduction. The fifth patient had a more generalized pattern of extraocular muscle involvement with marked restriction of eye movements in all directions, total ptosis, enophtalmos, microcornea and disc anomaly10. Our patients obviously represent an atypical form of CFEOM, by having clinical findings mostly consistent at least with the involvement of superior division of the N.III leading clinically to a double elevator palsy in different stages. The surgical management of patients with CFEOM is challenging. A staged approach to bring the eyes into a straight primary position with the order of first vertical, then horizontal and finally ptotic components is proposed11. In our study, moderate amount of surgery resulted in satisfactory results including normal head positions, better cosmesis and also improved vision in a young patient. We preferred an IR recession with/without a SR resection instead of a Knapp’s procedure because these patients had some degree of elevation above the midline. Supramaximal recessions12 are not always necessary because CFEOM phenotypes are highly variable13.
REFERENCES 1. Traboulsi EI, Lee BA, Mousawi A, Khamis AR, Engle EC. Evidence of genetic heterogeneity in autosomal recessive congenital fibrosis of the extraocular muscles. Am J Ophthalmol. 2000 May; 129(5):658–62. 2. Engle EC, Marondel I, Houtman WA, de Vries B, Loewenstein A, Lazar M, Ward DC, Kucherlapati R, Beggs AH. Congenital fibrosis of the extraocular muscles (autosomal dominant congenital external
139
3. 4. 5.
6. 7.
8.
9. 10. 11.
12. 13.
ophthalmoplegia): genetic homogeneity, linkage refinement, and physical mapping on chromosome 12. Am J Hum Genet. 1995 Nov;57(5):1086–94. Erratum in: Am J Hum Genet 1996 Jan;58(1):252 Engle EC. The molecular basis of the congenital fibrosis syndromes. Strabismus. 2002 Jun;10(2):125–8. Engle EC, Kunkel LM, Specht LA, Beggs AH. Mapping a gene for congenital fibrosis of the extraocular muscles to the centromeric region of chromosome 12. Nat Genet. 1994 May;7(1):69–73. Yamada K, Chan W-M, Andrews C, Bosley TM, Sener EC, Zwaan JT, Mullaney TZ, Akarsu AN, Sabol LJ, Demer JL, Sullivan TJ, Gottlob I, Roggenk P, Mackey DA, de Uzcategui CE, Uzcategui N, Ben-Zeev B, Traboulsi EI, Magli A, de Berardinis T, Gagliardi V, Awasthi-Patney S, Vogel MC, Rizzo JF, Engle EC. KIF21A mutations are a rare cause of congenital fibrosis of the extraocular muscles type 3 (CFEOM3). Invest Ophthalmol Vis Sci 2004, in press. Sener EC, Lee BA, Turgut B, Akarsu AN, Engle EC. A clinically variant fibrosis syndrome in a Turkish family maps to the CFEOM1 locus on chromosome 12. Arch Ophthalmol 2000, 118:1090–1097 Wang SM, Zwaan J, Mullaney PB, Jabak MH, Al-Awad A, Beggs AH, Engle EC. Congenital fibrosis of the extraocular muscles type 2, an inherited exotropic strabismus fixus, maps to distal 11q13. Am J Hum Genet. 1998 Aug;63(2):517–25. Nakano M, Yamada K, Fain J, Sener EC, Selleck CJ, Awad AH, Zwaan J, Mullaney PB, Bosley TM, Engle EC. Homozygous mutations in ARIX(PHOX2A) result in congenital fibrosis of the extraocular muscles type 2. Nat Genet. 2001 Nov;29(3):315–20. Doherty EJ, Macy ME, Wang SM, Dykeman CP, Melanson MT, Engle EC. CFEOM3: a new extraocular congenital fibrosis syndrome that maps to 16q24.2–q24.3. Invest Ophthalmol Vis Sci. 1999 Jul;40(8):1687–94. Hertle RW, Katowitz JA, Young TL, Quinn GE, Farber MG. Congenital unilateral fibrosis, blepharoptosis, and enophthalmos syndrome. Ophthalmology. 1992 Mar;99(3):347–55. Apt L, Axelord RN: Generalized fibrosis of the extraocular muscles. Am J Ophtalmol 1978, 85:822–829. Ferrer JA: General Fibrosis Syndrome. Second Congress of the International Strabismological Association. Paris: Diffus Générale de Librairie 1976, 352–361. Magli A, de Berardinis T, D’Esposito F, Gagliardi V. Clinical and surgical data of affected members of a classic CFEOM 1 family. BMC Ophthalmology 2003, 3:6
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Session 10: Superior oblique paresis
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Superior oblique palsy: a ten year survey Majid Farvardin & Alireza Alavi Shiraz University of Medical Sciences, Shiraz, Iran
ABSTRACT: Purpose: To evaluate the characteristics and surgical outcome of unilateral superior oblique palsy (SOP). Patients and methods: Charts of 114 patients with SOP referring to our center from 1993 to 2003 were reviewed retrospectively. Results: Vertical deviations ranged from 0 to 35 (mean:16.4 0.7) in primary position. As the first step 16.6% of surgeries were Inferior oblique (IO) myectomy, 10.5% IO recess, 56% anterior transposition of IO (ATIO), 1% Harada-Ito (HI) and in 15.7% two muscle surgery was done primarily and contralateral inferior rectus recess(CLIRR) plus ATIO (12.4%)was the most common. Success, defined as deviation 7 in primary position and 10 in adduction gazes was seen in 84% after the first and in 92% after the second operation. The deviation in primary position decreased to – 5 to 12 (mean; 2.4 0.4) after the first operation. Conclusion: Based on the mentioned data we conclude that with surgery of the IO muscle, SOP can be effectively treated in a majority of patients.
1
INTRODUCTION
Superior oblique palsy (SOP) is the most common cause of vertical strabismus encountered in the clinical practice. Both acquired and congenital palsies are common. Clinical presentation depends on several factors including etiology, severity of neural damage, age of onset and the duration of the paresis. Many patients with acquired superior oblique palsies recover spontaneously, so in acquired palsies the patients should be observed for at least 9–12 months1. Several studies have evaluated the effects of different muscle surgeries in superior oblique palsy, here we report the results of surgical management of 114 cases of unilateral SOP, treated with various inferior oblique (IO) weakening procedures.
2
SUBJECTS & METHODS
We conducted a retrospective chart study of 128 patients who underwent surgical correction of superior oblique paresis at Khalili Hospital, Shiraz University of Medical Sciences, Shiraz, IRAN between 1993 to 2003. All patients who had adequate preoperative information and at least three months of post-op follow up were included in the study. Overall 114 patients were enrolled in the study criteria for diagnosis of unilateral SOP included: A B C D
Hyperdeviation in primary position At least 2 increase in hyperdeviation with contralateral gaze Positive Bielschowsky head tilt test with 5 increase of hyperdeviation with ipsilateral head tilt Any evidence of underaction of the involved superior oblique and/or overaction of ipsilateral inferior oblique muscle 143
Table 1.
The result and success rate of various inferior oblique weakening procedures. Result Good 4–7
Poor 7
Preop deviation
Excellent 0–3
6–10
11–15
16–25
25
28 23 20 0
1 3 6 1
2 2 5 1
Total
71
11
10
Success rate 93.5% 89% 84% 50% –
Congenital superior oblique palsy was considered if the patient had history of eye deviation and head tilt since infancy, also reviewing old photographs.The palsy was considered traumatic in the case of any pertinent history of trauma. Age, sex and probable causes were recorded. Each patient was questioned about any possible symptom, ie. presence or absence of diplopia, asthenopia and any possible previous surgery. Best corrected visual acuity was determined in all cases. Amblyopia was diagnosed if at least a two line difference in best corrected visual acuity (BCVA) was present between the two eyes. During examination presence or absence of any abnormal head posture, ie. head tilt and head turn, and facial asymmetry was taken into consideration. Measurements of deviation in primary position and diagnostic positions were performed with the alternate prism cover test. Double Maddox rod testing was performed in all cooperative patients. Presence or absence of inferior oblique overaction and V-pattern was noted. The type and the number of surgeries performed were specified. Surgical procedures included inferior oblique weakening procedures (disinsertion, myectomy, recession or anterior transposition), Harada-Ito procedure; contralateral inferior rectus recess (CLIRR) and ipsilateral superior rectus recess (ILSRR). The results of the surgeries was considered as excellent, good and poor depending on the amount of post-op vertical deviation in primary position to be 3 , 4–7 and 7 . A successful surgical out come was defined as a good result (i.e. 7 deviation in primary position) plus 10 deviation in all adduction positions. 3
RESULTS
Charts of 114 cases of unilateral superior oblique palsy (SOP) were reviewed. The length of follow up was 3 months to 10 years (mean 9 month, SD 1.41)Among these cases 54 (47%) were male and 60 (53%) were female and 53 (46.5%) had left SOP and 61 (53.5%) had right superior oblique palsy. The age range of patients was 0.5–50 years (mean 13.6, SD 9.4). Etiology was congenital in 66 patients (58%), traumatic in 20 patients (17.5%) and unknown in 28 patients (24.5%). Head tilt was seen in 67 (59%), Face turn was present in 26 (23%) & diplopia in 23 (20%). Amblyopia was encountered in 17 (15%), 10 (59%) of which were in the normal eye( the so called fallen eye syndrome). 101 (88.5%) of the patients had some degrees of inferior oblique overaction. Over all 125 vertical muscle surgeries were performed in the patients (11 (8.8%) of which were reoperations), 104 (83%) single muscle surgery and 21 (17%) combined muscle surgeries were performed. Anterior transposition of the inferior oblique muscle (ATIO) in 62 (56%)was the most frequent surgery performed, followed by inferior oblique (IO) myectomy in 18 (16.6%), inferior oblique recess in 12 (10.5%) and Harada-Ito in 1 (0.9%)The mean angle of pre-operative vertical deviation in the primary position was 0–35 PD (mean 16.4, SD 7.3) which decreased to 15 PD to 12 PD (mean 2.4, SD 3.6) after the 1st operation. The result and the success rate of various inferior oblique weakening procedures and combined contralateral inferior rectus recession plus anterior transposition of IO are shown in table 1 and table 2 respectively. Overall we had good results in 97 (85%) of the patients after the 1st operation which improved to 106 (93%)after the second operation, similarly success rate was 96 (84%) after the 1st & 2nd operation respectively. The most significant complication in our patients was 5 cases (4.4%) of anti-elevation syndrome after anterior transposition of IO muscle. Other less clinically significant 144
Table 2. The result and success rate of combined contralateral inferior rectus recess and anterior transposition of inferior oblique muscle. Result Preop deviation
Excellent 0–3
Good 4–7
Poor 7
Success rate
6–10
11–15
16–25
25
Total
– – 4 1 5
– – – 2 2
– – 1 4 5
– – 80% 43% –
complications were the fullness of lower lid after anterior transposition of IO muscle and minor lid changes after vertical rectus muscle surgeries. 4
DISCUSSION
Surgical management of SOP depends on the laterality, the degree of superior oblique muscle underaciton and type of the muscle sequelae that has developed. It is generally believed that a V-pattern exotropia on up-gaze is usually associated with IOOA & can be treated with IO weakening procedures. However in the case of significant SO underaction, particularly if there is a V-pattern esotropia on down gaze a strengthening of SO muscle is indicated. Insuperable cyclotorsion also requires strengthening of the SO muscle. Most authors recommend that up to 15–20 PD hypertropia in primary position can often be successfully corrected by recession of the inferior oblique, while any deviation exceeding 20 PD requires additional recession of the ipsilateral superior rectus or contralateral inferior rectus depending on the nature of the muscle sequelae1. The role of SO tuck in managment of superior oblique palsy remains controversial. In several reports no correlation could be found between the size of the tuck and the amount of deviation corrected3,5. It has been suggested that other factors such as laxity of SO tendon and the amount of preoperative deviation are also important in influencing the outcome of SO tuck procedure. Simons et al in their series reported a 50% lower reoperation rate with SO tuck however they had a high rate of surgical Brown syndrome (61%),which in their opinion could be reduced with adjustment of the magnitude of SO tuck based on SO tendon laxity5. In contrary to their opinion, many surgeons feel that the complications of SO tuck outweight the advantages. Infact recent treatment protocols warrant SO tuck only in the case of marked SO tendon laxity during exaggerated SO tendon traction test2,4. This study shows our experience of treating superior oblique palsy with various IO weakening and vertical rectus muscle procedures. A single corrective surgery was successful in 96 patients (84%) while we had good results in 97 patients (85%). These figures improved to 105(92%) and 106(93%) after the second surgery, which are comparable to the results of previous studies1. According to the mentioned results we recommend IO weakening procedures combined with a vertical rectus muscle surgery (in more severe cases) for treating SO palsy. These procedures have comparable results to the SO tuck, need less expertise, are more predictable and have lower complication rates. In our experience up to 25 hyperdeviation in the primary position could be treated with ATIO alone and for any extra-deviation we recommend rectus muscle surgeries depending on the nature of the deviation. In our opinion superior oblique surgery is indicated only if 10 excyclotorsion is present, in which a Harada-Ito procedure is probably preferable. 5
CONCLUSION
In this study our 10 years experience in treating SOP with various IO weakening procedures was reviewed. The surgical outcome was quite comparable to the SO tuck, but on the other hand we had 145
a much lower complication rate. So it seems that inferior oblique weakening is an acceptable treatment for superior oblique palsy and one do not necessarily have to operate superior oblique muscle unless there is a significant excyclotorsion.
REFERENCES 1. Ansons, A. M., Davis, H.: Neurogenic palsies. In Diagnosis and Management of Ocular Motility Disorders, 3rd ed, p 377.Oxford, Blackwell Science, 2001. 2. Helveston, E. M., Mora, J. S., Lipsky, S. N., et al: Surgical treatment of superior oblique palsy. Trans Am Ophthalmol Soc 1996; 94:315. 3. Morris, R. J., Scott, W. E., Keech R. V.: Superior oblique tuck surgery in the management of superior oblique palsies. J Pediatr Ophthalmol Strabismus 1992; 29: 337–346. 4. Plager, D. A., Superior oblique palsy and superior oblique myokimia. In: Rosenbaum A. L., Santiago A. P., ed. Clinical Strabismus Management. Philadelphia: W. B. Saunders; 1999; chap 15, 219–229. 5. Simons, B. D., Saunders, T. G., Siatkowski, R. M., et al: Outcome of surgical management of superior oblique palsy: A study of 123 cases. Binocular Vis and Strabismus 1998; 13(4): 273–282.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Results of different surgical procedures in superior oblique palsy Serpil Akar, Birsen Gökyig˘ it, Pelin Kaynak Hekimhan & Ömer Faruk Ylmaz Beyog˘ lu Eye Education and Research Hospital, Istanbul, Turkey
ABSTRACT: Purpose: To evaluate the outcome of surgical treatment of superior oblique palsy. Material and methods: 43 superior oblique palsy(SOP) patients who had undergone surgical treatment between 1992–2003 were analysed retrospectively. In 22 cases (Group I), inferior oblique weakening, in 19 cases (Group II), superior oblique(SO) strengthening and inferior oblique(IO) weakening, in 2 cases (Group III) vertical rectus weakening operations were performed. The mean post-operative follow up period was 12.9 8.5 months. We used Wilcoxon Signed Ranks tests for statistical evaluations. Results: Abnormal head position had been improved in 93% of patients after the operation. There are statistically significant difference between preoperative near and distance vertical deviations and postoperative near and distance vertical deviations for Group I, Group II (p 0.001, p 0.001, p 0.001, p 0.001). There are significant improvement IO hiperfunction and SO hypofunction (p 0.05, p 0.05). Conclusion: It is concluded that in treatment of SOP, IO weakening procedure had enough effect in small vertical deviation and SO strengthening had a important effect in the patients who had large vertical deviation.
1
INTRODUCTION
Superior oblique palsy is the most common isolated cranial palsy of an extraocular muscle that requires surgery. The most common etiologies include congenital and idiopathic. The most common signs and symptoms include hypertropia, extorsion of the involved eye, head tilt, and/or diplopia. Many strabismologists directly or indirectly still use Knapp’s classification for, described in 1974 which maps the pattern of deviation as measured by the prism and cover test in the nine diagnostic positions of gase (Cogen 2003, Helveston 1992, Knapp 1974). Surgical treatment is highly effective (Cogen 2003). Treatment is generally directed toward achieving fusion in the practical field of gaze, elimination of abnormal head posture, and reduction in symptoms (von Noorden 2002). It was reported different surgical treatments and results by various surgeon (Cogen 2003, Helveston 1992, Knapp 1974, Saunders 1986). In this study, our purpose was to evaluate the outcome of surgical treatment of superior oblique palsy. 2
MATERIALS AND METHODS
The files of 61 patients with SOP, who were examined between 1992–2003 at the Pediatric Ophthalmology and Strabismus Department of our hospital, were retrospectively studied. This study covers 43 patients who had surgical treatment due to manifested head position or hypertropia, diplopia or image tilting.The study population consisted of 19(44%) female and 24(56%) male patients with ages ranging from 4 to 53 years (mean, 15.82 years). A complete eye examination was performed for all patients On the basis of these data, we determined classification of SOP as similar to classifications of Knapp(1974), von Noorden (1986). 147
In 22 cases (Group I), IO weakening, in 19 cases (Group II), SO strengthening (17 SO tendon tucking, 2 SO resection) and IO weakening, in 2 cases (Group III), IO weakening and vertical rectus weakening operations were performed. Suitable horizontal surgery was done on patients with horizontal deviations before, during or after oblique surgery. The ipsilateral IO muscle was weakened by myectomie, recession or anterior transposition (Knapp 1974, von Noorden 1986). SO muscle was weakened by tucking or rezection. It was performed tucks ranging from 12 to 10 mm with 5-0 Dacron nonabsorbable suture (Saunders 1985). The ipsilateral superior rectus was weakened by recession (Cogen 2003). The mean follow-up period was 12.9 8.5(6–14) months. We used Wilcoxon Signed Ranks tests for statistical evaluations. Surgery results were evaluated as post-operative findings in their last examinations. 3
RESULTS
Forty three patients were included in this series and preoperative data are given on all this cases; postoperative data were available for 43. Table I presents the patient demographics and some of the preoperative data along with the results of intraoperative SO traction testing. Table II, Table III and Table IV compare the preoperative and postoperative near and distance vertical deviations, maximum vertical deviation angles. Table V presents the effects of surgical treatment to abnormal head position in SO Palsy. There are significant improvement IO hiperfunction and SO hypofunction for Group I, Group II and total cases (p 0.05, p 0.05, p 0.05, p 0.05, p 0.05, p 0.05). Three (7%) patients had mild pseudo Brown syndrome. Preoperatively 11(38%) of the 29 patients who could be tested for torsion had no excyclotorsion. Postoperatively, 88% of those tested had no torsion. Many patients did not have their postoperative torsion documented, especially those without complaints. Table I.
Patient demographics and preoperative data for 43 cases of superior oblique palsy.
Congenital Acquired Knapp Class Class I Class II Class III Class IV Class V Class VI Lateralite Right Left Bilateral Table II.
40(93%) 3(7%) 21(49%) 0(0%) 19(45%) 1(2%) 1(2%) 1(2%) 19(44%) 23(54%) 1(2%)
Facial asymmetry Present Absent Unknown Abnormal head position Right tilt Left tilt Chin down Forced duction tests Tendon laxity No tendon laxity
21(48%) 12(28%) 10(24%) 19(44%) 23(54%) 1(2%) 32(74%) 11(26%)
Comparison of preoperative and postoperative near vertical deviations.
Surgery
Preop mean near dev. SD
Postop mean near dev SD
Mean correction(%)
p
Group I Group II *Group III Total
11.18 6.12 21.26 8.61 24.00 22.67 16.23 9.51
1.77 3.74 2.28 2.80 2.00 2.83 2.00 3.27
89.60 17.96 88.95 15.05 95.00 7.07 89.58 16.18
p 0.001 p 0.001 – p 0.001
*It wasn’t performed statistically evaluating for Group III because patient’s number was few.
148
Preoperatively 12(70%) of the 17 patients who could be tested for stereoacuity had no stereoacuity. Postoperatively, 95% of those tested had stereoacuity.
4
DISCUSSION
The surgical treatment of SOP is done for securing a symptomatic relief, for correcting abnormal head condition and deviation and for increasing concomitance and widening of binocular fixation area as much as possible (von Noorden 2002). The important factors that influence the choice of the surgical methods are the amount of deviation in down view and primary position, existence of paralysis in the muscle, function of other eye muscles, existence of horizontal, vertical or torsion components in deviation and existence of A and V patterns (von Noorden 2002). Knapp (1974) have suggested a treatment schedule based on deviation amount in motility defect and cardinal view positions. In this type of treatment, both the congenital and acquired SOP is viewed in the same group (von Noorden 1986, 2002). On the other hand, Helveston has separated his SOP into two groups as congenital and acquired according to etiology and suggested a new treatment schedule (Helveston 1992). It is advised that presence of extremely loose SO tendon, anomaly of insertion place and even tendon agnosia may be found in congenital SOP. It is reported that, in these cases, functional results are better when the treatment is directed to SO tendon (Helveston 1990). In our study, we also determined the type of surgery according to the results of forced duction test, amount of deviation in primary and cardinal view positions, the degree of IO hyperfunction and SO hypofunction and in accordance with the literature.
Table III.
Comparison of preoperative and postoperative distance vertical deviations.
Surgery type
Preop mean distance dev. SD
Postop mean distance dev SD
Mean correction(%)
p
Group I Group II Group III Total
11.36 6.24 20.95 8.10 25.00 21.21 16.23 9.54
2.14 4.02 2.39 3.58 3.00 4.24 2.29 3.74
82.53 22.95 88.61 15.82 92.50 10.60 85.61 19.69
p 0.001 p 0.001 – p 0.001
Table IV.
Comparison of preoperative and postoperative maximum vertical deviation angles.
Surgery type
Preop mean max angle SD
Postop mean max angle SD
% change max angle SD
p
Group I Group II Group III Total
20.09 3.65 33.79 6.05 27.50 17.68 26.49 8.68
3.77 2.71 4.32 5.54 3.00 4.24 3.98 4.17
81.81 12.51 82.58 11.62 92.50 10.61 82.65 11.99
p 0.001 p 0.001 – p 0.001
Table V.
The effects of surgical treatment to AHP in superior oblique palsy.
Surgery type
Preoperative AHP()(n)(%)
Preoperative AHP()(n)(%)
Postoperative AHP()(n)(%)
Postoperative AHP()(%)
Group I Group II Group III Total
22(100) 19(100) 2(100) 43(100)
0(100) 0(100) 0(100) 0(100)
1(5) 2(10) 0(0) 3(7)
21(95) 17(90) 2(100) 40(93)
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IO weakening operations in SOP are the most commonly used primary surgical procedure (Gonzales 1995, Toosi 1979, von Noorden 2002). Helveston (1996), in his series, has used IO weakening operation as a starting procedure in 90% of his 190 SOP cases and gives successful results. Several authors prefer to retard antagonist IO muscle at start (Parks 1971). We, in our series, have applied weakening operation in only 51% of the cases. We preferred this operation in the cases with IO hyperfunction and with deviation below 25 PD and after the operation, we obtained symptomatic relief, adequate correction in head position, vertical deviation and IO function. SO tucking surgery is defined by Mc Lean. With this operation, several authors have declared that they obtained successful results in the treatment of SOP with wide deviation angle (Knapp 1971, Saunders 1985,1986). In addition, it is written that it also gives positive results in congenital cases with loose tendons (Helveston 1992, Saunders 1986). It is determined that, in the operation of congenital SOP cases in infant age group, best results are obtained by combining IO weakening and SO tucking (Reynolds 1984). In our series, we also applied SO tucking and IO weakening surgery together to cases which have SO hypofunction with IO hyper function and vertical deviation angle more than 25 PD. We obtained successful results in regards to symptomatic relief and correction of AHP, vertical deviation and IO and SO functions. In literature, development of iatrogenic Brown syndrome ratio after the SO tucking surgery is given as 17%–60% (Helveston 1996, Simons 1998). Especially, in acquired SO paralysis, SO tendon formation is normal and even a small amount of folding causes symptomatic iatrogenic Brown syndrome (Helveston 1983, Saunders 1985). In order to avoid development of iatrogenic Brown syndrome, it is suggested that folding should be done in SO tendon excess ratio after making intra operative traction test (Saunders 1985). In our series, we have found. 7% residual Brown syndrome. All of our cases, whom we have applied tucking operation, were congenital SOP and forced duction test was made in all cases after the surgery. If the test was negative, surgery was stopped. If the test was positive, tucking amount was reduced and the test was repeated. CONCLUSION It is concluded that in treatment of SOP, IO weakening procedure had enough effect in small vertical deviation and SO strengthening had an important effect in the patients who had large vertical deviation. REFERENCES 1. Cogen, M.S., Roberts, B.W. 2003. Combined superior oblique tuck and adjustable suture recession of the ipsilateral superior rectus for long-standing superior oblique palsy. J AAPOS; 7: 195–9. 2. Gonzales, C., Cinciripini, G.1995. Anterior transposition of the inferior oblique in the treatment of unilateral superior oblique palsy. J Pediatr Ophthalmol Strabismus; 32: 107–13. 3. Helveston, E.M., Ellis, F.D. 1983. Superior oblique tuck for superior oblique palsy. Aust J Ophthalmol 11: 215–20. 4. Helveston, E.M. 1990. Classification for superior oblique palsy. In: Haik BG,ed. Transactions of Symposium on Oculoplastic Surgery, Strabismus, and Pediatric Ophthalmology, Horofare. Slack: 1–10. 5. Helveston, E.M., Krach, D., Plager, D.A., Ellis, F.D. 1992. A new classification of superior oblique palsy based on congenital variations in the tendon. Ophthalmology 99: 1609–15. 6. Helveston, H.M., Mora, J.S., Lipsky, S.N. 1996. Surgical treatment of superior oblique palsy. Trans Am Ophthalmol Soc 94: 315–2 7. Knapp, P. 1974. Classification and treatment of superior oblique palsy. Am Orthopt J 24: 18–22. 8. Parks, M.M., Hamtil, L.W. Surgical management of isolated cyclovertical muscle palsy. J Ped Ophthalmol Strabismus 1971; 8: 145–152. 9. Reynolds, J.D., Biglan, A.W., Hiles D.A. 1984. Congenital superior oblique palsy in infants. Arch Ophthalmol 102: 1503–5. 10. Saunders, R.A., Tomlinson, E. 1985. Quantitated superior oblique tendon tuck in the treatment of superior oblique muscle palsy. Am Orthopt J35: 81–89.
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11. Saunders, R.A. 1986. Treatment of superior oblique palsy with superior oblique tendon tuck and inferior oblique muscle myectomy. Ophthalmology 93: 1023–7. 12. Simons, B.D., Saunders, T.G., Siatkowsky, R.M., et al. 1998. Outcome of surgical management of superior oblique palsy:a study of 123 cases. Binocul Vis Strabismus Q 13: 273–87. 13. Toosi, S.H., von Noorden, G.K. 1979. Effect of isolated inferior oblique myectomy in the management of superior oblique palsy. Am J Ophthalmol 88: 602–8. 14. von Noorden, G.K., Murray, E., Wong, S.Y. 1986. Superior oblique paralysis. A rewiew of 270 cases. Arch Ophthalmol 104: 1771–6. 15. von Noorden, G.K. 2002. Paralytic Strabismus in Binocular Vision and Ocular Motility, Theory and Management of Strabismus. 6th ed. St. Louis:Mosby: 449–450.
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How predictable is muscles surgery in superior oblique palsy? L. Teodorescu & D. Cioplean Oftapro Ophthalmology Clinic Bucharest, Romania
ABSTRACT: We followed a treatment algorithm in IV Nerve palsy, based on the magnitude of hyperdeviation, assessment of versions and forced duction testing, in order to choose the muscles to be operated, one or multiple muscle surgery.
1
INTRODUCTION
SOP is the most common cyclovertical muscle palsy. Surgical indication include: diplopia, asthenopia, disturbing hypertropia and compensatory head posture. 2
PURPOSE
We aim to evaluate the effectiveness of one/multiple muscles surgery in SOP in one-step surgery. 3
MATERIAL AND METHODS
We studied 37 cases of congenital SOP with different surgical options depending on: the magnitude of hyperdeviation, versions, function of the inferior oblique (IO), superior rectus (SR) restriction, forced duction testing. Age range from 1 to 30 years old, the mean follow-up was 23 months. 10 adults patients complained of diplopia, no objective torsion measured. Facial asymmetry and head tilt to the opposite side in all cases. Treatment algorithm: A. Hypertropia 15 PD in the primary position – one-muscle surgery. 1. Overaction of the IO: IO recession – 3 cases and IO myectomy – 7 2. No IO overaction: SR recession – 13 B. Hypertropia 15 PD–surgery on 2–3 vertical muscles. IO myectomy SR recession – 7 IO myectomy contralateral IR recession – 3 IO myectomy SO tuck – 1 IO myectomy contralateral IR recession SR recession – 1 SO tuck contralateral SR resection contralateral IR recession – 1 4
RESULTS
19 cases (33%) were orthotropic after unilateral IO recession or myectomy. 11 (23%) needed 2 muscles surgery, 2 under corrected, and 2 overcorrected with 12 PD after IO myectomy and SR recession, with complains of diplopia. 153
2 (3.2%) with 30 PD hypertropia needed 3 muscle surgery, one under corrected. Only 2 (3.2%) had lax SO tendon for tuck. Generally, vertical deviation was corrected in 89%, torticolis improved and fusion present in 90%. No postoperative Brown syndrome.
5
CONCLUSIONS
5.1. IO myectomy corrects up to 15 PD of hypertropia in primary position as single procedure with no overcorrection. 5.2 Small under correction are comfortable. 5.3 Overcorrection should be avoided because of diplopia, in our experience after IO myectomy homolateral SR recession, requiring SR advancement resection as second surgery. 5.4 We prefer early surgery for congenital SOP, deviation and torticolis were corrected in all cases. 5.5 SOP is best treated with predictable results by selective surgical approach, based on patients measurement findings, including duction test and on etiology, as expressed by SO tendon pathologic anatomy.
REFERENCES Helveston, E.M. 1996. Surgical management of strabismus. An atlas of strabismus surgery. St. Louis: Mosby Helveston, E.M., Mora, J.S. & Lipsky, S.N. 1996: Surgical Treatment of Superior Oblique Palsy. Trans Am Ophthalm Soc 1996; 94: 315 Plager, D.A. 1992: Tendon Laxity in Superior Tendon Palsy. Ophthalmology 1992; 99: 1032 Von Noorden, G.K. 1996: Binocular Vision and Ocular Motililty. Theory and Management of Strabismus. St.Louis, Missouri: Mosby Prat-Johnson, J.A. & Tillson, G. 2001: Management of Strabismus and Amblyopia, New York: Thieme Rosenbaum, A.R. & Santiago, A.P. 1999: Clinical Strabismus Management. Philadelphia: W.B. Saunders Company
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Anterior transposition of inferior oblique muscle for treatment of unilateral superior oblique palsy with 16 to 25 prism diopters hyperdeviation in primary position Majid Farvardin, Abbas Attarzadeh & Alireza Alavi Shiraz University of Medical Sciences, Shiraz, Iran
ABSTRACT: Purpose: Superior oblique palsy is usually associated with inferior oblique(IO) muscle overaction, if the hypertropia in primary position(PP) is 15 , ordinary weakening of IO, often do not correct the hypertropia completely. In this study the effect of anterior transposition of IO in unilateral superior oblique palsy and 16–25 hypertropia in PP is evaluated. Methods: A prospective clinical trial was performed on 20 patients. Before surgery deviation was measured in the 9 cardinal positions, and was repeated 6 months after it. The data were statistically analyzed. Results: After surgery vertical deviation in the PP decreased from 20.70 1.90 to 2.10 2.50
(p 0.00001). In adduction this decrease, was from 29.20 to 5.20 (p 0.0001). In one patient the deviation was 5 at 6mo post-op. No case of hypotropia or diplopia was seen. In 4 patients mild limitation of up-gaze was encountered. Conclusion: Anterior transposition of IO muscle is a useful way to correct vertical deviation in unilateral superior oblique palsy with 16–25 hypertropia in the primary position.
1
INTRODUCTION
Anterior transposition of IO muscle converts IO from an elevator to an anti-elevator. Theoretically this change of action of IO muscle may be more effective in treating hypertropia caused by SO muscle palsy than ordinary procedures4. Reviewing literature, limited studies have been performed using transposition of IO muscle, to treat SO palsy4. The results of these studies are also not uniform. In this study the effect of anterior transposition of IO muscle in treating patients with unilateral SO palsy and hypertropia of 16 to 25 in primary position is evaluated. 2
MATERIAL & METHODS
A prospective clinical trial was done on 20 patients with SO palsy. Diagnosis of SO palsy was confirmed with increasing hypertropia in gaze toward the sound eye and head tilt to the other side (ve Bielschowsky’s test). After correcting refractive errors using a fixating target, eye deviations were measured in the 9 cardinal positions, using alternate prism and cover test. IO overaction was present in all patients and hypertropia in primary position was between 16 to 25 prism-diopters. Elliot and Nankin technique was used in anterior transposition of IO muscle with minimal modifications3. Six months after surgery any eye deviation was measured in two separate sessions. Success was defined as the presence of all of the following criteria5: 1. Decrease of hypertropia to 5 prism diopters in primary position 2. Hypertropia of 10 prism diopters in other positions of gaze 3. Improvement of head tilt 155
Table 1. Average of hypertropia in patients with unilateral SO Palsy depending on position of gaze before and after surgery (prism-diopters).
Position of gaze Before surgery After surgery Amount of change Percentage of change
Deviation in primary position ( )
Deviation in adduction ( )
Deviation in elevation & adduction ( )
Deviation in depression & adduction ( )
20.7 2.1 18.6 89.8
29.2 5.2 24 82.2
32.7 4.2 28.5 87.2
24.6 4.5 20.1 81.7
The result of treatment in each patient were evaluated statistically using t-test.
3
RESULTS
Study was performed on 20 patients including 9 male and 11 female. Fifteen patients had congenital palsy starting before the 1st year of life. Vertical deviation in primary position was 20.70 1.90
(range:16–25 ) before operation, which decreased to 2.10 2.50 (range: 0–7 ) post operatively(P-value 0.00001). The average hypertropia in the four cardinal positions of gaze before and six months after operation are shown in table 1. This table shows that 81.7% to 89.8% of hypertropia was reduced in all gaze positions. In the 18 patients who had head tilt, 14 (77.8%) were cured and in the remaining four (22.2%) head tilt was improved. Surgery was successful in 19 patients (95%). Eleven patients (55%) had no vertical deviation in primary position after operation. After the surgery none of the patients developed hypotropia in the primary position or diplopia. Limitation of upward gaze to 20–25 degrees was encountered in four patients and mild fullness of lower lidlower lid developed in another four.
4
DISCUSSION
Treatment of SO palsy is still controversial. Inferior oblique over-action is present in most of these patients, in which inferior oblique weakening is suggested. If hypertropia in primary position is more than 15 prism diopters, inferior oblique weakening alone usually cannot correct hypertropia. In these situations contralateral inferior rectus recess or ipsilateral superior oblique tuck is done simultaneously1. All of our patients had more than 15 hypertropia in the primary position, and only one of them needed reoperation. It seems that anterior transposition of inferior oblique muscle is an effective way to treat unilateral SO palsy patients with 16–25 hypertropia in primary position. Furthermore with this procedure the side effects and complications of inferior rectus recess including deformity of lower lid, failure to correct cyclotorsional deviations and the surgery on the sound eye (which ordinarily frightens the patients) are avoided. Our results are comparable to IO myectomy plus SO tuck, moreover the threat of postoperative Brown syndrome is also avoided. The most important complication following anterior transposition of IO muscle in the unilateral SO palsy is hypotropia and diplopia in the primary position plus severe limitation of motion of the eye in the upward gaze. It is mentioned that these complications are caused by anterior transposition of more than two millimeters in front of IR insertion. Lateralizing the posterior insertion of IO muscle in a point more than 5 mm temporal to the anterior insertion is another possible cause7. Limitation of upward gaze is encountered following various IO weakening procedures, mild limitation of upward gaze (between 20–25 degrees) was seen in 20% of our patients. Since under daily physiologic conditions the eyes rarely exceed 15 degrees in the upward gaze, this didn’t disturb normal activity and was not cosmetically significant. 156
In one study after anterior transposition of interior oblique in patients with SO palsy, palpebral fissure changes were reported, none of these were seen in our cases. In 20% of our cases mild fullness of lower lid was detected, although neither the patients nor their family complained of it.
5
CONCLUSION
With reference to the results of our study, we strongly recommend anterior transposition of IO muscle for treatment of unilateral SO palsy with 16–25 prism diopters hypertropia in the primary position.
REFERENCES 1. Bremer, D.L., Rogers, G.L., Quick, L.D. Primary position hypotropia after anterior transposition of the inferior oblique. Arch Ophthalmol 1986; 104: 229–232. 2. Elliott, R.L., Nankin, S.J. Anterior transposition of the inferior oblique. J Pediatr Ophthalmol Strabismus 1981; 18: 35–38. 3. Flanders, M., Draper, J. Superior oblique palsy; diagnosis and treatment. Can J Ophthalmol 1990; 25: 17–24. 4. Kushner, B.J. Restriction of elevation in abduction after inferior oblique anteriorization. J AAPOS 1997; 1: 55–62. 5. Muchnick, R.S., McCullough, D.H., Strominger, M.B. Comparison of anterior transposition and recession of the inferior oblique muscle in unilateral superior oblique paresis. J AAPOS 1998; 2: 340–343. 6. Plager, D. Superior oblique palsy and superior oblique myokymia. In: Rosenbaum Al, SantiagoAP. Clinical strabismus management. 1st ed. Philadelphia W.B. Saunders; 1999: 219–229. 7. Saunders, R.A. Treatment of superior oblique palsy with superior oblique pasy with superior oblique tendon tuck and inferior oblique muscle myectomy. Ophthalmology 1986; 93: 1023–1027.
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Familial congenital superior oblique palsy Majid Farvardin, Ali Banihashemi & Mostafa Saadat Shiraz University of Medical Sciences, Shiraz, Iran
ABSTRACT: Purpose: Eight patients from three families suffering from congenital superior oblique palsy (SOP) were studied, during a 7 year period in order to investigate the genetic transmission of this disease. Methods: One patient of each family came to the clinic complaining of eye deviation and head tilt. All available family members of these patients were invited and examined. According to results of the alternate prism cover” and “Bielschowsky” test and also presence of symptoms since early childhood and the absence of any history of trauma, congenital SOP was diagnosed. Results: In “Family A”, the father and his offsprings suffered from congenital SOP. Another family member also had a history of head tilt but didn’t come for examination. In “Family B”, three patients of two consecutive generations suffered from congenital SOP. Two other family members also had a history of head tilt, but didn’t come for examination. In “Family C”, the mother and her daughter suffered from congenital SOP. In the three families 4 patients were operated. Conclusion: An autosomal dominant inheritance pattern was seen.
1
INTRODUCTION
Paralysis of the fourth cranial nerve is the most common cranial nerve paralysis encountered in ophthalmology. 29–67 percent of cases of superior oblique palsy are of the congenital type.2 The congenital cases of this disease usually occurs sporadically. There are limited reports of familial superior oblique palsy in literature.3 Autosomal mode of transmission has been suggested.1,2,3 In this study patients of three families diagnosed with congenital superior oblique palsy have been studied. According to their family trees, a theory about the genetic transfer of this disease has been proposed and the results obtained have been compared to those reported in literature.
2
MATERIAL AND METHODS
This study has been conducted on three families at Shiraz Medical University eye clinics from 1995–2002. Each patient came to the clinic with a history of eye deviation and head tilt, and after being diagnosed with congenital superior oblique palsy, (considering the fact that in these patients’ families there were people suffering from eye deviation and tilting of the head), all members of these patients’ families were invited for eye examination. All family members recieved thorough eye examinations. According to “Alternate Prism Cover” and “three step” test results superior oblique palsy was diagnosed. The main findings included; hypertropia of the affected eye in primary position, increased hypertropia in adduction and increased hypertropia in tilting the head towards the affected eye. Superior oblique palsy was considered congenital when the patient had a history of symptoms from early childhood and no history of significant incidents such as severe blows to the head existed. 159
Figure 1.
3
Pedigree of family A, B & C.
RESULTS
Figure-1A shows three consecutive generations of “Family A”. There were no marriages between close relatives in this family. According to the history and existing pictures, patient no.4 also always tilted her head to the right, but she was not available for eye examinations. She probably suffers from congenital superior oblique palsy of the left eye. In both Patient no.1 & 2 children eye deviation and tilting of the head to the right existed before they were one year old. Both children suffered from congenital superior oblique palsy of the left side and were otherwise normal. Both underwent left inferior oblique surgery at the age of five and three respectively. The father of these children (patient no. 3) is now 40 years old. He underwent surgery of his left 30 years ago. According to old photographs, he suffered from hypertropia of the left eye and tilting of the head to the right in childhood and now has 5 prism diopter hypertropia of the left eye which increases with tilt of the head to the left and gaze to right. All these observations are infavor of congenital superior oblique palsy of the left eye. Figure-1B shows three consecutive generations of “Family B”. None of the marriages in this family were between close relatives. According to the history and available photographs, patient no.4 tilted his head to the left all throughout his life. He was not available for eye examinations but probably suffers from congenital superior oblique palsy of the right eye. Patient no.1 has been tilting his head to the left since childhood. He showed 10 prism diopter hypertropia, of the right eye in primary position. Hypertropia of the right eye increases with gaze to left and tilt to the right. He suffers from congenital superior oblique palsy of the right eye. Patient no.2 is a 34 year old woman, She had been tilting her head to the right since childhood. She suffers superior oblique palsy of the left eye. Surgery was suggested to these two patients but because they did not accept, none of them were operated on. According to available photographs, patient no.3 has an obvious head tilt to the left and this condition has existed since childhood. He was not available for eye examinations. He probably suffers from congenital superior oblique palsy of the right eye. Patient no.5 is a 7 year old girl. She was brought to the ophthalmologist at the age of five due to tilting of the head to the left from early childhood. She showed 8 prism diopter hypertropia in primary position. Hypertropia of the right eye increased with gaze to left and tilting of the head to the right. She was diagnosed as congenital superior oblique palsy of the right eye, and underwent right inferior oblique weakening. Nothing abnormal besides eye deviation was observed in the patients of “Family B” and none of them had a history of severe blows to the head. Figure-1C shows three consecutive generations of “Family C”. None of the marriages in this family were between close relatives. The mother of the family and her daughter suffer from superior oblique palsy of the left side. None of them have a history of severe blows to the head. Patient no.2 came to the clinic in early childhood complaining of tilting of the head to the right. In primary position she shows 10 hypertropia of the left eye which increased with gaze to right and tilt of the head to the left. Inferior oblique muscle of her left eye was overactive. She was diagnosed as congenital superior oblique palsy of the left eye and underwent inferior oblique weakening surgery of the left eye. Patient no.1 is a 44 year old woman. She has been tilting her head to the right since childhood. She shows 16 prism diopter hypertropia of the left eye. Hypertropia of the left eye increases with gaze to right and tilt to the left. She was diagnosed as congenital superior oblique palsy of the left eye, and surgery was suggested to her but she did not accept it. The father of 160
patient no.2, three sisters and a brother underwent eye examinations and were all healthy. None of the parents and siblings of patient no.1 had a history of tilting the head. The characteristics of the eight patients examined in these three families have been summarized in table 1. Also one person in “Family A” and two people in “Family B” with a lifelong history of tilting their heads were not examined. These three people also probably suffer from congenital superior oblique palsy. Of the eight patients examined, four of them were operated on by the authors of this article. All these patients showed an over action of inferior oblique muscle in examinations prior to surgery, and in the Knapps classification were placed in class one or three. In all patients traction test of the superior oblique muscle tendon was done during surgery which showed no sign of marked laxity in any of them, therefore inferior oblique weakening was done in all patients. The degree of vertical deviation after surgery in all patients was at an acceptable level and tilting of the head was significantly reduced or eliminated.
4
DISCUSSION
About 50 percent of all cases of superior oblique palsy are of the congenital type.4 Different theories have been suggested about the location of the lesion causing congenital superior oblique palsy. In some early studied nuclear aplasia of the fourth nerve is proposed as the cause of the disease. Fink and Helveston are of the opinion that most cases of superior oblique muscle palsy are due to a peripheral cause. In a study of 34 patients, six were seen to lack the superior oblique muscle tendon.3 In the current study, most of the patients were female and left eye involvement was seen more commonly; the results are comparable to that of Harris et al.2 All of our patients had unilateral involvement, in two families, left sided involvement was seen, and in one family, involvement of both right and left side was seen. In the 11 families previously reported in literature, in 8 families, unilateral involvement was seen and in 4 families only the left side was involved.2,3 Therefore in this regard the results of this study is comparable to previous reports, and it seems reasonable to conclude that the majority of cases of congenital superior oblique palsy are unilateral. Taking into view the incidence of the disease in consecutive generations, the equal involvement of males and females, the transmission of disease from father to son and the absence of consanguineous marriages in these two families an autosomal dominant pattern of inheritance of the disease seems very probable in family A&B. In “Family C”, due to the presence of only two cases in two consecutive generations, we cannot draw any definite conclusions regarding their inheritance pattern, but in spite of this, the inheritance pattern is explained with the autosomal dominant pattern. In most previous studies an autosomal dominant pattern of inheritance was also suggested. Severe laxity or the absence of the superior oblique muscle tendon was not seen in any of our patients undergoing surgery. Therefore we are of the opinion that the cause of superior oblique muscle palsy in our patients was a neurological cause rather than being due to lesions of the superior oblique muscle tendon. Giangiacomo and Botelho have reported the bilateral absence of the superior oblique muscle in one of their patients.2 This patient belonged to a family in which almost all patients in this family had bilateral involvement, but in our series. All the patients in the involved families had unilateral lesions. It seems accurate to conclude that different genetic lesions with different effector sites can cause congenital superior oblique palsy.
5
CONCLUSION
In this current study and previous series, an autosomal dominant inheritance pattern is seen. On this basis, it seems necessary to consider the presence of genetic inheritance, in any patient presenting with congenital superior oblique palsy. A thorough examination of family members of these patients, will enrich our medical knowledge in this field. 161
REFERENCES 1. Bhola, R.M., Horne, G.V., Squirrell, D.M., Chan, T.K., Kumar, D. Autosomal dominant congenital superior oblique palsy. Eye 2001; 15: 479–484. 2. Botelho, P.J., Glangiacoma, J.G. Autosomal dominant inheritance of congenital superior oblique palsy. Ophthalmology 1996; 103: 1508–1511. 3. Harris, D.J., Memmen, J.E., Katz, N.N.K., Parks, M.M. Familial congenital superior oblique palsy. Ophthalmology 1986; 93: 88–90. 4. Younge, B.R., Sutula, F. Analysis of trochlear nerve palsies, diagnosis, etiology and treatment. Mayo Clin Proc 1977; 52: 11–18.
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Session 11: Surgery in exotropia and special surgical methods
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Surgical results of lateral rectus muscle recession in intermittent exotropia in children B. Venkateshwar Rao, Jagroop Singh & Murali K Aasuri Department of Pediatric Ophthalmology and Strabismus, Jasti V Ramanamma Children’s Eye Care Centre, L V Prasad Eye Institute, L V Prasad Marg, Banjara Hills, India
ABSTRACT: Purpose: The purpose of the paper is to report the surgical results in a consecutive series of 80 children treated for intermittent exotropia using bilateral lateral rectus muscle recession as primary surgery. Patients and Methods: Restrospective chart review for age at initial surgery, type and amount of deviation, initial refraction, motor alignment on 1st postoperative day, at one week, 6 months and at the last visit were done. Results: Sixty nine (86.3%) of the patients were successfully aligned at six months by initial surgery performed for a mean of 31.2 6.5 prism diopters of preoperative deviation at a mean age of 6.6 years. At six months follow-up 11 patients were labelled as having surgical failure, with all having under correction. Mean follow up was 17.7 months. Esotropia on day one and one week post operative visit (P .005) was predictive of successful result. Conclusion: Successful alignment was achieved in majority of children by initial surgery using bilateral lateral rectus muscle recession. Postoperative esotropia during the 1st week was correlated with successful alignment at 6 months visit.
1
INTRODUCTION
We find that intermittent exotropia is quite prevalent in strabismic population of Asia, when compared to western world where esotropia is three times more common. Studies by Hiles et al1 and others have shown that not all children with intermittent exotropia necessarily progress to constant exotropia or greater amounts of deviation. Nevertheless, there are many young intermittent exotropia patients in whom the strabismus does, indeed, become more prominent. The parents often report increasing amounts of time in which a notable manifest deviation is present, especially when a child looks at a distant object across the room or is fatigued. There have been some advocates for nonsurgical therapy, such as overcorrecting minus lenses2 to alleviate the intermittent exotropia. However, surgical treatment such as bilateral lateral rectus recession has remained an option for many ophthalmologists.3–5 However, controversies have remained with regards to timing of surgery, criteria for success and predictors for long term successful motor alignment.4 Does delaying surgery until after the age of four protect against overcorrection or development of a monofixation syndrome result, and what percentage of patients have a monofixation syndrome result from this type of treatment4 It has been said that esotropia in the first postoperative week is an indicator of a long-term success.6 Many ophthalmologists delay surgery in children due to fear of overcorrection, but, it has been reported by some investigators that esotropia in the early postoperative period is correlated with greater percentage of successful result. The purpose of this paper is to report surgical results in consecutive series of children who were treated for intermittent exotropia with bilateral lateral rectus muscle recession. 165
2
PATIENTS AND METHODS
A retrospective chart review of 80 consecutive cases of intermittent exotropia treated by bilateral lateral rectus recession as primary surgery during a 3 year period (1991–2001) was performed. The diagnosis of intermittent exotropia was based on parental observation and confirmed by ocular motility examination with cover – uncover and alternate cover testing with prisms with targets at 6 meters and 1/3 meter to quantitate the deviation. The ocular deviation was measured in all patients for distance and near with proper refractive correction necessary for good vision. The surgery was performed by one of the authors (BVR). Indications for surgery in these children firstly was based on history of increasing phases of manifest deviation; more than 50% of waking time in a day. Secondly patients with poor control i.e. spontaneously manifesting deviation for distance at the time of examination confirmed by the surgeon, were taken for surgery. Inclusion criteria were no previous eye muscle surgery, no vertical muscle dysfunction, no neurological disorder and best corrected approximately equal vision in each eye. The patients who were less than 15 years of age and who followed up for a minimum of six months postoperatively were included in the study. A currently popular surgical dose values were used in the management of these patients (Table 1). For the purpose of this study success was defined as absence of any manifest deviation at any distance and phoria of upto 10 prism diopters or less. Data obtained was subjected to statistical analysis to see for any correlation with successful alignment and co-variables such as age at initial surgery, type and amount of deviation, initial refraction, motor alignment (Day 1 and at 1 week) and alignment at six months and at last visit. 3
RESULTS
Based on the success criteria defined above 69 (86.3%) of the patients were successfully aligned at six months by initial surgery performed for a mean deviation of 31.2 6.5 prism diopters of preoperative deviation at a mean age of 6.6 years. Mean followup was 17.7 months. At six months follow up, 11 patients were labelled as having surgical failure with all having under correction (Table 2). Table 1. Commonly used surgical dosage values for bilateral lateral rectus recession (in mm) for intermittent exotropia. Lateral rectus recession in mm OU Exodeviation in prism diopters
Parks & Mitchell
AAPOS Survey
15 20 25 30 35 40 40–50
4 5 6 7 7.5 8 8.5/9.0
4 5 6 6.5 7 7.5 8
Table 2.
Surgical treatment of intermittent exotropia in children.
Type of X(T)
Success(n)
Failure(n)
Total(n)
Basic Divergence excess Total
55 14 69
11 – 11
66 14 80
166
At six months, out of 11 patients with residual exotropia, 7 underwent resection of one or more medial recti for the residual deviation of 15 or more prism diopters. Four out of 11 patients who had residual exotropia were lost to follow up after they were advised to undergo secondary surgery. Five out of seven patients who underwent second surgery were converted to successful alignment (phoria) while two patients with residual exotropia after 6 months were overcorrected by secondary surgery resulting in monofixation syndrome at the last visit. Postoperative esotropia on 1st day and at one week was found in 41 patients out of the 69 patients who were successfully aligned at six months. Esotropia on day one and 1 week, postoperative visit (P .005) was predictive of successful motor alignment at 6 months.
4
DISCUSSION
The criteria to determine success in our study was comparable with previous studies by PrattJohnson et al.8 The success rates for initial surgery using bilateral lateral rectus recession in the treatment of intermittent exotropia in previous studies is shown in Table 3. The success rate in the present study was 83% which is higher compared to previous studies which possibly could be explained due to short follow-up period of 6 months only. From our study it does appear that postoperative esotropia finding on day 1 and at one week seems to be a desirable finding for a better long term successful alignment. This is in comparison with previous study of Richard & Parks6 which showed that post operative esotropia is predictive of successful outcome. However some other studies by Malcolm Ing et al4 and others have not shown the same result. A comparison of intended postoperative overcorrection in previous studies by various authors in shown in Table 4. In our study the intended postoperative overcorrection was between 10 to 15 prism diopters. The quantity of preoperative deviation, age of initial surgery and initial refraction did not correlate with success of the procedure which were similar to the findings in studies by Richard & Parks6 and Stroller et al.7 However motor alignment at one week postoperatively was predictive of successful alignment at 6 months in the present study. The patients in the present study were followed for a mean of 17.7 months as compared to previous studies where patients were followed for up to 4–5 years. However in view of follow-up being short in the present study, it remains to be seen, whether long term success depends on the initial postoperative alignment.
Table 3.
Surgical treatment of intermittent exotropia using bilateral lateral rectus recession.
Author
Success rate (%)
Pratt Johnson et al (1977) Richard & Parks et al (1983) Stoller et al (1994) Malcolm Ing et al (1998) (Follow-up period ranged from 2–4 years in the above studies)
41 56 58 62
Table 4.
Intended postoperative overcorrection in previous studies.
Cooper 1966, Raab & Parks 1969 Scott 1978 Jampolsky 1986 Malcolm Ing 1998
167
10 prism diopters 4 to 14 prism diopters 11 to 20 prism diopters 10 to 15 prism diopters
5
SUMMARY
We found an overall success of eliminating intermittent exotropia in 86.25% of the patients at 6 months postoperative visit from initial surgery. Motor alignment at one week postoperative, was highly correlated with successful alignment at 6 months. However a longer follow up is needed to comment whether this successful motor alignment persists and its correlation with the initial postoperative alignment.
REFERENCES 1. Hiles DA, Davies GT, Costenbader FD. Long term observations on unoperated intermittent exotropia. Arch Ophthalmol 1968; 80:436–442 2. Caltrider N, Jampolsky A. Overcorrecting minus lens therapy for treatment of intermittent exotropia. Ophthalmology. 1983; 90:1160–1165 3. Parks MM. Comitant exodeviations in children. In: Strabismus Symposium of the New Orleans Academy of Ophthalmology. St. Louis, MO: CV Mosby, 1962; 53 4. Malcolm R Ing, Julie Nishimura, Lisa Okina. Outcome study of bilateral lateral rectus recession for intermittent exotropia in children. Ophthal Surg Lasers 1999; 30:110–117 5. Raab EL, Parks MM. Recession of the lateral recti; early and late postoperative alignment. Arch Ophthalmol 1969; 82:203 6. Richard JM, Parks MM. Intermittent exotropia. Ophthalmology. 1983; 90:1172–1177 7. Stoller SH, Simon JW, Lininger LL. Bilateral lateral rectus recession for exotropia: a survival analysis. J Pediatr Ophthalmol Strabismus 1994; 31:93–95 8. Pratt-Johnson JA, Barlow JM, Tillson G. Early surgery in intermittent exotropia. Am J Ophthalmol 1977; 84:689–694
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Outcomes of consecutive exotropia surgery A.C. Bates, H. Newman, C. Hayden & J.P. Lee Moorfields Eye Hospital, London, UK
ABSTRACT: What constitutes success in consecutive exotropia surgery is discussed. The results of surgery on 120 patients are described. 71% of patients had a distance deviation measuring less than 10 prism dioptres at 3 months. Different outcomes among the consultant teams could be due to the different amounts of surgery performed.
1
INTRODUCTION
Overcorrection occurring after any length of time following esotropia surgery is termed consecutive exotropia (Ansons & Davis 2001). Various different procedures have been described as being effective in the treatment of consecutive exotropia. Unilateral medial rectus advancement to the original insertion, bilateral medial rectus advancement (Ohtsuki et al. 1993), and medial rectus advancement beyond the original insertion (Biedner et al. 1991) have all been utilised with previously recessed medial recti muscles. Other authors have followed “Cooper’s dictum” (Cooper 1961) and instead of undoing the previous esotropia surgery, managed the deviation as they would a primary exotropia and performed bilateral lateral rectus recession surgery (Patel et al. 2000). At our institution medial rectus advancement is carried out if the muscle is found recessed, combined with a resection if more surgery is thought to be necessary. If the medial rectus is found at the original insertion a resection is performed. In most cases the ipsilateral lateral rectus muscle is also recessed. Adjustable sutures are used in all cases, either on the lateral rectus only, or on both the medial and lateral recti. Adjustment is carried out on the ward between 2 and 8 hours following surgery. Most studies of outcome in this entity present success as an outcome between 10 prism dioptres of exotropia and 10 prism dioptres of esotropia. A previous study at our hospital illustrated that the tendency over the 5 years following consecutive exotropia surgery is for patients to become progressively more exotropic with a mean shift of 3.4 prism dioptres (Kousoulides et al. 1995). It is our view that this tendency to exotropic shift probably continues indefinitely in the absence of binocular function, as is usually the case. For this reason, in addition to the usual measure of “success”, we examined how many patients achieved a post-operative deviation in the distance of between 5 prism dioptres of exotropia and 15 prism dioptres of esotropia.
2
METHODS
120 patients operated on during 2000 and 2001 were retrospectively identified from the surgical diaries kept by four consultant teams at Moorfields Eye Hospital. 70 patients were female, 50 were male. The mean age was 33 years (range 6–79 years). There was a wide range of pre-operative deviations (table 1) with a mean deviation of 34 prism dioptres of exotropia. We also calculated the mean deviation amongst the 4 groups operated on by the different consultant teams in order to validate comparison of post-operative results (table 2). For the purposes of this presentation the consultants’ identities were kept anonymous. All patients had orthoptic measurements at 3 months post-operatively. 169
35
29
30
26
Frequency
25
23
23
20 15 10
7
7
5
3 1
1
0 0 to -10 -11 to -20 -21 to -30 -31 to -40 -41 to -50 -51 to -60 -61 to -70 -71 to -80 -81 to -90 Range (Prism Dioptres)
Table 1.
Pre-operative amount of exotropia measured by prism cover test (PCT).
Table 2. Pre-operative amount of exotropia by consultant team. Consultant A B C D Total
3
mean (prism dioptres)
SD
41 23 48 8
32.1 33.8 32.4 47.5
15.7 19.8 15.5 19.1
122
33.5
16.9
n
RESULTS
18 patients were excluded from most of the analyses as they were left exotropic in order to avoid post-operative diplopia. 49% of the rest of the patients (n 102) achieved an outcome of between 5 prism dioptres of exotropia and 15 prism dioptres of esotropia at 3 months post-operatively (table 3). 71% of the 102 patients achieved an outcome of between 10 prism dioptres of exotropia and 10 prism dioptres of esotropia at 3 months post-operatively. Consultant A had a larger proportion of patients achieving “success” using both definitions than the other consultants (tables 4 and 5). Analysing further differences between the consultant teams it was noted that consultant A performed more medial rectus surgery on average than the other consultants (table 6). 55 patients had orthoptic measurements immediately post-adjustment. These patients showed a mean exotropic shift of 8.7 prism dioptres from the day of surgery to 3 months post-operatively. In the absence of an abduction deficit in the operated eye (n 13) this shift increased to 10.2 prism dioptres. None of the 120 patients suffered a peri-operative complication of scleral perforation or a lost muscle. 4 patients had problematic diplopia post-operatively, three patients were able to ignore the diplopia after a period of time, two of whom had botulinum toxin treatment. One patient was fitted with an occlusive contact lens. 170
60 50
Frequency
50 40
34
30 20 11 6
10 1 0 greater than 25ET
25ET to 15ET
15ET to 5XT
6XT to 15XT
greater 15XT
Horizontal Angle (Prism Dioptres)
Table 3.
3 month post-operative horizontal deviation measured by PCT.
Table 4. 3 month post-operative horizontal deviation by consultant measured by PCT. Consultant in charge
15ET 15ET-5XT 6XT Unknown
n % n % n % n %
A
B
C
D
Total
3 7.9 27 71.1 8 21.1
1 4.8 8 38.1 12 57.1
1 2.8 14 38.9 20 55.6 1 2.8
1 14.3 1 14.3 5 71.4
6 5.9 50 49.0 45 44.1 1 1.0
Table 5. 3 month post-operative horizontal deviation by consultant measured by PCT. Consultant in charge
10ET 10ET-10XT 10XT Unknown
4
n % n % n % n %
A
B
C
D
Total
7 18.4 30 79.0 1 2.6
1 4.8 14 66.7 6 28.6
1 2.8 24 66.7 10 27.8 1 2.8
1 14.3 4 57.1 2 28.6
10 9.8 72 70.6 19 18.6 1 1.0
DISCUSSION
To our knowledge this is the largest published series of patients undergoing surgery for consecutive exotropia. We have shown that this approach has good success rates, and that larger amounts of medial rectus surgery are associated with greater success. Inducing an abduction deficit in the 171
Table 6.
Amount of surgery performed by consultant. Medial rectus surgery (mm)
A B C D
Lateral rectus surgery (mm)
Max
Min
mean
SD
Max
Min
mean
SD
13 7 8 8
5 4 3 2
8.2 5.4 4.6 5.3
1.9 0.7 1.2 2.2
8 8 8 10
1 4 0 2
6.4 6.3 4.7 5.8
1.5 1.1 2.1 2.9
operated eye by larger amounts of medial rectus surgery is associated with a smaller postoperative exotropic shift. We believe that “success” in surgery for consecutive exotropia should be defined as leaving the patient between 5 prism dioptres of exotropia and 15 prism dioptres of esotropia at 3 months post-operatively. This balances the immediate expectations of the patient with the known long-term prognosis as demonstrated in the previous study at this institution (Kousoulides et al. 1995). The final position in which the operated eye is left at adjustment of sutures should take account of the 8.7 prism dioptre mean exotropic shift over 3 months demonstrated in this study.
REFERENCES Ansons, A.M. & Davis, H. 2001. Diagnosis and management of ocular motility disorders. Oxford: Blackwell science. Biedner, B., Yassur, Y. & David, D. 1991. Advancement and reinsertion of one medial rectus muscle as treatment for surgically overcorrected esotropia. Binocular vision quarterly 6(4): 197–200. Cooper, E.L. 1961. The surgical management of secondary exotropia. Trans Am Acad Ophthalmol Otolaryngol 65: 595–608. Kousoulides, L., Lawson, J., Fells, P. & Lee, J. 1995. Long-term results of surgery for consecutive and secondary exotropia. In Spiritus, M. (ed.), Trans 22th Meeting Europ Strabismolog Assoc: 211–215. Buren: Aeolus Press. Ohtsuki, H., Hasebe, S., Tadokoro, Y., Kobashi, R., Watanabe et al. 1993. Advancement of medial rectus muscle to the original insertion for consecutive exotropia. J Pediatr Ophthalmol Strabismus 30: 301–305. Patel, A.S., Simon, J.W. & Lininger, L.L. 2000. Bilateral lateral rectus recession for consecutive exotropia. J Am Assoc Pediatr Ophthalmol Strabismus 4(5): 291–294.
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Surgical ancorage of the lateral rectus muscle to the periosteum of the orbit: a new tool to tuckle retraction in Duane syndrome and exotropia in 3rd cranial nerve palsy C. Schiavi, C. Bellusci, M. Fresina & E.C. Campos Ophthalmology Service, University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
ABSTRACT: Objective of the present study was to evaluate the possibility of surgically eliminating of any function of the lateral rectus muscle of the affected eye in patients with Duane syndrome with globe retraction in adduction and in patients with complete 3rd cranial nerve paralysis. Surgery was based upon a technique introduced by Alan Scott which consists in anchoring the lateral rectus detached from the globe onto the periosteum of the lateral wall of the orbit with a nonabsorbable 6–0 prolene suture. Two patients with complete 3rd cranial nerve paralysis and one patient with Duane syndrome type I underwent surgery with this technique. Eye position improved in the two patients with complete 3rd cranial nerve paralysis. The patient with Duane syndrome showed disappearance of globe retraction in adduction. Additional surgery was required to correct esotropia in the patient with Duane syndrome and to improve hypotropia in one patient with 3rd cranial nerve palsy.
1
INTRODUCTION
The results of surgical treatment of Duane syndrome (DS) often are disappointing. For this reason surgery is indicated only when there is a strabismus in primary position with a compensatory head turn or when there is a cosmetic problem due to a vertical displacement of the adducted eye (upshoot or down-shoot) or a narrowing of the palpebral fissure with retraction of the globe in adduction. A recession of the antagonist medial rectus muscle 6 mm should be performed to correct approximately 15PD of face turn in DS type I. If it is necessary to correct 30 PD, a further recession on the medial rectus of the other eye should be added. In DS type II recession of the lateral rectus muscle of the involved eye or recession of both lateral rectus muscles improves the anomalous head posture. DS type III is surgically managed with recession of both horizontal muscles. The recessions must be asymmetrical, depending on the type of deviation in primary position. Vertical displacement in adduction can be reduced with a maximal recession of both horizontal muscles (von Noorden 1992) or with a posterior fixation suture on the lateral rectus (Scott and Wong 1972). To increase the width of insertion of the lateral rectus and to decrease the bridle effect, the lateral rectus tendon can be split into a “Y” configuration (Rogers and Bremer 1984). Surgery for globe retraction in adduction consists of recession of the lateral rectus or maximal recession of both horizontal muscles (von Noorden 1992). But even large recessions of the lateral rectus may lack to resolve retraction in adduction, due to persisting co-contraction of the lateral and medial rectus muscles in adduction. Surgical management of complete 3rd c.n. paralysis is problematic. Surgical options include maximal resect/recess. procedures on the horizontal muscles (Metz 1993), transposition of the lateral or vertical rectus muscles, tenotomy of the superior oblique or superior oblique transposition, 173
adducting traction sutures, orbital anchoring sutures (Salazar-Leon, Ramirez-Ortiz, Salas-Vargas 1998, Goldberg, Rosenbaum, Tong 2000), eye muscle prostheses derived from silicone bands (Scott, Miller, Collins 1992, Bicas 1991). Goods results with transposition surgery on the rectus muscles can be obtained when a vertical rectus muscle of the affected eye, the superior rectus, is still functioning, like happens in the paralysis of the inferior division of the 3rd c.n. (Kushner 1999). In a complete 3rd c.n. paralysis the eye often maintains a fixed divergent position despite a maximal recession of the lateral rectus, due to residual overaction of this muscle. Objective of the present study was to reduce or eliminate any function of the lateral rectus in DS patients with retraction in adduction and in patients with complete 3rd c.n. paralysis by surgically anchoring to the orbit the lateral rectus muscle detached from the globe with a technique previously described by Alan B. Scott M.D. in a personal comunication.
2
MATERIALS AND METHODS
Three patients took part in the present study: 1. A 5 years old girl with DS type I of the left eye, who presented with left eye 15 PD esotropia in the primary position and globe retraction in adduction. 2. A 5 years old boy with complete congenital 3rd left c.n. palsy presenting with 45 PD left eye exotropia and 20 PD left eye hypotropia in the primary position after bilateral large lateral rectus muscle recession. 3. A 8 years old boy with complete congenital 3rd right c.n. palsy presenting with 35 PD right eye exotropia and 15 PD righr eye hypotropia in the primary position after bilateral lateral rectus muscle recession. Surgery consisted in anchoring the LR of the affected eye detached from the globe to the orbit with two 6–0 prolene non-absorbable sutures. The radial incisions of the conjunctiva were extended 5 mm or more. Two single armed prolene non-absorbable sutures were inserted and locked to the lower and upper edges of the lateral rectus muscle close to the insertion. The muscle tendon was dissected from the globe with curved Stevens tenotomy scissors. A speculum of Pannarale or Schepens or a similar shaped retractor was placed to expose the lateral orbital wall behind the lateral conjunctival fornix (about 20 mm from the limbus). The two prolene sutures were passed through the tissue covering the medial side of the lateral wall of the orbit and tied with a triple knot. Additional surgery was required in patient 1 and in patient 3. In patient 1, 6 mm recession of the right medial rectus muscle and 8 mm recession of the left medial rectus muscle were performed in the same session to correct esotropia. In patient 3, a transposition of the right superior oblique to the insertion of the medial rectus was added to the orbital anchoring procedure of the right lateral rectus to correct hypotropia. The follow-up ranged from 6 months (patient 1) to 15 months (patient 3).
3
RESULTS
In patient 1 (DS type I) an improvement of globe retraction and of the up-shoot in adduction was obtained. After surgery that consisted in bimedial recession and left lateral rectus anchorage to the periosteum, adduction of the left eye decreased and limitation of abduction of the same eye increased. In patient 2 (3rd left c.n. palsy previously operated on with bilateral recession of the lateral rectus muscle) exotropia of the left eye improved of 20 PD in the primary position, and abduction, though reduced, persisted. The vertical deviation of the left eye was unchanged. Patient 3 (right 3rd c.n. palsy previously operated on with bilateral large recession of the lateral rectus muscle) showed orthotropia in the primary position, with some degrees of adduction of the right eye and limitation of abduction of the same eye. In this case a transposition of the right superior oblique to the insertion of the paralytic medial rectus muscle was added to the anchorage of the 174
lateral rectus to the orbit. This probably explains the improvement of adduction and disappearence of hypotropia in the right eye.
4
CONCLUSIONS
Orbital anchoring sutures with prolene are widely used in plastic reconstructive surgery. This material has proved to be biocompatible with a low tendency to late failure. The results of this study confirm that surgical anchorage of the lateral rectus muscle to the periosteum of the orbit with a prolene suture is a safe, simple, and effective technique in reducing the effects of co-contraction of the horizontal muscles in adduction in patients with Duane syndrome, and in improving eye position in fixed divergent strabismus secondary to complete 3rd c.n. paralysis. In Duane syndrome type I additional surgery can be required to correct esotropia which may worsen after detaching the lateral rectus of the affected eye from the globe. Moreover, transpostion of vertical recti on the insertion of lateral rectus muscle may improve the abduction of the eye. In complete oculomotor palsy transposition of the superior oblique to the paralytic medial rectus improves the surgical results.
REFERENCES 1. Bicas, H.E.A. 1991. J. Pediatr. Ophthalmol. Strabismus, 28: 10–13 2. Goldberg, R.A., Rosenbaum, A.L., Tong, J.T. 2000. Arch. Ophthalmol.118: 431–437 3. Kushner, B.J. 1999. Surgical treatment of paralysis of the inferior division of the oculomotor nerve. Arch. Ophthalmol. 117: 485–489 4. Metz, H. 1993. J. Pediatr. Ophthalmol. Strabismus, 30: 346–353 5. Noorden, G.K. von 1992. Recession of both horizontal recti muscles in Duane’s retraction syndrome with elevation and depression of the adducted eye. Am. J. Ophthalmol. 114: 311–314 6. Rogers, G.K., Bremer, D.L. 1984. Surgical treatment of the up-shoot and down-shoot in Duane’s retraction syndrome. Ophthalmology, 91: 1380–1383 7. Salazar-Leon, J.A., Ramirez-Ortiz, M.A., Salas-Vargas, M. 1988. The surgical correction of paralytic strabismus using fascia lata. J. Pediatr. Ophthalmol. Strabismus, 35: 27–32 8. Scott, A.B., Wong, G.Y. 1972. Duane’s syndrome: an electromyographic study. Arch. Ophthalmol. 87: 140–147 9. Scott, A.B., Miller, J.M., Collins, C.C. 1992. J. Pediatr. Ophthalmol. Strabismus, 29: 216–218
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Excessive recession of horizontal rectus muscles in surgical treatment of congenital nystagmus M. Dogan, S. Akar, B. Gökyig˘it & O.F. Ylmaz Beyo˘glu Educational and Research Eye Hospital, Istanbul, Turkey
ABSTRACT: In this study 24 patients files, who underwent excessive recession of horizontal muscles operation between December 1992–March 2003 in Beyoglu Educational and Research Eye Hospital, were evaluated retrospectively. All patients were congenital motor nystagmus without blockage and nystagmus amplitude decrease at primary position and ages were between 2–28 years (mean 14,50 9,49 years). 5 of them have exotropia, 7 of them have esotropia, 2 of them were albinos. The preoperative and postoperative monocular and binocular mean visual acuity at near and distance and nystagmus amplitude biomicroscobically recorded. The differences were statistically significant. The excessive recession of horizontal muscles in surgical treatment of congenital nystagmus is effective for decreasing nystagmus amplitude and visual improvement.
1
INTRODUCTION
Congenital nistagmus is a well known syndrome of rhytmic, involuntary eye movements, primarily in the horizontal plane. Generally, it begins during the first several weeks of life(Cogan 1956). According to structural abnormalities, congenital nystagmus has two froms. First one is congenital motor nystagmus if no abnormalities and the other if there is abnormalities which are reasons of central vision impairement and called congenital sensorial nystagmus (Wybar 1967). Many surgical methods used for congenital nystagmus. In 1950’s the main goal is to correcting the secondary head psition. Later to improve visual acuity, to decrease oscillopsia, to gain cosmetic improvement; fixation if the extraocular muscles to the periosteum of the lateral orbital wall, transposition of the parts of the horizontal and vertical rectus muscles, or free tenotomy of opposing rectus muscles were performed (von Noorden 1991). Many authors reported, excessive recession decreased nystagmus intensity and improvement in visual acuity can obtained (von Noorden 1991, Bietti 1960, Alio 2003, Limon 1986).
2
MATERIALS AND METHODS
All patients have congenital nystagmus. But no blockage and nystagmus amplitude decreases at primary position. Retrospectively, all patient who underwent excessive recession of the all horizontal rectus muscles between 1992 December to 2003 March in amount of 10–13 mm were analysed. Preoperative and postoperative full ophthalmologic examination were noted. Preoperative and postoperative near and distance visual acuity monocular and binocular were recorded. The recession amount had calculated according to deviation in patients who have esotropia or exotropia. The same surgeon performed all operations. Nystagmus amplitude determined biomicroscopically. 177
Table 1.
3
Mean visual acuity results and p values.
Mean visual acuity
Preoperative
Postoperative
p
Right eye at near Right eye at distance Left eye at near Left eye at distance Binocular at near Binocular at distance
0,1904 0,1993 0,1409 0,1221 0,1704 0,1708 0,1471 0,1160 0,2422 0,1556 0,2002 0,1156
0,2159 0,2043 0,1533 0,0912 0,2173 0,1985 0,1733 0,1585 0,3061 0,1585 0,2561 0,1245
P 0,05 P 0,05 P 0,05 P 0,05 P 0,05 P 0,05
RESULTS
24 patients underwent excessive recession operation. 13 female (54.17%) 11 male (46.83%). The mean age was 14,50 9,49 (2–28) years. All have congenital nystagmus without blockage and their nystagmus amplitude decrease at primary position. 5 of them were Exotropia (20.83%) and 7 Esotropia (29,16%). Only 2 of them were Albinos (8,33%). The mean follow up time was 14,90 (2–72) months. The nystagmus amplitude in all patients was decreased biomicroscopically. Binocular mean visual acuity at near and distance improved. Statistically significant (p 0,05). In 13 eye’s visual acuity of right eye at near increased (54.13%), in 10 eye’s visual acuity were the same (41.60%) and 1 eye’s visual acuity decreased (4.17%). Visual acuity of right eye at distance; 11 eye’svisual acuity increased (45.83%), 12 eye’s visual acuity were the same (50.00%) and 1 eye’s visual acuity decreased (4.17%). Visual acuity of left eye at near;15 eyes’visual acuity increased (62.50%), 9 eyes’s visual acuity were the same (37.50%), Visual acuity of left eye at distance; 13 eye’s visual acuity increased (54.16%), eye’s visual acuity were the same (29.16%), 4 eye’s visual acuity decreased (16.66 % ). Binocular visual acuity at near;16 eye’s visual acuity increased (66.66%), 7 eye’s visual acuity were the same (29.16%), 1 eye’s visual acuity decreased (4.16%). Binocular visual acuity at distance; 14 eye’s visual acuity increased (58.33%), 8 eye’s visual acuity were the same (33.33%), 2 eye’s visual acuity decreased (8.33%). The mean visual acuity results of preoperative and postoperative and p value of difference shown at table 1.
4
DISCUSSION
Helveston et al. reported in 10 eyes visual improvement, 6 no change an 4 eye’s visual decreasing in 10 patients. Also they determined nystagmus amplitude biomicroscopically pre and postoperative and found decrease in 8 patients (Helvestone 1991). Von Noorden performed this surgery in 3 patients and found succesfull (von Noorden 1991). They noted in 2 of 3 visual improvement. Davis reported 7 of 12 albino patients, had 2 or more Snellen chart lines (58%) improvement after surgery. According to our exprience excessive recession of horizontal muscles in congenital nystagmus is effective for decreasing nystagmus amplitude and increasing visaual acuity at near and distance.
REFERENCES Alió JL. 2003. Visual performance after congenital nystagmus surgery using extended hang back recession of the four horizontal rectus muscles. Eur J Ophthalmol; 13: 415–42
178
Bietti GB. 1960. Bagolini B. Traitement medicochirurgical du nystagmus. L’Annee Ther Clin Opththalmol.; 11: 268–293 Cogan DG. 1956. Neurology of the Ocular Muscles. Ed 2. Springfield, IL, Charles C Thomas Helvestone EM. 1991. Large recession of horizontal recti for treatment of nystagmus. Ophthalmology, 98; 1302–5 Limon E. 1986. Surgical treatment of nystagmus, presented at first congress on practical management of nystagmus and strabismus, General hospital, Dr. Manuel Gea Gonzalez Mexico City, 5–7 Von Noorden GK. 1991. Large rectus muscle recessions for the treatment of congenital nystagmus Arch Ophthalmol 109; 2: 221–224 Wybar K. 1967. Significance of nystagmus in suspected. Can J Ophthalmol 2; 4
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Impact on deviation in primary position of vertical shift of horizontal recti muscles insertion R. dell’Omo, A. Salerni, S. Petroni, L. Guccione, G. Savino & A. Dickmann Department of Ophthalmology – Catholic University of Sacred Heart Rome, Italy
ABSTRACT: Objective: to evaluate, in A- and V-Patterns, the possible influence of vertical shift of horizontal recti insertions, associated to recession, on the deviation amount in primary position. Materials and Methods: 41 concomitant exodeviations and 40 EIE (both pure and presenting with A-V pattern) were examined. In order to evaluate the efficacy of the recession, the PD/mm ratio (the amount of Prismatic diopters corrected by 1 mm of recession) has been considered. Results: Concerning the exodeviations, in the pure recession the PD/mm is 1.33(0.72) at distance and 1.33(0.87) at near fixation; in vertical shift 1.37(0.65) and 1.46(0.8). About the pure recession in the EIE, the PD/mm is 1.68(1.1) for far and 2.2(1.21) for near distance, as in vertical shift 2.16(1.01) and 2.28(0.85) respectively. Conclusions: A significative difference between the two kinds of surgery could not be detected, but vertical shift in EIE shows a trend to increase the recession power.
1
INTRODUCTION
The occurrence of A- and V-patterns in otherwise concomitant horizontal strabismus has been recognised as an important clinical entity since the early 1950 (Urrets-Zavalia, 1948; Urist, 1958) and is now believed to occur in 15%–25% of all strabismus patients (Ophthalmology Basic and Clinical Science Course, 1983). In A-V pattern the angle of horizontal strabismus varies significantly while the gaze changing from elevation to depression or vice-versa. These patterns can be observed both in eso- and exodeviations. Different kinds of surgical procedures to correct A-V patterns have been proposed, criteria of choice being generally related to presence or absence of oblique muscles dysfunctions (Brown, 1953; von Noorden, 1996; Brooks, 1995).
• • • •
Oblique muscle surgery, in case of significant oblique muscles dysfunction (Parks, 1972). Horizontal muscle surgery with vertical displacement of insertions, if an oblique dysfunction is absent or not clinically relevant (Costenbader, 1958; Knapp, 1959). Surgery on vertical recti: nasal or temporal horizontal displacement of insertions (Fink 1959; Miller, 1960). Slanting of horizontal recti insertions (Bietti, 1970).
The aim of our study is to evaluate if, both in eso- and in exodeviations, the resulting angle of deviation, in primary position is influenced by the up or down insertion displacement associated to horizontal recti recession. 2
MATERIALS AND METHODS
A retrospective comparative study on 81 consecutive patients, affected by Essential Infantile Esotropia (40 patients, 18 males and 22 females, mean age 6.6 years) or concomitant Exodeviations 181
Table 1.
Essential Infantile Esotropia (40 cases).
Type
Case
Angle of deviation (PD) (preop) far distance
All Pure AV A pattern V pattern
40 23 17 12 5
33.37 (11.40) 34.86 (14.55) 31.35 (11.8) 30.25 (11.9) 34 (19.45)
Table 2.
38.35 (12.81) 39.60 (13.2) 36 (12.36) 35.66 (12.46) 35 (13.51)
Surgical Procedures LLRR (mm) Recession
Displacement
4–7 4–6.5 4–6 5–6.5
3–5 3–5 3–4
Exodeviations (41 cases).
Type
Case
Angle of deviation (PD) preop far distance
All Pure AV A pattern V pattern
41 26 15 11 4
26.79 (9.17) 26.93 (9.35) 26.56 (10.18) 20.75 (13.74) 28.5 (8.56)
Table 3.
Angle of deviation (preop) (PD) near distance
Angle of deviation (PD) preop near distance 27.08 (10.33) 27.6 (10.43) 27.62 (12.01) 20.75 (13.74) 29.91 (11.05)
Surgical Procedures LLRR (mm) Recession
Displacement
4.5–8 4–8.5 4–7 5–8
3–5.5 3–5.5
Exodeviations grouped for clinical type.
Type
Case
Angle of deviation (PD) preop far distance
14 Congenital
8 3A 3V
32.14 (9.94) 35 (5) 16 (12,16)
19 Intermittent
15 4V
8 Consecutive
3 4V 1A
Angle of deviation (PD) preop near distance
Surgical Procedures LLRR (mm) Recession
Displacement
33.57 (8.99) 38.33 (7.63) 16 (12.16)
4.5–8 4–7 5–8
5–5.5 3.5–5
25.28 (8.27) 21.5 (5.74)
25.35(10.67) 21 (14.9)
4.5–8.5 5–7
3–5 3–5
21.33 (8.08) 30.25(10.34) 35
20 32.5 (5) 35
5–6.5 5.5–7 7
3–4 3
(41 patients, 12 males and 29 females, mean age 14.1 years), observed in our clinic from 1999 to 2002 has been carried out. Characteristics of the sample are shown in Tables 1, 2 and 3. Exclusion criteria were prematurity, anatomic anomalies such as ocular coloboma, optic nerve hypoplasia, cataract, CVI or other structural factors affecting normal visual development, CNS disorders, sensorial exotropia and postoperative follow-up of less than 1 year. In all cases horizontal recti bilateral recession (medial recti in EIE, lateral recti in exodeviations) was performed. We associated up or down insertion displacement in A- or V-patterns just in case of obliques muscles disorders not detected at motility examination. Surgery was always perfomed by the same surgeon: A.D. The corrective power of the recession in primary position was evaluated by measuring the difference between the angles both for near and distance fixation, before and one year after surgery. The efficiency of surgery was defined by PD/mm ratio (amount of deviation in Prismatic Dioptres 182
Table 4. Type
Effectiveness of Bilateral LR recession in exodeviations. Shift
Pure AV A V
Far distance
Near distance
1.33 (0.72) 1.37 (0.65) 1.69 (0.50) 1.27 (0.68)
1.33 (0.87) 1.46 (0.8) 1.46 (0.58) 1.46 (0.88)
A
3 mm 4 mm 5 mm
2.07 1.47 1.62 (0.72)
1.92 0.84 1.55 (0.63)
V
3 mm 4 mm 5 mm
1.19 (0.48) 1.48 (1.11) 1.11 (0.36)
1.33 (0.85) 1.88 (1.21) 1.13 (0.32)
AV
3 mm 4 mm 5 mm
1.34 (0.56) 1.48 (0.96) 1.31(0.52)
1.42 (0.79) 1.67 (1.14) 1.3 (0.45)
For each group mean values (and standard deviation) are expressed in PD corrected by a mm of recession of Lateral Recti. Table 5. Type
Effectiveness of Bilateral MR recession in esodeviations. Shift
Pure AV A V
Far distance
Near distance
1.68 (1.1) 2.16 (1.01) 2.12 (1.08) 2.37 (0.78)
2.2 (1.21) 2.28 (0.85) 2.38 (0.98) 2.23 (0.43)
A
3 mm 4 mm 5 mm
1.83 2.11 (1.01) 2 (1.73)
2.16 2.16 (1.06) 2.55 (0.83)
V
3 mm 4 mm
2.21 (0.81) 3.15
2.04 (0.05) 3.53
AV
3 mm 4 mm 5 mm
2.14 (0.72) 2.22 (1.01) 2 (1.73)
2.07 (0.07) 2.31 (1.1) 2.55 (0.83)
For each group mean values (and standard deviation) are expressed in PD corrected by a mm of recession of Medial Recti.
corrected by 1 mm of recession in primary position). All the details about surgical procedures are shown in tables 1 and 2.
RESULTS Our findings are shown in Tables 4 and 5 (see explanations under the tables)
DISCUSSION In connection with insertion vertical shifting of horizontal recti, an increased recession power in primary position could be expected, since we induce a displacement of the muscle plane and, as a 183
consequence, a change of the strength vectors. Actually, our results seem to not confirm this hypothesis: very similar values of PD/mm both in pure recession and in recession associated with shift can be observed. Furthermore, comparing the results obtained in eso and exodeviations not relevant differences may be detected. Finally, the amount of the shift doesn’t seem to affect the PD/mm in primary position. The only slight remarkable exception regards the PD/mm in esodeviation in relation with angle deviation for far distance: in this case the vertical shift shows a trend to increase the recession power in primary position. Concerning these preliminary results, however some considerations should be made: a high standard deviation affects our data but this finding seems to be quite common in the literature; another limit of this study is the small number of recruited patients but, on the other hand, it is well known that oblique muscles surgery is indicated in A-V patterns where oblique muscles dysfunction is involved. Referring to our preliminary results, the amount of the recession surgery planned to correct the deviation in primary position doesn’t seem to be modified if a displacement of insertion is performed.
REFERENCES Bietti, GB. 1970. Su un accorgimento tecnico (recessione e reinserzione obliqua a ventaglio dei muscoli retti orizzontali) per la correzione di atteggiamenti a V o A di grado modesto negli strabismi concomitanti. Boll. Oculist. 49: 581–88. Brooks, S.E. Vertical shift of the medial rectus muscles in the treatment of A pattern esotropia: analysis of outcome. In Lennerstrand, G.: Update on strabismus and Pediatric Ophthalmology, Boca Raton, Florida, CRC Press, 1995, p. 256. Brown, H.W. Vertical deviations. Strabismus Symposium, Trans. Am. Acad. Ophthalmol. Otolaryngol. 57: 157, 1953. Costenbader F.D. 1958. Clinical course and management of esotropia. In: J.H. Allen. Strabismus Ophthalmic Symposium II. St. Louis: Mosby. Fink, W.H. 1959. The A and V syndromes. Am. Orthopt. J 9:105. Knapp, P. 1959. Vertically incomitant horizontal strabsimus: the so-called A and V syndrome. Trans. Am. Ophthalmol. Soc. 57: 666. Miller, J.E. 1960. Vertical recti transplantation in the A and V syndromes. Arch. Ophthalmol. 64: 175–9. Ophthalmology Basic and Clinical Science Course. 1983. Binocular Vision and Ocular Motility. Sect.6. American Academy of Ophthalmology. San Francisco. CA. Parks, M.M. 1972. The weakening surgical procedures for eliminating overaction of the inferior oblique muscle. Am. J. Ophthalmol. 73: 107. Urist, M.J. 1958. The ethiology of the so called A and V syndrome. Am. J. Ophthalmol. 46: 835. Urrets-Zavalia, A. Paràlisis bilateral congénita del musculo oblicuo inferior. Arch. Oftalmol. B. Aires. 23: 172. von Noorden, G.K. & Campos E.C. 2002. Binocular Vision and Ocular Motility: Theory and Management of Strabismus, 6th edition. St. Louis: Mosby-Year Book, Inc.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Use of augmented transposition surgery for complex starbismus . H.I. Altnsoy, F.M. Mutlu & Y. Uysal GATA Department of Ophthalmology, Ankara, Turkey
S. Çelebi Izzet Baysal University, Department of Ophthalmology, Bolu, Turkey
ABSTRACT: Purpose: To report our experience with augmented rectus muscle transposition surgery for the treatment of complex strabismus. Methods: Preoperative and postoperative data of 12 patients who underwent augmented transposition of vertical or horizontal rectus muscles for the treatment of compex strabismus were retrospectively analyzed. Results: Diagnoses included Duane syndrome with esotropia (5), double elevator palsy (6), and medial rectus palsy (1). Mean age was 21.75 years and mean follow-up was 5 months. Compared to the preoperative measurement, postoperatively esotropia in primary position improved a mean of 15 prism diopters in patients with Duane syndrome, hypotropia in primary position improved a mean of 8 prism diopters in patients with double elevator palsy, and orthophoria was obtained in primary position in patient with medial rectus palsy. Conclusions: Augmented vertical or horizontal rectus muscle transposition surgery which enhances the effect of transposition seems to be effective for treatment of complex strabismic disorders.
1
INTRODUCTION
Various transposition procedures have been promoted for the treatment of paralytic and other complex strabismus patients. Knapp proposed the use of a full tendon transposition of horizontal rectus muscles to superior rectus muscle for the treatment of double elevator palsy(Knapp, 1969). Foster described a full tendon transposition procedure of verdical rectus muscles to the lateral rectus muscle, augmented with a posterior fixation suture for the treatment of abducens palsy and Duane syndrome (Foster, 1997). This technique directs more vector forces laterally and has been reported to improve alignment and abduction, without the need for an ipsilateral medial rectus muscle recession. We report our results with augmented rectus muscle transposition surgery for the treatment of complex strabismus such as double elevator palsy, Duane syndrome and traumatic medial rectus palsy.
2
METHODS
A retrospective review of patients who underwent augmented rectus muscle transposition surgery for the treatment of double elevator palsy, Duane syndrome and traumatic medial rectus palsy between 2000 and 2004 was performed at the ophthalmology double elevator palsy at the Ophthalmology department of our institution. All patients with Duane syndrome had esotropia in primary position with marked limitation of abduction, globe retraction, and pseudoptozis on adduction of the affected eye. All patients diagnosed 185
with double elevator palsy had hypotropia in primary position with marked limitation of elevation, ptozis of the affected eye, and negative forced duction test in upgaze. Patient with traumatic medial rectus palsy after endoscopic sinus surgery had exotropia in primary position and negative forced duction test in adduction. All patients with Duane syndrome or medial rectus palsy had a horizontal transposition of vertical rectus muscles or a vertical transposition of horizontal rectus muscles for double elevator palsy similar to described by Foster for abducens palsy and Duane syndrome. Ocular alignment in primary position, presence of an anomolous head posture, presence of diplopia in primary position, additional surgical procedures, and complications were analyzed preoperatively and postoperatively.
3
RESULTS
Diagnoses included type 1 Duane syndrome with esotropia (5), double elevator palsy (6), and medial rectus palsy due to endoscopic sinus surgery (1). Mean age was 21.75 years (range 20 to 24 years) and mean follow-up was 5 months (2–10 months). Compared to the preoperative measurement, postoperatively esotropia in primary position improved a mean of 15 prism diopters in patients with Duane syndrome (Table 1), hypotropia in primary position improved a mean of 8 prism diopters in patients with double elevator palsy (Table 2), and orthophoria was obtained in primary position in patient with medial rectus palsy. Preoperative and postoperative data on diplopia, anomolous head posture, ocular alignment in primary position are summarized in Table 1 and 2. Compared to the 35 prism diopters exotropia preoperatively, angle of deviation decreased to 5 prism diopters postoperatively with a slight increase of adduction of the eye and face turn in patient with medial rectus palsy. No patient had additional surgery, and no change in interpalpebral distance was observed.
4
CONCLUSION
A variety of transposition procedures have been proposed for paralytic strabismus. Advantages and disadvantages of each are well-known. Recently, Foster reported a full tendon transposition of Table 1.
Summarized data of patients with Duane syndrome.
Characteristic
Preoperative
Postoperative
Diplopia (at PP) Esotropia (mean; pd)
5/5 19
0/5 4 (improvement 15)
Face turn Abduction
5/5 4
3/5 3.6
Table 2.
Summarized data of patients with double elevator palsy.
Characteristic
Preoperative
Postoperative
Diplopia (at PP) Esotropia (mean; pd)
5/5 12
0/5 4 (improvement 8)
Face turn Duction (elevation)
5/5 4
3/5 3
186
rectus muscles augmented with posterior fixation suture to enhance the effect of transposition (Foster, 1997). In the present study we aimed to report our results with augmented rectus muscle transposition surgery for the treatment of complex strabismus such as double elevator palsy, Duane syndrome and traumatic medial rectus palsy. Significant decrease in angle of deviation, slight to moderate increase of ductions are the main outcomes of our cases. Additionally, our cases did not need any other additional surgery to decrease the deviation angle at primary position. Paysee et al. also confirmed the effectiviness of rectus muscle transposition procedure augmented with posterior fixation suture in abducens palsy and Duane syndrome (Paysee, 2002). We also saw a marked improvement in head posture, and diplopia at primary position was releived in most cases. Conjunctival chemosis or hemorrage that resolved within 2 weeks was noted in most cases. In conclusion, rectus muscle transposition procedure augmented with posterior fixation suture for the treatment of cases with complex strabismus such as double elevator palsy, Duane syndrome and traumatic medial rectus palsy seems effective.
REFERENCES Foster, R.S. 1997. Vertical muscle transposition augmented with lateral fixation. J AAPOS 1: 20–30. Knapp, P. 1969. The surgical treatment of double-elevator paralysis. Tr. Am. Opht. Soc. 67: 304–323. Paysee, E.A. et al. 2002. Use of augmented rectus muscle transposition surgery for complex strabismus. Ophthalmology 109: 1309–1314.
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Posters
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Binocular functions in anisometropic and strabismic anisometropic amblyopes I. Akyol-Salman, Y. Karabela & O. Baykal Ataturk University Faculty of Medicine, Department of Ophthalmology, Erzurum, Turkey
ABSTRACT: To evaluate binocular functions in anisometropic and strabismic anisometropic patients with amblyopia, 30 anisometropic and 25 strabismic anisometropic patients with amblyopia were included in the study. Synoptophore, Titmus and TNO tests were used for evaluation of binocular functions and stereoacuities. Spherical equivalent and Safir and Kulikowski’s root mean square formulae were used as an index of anisometropia. Correlation analysis, the test of significance between pairs, Wilcoxon rank analysis tests were used for statistical analysis. Subnormal binocularity was observed in all cases. Decrease in binocular functions was more in strabismic anisometropic amblyopes when compared with anisometropic amblyopes. As a conclusion, in amblyopic patients, impairment in binocular functions was augmented by the presence of strabismus, in addition to anisometropia.
1
INTRODUCTION
Anisometropia and strabismus are the important causes of amblyopia. A strabismus frequently is associated with anisometropia, and to determine whether the amblyopia in an anisometropic strabismic patient is caused by the strabismus, the anisometropia, or both is difficult. As known, strabismic amblyopia is caused by active inhibition within the retinocortical pathways of visual input originating in the fovea of the deviating eye. This inhibition is the consequence rather than the cause of strabismus and is elicited by overlap of the different foveal images (confusion) transmitted to the visual centers from the retinas of the fixating eye and the deviating eye. As in the case of strabismic amblyopia, there is active inhibition of the fovea in anisometropic amblyopia; however, in the latter instance, the purpose of inhibition is to eliminate sensory interference caused by superimposition of a focused and a defocused image originating from the fixation point (abnormal binocular interaction). In spite of the similarities of the basic amblyopiogenic mechanisms, certain clinical differences exist between strabismic and anisometropic amblyopia in terms of severity, reversibility, and psychophysical characteristics (von noorden & campos 2002). In the present study we want to evaluate and compare the binocular functions in anisometropic and strabismic anisometropic patients with amblyopia.
2
MATERIALS AND METHODS
30 Anisometropic (Mean ages 22.10 7.62 years) and 25 strabismic anisometropic patients (Mean ages 16.32 7.37 years) with amblyopia were included in the study. After a complete ophthalmologic examination, the following data were recorded and analyzed: unaided visual acuity, cycloplegic refraction, best-corrected Snellen visual acuity( logMAR), interocular acuity difference, interocular difference in refraction (by using two methods: the difference in spherical equivalents and the root mean square difference as defined by Safir & Kulikowski (1975), angle of the squint in strabismic anisometropic patients (PD), grade of binocular vision (by using synoptophore), and stereoacuity (by 191
Table 1.
Acuity, Refraction and Binocularity Data’s in the Groups. Group A (Anisometropics with amblyopia)
Group B (Strabismic Anisometropics with amblyopia)
Mean interocular acuity difference (Log MAR)
0.38 (0.10)
0.54 (0.9)
Mean interocular difference in refraction (spherical equivalents)
1.80 (1.11)
1.57(1.02)
Mean interocular difference in refraction (as defined by Safir and Kulikowski)
2.29 (0.87)
1.90 (1.15)
Mean Stereoacuity with Titmus (seconds of arc)
204.33 (225.97)
1938.40 (1342.08)
Mean Stereoacuity with TNO (seconds of arc)
630.00 (700.73)
1502.40 (785.26)
Simultaneous perception
Positive (n 26) Weak (n 4)
Positive (n 9) Weak (n 6) Negative (n 10)
Fusion
Positive (n 18) Weak (n 6) Negative (n 6)
Positive (n 2) Weak (n 5) Negative (n 18)
Stereopsis
Positive (n 18) Weak (n 6) Negative (n 6)
Positive (n 2) Weak (n 5) Negative (n 18)
using Titmus and TNO Tests). Table 1 summaries some of these data’s. Mean angle of deviations in strabismic anisometropic patients was 15.86 5.4 PD (19 ET, 6 XT). Of these patients 19 were anisohypermetropic and 6 were anisomyopic. In anisometropic patient group, 17 were anisohypermetropic and 13 were anisomyopic. The test of significance between pairs, correlation analysis, Wilcoxon rank analysis tests were used for statistical evaluation. According to the statistical analysis of data’s between the groups: The significance was not observed on the, mean interocular acuity differences (P 0.564), mean interocular difference in refraction (the spherical equivalents) (P 0.362), and mean interocular difference in refraction (the root mean square) (P 0.163). The significance was observed on the mean stereoacuity with Titmus Test (P 0.000), mean stereoacuity with TNO Test (P 0.033), simultaneous perception (P 0.000), fusion (P 0.041), and stereopsis (P 0.041). According to the statistical analysis of data’s, strong correlation was found between: the type of amblyopia, the mean interocular acuity differences, the grades of binocular vision, the stereoacuity with Titmus test, the stereoacuity with TNO test (P 0.01), and the spherical equivalent index and the root mean square index (P 0.01). In the present study:
• • • • •
The degree of amblyopia was not correlated to the degree of anisometropia, for both anisometropic and strabismic anisometropic patients. The impairment in binocular functions increased with increasing degrees of amblyopia in both of the groups of anisometropic and strabismic anisometropic patients. Subnormal binocularity was found in all amblyopic patients. In spite of the similarities in the index of anisometropia of both groups, the degree of amblyopia was found to be more severe in strabismic anisometropic patients. In spite of the similarities in the index of anisometropia of both groups, impairment in binocular functions was found to be more in strabismic anisometropic patients. 192
3
CONCLUSION
In amblyopic patients, impairment in binocular functions was augmented by the presence of strabismus, in addition to anisometropia.
REFERENCES Safir, A. & Kulikowski, C.A. 1975. Problems in the evaluation of data. Am Acad Ophthalmol. Otolaryngol: OP488: 79. Von Noorden, G.K. & Campos, E.C. 2002. Binocular vision and ocular motility: Theory and management of strabismus. St. Louis: Mosby.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Thickness of the retinal nerve fiber layer and macular thickness and volume in patients with strabismic amblyopia Özgül Altıntas, Nursen Yüksel, Berna Özkan & Yusuf Çag˘lar. Department of Ophthalmology of Kocaeli University School of Medicine, Turkey
ABSTRACT: Objective: To evaluate and compare retinal nerve fiber layer thickness (RNFL), macular volume and thickness of amblyopic eye with that of the normal eye in patients with unilateral strabismic amblyopia using optical coherence tomography Model 3000(OCT-3) unit. Materials and methods: OCT-3 was performed on 14 patients with unilateral strabismic amblyopia who had an absence of neurologic disease. 9 male and 5 female patients, age range 5 to 18 years were enrolled in the study. The RNFL thickness avarage analysis program was used to evaluate superior, inferior, temporal, nasal mean RNFL thickness. The data in all clock quadrants (12 values avaraged) were identified as NFL overall. The retinal thickness/volume analysis program was used to evaluate macular scans Data were compared with Mann Whitney U test. Results: The mean age was 10,43 4,09 SD years. There were 6 right and 8 left amblyopic eyes, with the amblyopic group having mean visual acuity 0,3 5,70 SE. OCT parameters: RNFL measurements in all quadrants, RNFL overall, macular thickness and macular volume showed no significant differences between two groups.(p 0,05). Conclusion: Assessment of RNFL and macular thickness, and macular volume by means of OCT-3 revealed no difference between the two eyes in patients with unilateral strabismic amblyopia.
1
INTRODUCTION
Amblyopia is defined as a decrease of visual acuity in one eye when caused by abnormal binocular interaction or occuring in one or both eyes as a result of pattern vision deprivation during visual immaturity, for which no cause can be detected during the physical examination of the eye(s) and which in appropiate cases is reversible by therapeutic measures(Von Noorden, 1977). Previous studies assessing the retinal nerve fiber thickness by means of scanning laser polarimetry did not find any significant difference between the two eyes in patients with unilateral amblyopia (Bozkurt, 2003; Baddini-Caramelli, 2001; Colen, 1985). In the current study we aimed to evaluate and compare the retinal nerve fiber layer thickness, macular thickness and volume of the amblyopic eye and the sound eye in patients with strabismic amblyopia by means of optical coherence tomography Model 3000(OCT-3), which is latest model of commercially available OCT. 2
MATERIALS AND METHODS
14 patients with unilateral strabismic amblyopia who had an absence of neurologic disease, 9 male and 5 female patients, age range 5 to 18 years were enrolled in the study. The ophthalmological testing and examination protocol included visual acuity measurements, ocular motility and alignment evaluation, cycloplegic retinoscopy and autorefraction, and examination of external eye, anterior segment, and fundus. 195
Figure 1. Macular analysis of a 9 years old male patient with strabismic amblyopia whose visual acuities were 1,0 in the right eye and 0,1 on the left eye.
Each subject eye underwent fast RNFL and macula scan protocols. The RNFL thickness avarage analysis program was used to evaluate superior, inferior, temporal, nasal mean RNFL thickness. The data in all clock quadrants (12 values avaraged) were identified as RNFL overall. The retinal thickness/volume tubular analysis program was used to evaluate macular scans Statistical analysis were performed using a computer program system SPSS 10.0. Mann Whitney U test was used to determine whether differences between data of the amblyopic eyes and the normal fellow eyes were significant. The significance level was set as p 0.05.
3
RESULTS
This series of 14 unilateral strabismic amblyopic patients was consisted of 9 male and 5 females. 6 of the patients had exotropia and 8 had esotropia. The age of the children ranged between 5 years and 18 years.The mean age was 10,43 4,09 standart deviation (SD) years. The refraction of the amblyopic eyes ranged between 0,50 and 3 D and the refraction of the normal fellow eyes ranged between 0,50 and 2.0 D. There were 6 right and 8 left amblyopic eyes, with the amblyopic group having mean visual acuity 0,3 5,70 SE. There were no statistically significant differences in the mean values of all OCT parameters between the amblyopic and normal fellow eyes (p 0,05) (Figure 1). The means and SD for the OCT parameters of both groups are shown in Table 1 and Table 2. Mean RNFL overall thickness were 106,85 20,22 microns in ambylopic eyes and 104,35 17,84 microns in normal fellow eyes. Mean macular volume was 7,01 0,41 mm3 in ambylopic eyes and 6,97 0,47 mm3 in normal fellow eyes. 196
Table 1. Comparison of the mean retinal nerve fiber layer thickness of the amblyopic and normal eyes of unilateral strabismic amblyopia.
Thickness (microns)
Temporal RNFL Superior RNFL Nasal RNFL Inferior RNFL RNFL overall
Amblyopic eyes Mean SD
Fellow eyes Mean SD
p
72,71 29,63 129,07 23,95 98,21 43,56 120,50 30,23 106,85 20,22
73,50 29,39 129,35 20,41 86,14 19,13 122,71 26,53 104,35 17,84
0,63 0,82 0,45 0,66 0,52
Table 2. Comparison of the mean macular thickness and macular volume of the amblyopic and normal eyes of unilateral strabismic amblyopia. Amblyopic eyes Mean SD
Fellow eyes Mean SD
p
Average Retinal Thickness (microns)
Foveal minimum Fovea Temporal inner macula Superior inner macula Nasal inner macula Inferior inner macula Temporal outer macula Superior outer macula Nasal outer macula Inferior outer macula
199,86 18,83 221,28 24,70 252,57 24,67 271,64 26,19 266,78 28,57 264,28 15,71 228,21 22,63 240,21 19,58 263,35 25,13 243,64 17,03
181,43 40,30 201,64 30,53 253,92 16,98 273,35 16,17 269,92 27,27 270,50 17,54 223,14 16,71 246,35 19,71 256,35 22,06 243,07 23,25
0,53 0,69 0,91 0,94 0,61 0,28 0,49 0,39 0,27 0,96
Volume (cubic mm)
Fovea Temporal inner macula Superior inner macula Nasal inner macula Inferior inner macula Temporal outer macula Superior outer macula Nasal outer macula Inferior outer macula Total macular volume
0,176 002 0,396 0,03 0,426 0,04 0,418 0,04 0,414 0,02 1,209 0,11 1,272 0,10 1,395 0,13 1,291 0,09 7,01 0,41
0,159 0,02 0,398 0,02 0,428 0,02 0,423 0,04 0,424 0,02 1,182 0,08 1,347 0,15 1,358 0,11 1,288 0,12 6,97 0,47
0,56 0,91 0,94 0,61 0,28 0,49 0,16 0,27 0,96 0,96
4
DISCUSSION
Binocularly driven cells are found to disappear from the visual cortex and only monoocular neurons are identified in animal studies where binocular vision is prevented by inducing unilateral strabismus or deprivation (Wiesel & Hubel,1965; Crawford & Von Noorden, 1979). Changes in the distribution of cortical neurons and a decrease in size of the layers of the lateral geniculate nucleus (LGN) are found to be common in all forms of unilateral amblyopia(Von Noorden & Middleditch, 1975; Von Noorden & Crawford,1992) . Two types of retinal ganglion cells have been demonstrated: Y and X cells. X cells , which are mainly found in fovea and are thought to have role in providing high visual acuity were shown to be reduced in animals with induced amblyopia (Ikeda & Tremain,1979). Previously done assesments of RNFL thickness by means of scanning laser polarimetry revealed also no difference in RNFL thickness between the two eyes in patients with unilateral anisometropic and strabismic amblyopia (Bozkurt, 2003; Baddini-Caramelli, 2001; Colen, 1985). The macula is defined anatomically as that region of the retina where the ganglion cell layer is more than one cell thick. The ganglion cells and RNFL contribute 30% to 35% of the retina thickness 197
in the macula, where the ganglion cells are known to be most concentrated (Zeimer, 1998). Depending upon the results of the animal studies where ganglion cell lost were shown in amblyopic eyes, we hypothesized it would be logical to expect that macular volume and thickness would be reduced. However, mean foveal thickness and volume measurements of amblyopic eyes were slightly higher than measurements of normal eyes in our study but these differences were not statistically significant. To our knowledge, so far no attempt has been made to measure RNFL thickness and macular thickness and volume in amblyopic eyes by means of OCT. In our study, OCT-3 was performed in only unilateral strabicmic amblyopia patients under between age 5–18 years. This present study also revealed no difference in RNFL thickness and macular thickness and volume between the two eyes in patients with unilateral amblyopia by means of OCT-3.
REFERENCES 1. Baddini-Caramelli C, Hatanaka M, Polati M, Umino AT & Susanna R Jr. 2001. Thickness of the retinal nerve fiber layer in amblyopic and normal eyes: a scanning laser polarimetry study. J AAPOS. Apr;5(2):82–4. 2. Bozkurt B, Irkeç M, Orhan M & Karaag˘aog˘lu E. 2003.Thickness of the retinal nerve fiber layer in patients with anisometropic and strabismic amblyopia. Strabismus 11(1):1–7. 3. Crawford MLJ & Von Noorden GK. 1979.Concomitant strabismus and cortical eye dominance in young rhesus monkeys. Trans Ophthalmol Soc UK. 99:369–374. 4. Colen TP, de Faber JT& Lemij HG. 2000.Retinal nerve fiber layer thickness in human strabismic amblyopia. Binocul Vis Strabismus Q. Summer;15(2):141–6.2. 5. Ikeda H & Tremain KE. 1979.Amblyopia occurs in retinal ganglion cells in cats reared with convergent squint without alternating fixation. Experimental Brain Research 35:559–582. 6. Wiesel TN & Hubel DH. 1965.Comparison of the effects of unilateral and bilateral eye closure on cortical unit responses in kittens. Journal of Neurophysiology. 28:1029–1040. 7. Von Noorden GK & Middleditch PR. 1975. Histology of the monkey lateral geniculate nucleus after unilateral lid closure and experimental strabismus. Further observations. Invest Ophthalmol Vis Sci 14:674–683. 8. Von Noorden GK. 1977. Mechanism of amblyopia. Doc Ophthalmol.;34:93. 9. Von Noorden GK & Crawford MLJ. 1992. The lateral geniculate nucleus in human strabismic amblyopia. Invest Ophthalmol Vis Sci. 33:2729–2732 10. Zeimer R. 1998. Application of the retinal thickness analyzer to the diagnosis and management of ocular diseases. Ophthalmol Clin North Am. 11:359–379.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Evaluation of intranasal midazolam in young strabismic children undergoing refraction and fundus examination . Özgül Altıntas, V. Levent Karbas, Göktug˘ Demirci, Inci Onur & Yusuf Çag˘lar Department of Ophthalmology of Kocaeli University School of Medicine, Turkey
ABSTRACT: Introduction: The objective of this study was to determine the clinical sedative effect and the dosage of intranasal midazolam in fundus and refraction examination of children with strabismus. Materials and Methods: In this prospective study, fundus and refraction examinations with (28) and without (24) sedation were performed in 52 children with strabismus , aged 7 to 26 months of age. We delivered midazolam 5 mg/ml solution by a syringe over a period of 60 seconds to provide a dose of 0.2 mg/kg. We repeated the dose to a maximum of 0.3 mg/kg if there was no clinical sedative response after 10–15 minutes. The ease of examination and sedation were scored by a blind observer in each patient. The groups were evaluated for ease of examination and time needed for completion of examination. Results: We obtained clinically adequate sedation at a mean of 15 2,69 SD minutes. Sedation was achieved with a mean of 2,64 0,66 SD mg/kg. Children receiving midazolam had significantly calmer examination scores. The time needed for completion of examination was statistically significantly shorter than the time needed for children without sedation.(p 0,05) Conclusions: Our study suggests that intranasal midazolam approaches the beneficial drug and method of delivery for the sedation of anxious children with strabismus undergoing refraction and fundus examination. Sedation prior to examination is effective in reducing anxiety and time in ophthalmological examination of children with strabismus.
1 INTRODUCTION The ophthalmic examination of children with strabismus should be carried out in a logical sequence, using a cycloplegic agent for fundus examination and refraction at the end of the sequence so it does not interfere with the performance and interpretation of other tests (Ansons & Davis H, 2001). Cycloplegia is essential for accurate refraction of children, otherwise full correction of the refractive error may not be achieved. The fundi should be carefully examined since a concomitant strabismus may be the first outward sign of ocular pathology. A child with optic nerve glioma or retinoblastoma can present in a constant unilateral esotropia or exotropia (Ansons & Davis, 2001). Office ophthalmological examination of children is not always an easy procedure. In the case of uncooperative children, repeating the examination on another day when the child might be more cooperative or examining under sedation or general anesthesia are the alternatives. These children may benefit from medication that provides sedation, anxiolysis, and amnesia. Midazolam’s rapid onset, minimal effect on cardiorespiratory status, amnestic effect, and brief duration of action make it an ideal sedative agent (Kupietzky & Houpt,1993; Tolia, 1991). Intranasal midazolam was demonstrated to be safe and effective in various minor interventions for example in pediatric dentistry or wound repair in pediatric age group (Fuks,1994; Theroux,1993; Connors & Terndrup, 1994). The objective of this study was to determine the clinical sedative effect and the dosage of intranasal midazolam in fundus and refraction examination of children with strabismus. 199
Table 1. 1 2 3 4 Table 2.
Ease of examination scores. Excellent Good Fair Poor
Patient unafraid, cooperative, or asleep Slight fear and/or crying, quiet with reassurance Moderate fear and crying, not quiet with reassurance Crying, need for restraint
Clinical details of children (n 52).
Sex: Male Female Age (months (Means SD) Weight (kg) (Mean SD) Time for needed for examination(min) (Mean SD) Ease of examination score
Intranasal Midazolam (n 28)
Control (n 24)
15 13 16,54 5,04 11,78 1,96 11,25 2,07* 1,89 0,69*
11 13 15,05 4,93 11,33 1,82 16,10 3,27 2,76 0,54
*p 0,05.
2
MATERIALS AND METHODS
This study was approved by the Ophthalmology Department of Medical School of Kocaeli University between September . In this prospective study, fundus and refraction examinations with (28) and without (24) sedation were performed in 52 children with strabismus. We delivered midazolam 5 mg/ml solution by a syringe over a period of 60 seconds to provide a dose of 0.2 mg/kg. We repeated the dose to a maximum of 0.3 mg/kg if there was no clinical sedative response after 10–15 minutes. At the time of refraction and fundus examination a four point ‘ease of seperation score’ was assigned and recorded for each child by a blind observer (Table 1). We also recorded the dose of midazolam given(mg/kg) and time to onset of sedation. All children were observed for at least 1 hour after the sedation. Parents were instructed that their child should not walk independently for the first two hours after discharge and only clear fluids should be allowed during this time. Statistical analysis were performed using a computer program system SPSS 10.0. Results are displayed as the mean SD. Differences between the groups were analyzed by unpaired Student t test. The significance level was set as p 0.05. 3
RESULTS
Clinical details of the 52 children are shown in Table 2. Both groups were similar in age, weight, and sex.We obtained clinically adequate sedation at a mean of 15 2,69 SD minutes. Sedation was achieved with a mean of 2,64 0,66 SD mg/kg. Children receiving midazolam had significantly calmer examination scores (1,89 0,69 vs 2,76 0,54)(p 0,05). The time needed for completion of examination was statistically significantly shorter than the time needed for children without sedation (p 0,05). (Table 2, Figure 1).We did not observe any instances of respiratory depression or oxygen desaturation below 96% on pulse oximetry. No supplemental oxygen was required and no other complications arose. 4
DISCUSSION
Midazolam has a short onset time, rapid redistribution phase, and a plasma half life of approximately 2 hours (Connors & Terndrup,1994; Wahlberg, 1991). Intranasal midazolam acts rapidly and reliably 200
time (min)
Score 3
18 16 14 12 10 8 6 4 2 0
2,5 2 1,5 1 0,5 0 (n=28) Intranasal Midazolam
Figure 1.
(n=28) Intranasal Midazolam
(n=24) Control
(n=24) Control
Ease of examination and time needed for examination.
because delivery by the nasal route avoids first pass hepatic metabolism allowing maximum serum levels to be reached at 12–16 minutes (Rey, 1991) and a sedation at a mean of 15 minutes in this study. It seems better than oral midazolam where absorption is affected by first pass hepatic metabolism, and gastric contents and emptying, which produce peak plasma levels at 45 minutes, sedation at 20–30 minutes, a wider dosage range of 0,2–0,75 mg/kg (Kassoff, 1995; Smith, 1980). The sedation induced by midazolam given rectally is similar to that delivered intranasally but the onset of action delayed to 20 minutes(Geldner, 1997). Intranasally administered midazolam fulfill many criteria of an ideal sedative drug (Wahlberg, 1991;Rey, 1991). Disadvantages of examination under anesthesia include cost, inconvenience, and exposure of the child to the potential hazards of general anesthesia (Kassoff, 1995; Smith, 1980). Prior to general anasthesia sedation with midazolam is used as premedication for ease of seperation from family and induction of anesthesia. We administered midazolam intranasally while the children beside on the arms of their parents. The sedative effect of midazolam and changes of the behavioral status were started after 3–5 minutes and the patients became ready for the examination after 10–15 minutes. This administration procedure and the amnestic effect of midazolam sedation is highly favorable by the patient and the parents’ psychological status by avoiding the traumatic effect of transport and care in the operating room or preoperative care room without parents presence. Even respiratory and circulatory depression are unlikely when midazolam is used as a single drug (Geldner, 1997), pulse oximetry was used after nasal midazolam administration for safety reasons, we did not observe any impairment of vital functions. Our study suggests that intranasal midazolam approaches the beneficial drug and method of delivery for the sedation of anxious children with strabismus undergoing refraction and fundus examination. Sedation with a dose of 0,2–0,3 mg/kg of midazolam delivered intranasally prior to examination is effective in reducing anxiety and time in ophthalmological examination of children with strabismus.
REFERENCES 1. Ansons AM, Davis H. 2001.Ophthalmic Examination. In:Diagnosis and management of Ocular Motility Disorders, Ansons AM, Davis H (eds).:8–22. :Blackwell Science KK. 2. Connors K, Terndrup TE. 1994 . Nasal versus oral midazolam for sedation of anxious children undergoing laceration repair. Ann Emerg Med. Dec;24(6):1074–9. 3. Fuks AB, Kaufman E, Ram D, Hovav S, Shapira J. 1994. Assesment of two doses of intranasal midazolam for sedation of young pediatric dental patients. Pediatr Dent. Jul-Aug;16(4):301–5. 4. Geldner G, Hubmann M, Knoll R, Jacobi K. 1997. Comparision between three transmucosal routes of administration of midazolam in children. Paediatr Anaesth. 7:103–109.
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5. Kassoff J, Meyer DR. 1995. Early office-based vs late hospital-based nasolacrimal duct probing. A clinical decision analysis. Arch Ophthalmol. Sep;113(9):1168–71. 6. Kupietzky A, Houpt MI. 1993. Midazolam: a review of its use for conscious sedation of children. Pediatr Dent.15:237–241. 7. Rey E, Delaunay L, Pons G, et al. 1991. Pharmocokinetics of midazolam in children : comparative study of intranasal and intravenous administration. Eur J Clin Pharmacol.41:355–357. 8. Smith RM. 1980. Anesthesia for infants and children. 4th.Ed:634–646. St louis: Mosby Co. 9. Theroux MC, West DW, Corddry DH, Hyde PM, Bachrach SJ, Cronan KM, Kettrick RG. 1993. Efficacy of intranasal midazolam in facilitating suturing of lacerations in preschool children in the emergency department. Pediatrics. Mar;91(3):624–7. 10. Tolia V, Brennan S, Aravind MK, Kauffman RE. 1991. Pharmokinetic and pharmacodynamic study of midazolam in children during esophagogastroduodenoscopy. J Pediatr.119:467–71. 11. Wahlberg E, Wills R, Echert J. 1991. Plasma concentrations of midazolam in children following intranasal administration. Anesthesiology. 74:233–235.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Dissociated Vertical Deviation and its relationship with time and type of surgery in infantile esotropia Umut Arslan, Huban Atilla & Necile Erkam Ankara University, School of Medicine, Department of Ophthalmology, Ankara, Turkey
ABSTRACT: Purpose: To investigate the development of Dissociated Vertical Deviation (DVD) in infantile esotropia and its relationship with the age and the technique of the surgical intervention. Material and Method: Retrospectively records of 144 infantile esotropia cases that were followed in our clinic between the dates January 1991 – December 1997 were examined. Their ages at the time of admission, risk factors, ophthalmologic examinations before and after treatment and treatment mode were recorded and compared. Results: DVD was found to develop in approximately half of the cases (47.9%) at an average age of 3.2 years (20 months–5.5 years) regardless of the treatment. DVD developed in 80.5% of cases that had no surgery and 37.5% of the cases that were treated surgically. When we compared according to the age, it was seen that 24.1% of the cases that were treated between ages 6 months and 2 years and 52% of the cases that were treated after 2 years of age had DVD and the difference was significant (p 0.01). In comparison to the surgical technique, DVD developed in 34.8% of the cases that had bimedial rectus recession and in 38% of the cases with unilateral recession and resection of rectus muscles without any significance (p 0.05). Conclusion: As a result, the most efficient treatment mode in infantile esotropia is surgical intervention in early periods to obtain less DVD development as well as other established goals such as to obtain binocularity and prevent amblyopia. It is concluded that DVD development increases if surgery is not performed, if it is performed at later ages, and if additional muscle surgery is needed in time for undercorrection. 1
INTRODUCTION
Dissociated Vertical Deviation (DVD) describes the condition in which either eye, or occasionally only one eye elevates when the amount of light is reduced, for example by an occluder during the cover test. The elevated eye returns to its original position when the cover is removed. It can become manifest spontaneously, often occuring when the patient is fatigued or daydreaming. DVD is characterized by a slow drift of one eye up and out with slight extorsion. It is almost always bilateral, but often asymmetric. DVD can be distinguished from a true hypertropia by a lack of a corresponding contralateral hypotropia. DVD is an acquired condition that usually develops between the ages of 18 months and 3 years. It is rarely seen under 1 year of age but can occur as late as 5 or 6 years. It can be associated with all types of motility defects, including limited elevation, although infantile esotropia is the most common and often occurs after treatment of the horizontal deviation (1, 2). The purpose of this study to investigate the development of DVD in infantile esotropia and its relationship with the age and the technique of the surgical intervention. 2
MATERIAL AND METHOD
Retrospectively, records of 144 infantile esotropia cases that were followed in Ankara University Medicine Faculty Ophthalmology Department between January 1991–December 1997 were 203
included in the study. Their ages at the time of admission, risk factors, visual acuity, anterior segment and fundus findings, cycloplegic refraction, deviation measurements with Krimsky and/or alternating prism-cover tests, eye movements, binocularity with Worth 4 dot and Titmus tests before and after treatment, treatment mode and treatment age were recorded and compared. 3
RESULTS
When the entire data of the 144 cases with infantile esotropia was reviewed, the average age at the time of application for all the cases was 1.8 years (4 months–28 years). Seventy-five of the cases (52.1%) were girls, and 69 (47.9%) were boys. According to the results of retinoscopy with cycloplegia, 130 cases were emmetropic (90.2%), 4 cases were myopic (2.8%), 5 cases were hyperopic (3.5%), 3 cases were astigmatic over 1.5 D (2.1%), and 2 cases were anisometropic (1.4%). In 34 cases (23.6%) out of 144, family history was positive, there was history of hypoxia at birth in 7 cases (4.8%) and preterm labor history was present in 5 cases (3.5%) as risk factors to infantile esotropia. While DVD was present in 69 of the cases out of 144 (47.9%), it was symmetrical in 12 cases (17.4%), and asymmetrical in 57 (82.3%). Overaction of the inferior oblique muscle associated DVD in 30 cases (43.4%). As treatment mode, bimedial rectus recession was performed in 93 cases of infantile esotropia out of 144 (64.6%), followed by recession of the inferior oblique muscles in 13 cases because of the overaction of the inferior oblique muscles (13.9%), resection of the lateral rectus muscles because of residual esotropia in 7 cases (7.5%), and resection of lateral rectus muscles and recession of inferior oblique muscles in another 6 cases (6.4%). Single surgical intervention was considered sufficient in 67 cases (72.2%) and deviation under 20PD was obtained in these cases. In 21 cases out of 144 (14.5%) recession of the medial rectus and resection of lateral rectus muscle was performed unilaterally, and in 15 cases (71.4%) necessity for recession of inferior oblique muscle occurred in the same session, or more frequently, in a later session. In 30 cases out of 144 (20.9%), including the patients presenting in later ages, no surgical intervention was performed. In 11 cases (36.6%) deviation was under 20 PD and surgery was not performed. In 23 of the 30 cases, for whom no surgical intervention was performed, and in 6 of the cases for whom surgical intervention was performed, DVD developed before surgery; in other words, in 29 of the 36 cases that had not undergone surgery (80.5%) DVD developed. In 40 cases out of 108 (37.5%) for whom surgical intervention was performed, DVD was found at a mean age of 3.2 years (min-max: 20 months–5.5 years) and after the surgery. While DVD was found in 23 cases out of 67 (34.8%), for whom recession of bilateral medial rectus muscles were performed, it was seen that DVD developed in 9 cases out of 13 (69.2%) requiring additional surgery. It was noted that DVD developed in 8 cases out of 21 (38%) that had unilateral surgery. There was no statistically significant difference between bilateral and unilateral surgery groups (p 0.05). The age of the surgical intervention was 6 months–2 years in 59 of the 114 cases that had surgery, and in only 1 case DVD developed in this interval, and in the remaining 14 cases out of 58 (24.1%) DVD was found after the surgery. In 55 cases (48.3%) surgery was performed after 2 years of age and in 5 cases DVD developed in pre-operational period and in 26 cases (26/50–52%) DVD developed in post-operational period. Difference between early and late surgery was statistically significant (p 0.01). In 32 cases out of 144 (22.2%) monoocular amblyopia was found, and in 112 cases there was no amblyopia. Binocularity was not present in 91.6% and 4 of these cases who were amblyopic (2.7%), and all of the 12 cases with binocularity were cases that had surgery performed during 6 months–2 years of age. 4
DISCUSSION AND CONCLUSION
DVD ratios in infantile esotropia reported by Weakley et al. was 36% (3). We found in our study that DVD developed in approximately half of the cases (47.9%) in an average age of 3.2 years 204
(20 months–5.5 years) in cases with infantile esotropia that were treated or not treated. It was observed that DVD developed in 80.5% of the cases with infantile esotropia, for whom surgical intervention was not performed, and in 37.5% of the cases that were treated surgically and this higher incidence is statistically significant in untreated group. Zak et al. reported that in patients with infantile esotropia who initially underwent corrective surgery between 5 and 24 months of age, successful alignment of the eyes was associated with a higher prevalance of fusion and stereopsis and a lower prevalance of DVD (4). Neely et al. reported occurrence of DVD in almost all patients with surgically treated congenital esotropia, and its development was found to be unrelated to the timing of surgical intervention during the first 24 months of life (5). In our study, it was seen that in 24.1% of the cases that were treated with surgery between ages 6 months and 2 years DVD developed, on the other hand DVD developed in 52% of the cases that were treated after 2 years of age and the difference was significant (p 0.01). Late surgery was found to have higher risk for DVD development. Tolun et al. (6), Altintas et al. (7), Vroman et al (8), and Bartley et al. (9) reported that when deviations smaller than 50 PD, bilateral medial rectus recession would be quicker, simpler, less traumatic, and leave the lateral rectus muscles unoperated for patients requiring a second surgery. In our study, when the surgical methods were compared, DVD was detected in 34.8% of the cases that had bimedial rectus recession, and in 38% of the cases that had unilateral recession of medial rectus muscle and resection of lateral rectus muscle and the difference was not statistically significant in terms of surgical method (p 0.05). However, in bilateral surgical interventions, it was observed that in 69.2% of the cases required additional surgical intervention in addition to recession of medial rectus muscles. The most efficient treatment mode in infantile esotropia is surgical intervention in early periods to obtain less DVD development as well as other established goals such as obtaining binocularity and prevention of amblyopia. It is concluded that DVD development increases if surgery is not performed, if it is performed at later ages, or if additional muscle surgery is needed for undercorrection or overaction of inferior oblique muscle.
REFERENCES 1. Ansons AM. Davis H. Infantile strabismus. Diagnosis and management of ocular motility disorders 2000; 3rd edition-Chapter 14:294–98. 2. Wright KW. Complex strabismus and nystagmus. Strabismus Surgery 2000; 2nd edition-Chapter 6:41–2. 3. Weakley DR Jr. Parks MM. Results from 7-mm bilateral recessions of the medial rectus muscles for congenital esotropia. Ophthalmic Surg 1990;21(12):827–30. 4. Zak TA. Morin JD. Early surgery for infantile esotropia: results and influence of age upon results. Can J Ophthalmol 1982;17(5):213–8. 5. Neely DE. Helveston EM. Thuente DD. Plager DA. Relationship of dissociated vertical deviation and the timing of initial surgery for congenital esotropia. Ophthalmology 2001;108(3):487–90. 6. Tolun H. Dikici K. Ozkiris A. Long-term results of bimedial rectus recessions in infantile esotropia. J Pediatr Ophthalmol Strabismus 1999;36(4):201–5. 7. Altintas AK. Yılmaz GF. Duman S. Results of classical and augmented bimedial rectus recession in infantile esotropia. Strabismus 1999;7(4):227–36. 8. Vroman DT. Hutchinson AK. Saunders RA. Wilson ME. Two-muscle surgery for congenital esotropia: rate of reoperation in patients with small versus large angles of deviation. J AAPOS 2000;4(5):267–70. 9. Bartley GB. Dyer JA. Ilstrup DM. Characteristics of recession-resection and bimedial recession for childhood esotropia. Arch Ophthalmol 1985;103(2):190–5.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Ocular abnormalities associated with cerebral palsy Huban Atilla, Figen Batiog˘lu, Ertug˘rul Can & Necile Erkam Ankara University, School of Medicine, Department of Ophthalmology, Ankara, Turkey
ABSTRACT: Purpose: To document the incidence of ocular abnormalities in children with cerebral palsy. Methods: Retrospectively, the records of 18 children that were diagnosed and followed up for cerebral palsy in pediatric ophthalmology and strabismus clinic were examined. Results: The mean age of the patients was 5.7 years (10 months–19 years). Preterm birth history was present in 38.9% of the patients. Strabismus was detected in 15 cases (83,3%), 3 cases (16,6%) had esotropia and 12 cases had exotropia-exophoria (61,1%). Fixation reflex was poor in 2 cases and visual acuities varied from positive fixation reflex to 20/20. Optic nerve pallor was detected in 7 cases (38,9%). Associated systemic anomalies were flaccid or spastic upper and lower extremities and mild to severe mental retardation. Conclusion: Even though cerebral palsy is accepted to be related to preterm birth, it can be seen at term babies as well. Due to high incidence of ocular abnormalities, complete ophthalmological examination should be a part of routine assessment and follow-up of the children diagnosed with cerebral palsy. Even though there is no high refractive error, visual acuities were subnormal because of associated cerebral pathologies and unreliable visual acuity measurements associated with mental retardation and cooperation insufficiency.
Cerebral palsy (CP) is a neuromuscular disability resulting from an injury to the motor centers of the brain (1). It was first described by Little in 1843. CP consists of a group of conditions of different etiologies but with distinctive clinical features. This is a persistent but changing disorder of movement and posture, appearing in the early years of life, and due to a non-progressive disorder of the brain, the result of interference during its development (2). It is caused by damage to the brain, rather than muscle and this damage can occur before, during or shortly after birth. Lack of oxygen, illness, poisoning, and head injury are some factors that can cause cerebral palsy. The incidence of cerebral palsy is difficult to determine and estimated to be 6 in every 1000 live births. CP is associated with an increased risk of ocular abnormalities, particularly strabismus, and cortical visual impairment (1,3,4). The incidence of associated ocular abnormalities vary according to the timing, severity and etiology of the brain damage (3,5) but the most common ones were accepted as horizontal gaze defects and esotropia (1). Lossef reported ocular abnormalities in 50% of CP cases as compared to 1–2% in the general population (4). Breakey found 56% ocular abnormalities in 100 CP patients and esotropia was found (40%) to be the most frequent one (1). In this study, we aimed to report the eye findings in cerebral palsy cases especially in terms of motility and refractive status and the neuro-radiological findings.
1
MATERIAL AND METHODS
Retrospectively records of the patients with the diagnosis of cerebral palsy were evaluated and ocular findings were defined. Medical history as well as developmental and neurological findings 207
were included. Examination comprised of visual acuity, cover-uncover test at near and distance (if possible due to cooperation of the patient), motility, cycloplegic refraction and fundus findings. Cyclopentolate 1% was instilled 3 times prior to refraction and fundus examination. MRI was performed in cases that were cooperative to the procedure. 2
RESULTS
Eighteen patients (13 male, 5 female, M/F:2,6) with the diagnosis of CP were included in the study. The mean age of the patients was 4,99 years (range 9 months–19 years with a mean followup time of 3,71 years (range 1–6 years). Preterm birth history was present in 7 cases (38.9%), low birth weight history in 3 cases (16,7%). When we evaluated the mean refractive errors that were detected after cycloplegia hypermetropia (mean 1,58 D) (0,50 – 7,50 D) was detected in 16 cases (88,9%), myopia in 1 case (5,5%) (0,50 D) and astigmatism in 10 cases (55,6%) (mean 1,50 D) (0.50 – 4,00 D). Mean visual acuity was at fixation-follow and maintain level in 11 cases (in 2 cases fixation reflex was poor), finger counting from 75 cm to 20/20 in 7 cases and this low visual acuity was due to lack of cooperation. Congenital cataract was detected in 1 case (5.5%). Alignment and the motility problems are the most frequent and strabismus was detected in 15 cases (83,3%), 3 cases (16,6%) had esotropia and 12 cases had exotropia-exophoria (61,1%). Strabismus surgery was performed in 2 cases (11,1%) of exotropia and the mean pre-operative angle of deviation was 40–45 PD and the mean postoperative angle of deviation was 8–10 PD XT. Both cases gained fusion with Worth 4 dot test at distance and near after surgery. Nystagmus was detected in 10 cases (55,6%). Cranial MRI was done in 6 cases and periventricular leukomalacia was reported in 3 cases (16.7%) and dysmyelinization in white matter in 2 cases and occipital cortex infarct in 1 case. Optic disc pallor and atrophy was seen in 7 cases (38,9%) and associated with severe mental retardation and cerebral dysfuntion. 3
DISCUSSION
The classification CP was divided into 3 major groups on the basis of the type of motor abnormality and its topography; 1) spastic, with lesions in the cerebral cortex or pyramidal tract, about 60% of all cases and have increased stretch reflexes of the skeletal muscles and findings of upper motor neuron lesion, 2) dyskinesic, with lesions in the basal ganglia, about 35% of cases, with athetoic movements, rigidity and tremor, 3) ataxic, with lesions in cerebellum, about 5% of cases. This classification is based on clinical findings and in general 95% of the cases are diagnosed as one of these types and there are also mixed cases (1,2,6). In addition, sensory abnormalities particularly deafness and visual disability are common and these multiple manifestations lead to the term “brain damage syndrome” or “perinatal encephalopathy” (2). Cerebral palsy is a well-known clinical sequela to periventricular leukomalacia (PL) and 72–90% of all children with CP have PL. MRI studies in children with spastic diplegia have shown a high prevalance of PL especially in pre-term born children (87%). Visual dysfunction in PL includes a spectrum from near normal to severe visual impairment and primarily correlated and dominated by visual cognitive deficiencies raher than visual acuity and visual problems including crowding, visual field defects, strabismus and visual perceptual – cognitive deficits, together with nystagmus can be seen (7,8). Lesions of PL could be expected to affect visual function, particularly the visual fields as the axons in the optic radiation were interrupted and due to problems with simultaneous attention. Visual field defects may cause additional visual problems to an affected child especially during occlusion therapy for amblyopia and during educational programmes. In this study, periventricular leucomalacia was detected in 16.7% of cases and abnormal findings such as dysmyelinization and occipital infarct were present in the rest. All cases with PL had nystagmus also. Although normal stereopsis is rare in children with PL, a few have been orthophoric with measurable stereoacuity (7). 208
CP may be congenital due to hereditary causes, prenatal influences and birth trauma or acquired due to postnatal causes such as trauma, infections, vascular accidents and neoplasm (1). CP associated with prematurity is usually due to perinatal cerebral ischemia or hemorrhage and decreasing gestational age at birth is associated with an increased incidence of both CP and ROP. In our cases preterm birth history was present in about 40% of cases. As reported previously strabismus is common in CP than the general population (4). The incidence of strabismus has been varying between 37–60% in CP cases (9) and in our cases heterotropia was detected in 83% of cases. If we consider the situation in either sides; any baby with eye abnormalities at birth must be considered to have brain damage until it is proved otherwise and needs a complete neurologic examination and if the baby is diagnosed to have a neurological problem, eye examination must be performed between 6 months to 1 year of age. Children with CP and visual dysfunction caused by PL may have exo or esotropia whereas those who have escaped CP often present with esotropia. If we evaluate the treatment options, generally accepted principles for the management of heterotropias can be applied in cases with cerebral palsy. There is no contraindication to surgery in cases with relatively constant deviation. However due to possible chance of recovery, surgery can be delayed for a while, after institution of other treatment methods. Spontaneous conversion from eso to exotropia has been seen in children with periventricular leukomalacia so the optimal timing of strabismus surgery differs from that in congenital esotropia (7). Many authors have considered the treatment of squint unrewarding because of the low rate of success and the high incidence of consecutive deviation following surgery, due in part at least to central obstacles to fusion (2). We prefer early surgery in cases with CP because of additive effects of eye alignment on motor development of these cases. Also amblyopia treatment should be performed vigorously to ensure that both eyes have useful vision. In our series, two cases of exotropia were operated and both of them acquired fusion after surgery. In literature incomitant strabismus was reported due to Duane syndrome and cranial nevre palsies (2) and we observed one case of 6th nerve palsy associated with 7th nerve palsy and hemiplegia. The measurement of visual acuity is usually not eligible because of low levels of intellect or inability to communicate so an estimate of visual ability can be made on the basis of visual behaviour, retinoscopy, fundoscopy and the presence or absence of pathologic findings (4). Even the responsive children may be unreliable because of fatigue, drowsiness or disinclination to be examined. Dysfunction of the pathways subserving saccadic eye movements may limit the utility of preferential looking techniques in evaluating visual function (7). When the refractive errors were evaluated in the cerebral palsy cases, Schrire reported normal distribution in 68 children whereas Schachat et al reported a high incidence of myopia in 89 patients and found that refractive errors predominated in spastic cases. Meyerson also noted high incidence of high myopia. On the other hand, Fantl and Perlstein showed that children with cerebral palsy often had high refractive errors and generally tended to be more hyperopic than normals and proposed that hyperopia was more frequent in dyskinetics (6). While a gradual decrease of hyperopia and a trend toward myopia was observed in normal cases, in cerebral palsy cases this tendency is only to a minor degree and children retain hyperopia throughout their teens (6). In our cases, hyperopia was found to be higher than myopia and this can be related to the younger age of the patients in this series. A correlation between brain damage and hyperopia or high refractive errors was noted by several authors and it was speculated that apparently healthy children with strabismus may have some brain damage and were subclinical cases of cerebral palsy. Incidence of other refractive errors including high myopia was found to be variable with the etiology of the disease. Other factors such as; the age of the fetus at the time of damage, the severity and site of the lesion and the possibility that several factors may act simultaneously to modify the refractive behaviour of a cerebral palsy child (6). It was speculated also that disturbed ability to interpret visual information could interfere with the process of emmetropisation. Impairment of accommodation has also been described in children with CP and this may be associated with low visual acuity due to difficulty in keeping the hyperopia as latent (7). For near work, glasses with near add can be helpful in these children and defective accomodation can be diagnosed with dynamic retinoscopy. 209
Even though ophthalmological examination of children with cerebral palsy may requir more time and patience, examination is needed to be done in all cases of cerebral palsy around the age of one. The indications of surgery or spectacle prescription are almost same with normal children. Especially retinoscopy should not be delayed. If the child has correctable visual problems, this may increase the effectivity of the educational or rehabilitation programmes. In cases with poor visual prognosis, special educational assistances or visual rehabilitation programmes may be needed.
REFERENCES 1. Breakey AS. Ocular findings in cerebral palsy. Arch Ophthalmol 1955;53:852–6. 2. Black P. Visual disorders associated with cerebral palsy. Br J Ophthalmol 1982;66:46–52. 3. Pennefather PM, Tin W. Ocular abnormalities associated with cerebral palsy after preterm birth. Eye 2000;14:78–81. 4. Lossef S. Ocular findings in cerebral palsy. Am J Ophthalmol 1962;54:1114–8. 5. Stanley FJ. The etiology of cerebral palsy. Early Hum Dev 1994;36:81–8. 6. Fantl EW, Perlstein MA. Refractive errors in cerebral palsy. Their relationship to the causes of brain damage. Am J Ophthalmol 1967;63:857–63. 7. Jacobson LK, Dutton GN. Periventricular leukomalacia: An important cause of visual and ocular motility dysfunction in children. Surv Opthalmol 2000;45:1–13. 8. Jacobson L, Ygge J, Flodmark O. Nystagmus in periventricular leucomalacia. Br J Ophthalmol 1998;82:1026–32. 9. Harcourt B. Strabismus affecting children with multiple handicaps. Br J Ophthalmol 1974;58:272–9.
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Alexander the Great’s abnormal headposture due to Brown’s Syndrome? B. de Vries Ophthalmological Department, Academic Hospital Groningen, Groningen, The Netherlands
1
INTRODUCTION
Alexander the Great, born in macedonia in 356 BC, started in 334 BC his war against the persians. In the winter of 334–333 BC he penetrated the western part in Asia Minor, nowadays known as Turkey. Many contemporaries mentioned an abnormal headposture of the great emperor and many artists depicted Alexander with the chin up, face-turn and head-tilt to the left. Lysippos, the Emperor’s personal sculptor, modelled statues of Alexander which represented him looking up with his face towards heavens, to Zeus! It was well known that statues of Lysippos were fashioned with a true likeness of his models. Plutarch (ca 80–110 AD) noted that Lysippos represented Alexander with a slight inclination of his head to one side “as indeed Alexander often did look”. But Plutarch could not have known Alexander, he lived about 400 years later. 2
RESULTS
A. Many authors attribute the abnormal headposture as due to the pride of youth and a strongly will of a hero. (Schwarzenberg, 1975). B. In literature were found medical explanations for the headposture of Alexander the Great 1. Orthopaedic torticollis. (Dechambre, 1851) 2. Kyphosis, derived from an injury during childbirth. (Schachermayer, 1973)
Figure 1.
Alexander The Great.
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Figure 2.
Left: Philip, Alexander’s father, Right: Alexander.
3. Acquired Brown’s Syndrome. (Lascaratos-Damanakis, 1996) 4. Familial Brown’s Syndrome, Ivory statues of other Macedonians were found in the royal tombs of Vergina, they all appear to have torticollis, including Alexander’s father Philip. However, the artist depicted Alexander with a head-tilt to the right! (Acheson-Nitsas, 1996) C. In Classical Art many statues and portraits show a inclination of the head. D. It is almost impossible to diagnose an orthoptic disease without clinical observation and examination.
3
CONCLUSION
Alexander the Great’s abonormal headposture due to Brown’s Syndrome? The answer is: no! It seems to be that the abnormal headposture of Alexander the Great is due to the artistic style of the Ancient Art.
REFERENCES Acheson, J.F., N. Nitsas, Ocular torticollis in the Macedonians, Lancet 1996; 347: 1126. Boardman, J., The Oxford History of Classical Art, Oxford University Press, 1993. Lascaratos, J., A. Damanakis, Ocular torticollis: e new explanation for the abnormal head-posture of Alexander the Great, Lancet 1996; 347: 521–23. Lascaratos, J., A. Damanakis, Torticollis in ancient Macedonians, Lancet 1996; 348: 346. Vries, B. de, Alexander de Grote: Torticollis ocularis?, Tijdschrift voor Orthoptie.
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Role of spectacle correction and orthoptic exercises in non-surgical management of exodeviations Fazil Sezen, Özlem Balcı & Acun Gezer Istanbul University, Istanbul Medicine Faculty, Department of Ophthalmology
ABSTRACT: Purpose: To examine the effects of spectacle correction and orthoptic management in controlling of exodeviations. Methods and Materials: Medical records of 96 patients with inttermittent and phoric exodeviations were reviewed retrospectively. All available data regarding the ophthalmic and orthoptic examinations were noted. Patients are grouped according to their refractive errors, state of binocularity and applied treatment. Results: Mean age of patients at the introduction of treatment were 8.1 5.6 (1 to 24 years). Patients were followed up at least 12 months with median of 60.02 months. At the end of follow up yielding an exodeviation of 10 pd or less has been accepted as the success criteria. According this, 65.6% of patients has achieved a successful result. Patients who received orthoptic exercises in addition to spectacle correction improved better as compared to patients who only weared undercorrecting or full correcting spectacles. Conclusion: Binocular status of patients with exodeviations should be considered when deciding to undercorrect the refractive error.
1
BACKGROUND
Treatment of exodeviations is usually surgical, however certain nonsurgical treatments including optic and orthoptics may be indicated to create optimal sensory conditions. The goal of non surgical treatment is to maximize vision by treating amplyopia or anisometropia. Orthoptic treatment consists of antisupression therapy, diplopia awereness and fusional convergence training. Significant refractive errors such as anisometropia, myopia, and astigmatisms which can impair fusion and promote a manifest deviation should be corrected full correction is advised in myopia, but hyperopia should be corrected partially or fully to its degree (1,2,3). The aim of this study is to examine the effects of spectacle correction and orthoptic managements in controlling of exodeviations. 2
METHODS
Medical records of 96 (44 male, 52 female) patients with exodeviations were reviewed retrospectively. Patients with a deviation more than 10 prism diopters (pd) included in this study. None of the patients had previous strabismus surgery. All of the patients had normal biomicroscobic and fundoscopic examination findings. At each visits, all patients had complete routine ophthalmic examinations. Orthoptic measurements with the prism and cover test were made with distant (6 m) and near (0.3 m) target. Depending on the cooperation of the patient, visual acuity was evaluated with the picture optotypes, tumbling E or Snellen letter charts. In too young children visual acuity was assed by the ability to fixate on and follow a test object. Binocular sensory status was assed with Worth 4-dot flash light, synoptophore and Titmus stero tests in cooperating patients. 213
Table 1.
Mean deviation angle (pd) at initial examination. 20.8 8.9 (12–40) pd 20.2 9.2 (12–40) pd
Mean deviation at distant: Mean deviation at near:
Table 2. Refractive errors recorded in patients at initial examination. Number of patients Myopia Emmeropia Hyperopia
(1.0 to 11.0D) (1.0 to 8.0)
26 (27%) 39 (40.6%) 31 (32.3%)
Table 3. Number of patients Myopia Undercorrected Full corrected Emmetropia Under corrected Full corrected Hyperopia Full corrected Under corrected
9 17 30 9 7 24
Cycloplegic retinoscopy was performed with 1% cyclopentolate. Patients were grouped according to their refractive error (myopia, emmetropia and hyperopia) state of binocularity (low fusional amplitude; 18 , supression, adequate fusional amplitude; 18 ) and applied treatments. Orthoptics consists of synopthophore, home based training including; stereograms, pencil exercises applied in suitable patients to increase fusional ranges. Changes in the deviation of the angle, improvement in fusional ranges were recorded. Yielding an exodeviation of 10 pd or less has been accepted as the success criteria. Students-t tests used for statistical comparison and p 0.05 is considered significant. 3
RESULTS
96 patients were followed up at least 12 months with a median of 60.0 2 months (12 to 212 months). Mean age of the patients at the introduction of the treatment were 8.1 5.6 (1 to 24 years). Of 96 patients, 72 (75%) patients had intermittent exotropia, 24(25%) had exophoria. Mean deviation at initial examination were given on the Table 1. Baseline refractive errors ranged from 11.0 to 8.0 D with a median of 0.2 D. Refractive errors recorded in patients at initial examination were given on Table 2. Spectacle correction were prescribed according to the cycloplegic refraction (Table 3). Central supression scotoma were recorded in 21.8 % (n 22) of the patients (Table 4). 25 patients were treated with orthoptics, including; synoptophore, stereograms, pencil pushups to increase fusional ranges. At the end of the follow up, mean deviation at distant and near decreased to 9.05 9.7 (0–40) and 8.9 8.8 (0–40). 63 (65.6%) patients yielded an exodeviation of 10 pd or less (Table 5). In the remaining of 33 patients in whom the deviation angle is greater than 10pd, 14 had central supression 19 had an exodeviation greater than 25pd before the treatment. Fusional amplitude improved in all of the patients treated with additional orthoptics. 214
Table 4.
Binocular status of the patients at initial examination. Number of patients
Myopia – Adequate fusional amplitude – Low fusional amplitude – Central supression scotoma Emmetropia – Adequate fusional amplitude – Low fusional amplitude – Central supression scotoma Hyperopia – Adequate fusional amplitude – Low fusional amplitude – Central supression scotoma
18 4 7 18 11 9 17 9 5
Table 5. Number of patients (%) with a deviation of 10pd at the end of the follow-up. 69.2% (n 18) 61.5% (n 24) 67.7% (n 21)
Myopia Emmetropia Hyperopia
Table 6.
Amount of undercorrection and changes in the deviation angle. Amount of undercorrection
Hyperopia – Adequate fusion – Low fusion – Central supression Emmetropia – Adequate fusion – Low fusion – Central supression Myopia – Adequate fusion – Low fusion – Central supression
Changes in the deviation angle (pd)
1.3 1.4 0.6 1.0 1.2 1.0
12.8 11.5 11 9.4 7.2 12.4
p 0.001 p 0.007 p 0.5
0.6 0.8 0.6 0.5 0.8 0.3
8.9 11.1 10 10 7.1 14.1
p 0.001 p 0.01 p 0.11
0.2 2.4 2.3 4.8 1.1 3.1
7.3 9.4 9 8.8 13.2 13.2
p 0.005 p 0.08 p 0.04
Changes in the deviation angle in patients with central supression scotoma were significantly less than the other patients (p 0.05, Table 6.) 4
DISCUSSION
Spectacle correction and orthoptic management in controlling of exodeviations depends on the stimulation of accomodative convergence. Caltrider and Jampolsky4 reported that little accomodative effort can trigger a large vergence response that can be enough to control the exodeviation. In this study the success rate was 65.6% when all the patients was considered. In literature Caltrider and Jampolsky4 reported a success rate of 72% in their series. Reynolds5 and Basar6 also achieved a success rate of 61.7% and 63.6% in their series. In this study 19 of 33 patients whom 215
the deviation angle 10pd after the follow-up had a deviation angle greater than 25pd before the treatment and the success rate was also higher in patients with small angle of deviation before the treatment. Reynolds also achieved a smilar result; they stated that the success rate was higher in cases with small angle exotropias5. In our study patients with supression scotomas had the worst prognosis. We observed that if the patient had adequate accomodative capacity, than undercorrection can resolve the exodeviation. So binocular status of the patients should be considered when deciding the undercorrect the refractive error. Spectacle correction and orthoptic exercises can delay the surgery or decreases the deviation angle in suitable cases but overcorrecting lens therapy or undercorrection in our study can cause accomodative astenopia so in our opinion it can be used in children with high accomodative amplitude.
REFERENCES 1. Von Noorden GK. Exodeviations. In: Binocular Vision and Ocular Motility. Theory and Management of Strabismus. Sixth Edition. St. Louis: CV Mosby; 2002, 326 2. Hardesty HH, Boynton JR, Kenan JP: Treatment of internittent exotropia. Arch Ophthalmol 96: 268; 1978 3. Iacabucci Il, Archer SM, Giles CL. Children with exotropia responsive to spectacle correction of hyperopia. Am J Ophthalmol 93; 116(1): 79–83 4. Caltrider N, Jampolsky A. Overcorrecting minus lens therapy of intermittent exotropia. Ophthalmology 1983; 90: 1160–1165 5. Reynolds JD, Wackherhagen M, Olitsky SE. Overminus lens therapy for intermittent exotropia. Am Orthopt J 1994; 44: 86–91 6. Bas¸ ar E, Oguz H, Ermis¸ S. Overcorrecting minus lens application for intermittent exotropia. Ann Med Sci 2000; 9: 132–134
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Moebius syndrome with limb abnormalities E. Bas¸ar & T. Aras Ists¸bul University, Cerrahpas¸a Medical Faculty, Department of Ophthalmology, Istanbul, Turkey
ABSTRACT: Introduction: Moebius Syndrome is a rare congenital disorder with the primary diagnostic criteria of bilateral limited ocular abduction with or without esotropia, seventh nerve upper motor neuron palsy, sixth nerve palsy and twelft nerve palsy with atrophy of tongue. Some patients have orofacial anomalies and limb malformations. Mental retardation and autism have been reported. Material and methods: Our case of Moebius syndrome (a 28 years old female) has been evaluated. The patient had been esotropia (nearly 40 degree) and bilateral limited abduction. She had abnormalty of the hands and feet. Both eyes had been found to have normal elevation and depression. Visual acuities were normal. Results: Esotropia had successfuly corrected by surgical recession of both medial recti muscle. Satisfactory result was obtained. Conclusion: In this poster, we present our patient’s face and eyes appearence as well as her limb abnormalities pictures. Also, we mention the teratment of this rare syndrome.
1
INTRODUCTION
Moebius syndrome is classified under the congenital abduction deficits in ophthalmology. Firstly it was described by von Graefe in 1880 and more completely described by Möbius in 1881 (1). It was characterized by congenital facial diplegia and bilateral absent abduction. In addition 5th, 9th and 12th cranial nerve deficits and abnormalities of extremities such as clubfoot, brachydactyly, congenital amputation and absense (or hypoplasia) of the brachial musculature, particulary the pectoral muscule (Poland Syndrome) have been descibed within this syndrome (2). Here in this study, we present a case of Moebius syndrome with multiple limb abnormalities. 2
CASE REPORT
28 years old female with bilateral congenital oculofacial palsy applied to our clinic for the treatment of marked esotropia on primary position. On examination, her face expression was dull with flat lower face, bilaterally her abductions were absent beyond midline. Congenital multiple limb abnormalities were present such as syndactyly on feet and brachydactyly on right hand. Her left anterior arm was absent as well. In her family history there were not such similar case. Her visual acuities were 10/10 with 0.50 glasses. She had latent nystagmus and nearly 40 degree esotropia (V-pattern) with asymetrical sixth nerve paralysis (Picture 1–2). Vertical conjugate movement and convergence were normal. Her abduction and adduction were limited. Her slit lamp examination were normal. She was not able to whistle with facial diplegia. In addition she had bilateral mild lagophtalmos. Mentally, she was normal and her skeletal abnormalities (Picture 3–4). supported our diagnosis of Moebius syndrome. She was operated under general anesthesia and bilateraly her medial rectus muscles were recessed 6 mm. Postoperatively with her glasses the esotropic deviation was reduced to 12 prism diopter on primary position. 217
Picture 1. Patient’s appearence primary position.
Picture 3.
3
Picture 2.
Patient’s appearance on elevation.
Patient’s feet abnormalities.
DISCUSSION
Most syndromologist believe that Moebius is not syndrome but rather a true sequence, that is multiple etiologies potentially cousing some developmental insult with secondary ocurrences (3). There are several teories that Moebius sequence is caused by vascular distruption in the developing brain stem. Destruction of the embrionic blood supply to the brain stem couses hypoxia and necrosis and also damage to the limb buds. On the other side some researchers believe that the HOX developmental genes are responsible for initiating a sequence of events that results in destriction of the brain stem (2). Resently MRI studies were performed for the neuroradiologic findings of Moebius Syndrome (4,5) This MRI studies were consistent with ischemic central nervous system demage. Like infact 218
Picture 4.
Patient’s hand and arm abnormalities.
in the head of coudate nucleus and in the cerebellopontine junction and ischemic changes in the thalamus. Also quadrigeminal plate abnormalities and pontine hypoplasia were mentioned (4,5). Different scheamas. of etiologies have been proposed in an attempt to understand the pathogenesis of his disorder. This categories Expanded Moebius Syndrome. Different schemas of etiologies have been proposed in an attempt to understand the pathogenesis of his disorder. These categories are summarized as follows: aplasia or hypoplasia of cranial nerve nuclei, cranial nerve nuclei destruction, peripheral nerve abnormalities and primary myopathies as the result of an hypoxic/ischemic event aplasia or hypoplasia resulting from hypoxic demage is proposed to have two possible etiologies. The first is vascular insufficiency secondary to an interruption of blood flow from the comperession of fetal vessels near the developing cranial nerve nuclei 6 and 7. Multiple causes of the interruption of blood flow are proposed, including travma, plesental obruption, and others. The second possible etiology is an anomaly of cerebralcirculation development. Critical time of development can result in an hypoxic/ischemic lesion, which leads to Moebius Syndrome. Both of these etiologies can account for the concurrent skelatal anomalies observed in some patients (6,7).
4
CONCLUSION
Our case features are consistant with the findings of Moebius Syndrome description in the literature (1,2,3,4,5,6,7). Esotropia, V-pattern, abduction limitation and hyperopia are the main ophthalmic clinical findings of our case and multiple skeletal limb abnormalities and facial palsy were the other important characteristics of this syndrome or sequence. Unfortunately we were not able to obtain her mother’s history during her pregnancy for our case to illuminate whether there was a drug intake (benzodiazepine, thalidomide, misoprostol) (8) or another event to couse hypoxic or ischemic insult during early gestation (9). 219
REFERENCES 1. Hall, C.J. 2000. Abduction deficits in strabismus: Differential diagnosis. Am. Orthoptic J. 50: 8–10. 2. Cronemberg, M.F., Moreria, J.B., Brunoni, D., Mendança, T.S., Alvarenga, E.H. et al. 2001. Ocular and clinical manifestations of Moebius’ Syndrome. J. Ped. Ophtal & Strabismus 38(3): 156–162. 3. Miller, M.T. 2000. Lateral rectus dysfunction and “associated things”. Am. Orthoptic J. 50: 47–63. 4. Lengyel, D., Zaunbauer, W., Keller E., Gottlob I. 2000. Möbius Syndrome: MRI findings in three cases. J. Ped. Ophthalmology & Strabismus 37(5): 305–308. 5. Kratli, H., Erdener, U. 2000. A case report. Jpn. J. Ophthalm. 44: 679–682. 6. Peleg, D., Nelson, G., Williamson, R., Widness J. 2001. Expanded Möbius Syndrome. Pediatric Neurology. 24(4): 306–309. 7. Predza, S., Gamez, J., Rovira, A., Zamora, A., Grive, E., Raguer, N., Ruscalleda, J. 2000. MRI findings in Möbius syndrome: Correlation with clinical features. Neurology 55: 1058–1060. 8. Vargas, F.R., Schuler-Faccini, L., Brunoni, D., Kim, C., Meloni, V.F.A., Sugayama S.M.M., Albano, L., Lienera, J.C., Almeida, J.C.C., Duarte, A., Cavalcanti, D.P., Goloni-Bertollo, E., Conte, A., Koren, G., Addis, A. 2000. Prenatal Exposure to misoprostol and vascular disruption defects: A case-control study. American Journal of Medical Genetics 95: 302–306. 9. Von Noorden, G.K. Campos Ec. 2002. Paralytic Strabismus. In Binocular Vision and Ocular Motilty. 440–442, St. Louis, Mosby.
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Long-term binocular functional outcome after strabismus surgery in a case of cyclic esotropia B. Venkateshwar Rao & Prashant Sahare Department of Pediatric Ophthalmology and Strabismus, Jasti V Ramanamma, Children’s Eye Care Centre, Hyderabad, India
ABSTRACT: Introduction: Cyclic esotropia is a rare form of strabismus and poorly understood disorder of ocular motility which is characterized by a regular cycle of squinting and non squinting days. It is typically an acquired form of concomitant non-accomodative strabismus and usually lasts for 48 hours. Purpose: To report long-term binocular vision outcome after strabismus surgery in a case of cyclic esotropia with 24-hour cyclic pattern. Methods: Interventional case report. Results: A healthy 4-year-old female child with alternative day esotropia with 24-hour cyclic pattern that persisted for one year, underwent bimedial rectus recession of 11.0 mm from the limbus through fornix approach. After the surgery the cyclic pattern was abolished with straight eyes at 5 years follow up with normal binocular function as exemplified by fusion on worth 4 dot test and stereopsis of 30 secs of arc with Randot stereotest. Conclusion: This case highlights the importance of awareness of this rare ocular motility disorder, with need for repeated examinations, to confirm the diagnosis and treat early with surgical intervention, thereby re-establishing the normal binocular vision.
1
INTRODUCTION
Cyclic esotropia is a rare form of strabismus and poorly understood disorder of ocular motility which is characterized by a regular cycle of squinting and non squinting days.1 It is typically an acquired form of concomitant non-accomodative strabismus and usually lasts for 48 hours, however there are known cases with cycles that range from 24 to 96 hours in length.1–2 It has been estimated that cyclic strabismus has an incidence of 1 in every 3000 to 5000 cases of strabismus.2 In cyclic esotropia on “straight days” no anomalies of binocular vision are observed, though heterophoria may be present, whereas on strabismic days a large-angle esotropia will appear and sensory anomalies are often found. The mechanism of cyclic strabismus is still unknown, however most cases require strabismus surgery. Surgery based on amount of heterotropia as it occurs on the squinting days has been successful in curing this condition and reestablishing normal binocular function.3 We herein report a case of cyclic esotropia with 24-hour cyclic pattern that persisted for one year. Following a successful bimedial rectus recession, eyes have remained straight with normal binocular vision and the cyclic pattern has been abolished for 5 years follow-up now.
2
METHODS
Case report: A healthy 4-year-old female child presented with her parents on 17/07/98 with chief complaints of squinting of her right eye since one year duration every alternate day. There was no previous history of diplopia surgery or any associated trauma. The family history was negative for strabismus. The mother stated that the pregnancy and delivery were normal with no history 221
of any use of forceps or birth trauma. The visual acuity at the time of presentation was fixing and following light with central, steady and maintained fixation with each eye. The child was not co-operative for visual assessment with allen pictures. Cycloplegic refraction revealed a hypermetropia of 1.75 Ds in both eyes. Slit lamp biomicroscopy, pupillary reaction and fundoscopic examination were normal in both eyes. Ocular motility examination revealed orthotropia for near and distance (Figure 1) with normal ductions and versions. Patient was not cooperative for stereopsis testing with titmus fly stereotest. Since the parents gave a history of alternate day squinting they were asked to bring the child for examination on the day of crossing. Patient was reexamined on 18/07/98 and was noted to have 45 prism diopters baseout comitant alternate esotropia, with no fixation preference. (Figure 2) The ductions and versions were normal and there was no associated A or V pattern. A repeat cycloplegic refraction on squinting day revealed hypermetropia of 1.75Ds in both eyes. Based on the above clinical findings a
Figure 1.
Cyclic ET. No deviation (Non-squinting day).
Figure 2.
Cyclic ET. Large angle constant esotropia (Squinting day).
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presumptive diagnosis of cyclic esotropia was made. The patient was also seen in consultation by a neurologist and found to be neurologically normal. Contrast enhanced computed tomography (CECT) of head and orbits was done and reported as normal. Patient was prescribed glasses and asked to follow up after 4 weeks. Four weeks later when patient presented on 13/08/98 she was orthotropic for near and distance with glasses (Figure 3) and no deviation could be elicited with accomodative target and after repeated alternate cover test. Binocular function testing with titmus fly stereotest revealed presence of gross stereopsis. The following day on 14/08/98 the patient was again re-examined and noted to have 45 prism diopters of esotropia with glasses (Figure 4) both for near and distance which was freely alternating and with normal ductions in both eyes. Stereopsis was absent on testing with titmus fly stereotest. The diagnosis of cyclic esotropia was confirmed and patient was advised eye muscle surgery. A bimedial rectus recession of 11.0 mm from the limbus was done through fornix approach on 07/10/98 which happened to be the nonsquinting day. On the first post operative day, patient was orthotropic for near and distance(Figure 5), with normal versions, and which infact should have been the squinting day according to her cyclic
Figure 3.
Cyclic ET. No deviation with glasses (Non-squinting day).
Figure 4.
Cyclic ET. Alternating constant esotropia with glasses (Squinting day).
Figure 5.
Cyclic ET. First postoperative day showing orthotropia.
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Figure 6a.
Cyclic ET. Five year follow-up photograph showing Orthotropia with normal versions.
Figure 6b. Cyclic ET. Five year follow-up photograph showing Orthotropia for distance and near with accommodative target.
nature. Patient is now followed up regularly for nearly more than 5 years and when last seen on 15/12/03 was having unaided visual acuity of 20/20 in both eyes. Ocular motility showed orthotropia for near and distance (Figure 6 a & b) Ductions and versions were normal in both eyes with fusion on worth 4 dot test. Stereopsis was 30 secs of arc on testing with Randot stereotest.
3
DISCUSSION
Cyclic strabismus was first mentioned at the strabismus ophthalmic symposium II4 in 1958 and was first described in a publication by Costenbader and Mousel in 1964.2 The onset of this extremely unusual and rare form of esotropia usually occurs at 3 to 4 years of age5, which appears and disappears in a regular cycle. The duration of cycle may be as short as two weeks6 in which case the diagnosis can be missed, or it may persist for several years before becoming a constant deviation7. Our case had a relatively long cyclic phase of approximately one year. Patients with cyclic strabismus usually have a family history of strabismus. There is no sex predilection or relationship to refractive error or visual acuity. The fact that most cases occur in the mid-preschool years may explain the frequency of mild hyperopic error. The effectiveness of correction of hyperopia is unpredictable as well, but it may be reasonable to correct the refractive error and observe the deviation before resorting to surgery. Refractive error in our patient was mildly significant and therefore optical correction was given before surgical correction. Cyclic strabismus must be differentiated from intermittent strabismus, which is more irregular and is often precipitated when the binocular vision is compromised with disruption of fusion.6 Accidental or surgical trauma has been associated with cyclic strabismus in few cases.7,8 Two cases of cyclic esotropia with associated central nervous system lesions has been reported from India.9 Three 224
cases of Cyclic esotropia with over-elevation in adduction and V-pattern have been described and treated successfully with bi-medial rectus recession and inferior oblique weakening in one case. 10 Surgical correction of total esotropia with either a bimedial rectus recession or a unilateral medial rectus recession and lateral rectus resection has been the most effective mode of therapy.3 Repeated surgery may be necessary in rare instances.3,11 The cyclic nature is probably the result of many interacting factors. It may be related to a change in cellular metabolism in muscle and/or nervous tissue. One cannot say whether any biological clock mechanism is located in the extraocular muscle and possibly regulated or influenced by the central nervous system or whether there is an irritable focus in the oculomotor nucleus which then transmits cyclic stimuli to extraocular muscle.12
4
CONCLUSION
This case highlights the importance of awareness of this rare ocular motility disorder, with need for repeated examinations, to confirm the diagnosis and treat early with surgical intervention, thereby re-establishing the normal binocular function.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
12.
Windsor CE, Berg EF. Circadian heterotropia. Am J Ophthalmol 1969; 67: 565. Costenbader FD, Mousel DK: Cyclic esotropia. Arch Ophthalmol 1964; 71: 180. Helveston EM. Surgical treatment of cyclic esotropia Am Orthopt J 1976; 26: 87–88. Burian HM: Round table discussion in Allen JH (ed) Strabismus Ophthalmic Symposium II. St.Louis Mosby Co.1958, p 488. Helveston EM. Cyclic strabismus. Am Orthoptic J 1973; 23: 48–51. Costenbader FD, O’Neil JF. Cyclic strabismus, in Bellows JG (ed) Contemporary ophthalmology Honoring Sir Stewart Duke Elder, Baltimore, Williams & Wilkins Co. 1972, p 422. Uemura Y, Tomila M, Tanaka Y. Consecutive cyclic esotropia. J Pediatr Ophthalmol Strabismus 1977; 14: 278–280. Muchnick RS, Sanfilippo, S, Dunlap EA. Cyclic esotropia developing after strabismus surgery. Arch Ophthalmol 1976; 94: 459–460. Pillai P, Dhand UK. Cyclic esotropia with central nervous system disease: Report of two cases. J Pediatr Ophthalmol Strabismus 1987; 24(5): 237–241. Pott JWR, Godts D, Kerkhof DB, de Faber, JTHN. Cyclic esotropia and the treatment of over-elevation in adduction and V-pattern. Br. J Ophthalmol 2004; 88: 66–68. Cahill M, Walsh J., McAleer, A. J AAPOS 1999; 3: 379–380. Caputo AR, Greenfield PS. Ann Ophthalmol 1978; 10(6): 775–778.
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Interrelationship of binocular and monocular functions in anisometropic amblyopia I.M. Boychuk Filatov Institute of Eye Diseases, Odessa, Ukraine
ABSTRACT: Quantity and quality of passing signals to both hemispheres from amblyopic and pair eye causes the return reaction of both hemispheres, but different in degree and so form different types of binocular interrelationship. To prove this fact in clinic – functional indices of both eyes, accompanying the presence or absence of binocular vision and, in particular, central and peripheral stereovision in children with anisometropic amblyopia were observed. 84 children with central (I), 28 with eccentric fixation (II) aged 5–8 y. o. were observed. Visual acuity, functional state of retina and optic nerve of both eyes and difference ( ) between them were studied with routine methods. To study binocular functions Worth test, Lang test II and suggested device for central stereovision were applied. Degree of decline of binocular functions depends on ( ) in refraction (6,0 dptr.), light sensitivity between both eyes (1, 3 log unit) and liability of visual nerve of amblyopic eye.
1
INTRODUCTION
Anisometropic amblyopia is developing on to the eye with the higher degree of refraction (hypometropic or myopic), some authors link forming of anisometropia with asymmetry of the brain [2]. About 1/3 of amblyopic children are anisometropic. The greater part of patients with anisometropic amblyopia has no visible deviation, however binocular vision is often absent and rare is recovering. One of the causes of given fact there is aniseikonia and impossibility of fusion of both images. However even in case of correction of aniseikonia, improving of binocular vision succeeds only in the 57% cases [4]. Horizontal disparity of retinal images secures information, necessary for the binocular evaluation of depth and stereopsis [1]. Anatomic substrate, due to which the brain recognizes disparity of retinal images, is partial crossing of visual fibers in area of chiasm, and also interaction of halves of visual analyzer through the corpus callousum. Transformation through the corpus callousum is necessary for stereopsis in the case if the images get on the nasal or temporal halves of retina at the same time [3]. A question about interaction of functional indices of retina with the state of binocular co-operation of both eyes was not studied. However interaction between them is obvious, because quantity and quality of passing signals in both hemispheres from stimulating amblyopic or dominant eye causes the return reaction of both hemispheres, but different in the degree, that produces varies on force and type binocular links. Therefore given work is conducted with the purpose to determine what kind of functional indices of both eyes accompany a presence or absence of binocular vision in children with anisometropic amblyopia.
2
MATERIALS AND METHODS
Studies of visual functions in children (112) aged 5–8 y.o. with anisometropic amblyopia was conducted. Children with amblyopia were devided in dependence of monocular fixation into groups: with 227
Table 1. Visual functions in the I group of children with anisometropic amblyopia depending on the presence or absence of stereopsis by device for measurements of stereo vision disturbances. Functions
F
Threshold 0 n 28
Threshold 0 n 56
P 1,2
Threshold by Haidinger brush (in units) Distinction ( ) of light sensitivity between both eyes (in log units)
24,57
5,0 0,05
6,5 0,01
0,00001*
31,9
1,3 0,9
0,3 0,07
0,00001*
*P 0,05.
central fixation there were 84 (I group) and with eccentric 28 (II group) children, among them parafoveal had 20 and macular fixation had 8 children. Refraction of amblyopic eyes was hyperopic. Binocular vision by four dot test was in all children of the I group and in the 23,1% (6) of II group; simultaneous vision was in 30,8% (9) and monocular in 46,1% (13) of children of the II group. The following monocular functions of both eyes and the difference ( ) between the values of indexes of both eyes were determined in all children: visual acuity, refraction, threshold by maculotest (Haidinger brushes), threshold of electrical sensitivity by phosphen (mA), critical flicker fusion by phosphen (Hz), light sensitivity of cones (log units), light sensitivity of rods (log units), colour thresholds (red, green, blue), mesopic vision, monocular fixation of amblyopic eye. Binocular functions also were explored: character of binocular vision by Worth Dot test, sinoptophore (junction, fusion), macular stereovision by Test Lang II, fovea (central) stereovision by suggested device. Statistical evaluations were conducted by the STATISTICA program for Windows 98, for comparative estimation of indexes a criterion of Newman Keuls Test (Breakdown & one way ANOVA) was applied. Analysis of variance of monocular and binocular functions in groups was done in dependence of presence or absence of binocular vision by Worth Dot test and also threshold of fovea (central) and macular (peripheral) stereovision.
3
RESULTS AND DISCUSSION
Threshold of stereopsis by the Lang test II was established positive at 100% of children in the I group, and 23,1% in the II group, among them a threshold within the limits of normal was in 16,7% and higher than normal in 83,3%. A threshold of stereopsis on device for estimation of stereovision was positive in 33,3% and equal to 0 in the 66,7% of children of the I group, and in the II group positive threshold in 15,4% and equal to 0 was established in 84,6% of cases accordingly. In the I group all children had binocular vision on the four dot test and there was a positive result by the Lang test II, therefore an analysis of visual functions depending on presence or absence of the central stereopsis, by elaborated device for measurements of stereo vision disturbances was conducted. Comparative evaluation of averages of indices of the visual functions, having reliable distinctions (by F criterion) in cases with the positive threshold on the device and equal to 0 is presented in the Table 1. From the data presented in the Table1 it follows, that absence of central stereopsis in cases with the central fixation of amblyopic eyes is accompanied by the lower thresholds by Haidinger brush phenomenon of the sound eye and by the greater difference between the values of light sensitivity of cones (P 0,05). Data about the visual functions in children of the II group with amblyopia and eccentric fixation, having binocular and simultaneous vision by the four dot test are presented in the Table 2. From presented data it follows, that in children with the parafoveal and macular fixation in the group of children who had binocular vision, refraction of amblyopic eyes was lower in values, 228
Table 2. Average indices of central functions in the II group of children with anisometropic amblyopia having binocular and simultaneous vision by the four dot test. Binocular vision (n 6)
Simultaneous vision (n 9)
Functions
F
Refraction of amblyopic eye, in dptr. Distinction in the refraction ( ) of both eyes, in dptr. CFf by phosphen of amblyopic eye (in Hz) Threshold of stereopsis by the Lang test II, in arc sec Threshold of depth perception (in mm) from 5 m
54,3
4,05 0,22
6,0 0,01
0,01*
29,46
3,6 0,34
5,75 0,17
0,03*
43,5 0,05
0,04*
0
0,04*
64,0 0,08
0,005*
12,5
53,5 0,7
16,0
533,3 115,4
10,3
52,6 3,05
P 1,2
*P 0,05.
visual nerve liability was higher (CFfph), distinction in force of refraction of both eyes was less, threshold of stereopsis by the Lang test II was positive (better), and threshold of depth perception (in mm) from 5 m lower (better) in comparison to group, in which simultaneous vision was established (R 0,05). The obtained data first allowed revealing broken mechanisms of monocular and binocular vision in anisometropic amblyopia and taking it into consideration during treatment.
4
CONCLUSIONS
In anisometropic amblyopia with the central fixation of amblyopic eye binocular vision by four dot test was established in 100% of children, peripheral stereo acuity by the Lang test II in 100%, among them in accordance with normal (200 arc. sec) in 16,7% and higher than normal in 83,3%. In anisometropic amblyopia with the eccentric fixation of amblyopic eye binocular vision by four dot test was established in the 23, 1% of cases, positive threshold of stereoacuity by the Lang test II was in 15, 4%. In children with anisometropic amblyopia degree of decline of binocular functions depends on difference in refraction (6, 0 dptr.), light sensitivity between both eyes (1, 3 log unit) and liability of visual nerve of amblyopic eye.
REFERENCES Adler F.H Physiology of the Eye. St. Louis, Mosby C.V. 1959, p. 145–180. Campos E.C. Invest. Ophthalmologic, 1989: vol. 13, N5, p. 327–330. Hubel D.H. & Wiesel T.N.: Receptive fields, binocular interaction and functional architecture in the cat’s visual cortex, Physiology (Lond) 160: 106, 1962. Spiritus M., Xuksel D., Vandelammoitle S. Anisometropia and amblyopia in non strabismic children. Transactions 23rd Meeting, ESA, Nancy, Eolus Press, 1996.
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Influence of orbital factor on development and outcome of surgery for intermittent exotropia Y.A. Cho, S. Kim & S. Yi Korea University College of Medicine, Seoul, Korea
ABSTRACT: Purpose: To evaluate the influence of orbital factor on the development and outcome of surgery for intermittent exotropia. Methods: This study includes 210 intermittent exotropes (X(T)), 27 esotropes (ET), and 22 children without strabismus (Normal). The width and height, inner interorbital distance (IIOD), and outer interorbital distance (OIOD) in both orbits were measured with skull A-P roentgenogram. Orbital index (OI, IIOD/OIODX100) was calculated. In X(T), the results of 16 recurrent X(T) and 24 consecutive ET were also analyzed. Results: The IIOD was 25.2 3.19 mm in X(T), 21.2 3.41 mm in ET, and 22.7 4.44 mm in Normal. OI was also greater in X(T) (24.6 2.47 mm) than in ET (22.2 2.62 mm) and Normal (23.1 4.21) (p 0.05). It was greatest in 16 recurrent X(T) (25.7 2.01) and was smallest in 24 consecutive ET (23.8 1.46) (p 0.035). Conclusions: X(T) and recurrence after surgery for X(T) is more prevalent in children with longer IIOD and larger OI than in orthophoric children.
1
INTRODUCTION
Intermittent exotropia (X(T)) is a common form of strabismus in Korean and Japanese who have wide faces.1,2 Exodeviation also frequently occurs in Apert’s or Crouzon’s syndrome associated with hypertelorism.3,4 Recurrence and consecutive esotropia are frequently shown after surgery of X(T).1,2 The causes of X(T), however, have not been clarified yet. The purpose of this study is to evaluate the influence of orbital size and interorbital distance on the development and surgical outcome of X(T), using simple skull A-P image.4,5 2
SUBJECTS & METHODS
This study includes 3 children’s groups which are composed of 210 X(T), 27 esotropes (ET), and 22 normal children without strabismus (Normal). The age of children ranged from 4 to 10 years. Patients with X(T) or ET had an angle of more than 25PD. Normal children were orthophoric children with entropion. The width and height of orbit, inner interorbital distance (IIOD), and outer interorbital distance (OIOD) in both orbits were measured with skull A-P (Antero-Posterior) Roentgenogram (Fig. 1).4,5 IIOD was defined as innermost distance between medial orbital walls, and OIOD as outermost distance between lateral orbital walls. Orbital index (OI, IIOD/OIODX100), as previously described by Morin et al6, was calculated because it was a reliable value regardless of age difference. After surgery of X(T), the cephalometric results of 16 recurrent X(T) and 24 consecutive ET were also analyzed. Orthotropia was defined as esophoria of less than 5PD to exophoria of less than 231
Figure 1.
Skull A-P image. Table 1.
Age and sex distribution. Age (Year)
No. of patients (%)
Group
Mean SD (Range)
Male
Female
X(T) ET Normal
7.14 4.78 (4⬃10) 6.89 1.19 (4⬃10) 6.86 1.55 (4⬃10)
78 (37) 10 (37) 11 (50)
132 (63) 17 (63) 11 (50)
Table 2.
Size of orbit in each group (Mean SD, mm). Orbital width
Orbital height
Group
Rt
Lt
Rt
Lt
X(T) ET Normal
38.6 2.88 36.6 2.82 37.8 3.36
38.7 2.48 36.4 2.85 37.7 3.92
37.8 5.82 33.7 4.69 35.0 4.55
37.7 6.02 33.9 4.53 34.6 4.54
10PD. Exotropia of more than 10PD was regarded as recurrence at 1 year follow-up. Consecutive esotropes were the patients who had esotropia of more than 10PD, diplopia, suppression, and amblyopia for more than 3 months, and underwent recession of medial rectus muscle. 3
RESULTS
Though age distribution is similar in each group, the mean age of X(T) was 7.14 4.78 years of age, slightly higher than ET and Normal. Females slightly outnumbered males (Table 1). There was no significant difference in orbital height and orbital width among X(T), ET and Normal (Table 2). In X(T), IIOD was 25.2 3.19 mm and OIOD was 102.6 6.93 mm. These values were much higher than those of ET and Normal. X(T) also showed the largest orbital index(OI), 24.6 2.47, compared with 22.2 2.62 of ET and 23.1 4.21 of Normal. IIOD and OIOD were the longest in X(T) and the shortest in ET (p 0.05), and a similar result was obtained in OI (p 0.00). 232
Table 3.
Cephalometric values of orbit in each group (p 0.05*, p 0.00**). IIOD*
OIOD*
OI**
Group
(Mean SD, mm)
(Mean SD, mm)
(Mean SD, mm)
X(T) ET Normal
25.2 3.19 21.2 3.41 22.7 4.44
102.6 6.93 95.3 7.41 98.5 5.74
24.6 2.47 22.2 2.62 23.1 4.21
Table 4. Cephalometric values of orbit in patients with recurrence, in patients with consecutive esotropia and in patients with orthophoria after surgery for intermittent exotropia (p 0.05*, p 0.035**). IIOD*
OIOD*
OI**
Patients
(Mean SD, mm)
(Mean SD, mm)
(Mean SD, mm)
Recurrent X(T) Consecutive ET Orthophoria
27.3 2.18 24.3 1.60 25.1 3.39
105.9 2.57 102.2 5.83 102.3 7.33
25.7 2.01 23.8 1.46 24.6 2.60
After surgery of X(T), IIOD and OI of the children with orthophoria was 25.1 3.39 and 24.6 2.60, respectively. The 16 recurrent X(T) showed largest IIOD (27.3 2.18) and OI (25.7 2.01), and 24 consecutive ET showed smallest IIOD (24.3 1.60) and OI (23.8 1.46) (p 0.05, p 0.035, respectively) (Table 4). 4
DISCUSSION
Exodeviation is a characteristic feature in Apert’s or Crouzon’s syndrome associated with hypertelorism.3,4 In hypertelorism, IIOD and intercanthal distance are longer than in normal children. Freihofer 5 and Cohen et al4 mentioned that a barometer of hypertelorism was related to IIOD. In our study, there was no significant difference in orbital height and orbital length among X(T), ET and Normal (Table 2). However, the mean IIOD and OIOD was longest in X(T) children, and shortest in ET (p 0.05) (Table 3). The mean age of X(T) children is a little older than ET or Normal (Table 1). We may take into account the age difference among the three groups because of the age-range of 4–10 years. Cohen et al4 suggest that interorbital distance between eyes develops 50% until age 3, and then the rate of growth decreases and reaches a plateau until puberty.6 This means that the sizes around orbit after 4 years of age are similar, and supports that the comparison of the measurements is meaningful. However, OI (IIOD/OIODX100) may be constant regardless of age or physical development (p 0.05) (Table 5). OI is a good tool to compare with 3 different age groups. It was greater in X(T) children than in ET or Normal (p 0.05) (Table 3) in our results. IIOD and OI were also greatest in 16 recurrent X(T) and smallest in 24 consecutive ET (Table 4). The mean value of IIOD in recurrent X(T) was 27.3 2.18 mm, which was mild hypertelorism by classification (mild, moderate and severe) of Farkas et al.7 In their results, IIOD in mild hypertelorism was 27.3 mm and interepicanthal distance was 38.1 mm. Our results show that the larger the IO or IIOD, the more common X(T), and vice versa. ET and consecutive ET occurred more in patients with small OI or IIOD. The longer IIOD and larger OI may contribute to the development of exodeviation and recurrent exotropia after surgery. This may be evidence that orbital factor contributes to the occurrence of horizontal strabismus and the outcome of surgery. Consideration of orbital factor will be helpful in planning the amount of surgery. 233
5
CONCLUSION
X(T) is more prevalent in children with longer IIOD and larger OI than normal children, and ET is more prevalent with shorter IIOD and smaller OI. The possibility of recurrence after surgery of X(T) was high in children with larger OI than in orthophoric children, and consecutive ET frequently occurred in children with smaller OI.
REFERENCES 1. Cho, Y.A. & Yoo, C.K. 2001. Consecutive esotropia after surgical correction of intermittent exotropia. J Kor Ophthalmol 42(2): 335–41. 2. Maruo, T. et al. 2001. Intermittent exotropia surgery in children: long-term outcome. Binocular Vis Strabismus Q 16(4):265–70. 3. Cohen, M.M. & Kreiborg, J.S. 1996. A clinical study of the craniofacial features in Apert syndrome. Int J Oral Maxillofac Surg 24:45–53. 4. Cohen, M.M. et al. 1995. Hypertelorism: interorbital growth, measurements, and pathogenetic considerations. Int J Oral Maxillofac Surg 24:387–95. 5. Freihofer, H.S. 1980. Inner intercanthal and interorbital distance. J Cranio-Max-Fac Surg 8:324–6. 6. Morin, J.D. et al. 1963. A study of growth in the interorbital region. Am J Ophthalmol 56:895–901. 7. Farkas, L.G. et al. 1989. Orbital measurements in 63 hyperteloric patients. J Cranio-Max-Fac Surg 17:249–54.
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Ocular motility problems following treatment for uveal malignant melanoma E.L.M. Dawson & J.P. Lee Moorfields Eye Hospital, London, England
ABSTRACT: A retrospective review of case notes was carried out of referrals over the past 5 years, from our Ocular Oncology service of patients treated with a plaque for uveal malignant melanoma, that developed ocular motility problems after the removal of the plaque. There were 9 males and 6 females, with an average age of presentation of 56 years. In 5 cases the superior oblique was disinserted. The other muscles reported as disinserted were the lateral rectus, inferior oblique, inferior rectus, superior rectus and medial rectus. Three patients did not have muscles removed. Six patients developed vertical strabismus, 2 horizontal, the other patients were aware of diplopia in different positions of gaze post removals. Eleven patients complained of diplopia. The 4 patients without diplopia developed central scotomas. Five patients were treated with fresnel prisms, 3 underwent successful superior oblique surgery, one had inferior rectus surgery, 4 had botulinum toxin and 2 patients had no treatment. Treatment using plaques can result in troublesome diplopia but can be treated with prisms, botulinum toxin or surgery.
1
INTRODUCTION
Patients may complain of binocular diplopia after treatment for uveal malignant melanoma. When melanomas are treated by brachytherapy it is often necessary to disinsert extra ocular muscles. In addition, patients with poor vision post-treatment may develop sensory deviations. Plaque brachytherapy has the advantage of preserving the globe with relatively low radiation exposure to healthy adjacent tissues.
2
METHOD
A retrospective review of case notes was carried out of referrals from our Ocular Oncology service over the past 5 years treated with a plaque for uveal malignant melanoma, that developed ocular motility problems after the removal of the plaque. The plaques were applied was under general anesthesia. The conjuctiva and Tenon’s capsule were dissected and the borders of the tumour were defined. The plaque was placed on the sclera in correct alignment with the tumour to completely cover the tumour margins by more than 2 mm. When the exact location of the tumour was under an extra ocular muscle, the muscle was temporarily disinserted using the hang-back technique. After the radiation was delivered to the tumour apex, the plaque was removed within 5 days.
3
RESULTS
There were 9 males and 6 females, with an average age of presentation of 56 years. There was a wide range of 23 to 80 years. In 5 cases the superior oblique was disinserted. The other muscles 235
reported as disinserted were the lateral rectus in 5 cases. The superior rectus in 3 cases. The inferior rectus and medial rectus in 2 cases and the inferior oblique in one case. Three patients did not have muscles removed. Six patients developed vertical strabismus, 2 horizontal, the other patients were aware of diplopia in different positions of gaze post removal. Eleven patients complained of diplopia. The 4 patients without diplopia developed central scotomas. Five patients were treated with fresnel prisms, 3 underwent successful superior oblique surgery. In 2 cases the superior oblique tendon was found to be displaced by the plaque and was dissected free. A similar appearance has been seen following encirclement for retinal detachment. One patient underwent inferior rectus surgery, 4 had botulinum toxin and 2 patients had no treatment.
4
CONCLUSIONS
Treatment using plaques can result in troublesome diplopia but can be treated with, prisms, botulinum toxin or surgery.
REFERENCES 1. Langmann A, Langmann G, Unlucerci G, Haleer E.1995. Motility disorders after brachytherapy for uveal melanomas with 106 ruthenium plaques. Ophthalmologe;92:76–78. 2. Sener E, Kiratli H, Gedik S, Sanac A. 2004. Ocular Motility Disturbances After Episceral Plaque Brachytherapy for Uveal Melanoma J AAPOS;8:38–45.
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Recurrent strabismus caused by orbital tumour arising from pulley smooth muscle tissue? P.Ph. van den Broek, J.T.H.N. de Faber & A.D.A. Paridaens The Rotterdam Eye Hospital, Rotterdam, The Netherlands
M. Kliffen Department of Pathology, Erasmus University, Rotterdam, The Netherlands
ABSTRACT: A 35-year-old female patient presented a vascular conjunctival lesion and recurrent exotropia with limitation of adduction. Although at first a retention cyst was suspected, the lesion was not located at a former surgical site. Imaging revealed a well circumscribed anterior tumour located medial to the medial rectus muscle. Following excision, pathological examination demonstrated a benign smooth muscle neoplasm.
1
INTRODUCTION
Orbital smooth muscle neoplasms are exceedingly rare and only sporadically reported in literature. Most cases of benign orbital leiomyoma are located in the posterior orbit and often a vascular wall origin is speculated (Nath et al. 1969, Jacobiec et al. 1975).
2
CASE REPORT
A 35-year-old Caucasian female patient, with previous recession of the IO and LR muscles for exotropia and elevation in adduction with V-pattern, presented a painless vascular conjunctival lesion and recurrent exotropia with limitation of adduction (Fig. 1). She had first noticed the lesion during her pregnancy ten months earlier. On examination there was a large, round, subconjunctival swelling with prominent overlying vessels, a superotemporal translation of the right bulbus and minimal proptosis. Best corrected visual acuity was 20/20 in both eyes. Fundoscopy showed an inferomedial indentation of the right eye. MR-imaging showed an extraconal oval soft tissue mass, inferomedial to the bulbus in the anterior right orbit (Fig. 2). A large yellow-white tumour (23 15 10 mm) was dissected free from its attachment to the medial rectus muscle via a transconjunctival incision. Histopathological and immunohistochemical examination showed the characteristic picture of a benign smooth muscle tumour: leiomyoma. Postoperatively the patient had normal eye motility and visual acuity.
3
DISCUSSION
The paucity of smooth muscle cells might explain why leiomyoma is exceedingly rare in the orbit. Most of the sporadic cases reported in literature are located in the posterior orbit and a vascular wall origin is often speculated (Sanborn et al. 1979). We suggest this anterior located leiomyoma may have arisen from the pulley of the medial rectus muscle because Miller described a relatively abundant presence of smooth muscle cells in this pulley and a dense band connecting it with the inferior rectus muscle around the globe equator (Miller et al. 2003). 237
Figure 1. Clinical photographs showing a large subconjunctival swelling with prominent vessels medial in the right orbit and exotropia with limitation of adduction.
Figure 2. Coronal T1-weighted MR-image showing an extraconal tumour located medial to the medial rectus muscle.
Although very rare, leiomyoma should be considered in the differential diagnosis of a well circumscribed orbital tumour.
REFERENCES Jakobiec FA, Howard GM, Rosen M, Wolff M. Leiomyoma and leiomyosarcoma of the orbit. Am J Ophthalmol. 1975 Dec; 80(6): 1028–42. Miller JM, Demer JL, Poukens V, Pavlovski DS, Nguyen HN, Rossi EA. Extraocular connective tissue architecture. J Vis. 2003; 3(3): 240–51. Nath K, Shukla BR. Orbital leiomyoma and its origin. Br J Ophthalmol. 1963 Jun; 47: 369–71.
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The functional outcome of very late surgery in infantile strabismus E.Ch. Schwarz, K.S. Kunert, G. Wunsch & H. Zappe Charité- University School of Medicine Berlin, Campus Virchow Klinikum, Clinic of Ophthalmology, Germany
1
INTRODUCTION
The number of adult squint patients being operated is rising (Figure 1). An important question to answer is: How often do we restore binocular vision in these patients? The prospective multi-centre clinical trial “Early versus Late Infantile Strabismus Surgery Study” (EOLISS) conducted in 11 European countries showed that binocular vision (striated glasses of Bagolini positive) is significantly better in the early treatment group (age at surgery 6–24 months) than in the late treatment group (age at surgery 32–60 months), but there was no difference beyond Housefly positive between both groups. Therefore we were interested to learn, what degree of binocular vision can be obtained in patients with infantile convergent strabismus having with their first surgery as an adult.
2
MATERIALS AND METHODS
All adult patients with infantile convergent strabismus beginning in the first or second year of life who underwent first strabismus surgery after age 18 in our eye-clinic were collected consecutively. These patients had a permanent great angle and had not received any orthoptic training or prism correction in the past. All patients were examined pre- and postoperatively receiving a full orthoptic status especially tests for binocularity including Bagolini and Titmus tests.
450 400
Number of patients
350
Children Adults
300 250 200 150 100 50 0 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Year
Figure 1.
Squint operations at the Charité.
239
0
1
2
3
3
RESULTS
We collected 258 patients who were operated between the years of 1975 to 2002 at age 18 up to 80 years with a mean age of 33, 3 years. Seventy seven percent were female and 23% were male. The median of preoperative squint angle was 17° convergent with a range of 6° to 30° convergence. Forty three percent of the patients had no amblyopia, 35% showed had mild (0,3–0,8), 20% a moderate (0, 1–0, 3) and only 2% a severe ( 0,1) amblyopia. We found a lack of correspondence in the after image test in 49% of our patients, an anomalous retinal correspondence in 46% and a normal retinal correspondence in 2%. The drop out rate was 3%. In the prism adaptation test done preoperatively, 57% of the patients were Bagolini positive, 41% Bagolini negative and 2% Housefly positive. Ninety five percent of these patients received a combined operation (medial rectus recession combined with resection of the opponent lateral rectus on the same eye). Only 5% got a bilateral recession of the medial rectus muscle. The postoperative angle ranged from 0° to 5° convergence and the median was 0°. Sixty five (25%) of our adult patients with infantile convergent strabismus with very late first squint surgery showed postoperatively binocular vision in the form of Bagolini positive and 5 patients had a positive Housefly or Titmus circle up to 140’’ (Figure 2). 6%
2%
92% Bagolini +
Figure 2.
Housefly +
Titmus rings 140''
Tests of binocularity in patients with postoperative binocular vision (25%).
100% 23%
90% 45%
80%
Patients
70%
51%
60%
Stereo + Bagolini + Bagolini -
50% 40% 30% 20%
n=170
n=228
n=258
10% 0% Early Surgery*
Figure 3.
Late Surgery*
Binocular vision after very late squint surgery.
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Very Late Surgery
* EOLISS-study
4
CONCLUSIONS
The functional outcome in very late strabismus surgery in adult patients is not as good as in late or early surgery during childhood, but an improvement of simple binocular vision is possible in 23% and in some cases with stereopsis (Figure 3), if there is a postoperative microtropia. The good functional outcome was preoperatively predictable in 57% of the patients with the prism test. The restored binocular vision is very useful for the patients. If preoperatively no signs of diplopia are found, squint surgery in adults is recommendable, can be successful and should be done.
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LITERATURE
Unnebrink K, Bauer C, Kolling GH, Simonsz HJ. The early versus late infantile strabismus surgery study: first results (EOLISS). Transactions 28th meeting European Strabismological Association, de Faber (ed.) 2004.
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A binocular scanning laser ophthalmoscope O. Ehrt Department of Ophthalmology, Ludwig-Maximilians-University Muenchen, Germany
ABSTRACT: The purpose of this project was to develop a technical modification of the scanning laser ophthalmoscope (SLO) for simultaneous binocular real-time imaging and stimulation of the retina. External optical elements only were added to a standard SLO 105 (Rodenstock). A system of two pairs of mirrors split the scanning field horizontally and divert the laser beams so that half of the scanning beams enters each pupil. A graphic board is used to generate psychophysical stimuli that are projected onto both central retinas. Adjustment of all four mirrors was critical to get symmetrical and parallel images. Image size was 14° 20° and image quality was good. Demand for good patient cooperation (i.e. steady head position) was slightly higher than for monocular investigations. Simultaneous binocular SLO imaging and psychophysical testing is possible with relatively little technical modifications. This opens a wide field of future research in strabismology.
1
INTRODUCTION
The scanning laser ophthalmoscope (SLO) is a real-time video camera that can simultaneously project psychophysical stimuli onto the central retina (Fig. 1) (Webb 1987). This unique feature allows a very precise functional – topographic correlation especially for visual field testing in macular disease (Timberlake 1987). Several strabismological applications of the SLO have been presented in recent years: funduscyclometry (Schworm 2002, Ehrt 2001b), nystagmography, analysis of the retinal fixation area (Ehrt 2001a). These investigations were done monocularly or consecutively on both eyes.
Figure 1. Standard SLO for monocular imaging and functional testing of the retina: schematic drawing of monocular scanning field.
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Figure 2. Adapter for simultaneous binocular scanning laser ophthalmoscopy: schematic drawing. The distance between the lateral mirrors can be adjusted to the pupillary distance.
Strabismology however, deals with binocular problems and interactions. The purpose of this project was to develop a technical modification of the SLO for simultaneous binocular real-time imaging and stimulation of the retina. 2
METHODS
There are several technical options to simultaneously image both retinas: 2 SLOs: no restricted scanning field, high spatial and temporal resolution but very expensive, needs major modifications to position the patient and very demanding synchronisation of video signals. Semitransparent mirrors and LCD shutter: no restricted scanning field, easy cover testing but loss of light intensity, reduced spatial or temporal resolution, major modification to hard- and software. Splitting the scanning field horizontally or vertically: no modification to original SLO, high spatial and temporal resolution, but reduced scanning field. The third option was chosen. Only external optical elements were added to a standard SLO 105 (Rodenstock). A system of two pairs of mirrors split the scanning field vertically and divert the laser beam so that half of the scanning field enters each pupil (Fig. 2). The video output of a frame grabber and graphic board is synchronised with the SLO and used for the generation of psychophysical stimuli that can be projected independently and simultaneously onto both central retinas. An acousto-optic modulator translates the video signal into high frequency brightness changes of the HeNe-laserbeam. 3
RESULTS
Adjustment of all four mirrors was critical to get symmetrical and parallel images that were not tilted. Image size was 12° wide by 20° high and image quality was good. Fusional movements can be visualized. Objective cyclodeviation: Because the scanning field does not fit the fovea and the optic disc together, monocular reference pictures of each eye have to be taken (Fig. 3). Simultaneous bilateral measurements of objective cyclodeviation may differ significantly from consecutive measurements (5–10°) (e.g. change of head position between measurements, torsional fusion). 244
monocular
Sum = 17.9°° binocular
rotated overlay
rotate 5.2°in
1.8°in
Sum = 10.9° Figure 3. Objective absolute cyclodeviation in a patient with strabismus sursoadductorius (congenital inferior oblique overaction). The monocular measurements of cyclodeviation – defined by the angel between a line connecting the centre of the optic disk with the fovea and the horizontal line – are shown in the top row and binocular images in the middle row. Those are used to rotate the monocular images so that the cyclodeviation during binocular viewing can be measured (bottom row).
4
CONCLUSIONS
Simultaneous binocular SLO imaging and psychophysical testing is possible with relatively little technical modifications. This opens a wide field of future research in strabismology as eye position can be measured with good temporal and very good spatial resolution at the same time as precise 245
functional – topographical correlations can be analysed binocularly. Future applications of the binocular SLO may include objective absolute and subjective cyclometry, investigations into suppression and retinal correspondence even in cases with unstable fixation, simultaneous angiography.
REFERENCES Ehrt, O. & Boergen, K.-P. 2001a. Relative amblyopia: functional chances of early treatment. In J.-T. de Faber (ed.) Transactions of the 26th Meeting of European Strabismological Association: 14–17. Lisse: Sweets & Zeitlinger. Ehrt, O. & Boergen, K.-P. 2001b. Scanning laser ophthalmoscope funduscyclometry in near – natural viewing conditions. Graefes Arch Clin Exp Ophthalmol 239(9): 678–682. Schworm, H.D., Sauter, P., Ehrt, O., Rudolph, G. & Boergen, K.-P. 2002. Long term follow-up of subjective and objective cyclorotatory changes after surgery of the oblique eye muscles. In J.-T. de Faber (ed.) Transactions of the 27th Meeting of European Strabismological Association: 177–180. Lisse: Sweets & Zeitlinger. Webb, R.H., Hughes, G.W. & Delori, F.C. 1987. The confocal scanning Laser Ophthalmoscope. Appl. Optics 26(8): 1492–1499. Timberlake, G.T., Peli, E., Essock, E.A. & Augliere, R.A. 1987. Reading with a macular scotoma. II. Retinal locus for scanning text. Invest. Ophthalmol. Vis. Sci. 28(8): 1268–1274.
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The effect of reducing anticipation anxiety by psychoeducation techniques on vasovagal responses during manipulation of adjustable sutures Orhan Elibol SSK Kocaeli Hospital, Turkey
Levent Karabas, Özgül Altıntas & Yusuf Çag˘lar Kocaeli Üniversity Medıcal Faculty Ophthalmology Dept., Turkey
ABSTRACT: Objective: Significant vasovagal responses bothers strabismus surgeon during the postoperative adjustment process. The aim of this study was to evaluate if vasovagal responses during manipulation of adjustable sutures are affected with reducing anticipation anxiety by psychoeducation techniques. Materials and methods: Sixty-two patients aged between 14–64 were studied prospectively. All patients were operated under general anesthesia and were adjusted 24 hours later. Psychoeducation techniques to reduce anticipation anxiety were performed before adjustment process in 32 patients (Group A). Adjustments were performed by the routine way in 30 patients (Group B). A positive vasovagal response was defined as existence of one or more subjective findings (dizziness, lightheadedness, nausea) and two or more objective findings (10% or greater change in heart rate, pallor, diaphoresis, vomiting, disorientation or loss of consciousness). Positive vasovagal responses during manipulation of adjustable sutures were recorded and compared between the two groups. Results: Positive vasovagal responses were found in 7 patients (21.8%) in Group A, and 11 patients (36.6%) in Group B. Conclusion: Anxiety of the patient is one of the major reasons of vasovagal responses. We noticed that vasovagal responses during postoperative suture adjustment process, are affected by the psychological status of the patient. Before postoperative adjustment, to try to reduce patient’s anticipation anxiety by psychoeducational techniques makes the process more comfortable for both the patient and the surgeon. 1
INTRODUCTION
Unpredictable results after surgical therapy for strabismus have been frustrating for physician and patient alike. The same operation for a similar angle of deviation may yield different results in each patient. In response to the suboptimal results of fixed suture techniques, Jampolsky developed and popularized the adjustable suture technique (JAMPOSKY). Nowadays variations on this technique have become standard treatment method in adult strabismus surgery. In general complications related to adjustable suture surgery are not different than fixed suture techniques. Because of the need for postoperative adjustment of operated muscles, the patients are subjected to some increased discomfort anxiety and possibility of vasovagal responses. Oculocardiac reflex may be a complication of many types of ocular procedures including strabismus surgery, cataract extraction, iridectomy, pressure on the globe, retinal surgery, intraocular and orbital injections, injury to the eye and orbit and blepharoplasty (ALEXANDER, HERTLE, MATARASO). The afferent loop of the reflex is the first division of the trigeminal nerve, the efferent loop is the vagus nerve. The reflex results in a decrease in the heart rate, decreased conduction of the nerve impulses through the heart, and increased muscle contractibility. This trigemino-vagal reflex is part 247
of the vasovagal response (HERTLE). Vagus nerve stimulation in the vaso-vagal response involves the visceral tissues and cerebral blood flow (HERTLE). The most common precipitating stimuli are trauma, pain, fear, Valsalva maneuver, and emotional shock. Premonitory symptoms include feeling alternatively hot and cold, yawning, sweating, nausea, dizziness, and light-headedness. Signs include bradycardia, pallor, emesis, disorientation, loss of consciousness, cardiac arrhythmias, cardiac arrest, and death (HERTLE). It has been suspected that fear, apprehension and anxiety contribute to vagal responses (VRABEC). We conducted this study to identify the incidence of vagal responses occurring during suture adjustment and to determine whether these responses are affected with reducing anticipation anxiety by psychoeducation techniques. 2
MATERIALS AND METHODS
Sixty-two patients undergoing planned adjustable suture surgery from September 1998 to December 2003 were studied prospectively. All patients were operated under general anesthesia. The operations and adjustments were all performed by one of us (O.E). Surgery was performed through a limbal incision, sliding knot is placed at the desired distance from the stump, after tying the muscle suture conjunctiva was recessed to the insertional stump. The 62 patients were assigned to two groups randomly. In Group A (32 patients) psychoeducation techniques (The term describes psychological preparation of the patient for the procedure and education of the patient about all the steps and all the possibilities and expectations during this minor surgical intervention. For this reason a thorough discussion were made between the surgeon and the patient at least 15 minutes in a warm environment.) to reduce anxiety were performed before adjustment process. In Group B (30 patients) adjustment process was performed after a quick explanation about the procedure to the patient, that takes maximum 3 minutes. On the morning after surgery baseline heart rate was recorded before starting adjustment procedure. Then a digital pulsemeter was placed on the patients index finger. The heart rate was continuously monitored throughout the adjustment process. The adjustment was performed 20 to 26 hours after the operation with the patient in a seated position with best corrected refraction, and at least 30 minutes after the eye patch has been removed. We divided the adjustment process in 6 steps including instillation of topical anesthetic in the eye (1) placement of eyelid speculum (2) removal of mucus from the eye (3) measurement of the angle of deviation and assessment of diplopia if present (4) adjustment of the muscle if needed (5) tying the muscle suture (6) And the vagal responses were recorded for each step. A positive vaso-vagal response during adjustment was defined as existence of one or more subjective occurrences (dizziness, light headedness, and nausea) and two or more objective findings (10% or greater change in heart rate, pallor, diaphoresis, vomiting, disorientation or loss of consciousness) (HERTLE). During adjustment process these occurrences and findings were recorded and compared between the two groups. 3
RESULTS
Demographics of the groups were similar. Group A consisted of 15 males and 17 females with age range 14 to 55 years. Group B consisted of 15 males and 15 females with an age range 14 to 64 years. Seven of 32 group A patients (21.8%) that were psychoeducation techniques have been used to reduce anticipation anxiety and 11 of 30 group B patients (36.6%) were noted to have a positive vaso-vagal response. This was not statistically significant (p 0.05). According to our data only in one patient in group B adjustment process was postponed 15 minutes due to the occurrence of disorientation. Vaso-vagal responses were noticed frequently in muscle adjustment step of the adjustment procedure, and than placement of eyelid speculum step in each group. In group A 10 patients had heart rate changes, in 7 of them heart rate had decreased and remaining 3 had increased. In group B 14 patients had heart rate changes, in 11 of them heart rate decreased and 248
remaining 3 had increased. All patients of each group with a positive vaso-vagal responses noticed a decrease in heart rate.
4
DISCUSSION
It is known that most of the patients undergoing adjustment after strabismus surgery experience some level of anxiety and discomfort. Surgeons expect some degree of vaso-vagal responses during postoperative adjustment process. Vrabec et al (VRABEC), noticed the incidence of oculocardiac reflex 4.5%. During postoperative adjustment process vaso-vagal response was observed by . Eustis et al (EUSTIS), 65%, and by Hertle et al (HERTLE) 41.6% of their patients. In our study vaso-vagal response was 21.8% in group A that was psychoeducation techniques have been used to reduce anticipation anxiety and was 36.6% in group B. There are many factors affecting vaso-vagal response during adjustment process such as medication, time of adjustment, patient position, use of eyelid speculum. In our study we observed that psychological preparation of the patient also affect vaso-vagal response during adjustment process. We use eyelid speculum routinely in our patients and we observed that almost 1/3 of the vasovagal responses were occurred in placement of eyelid speculum. This study shows that trying to reduce patient’s anticipation anxiety or discomfort before adjustment process, reduces the vaso-vagal response. We noticed that there is a relation between vasovagal responses and psychological status of the patient. And the surgeon may reduce anxiety and discomfort of patient due to this minor surgical procedure by spending enough time with the patient. By this way postoperative suture adjustment will be more comfortable for both the patient and the surgeon.
REFERENCES ALEXANDER, J.P. Reflex disturbances of cardiac rhythm during ophthalmic surgery. Br J ophthalmol 1975, 59: 519–523. EUSTIS, H.S., CLEMENT, C.E., SMITH, D.R. Vagal responses to adjustable sutures in strabismus correction. Am J Ophthalmol 1992, 114: 307–310. HERTLE, R.W., GRANET, D.B., ZYLAN, S. The intraoperative oculocardiac reflex as apredictor of postoperative vaso-vagal responses during adjustable suture surgery. J Pediatr Ophthalmol Strabismus 1993, 30: 306–311. JAMPOLSKY, A.L. Current Techniques o adjustable strabismus surgery. Am J Ophthalmol 1979, 88: 406–418. MATARASO, A. The oculocardiac reflex in blepharoplasty surgery. Plast Reconstr Surg 1989, 83: 243–248. VRABEC, P.V., PRESLAN, M.W., KUSHNER, B.J. Oculocardiac reflex during manipulation of adjustable sutures after strabismus surgery. Am J Ophthalmol 1987, 104: 61–63.
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A new scoring method for lees charts M. Eliaçik, S. Akar, B. Yilmaz, B. Gökyig˘it & Ö.F. Yılmaz Beyoglu Eye Research and Education Hospital, Istanbul, Turkey
ABSTRACT: Aim: To evaluate lees screening test charts with a new graphic programme. Method: 33 Patients with paralitic or restrictive diplopia gone into lees screening test had been observed by BEYOGLU EYE RESEARCH AND EDUCATION HOSPITAL STRABISMUS DEPARTMENT between August 2003 and February 2004. Conclusions: The new method is an useful way to evaluate the lees charts objectively. Lees charts provide a useful means analyzing and recording muscle imbalance in patients with diplopia. Lees screen test is used to find the orbital muscle or muscles affected by restrictive or paralitic disorders. However, their interpretation is subjective, and comparison between charts may be difficult. In Lees Screen eyes dissociated using two opalescent glass screens at right angles to each other bisected by a two sided plane mirror. (Pediatric Ophthalmology and Strabismus 2000–2001) The points on the chart are shown to patient one by one and told to show the projections of those points on the other side of the chart. The patients answers are checked on a paper by a specialist.(Fig. 1) In Lees Charts there are 16 outer, 8 inner points and at the middle of the chart there is a central point. Scores for both horizontal and vertical deviations are calculated from the displacement of individual point on the lees chart, using weighting factors fot the center, inner, outer zones. (Sullivan TJ 1992, Fitzsimmons R & White J 1990, Woodruff G 1987) In 1992 G.W. ALYWARD and et al used a new scoring test to calculate the horizontal and vertical scores easily. (Aylward G. W 1992) The programme that they used, did not have an advanced graphical programme so they could not calculate the scores correctly. Their program measured the displacements only in linear mode. Also their program could not compare the tests that were done before at the same time on a screen (Fig. 2)
1
MATERIALS AND EXPERIMENTAL METHODS
The scoring system was validated in a group of 33 patients with paralytic or restrictive diplopia who were undergoing surgery, 29 patients had paralitic disordersm 18 (57%) of them had sixth nerve palsy, 6 (19%) of them had third nerve palsy and the others (12%) had fourth nerve palsy,
Figure 1.
Lees chart.
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Figure 2. Screenshot of Aylward G.W., McCarry B., Kousoulides L., Lee J.P., Fells P. (1992) “A Scoring Method for Hess charts” Moorfields Eye Hospital, London.
Figure 3.
Figure 5.
Figure 4.
Screenshots (4. nerve paralysis).
Screenshots (4. nerve paralysis).
(4. nerve paralysis output).
4 patients had restrictive disorders, 2 (8%) of them had troid ophtalmopaty, one (2%) of them adorbital base fracture and the other (2%) had a diplopia after vitreoretinal surgery. Before and after strabismus surgery these patients had Lees Screen Test and their horizontal and vertical scores were calculated by using a new computer program. Our program software was written by professional pc programmer by using Dat Set 1.1 Microsoft Tech. And graphics were illustrated by 252
using visual basic dat.net. (Visul Basic Net 2. Edition) Datas were collected by microsoft access. Datas were transferred between visual dat.net and microsoft access by C sharp software. The displacements of the points on charts were analyzed with fuzzy logic. The displacements of the points were made on program screen by computer mouse and the scores automatically were shown at the left side of the table. Figures 3–4 Also we could compare preoperative and postoperative tests on screen at the same time at the end of the observation we could print results as a special format Fig. 5 and put them patient files.
2
CONCLUSION
In 1992 G.W. ALYWARD and et al wanted to calculate the horizontal and vertical scores by using a computer program but that one could not determine distances between the points. Their graphic programme could not show gradients between the points so it only used linear distances between them. In our recent study we used a new graphic programme to remove that problem. So we calculated the scores definitely. We used the same formulas with G.W. ALYWARD and et al. Our scoring system has applications in both research and clinical practice, allowing objective analysis of changes in muscle balance in a variety of motility disorders.
REFERENCES 1. Aylward GW, McCarry B, Kousoulides L, Lee JP, Fells P (1992) “A Scoring Method For Hess Charts” Moorfields Eye Hospital London 6. pp. 659–661 2. Fitzsimmons R & White J. “Functional scoring of the field of binocular single vision” Ophthalmology 1990, 97. pp. 33–35 3. Sullivan TJ, Kraft SP, Burack C, O’Reilly C “A functional scoring method for the field of binocular single vision” Ophthalmology 1992, 99. pp. 575–581 4. Pediatric Ophthalmology and Strabismus 2000–2001 (The Foundation of The American Academy section 6) pp. 64–67 5. Visual Basic Net 2. Edition 6. Woodruff G, O’Reilly C, Kraft SP “Functional scoring of the field of binocular single vision patients with diplopia”. Ophthalmology 1987, 94. pp. 1544–1561
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About a case of children’s myasthenia gravis Dora Fernández Agrafojo Doctor in Medicine and Surgery, Ophthalmologist, Spain
Pedro Martín Enrile Optometrist, Graduate in Optics and Optometry, Masters in Optometry and Vision Science, Spain
Jaime Pauné Fabré Optometrist, Graduate in Optics and Optometry, Spain
ABSTRACT: Myasthenia is an autoimmune disorder, characterised by a reduction of the postsynaptic receptors of acetylcholine (ACh) and affectation of the skeletal muscle as main clinical signs. The present study describes a purely ocular form of child myasthenia, and the treatment and monitoring during 12 months of evolution of a 4 years old patient that came to our office with bilateral paralytic ptosis and an apparent incomplete paralysis of III cranial nerve.
1
INTRODUCTION
Nowadays, it is commonly known that myasthenia is an autoimmune disorder, characterised by a reduction of the post-synaptic receptors of acetylcholine (ACh), which are useful at the level of the neuromuscular end-plate membrane of the skeletal muscle. Apparently, the humoral immune response has an important role in the production of this disease. (This is, G immunoglobulins – Ig G – polyclonals produced by B-cells). This can be proved by the fact that anti-bodies can be found against the receptors of acetyl-cholinesterase in patients with generalised illness in 80% of the cases, and around 50% of the patients with myasthenia restricted to the ocular muscle.1 This disease is twice as common in women than men, and it usually develops in young adults.2 1.1
Myasthenia in young people
Myasthenia in young people usually starts from 10 years old onwards. However, there are cases of children’s disease from two year old onwards. The non existence of family history makes diagnosis more difficult. 1.2
Clinical signs
The beginning is often insidious. On the first stage, signs are not very clear. When it starts, ptosis doesn’t exist and it is hardly noticeable and it becomes more pronounced during the day. In the purely ocular forms, as the one we describe here, the oculomotor muscles are the only responsible for it. In the generalised forms, ptosis and/or diploplia are the two initial signs in approximately two thirds of the cases. One or several oculomotor muscles can be affected. This fact can create confusion and make us pronounce a wrong diagnosis of oculomotor paralysis of neurological origin either unilateral or bilateral. If we are not sure about it, we have to consider that with myasthenia the pupillary reflex is always conserved thanks to the preservation of the pupillary muscles and the accommodation. 255
Myasthenia usually appears as: muscles weakness without other signs of neurological deficit, variations of the muscular function in several minutes, hours or weeks. Infections, fevers or traumatisms can provoke aggravations. There use to be a betterment or normalisation after using acetylcoline drugs. There is an association between myasthenia and thymoma (around 10% of the cases). When this happens, the clinical evolution is serious with an important rate of mortality. Besides, 5% of people suffering from myasthenia suffer as well of dysthyreosis, so ocular signs can be mixed, i.e.: ptosis and exophthalmos. The affectation of ocular muscles represents 90% of myasthenia and is the first manifestation of the disorder in 75% of the cases.3 Several researches4 show than from the 50% of patients that presented strictly ocular manifestations a month after the beginning, 34% continued presenting a myasthenia purely ocular during the four decades of monitoring. The humoral immune response in ocular myasthenia is different from the generalised myasthenia in the fact that there is a low rate of antibodies, which inhibit the acceptance of acetylcholine (ACh)1,5 with significant low levels of serum. This discovery suggests that both the auto-antigenic nature as the place of autosensitization and the antibody characteristics limit the ocular expression of the disorder. Oculars signs change in the lapse of several hours, weeks or months. But there is almost always a certain degree of ptosis. Ptosis can be unilateral at the beginning and become apparent with tiredness or illness. As in the case we describe here, the oculomotor paralysis can “jump” from one eye to the other. The initial ocular appearance of myasthenia can be any kind of oculomotor affectation from isolated muscular paralysis to total extrinsic ophthalmoplegia.
2
MATERIAL AND METHOD
The patient is a four years old male without ophtalmologic history, that comes to our office with bilateral paralytic ptosis more pronounced in the right eye with 48 hours of evolution. This ptosis goes with an apparent incomplete paralysis of III cranial nerve with the corresponding diplopia. We classified this paralysis as incomplete as it didn’t show pupillary affectation. The study of fundus oculi and the rest of the ophtalmological study is normal. The mother explains that the child shows a clear variability during the day, with a neat worsening in the evening. Because of the apparent gravity of this picture, we decide to get him to hospital to carry out and neurological test. After his admission in hospital, complementary diagnostic studies were conducted in otolaryngology and neurology, obtaining normal results. After that, it was decided to carry out a cranial NMR with contrast and chest CAT, which gave normal results as well.
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In order to confirm our diagnostics hypothesis of ocular myasthenia gravis, we asked for an analysis and EMG that confirm it, and afterwards we made a chest scanner with normal radiological characteristics in relation with his age. 2.1.1 Evolution We start with an oral treatment with prostigmin in a rising dosis, with a slight betterment of the ocular motility and of ptosis. According to that, he is discharged from hospital, asking him however to continue with 60 mg of prostigmin every 6 hours and with external monitoring. After 10 days of treatment during which there still is a ptosis in the right eyelid more pronounced in the evening with a paresis of the right inferior rectus muscle, we decide, in accordance with the Neurology Service, to add 1mg of prednisone for kg of weight, reducing the dose of prostigmin to 30 mg every 6 hours. 10 days after that, the extraocular muscles seem normal, even though there still is a slight right paralytic ptosis with worsening in the evenings. After 3 weeks, the opthalmological examination is normal. Two months after the medical treatment, during which there still persists a slight evening intermittent ptosis, we reduce corticoisteroids following a pattern of 5 mg per month. The evolution of the patient continues to be good.
3
DISCUSSION
In occasions, myasthenia diagnosis has to be based in the clinical history and in the meticulous physical exploration. One of the most valuable test is the intravenous use of edrofonium. However, this test has problems in its interpretation when signs are minimal or not constant. The response of these patients to an anticolinesterasic treatment is difficult to evaluate. The experts in myasthenia agree that preservation of the pupillary muscles and accommodation is a characteristic of myasthenia. Isolated descriptions6 and laboratory data7,8 that establish conclusions in the opposite sense, lack of strength. In those cases, we have to take into account other diagnosis. Because of this flimsiness, we haven’t been able to assess the so-called “Ice Test”. This is a very simple and quick to interpret test. Ice has to be applied for five minutes. When ice is taken of, the eyelid has to be pulled up during some minutes in a patient with possible ptosis of myasthenic origin9. The evolution of electromyography of single fibre (SFEMG), since Erik Stalberg and Jan Eksed studies10, has allowed the examination of the micro physiology of the unit motor showing the spectrum of the functional changes in the individual motor plaques. This study (SFEMG), through axonal activation or micro stimulation, has shown to be more sensible than the rest of techniques 11,12,13,14,15 , as it detects an important percentage of alteration according to the clinical form and the explored muscle. For ocular myasthenia it is studied the frontalis and orbicularis oculi. On the other hand, some jitter serial measurements in patients with myasthenia can be very useful as support to the clinical picture in progression16,17. 257
Finally, we just want to add that the ocular myasthenia has to be treated with anticolinesterasic, even though the response uses to be poor4. If this happens, the use of corticoisteroids will be justified18.
4
CONCLUSIONS
I. We consider that the medical treatment of ocular myasthenia is basically the job of a neurologist. However, the collaboration of the ophthalmologist is the revaluation of the ocular motility and the use of prisms, ocluders and eyelid support if necessary. II. Surgery of ptosis in those cases is dangerous, as the defects of palpebral motility are variable. III. The treatment of myasthenia nowadays is based both in the increasing of the useful acetylcholine through inhibitors of cholinesterase as in the reduction of the autoimmune response with corticoisteroids, mainly in the case of the resistant ocular signs. IV. As an alternative, we have the immunosupressors agents4,19,20, plasmapheresis21 or thymectomy22.
BIBLIOGRAPHY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
11. 12. 13. 14.
15. 16. 17. 18.
Soliven BC, Lange DJ, Penn AS: Seronegative myasthenia gravis. Neurology 38: 514, 1988. Seybold ME, Lindstrom JM: Myasthenia gravis in infancy. Neurology 31: 476, 1981. Osserman KE: Ocular myasthenia gravis. Invest Ophthalmol 6: 277, 1967. Grob D, Arsura EL, Brunner NG, Namba T: The course of myasthenia gravis, and therapies affecting outcome. Ann NY Acad Sci 505: 472, 1987. Vincent A, Newsom-Davis J: Acetylcholine gravis. I. Patients with generalized to ocular muscles. Clin Exp Immunol 49: 257, 1982. Romano PE, Stark WJ: Pseudomyopia as a presenting sign in ocular myasthenia gravis. Am J Ophthalmol 75: 872, 1973. Bryant RC: Asymmetrical pupilary slowing and degree of severity in myasthenia gravis. Ann Neurol 7: 288, 1980. Dutton GN, Garson JA, Richardson RB: Pupilary fatigue in myasthenia gravis. Trans Ophthalmol Soc UK 102: 510, 1982. Ellis FD, Hoytcs, Ellis FJ, Jeffery AR, Sondhi N.: Extraocular muscle responses to orbital cooling (ice test) for ocular myasthenia gravis diagnosis. JAAPOS 2000 Oct; 4(5): 271–281. Stälberg E, Ekstedt, J. Single fibre electromyography and mycrophysiology of the motor unit in normal and diseased muscle. En: Desmedt, J.E. (ed). New developments in electromyography and clinical neurophysiology. Karget, Basel 1973, 1: 113–179. Sanders DB, Massey JM: Electrodiagnostico de miastenia gravis y sindrome miasténico de LambertEaton. Clínicas Neurológicas de Norteamérica 1994, 2: 283–307. Keesey JC.AAEE Minimonograph # 33: Electrodiagnostic approach to defects of neuromuscular transmission. Muscle Nerve 1989; 12: 613–626. Stalberg E, Trontelj JV. Single fiber electromyography. Studies in Healthy and diseased muscle. 2nd ed. Ravn Press, New York 1994. Cruz Martínez A, Ferrer MT, Pérez Conde MC. y cols. Miastenia gravis. Actualización del diagnóstico electrofisiológico (II). Electromiografia de fibra única (SFEMG). Correlación con los resultados de otras técnicas diagnósticas. Rev Neurol 1981; 42: 197–211. Oh SJ, Kim DE, Kuruoglu R, Bradley RJ, Dwyer D. Dignostic sensitivity of the laboratory tests in myasthenia Gravis. Muscle nerve 1992; 15: 720–724. Cruz Martínez A, Montero J. EMG fisiopatología de la transmisión neuromuscular. En Diez Tejedor E (ed.). Miastenia gravis y síndromes miasténicos. J.R. Prous. Barcelona 1995; 17–75. Sanders B. Single fiber electromyography. Introduction to fiber density & jitter. International course on single fibre emg. September, 1998, Vigo-Spain. Kupersmith MJ, Latkany R, Homel P. Development of generalized disease at 2 years in patients with ocular myasthenia gravis. Arch Neurol. 2003 Feb; 60(2): 243–248.
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19. Tindall RSA, Rollins JA, Phillips JT et al: Radiologic liminary results of a double-blind, randomized, placebo-controlled trial of cyclosporine i myasthenia gravis. N Engl J Med 316: 719, 1987. 20. Hohlfeld R, Michels M, Heininger K et al: Azathioprine toxicity during long-term immunosuppression of generalized myasthenia gravis. Neurology 38: 258, 1988. 21. Thorlacius S, Lefvert AK, Aarli JA et al: Plasma exchange in myasthenia gravis: Effect on antiAChR antibodies and other autoantibodies. Acta Neurol Scand 74: 486, 1986. 22. Rowland LP: Controversies about the treatment of myasthenia gravis. J Neurol Neurosurg Psychiatry 43: 644, 1980.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Strabismus after in-vitro fertilization R. Gomez de Liaño, I. Genol, I. Iglesias, Y. Fernandez & M. Barrio Hospital Clinico Universitario San Carlos De Madrid, Spain
ABSTRACT: Introduction/Objective: Although different ophthalmological complications have been reported after in vitro fertilization, up to now there is no data available concerning strabismus. We present 7 patients with different types of strabismus and the pathogenesis will be discussed. Materials and methods: Patients 1 and 2 had Bilateral Duane Syndrome. Patient n° 3 had an Infantile Esotropia, Patients 4 trough 6 had acquired esotropia and patient n° 7 had an intermittent exotropia. Results: Multiple factors have been described as possible pathogenic factors in other ocular or systemic complications as: genetic (due to manipulation, to ovarian stimulation or to pathologic oocytes), vascular (abortion menace), the use of progesterone and antiabortive products and children of very low weight at birth (multiple deliveries, prematurity, mother age at pregnancy). Conclusions: Strabismus may appear after in vitro fertilization. Although different mechanisms may be the cause, we do not think our cases were due to the technique it self, but rather to the complicated characteristics of the women, who went through in vitro fertilization or to the multiple deliveries.
1
INTRODUCTION
Although different ophthalmological complications have been reported after in vitro fertilization (IVF)1–4 (Figure 1), up to now there is no data available concerning strabismus. We present 7 patients with different types of strabismus presented after in vitro fertilization. We discuss different mechanisms involved to associate an etiopatogenic relationship between IVF and the development of a strabismus. 2
CLINICAL CASES
We present 7 patients that presented strabismus and that have been conceived by IVF. Figure 2 shows obstetric antecedents, the cause of infertility, medication used to stimulate IVF, evolution of
Figure 1.
Reported ocular manifestations after IVF.
261
Figure 2.
pregnancy, abortion menace, maternal age, duration of gestation, multiple deliveries, weight at birth, cariotip and strabismus, familial strabismus history and type of strabismus they presented. 3
DISCUSSION
The appearance of a strabismus after IVF may be due to different pathogenic mechanisms. 1. An associated pathology: All described ocular pathologies may appear spontaneously or be related to familial transmission. 1/7 of our patients had familial history of strabismus or amblyopia. (Patient n°5). 2. Oocyt characteristics, stimulation and IVF: There has been reported a raised relative risk for Retinoblastoma. Maybe several factors contribute, as: a. The characteristics of the oocytes in some cases of infertility. b. There is a higher frequency of cytogenetic abnormalities and errors in cell-cycle regulation in oocytes generated from IVF or intracytoplasmic sperm injection. c. An increased risk of developing neuroblastoma, and leukemia among offspring of women treated with infertility drugs has been reported. Maybe those factors could increase the rate of retinoblastomas or other ocular genetic malformations but it does not likely will conduce to strabismus alone. 3. Factors associated to a higher risk pregnancy: a. Increased rate of abortion menace in the first trimester (embryonic genetic abnormalities, mother higher age, cause of infertility). 3 of our patients had an important abortion menace 2 of them were the two cases of bilateral Duane syndrome with abortion menace precisely at the time of the development of the oculomotor nucleus. Abortion menace, and other insults between the 7–8 week has been considered as a probable cause of some cases of Duane syndrome6. This pathogenic mechanism may have contributed conduce to other ocular abnormalities. b. Low weight at birth: An increase of multiple deliveries and higher mother age may conduce to early delivery, pre-maturity and lower weight at birth. Low weight at birth, maternal age and multiple deliveries have been related in the literature to develop ROP, refractive abnormalities and other ocular pathologies6. An important number of our patients (Table II) were born before week 37, 4 of them were multiple deliveries and 3/7 weighted below 2000 gr., Different etiologies have been considered as the cause of strabismus. Lower weight at birth has been associated to a higher rate of infantile and acquired strabismus7. 262
4
CONCLUSIONS
1. There are several pathogenic mechanisms that can conduce to ocular complications after invitro fertilization: genetics (due to ovarian stimulation or oocyt manipulation), vascular (abortion menace), The use of antiabortive, progesterone and other substances and the low weight at delivery (multiple deliveries, higher mother age, prematurity). 2. In our series we present different types of strabismus. Although different pathogenic mechanisms may provoke or decompensate a predisponent strabismus, we consider that in-vitro fertilization in itself, is not necessarily an important risk factor causing strabismus, but rather the complicated characteristics of the infertility and pregnancies of women going to IVF: quality of oocyts, maternal age, history of abortion, multiple deliveries, prematurity.
BIBLIOGRAPHY 1. Saunders K, Spensley J, Munro J, Halasz G. Growth and physical outcome of children conceived by in vitro fertilization. Pediatrics. 1996; 97: 688–692. 2. Olivennes F, Kerbrat V, Rufat P, Blanchet V, Fanchin R, Frydman R. Follow-up of a cohort of 422 children aged 6 to 13 years conceived by in vitro fertilization. Fertil Steril. 1997; 67: 284–289. 3. Anteby I, Cohen E. Ocular manifestations in children born after in vitro fertilization. Arch Ophthalmology 2001; 119: 1525–1529. 4. Misoprostol and pregnancy. N. Engl J Med 2001; 344(1): 38–47. 5. Kitchen WH, Richards A, Ryan MM et al: A longitudinal study of very low-birth infants: II Results of controlled trial of intensive care and handicaps. Dev.Med.Child. Neuro, 1979; 21: 582. 6. O’Connor A, Stephenson T. Strabismus in children of birth weight less than 1701 gr. Arch Ophthalmology. 2001; 120: 767–773.
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Surgical treatment of strabismus fixus with high myopia B. Gökyig˘it, S. Akar, A. Basoglu, O. Oral & Ö.F. Ylmaz Istanbul Beyog˘lu Educational and Research Eye hospital, Istanbul, Turkey
ABSTRACT: Purpose: We aimed to investigate surgical treatment of convergent strabismus fixus patients who have acquired high myopia and its efficiency. Materials & Method: Files of nine high myopia patients with strabismus fixus, operated and followed-up in our hospital, were retrospectively investigated. Findings: The patients were between 32–63 years old and were followed up 1–12 months. Deviations in all patients were more than 45° Hirschberg. Excessive recession for two eyes’ medial rectus of all the patients (11–13 mm), excessive resection of lateral rectus in five patients (10 mm), Jensen procedure to one patient between superior and lateral rectus behind the equator and tucking surgery to three patients were performed. Adjustable recession to inferior rectus was carried out with second operation to three patients and with first operation to four patients. Result & Conclusion: Excessive horizontal muscle and/or Jensen is surgery not always adequate at that patients and inferior rectus surgery may be necessary. 1
INTRODUCTION
Strabismus fixus is a rare condition of one or two eye’s extreme adduction or abduction character. In this position, effected eye is fixed, it cannot move and this can be shown in forced duction test. Hugonier and Magnard were the first authors to direct attention to restrictive motility disturbances in severe myopia (von Noorden 2002). They believed it was caused by an unspecific myositis. Since than, it was shown that this progressive strabismus formed in high myopia cases may be due to several causes. One of the causes is a disproportion between the size of the orbit and the volume of an enlarged and elongated myopic globe (Aoki 2003, Aydin 1992, Bagolini 1990, Ohta 1999). One of the best-known forms of restrictive strabismus in high myopia is heavy eye syndrome which was first described by Bagshaw (1966). It is also claimed that strabismus fixus with high myopia is a mitochondrial myopathy (Venkatesh 2003). In the treatment, different methods such as extreme recession or desensertion of medial rectus, upward transposition of horizontal recti and/or recession of inferior rectus were used. Recently, operation of tying superior and lateral rectus to each other at equator is used as an additional surgery in early cases. With this study, we aimed to investigate the effectiveness of our surgical treatment applied to nine patients in our hospital. 2
MATERIALS AND METHOD
Files of nine patients, operated and followed-up in the Strabismus Department of our hospital, between 1992–2004, were retrospectively investigated. 3
FINDINGS
The patients, 4 male and 5 female, were between 32–63 years old (med 52 years old). While right eye of one patient and left eye of five patients were effected, three patients had their both eyes 265
effected. Refractive errors in the measurable eyes of patients who did not have anterior segment operations, changed between (18.00) – (24.00) Diopter and the axial length in all were above 33 mm. Patients’ configurations and some of the preoperative findings and duration of the deviations are shown at the Table 1. Deviations in all patients were more than 45 degrees Hirschberg. 3 of the patients’ corneas were out of the rima palpebrarum in nasally (no.1, 5, 8). Their strabismus increased during the last 5–25 years. There was cataract in addition to high myopia on 2 patients (no.5, 8), due to strabismus on 4 patients (no.2, 5, 8, 9) and 3 patients due to cataract or refractive reasons had lens extraction (no.5, 7, 8). During the MR examination of 2 patients, all 4 recti were found to be approaching each other. Eyes had changed position in opposite direction of two recti which were separated from each other. Pre-operative gazes of cases 6 and 9 are shown in Figures 1, 2. Preoperative ocular examination findings, past surgeries, operations applied and recent visual acuity and deviation findings in our patients are shown in Table 2. Medial recti in all patients were found stretched and recessions were done in reachable distances (8–10 mm). One-year post-operation controls of 6 patients who were within 15° Hirschberg, showed no increase in their strabismus. Table 1.
Patients’ findings.
Age
Sex
Side
V.A. R/L
Refractive Error
Axial Length
Duration
1
58
F
L
0.1 0.1
22.00 24.00
33 33
11 years
2
59
F
R
0.1 0.1–0.2
immeasurable 18.00(1.25 60)
33 33
9 years
3
49
F
L
5 m.fc. 3 m.fc.
21.00 (1.25 150) 22.00 (3.25 150)
33 33
5 years
4
56
M
L
0.2 0.2
19.00 (2.25 35) 21.00 (2.00 140)
33 33
5 years
5
63
F
B
0.3 0.2
immeasurable 1.25 (0.50 125)
33 33
9 years
6
60
M
L
0.1 hm
6.00 (5.00 35) immeasurable
33 immeasurable
25 years
7
33
M
L
0.1 0.1
1.25 (2.00 17) 1.50 (1.75 12)
33 33
10 years
8
63
F
B
PP 0.1
immeasurable immeasurable
immeasurable immeasurable
25 years
9
33
M
B
0.2 0.2
11.50 (5.50 90) 10.00 (2.00 100)
32.64 33.26
13 years
V.A-Visual Acuity; R-Right; L-Left; F-Female; M-Male; fc.-Finger count; hm.-Hand movement; P P Light Perception and Projection .
Figure 1. Case 9, pre-operative gazes.
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Figure 2. Case 6, pre-operative gazes. Table 2.
Patients’ preoperative findings, applied surgery and recent findings.
Preoperative ocular findings
Surgery (past)
Left medial rectus 10 mm recession lateral rectus 9 mm resection Left inferior rectus 5 mm recession Right medial rectus 10 mm recession
0.1 0.1
2 Lateral & Superior Gaze Squint Limitation ET (45° Hirschberg)
Right medial rectus 10 mm recession lateral rectus 9 mm resection Right inferior rectus 5 mm recession
0.1 0.2
1–10°H.
3 Lateral & Superior Gaze Limitation ET (45° Hirschberg)
Bilateral medial rectus 10 mm recession left lateral rectus 9 mm resection both left recti supraposition Left inferior rectus 5 mm recession
5 m.fc 3 m.fc
1–10°H.
4 Lateral & Superior Gaze Limitation ET (45° Hirschberg)
Bilateral medial rectus 10 mm recession left lateral rectus 9 mm resection both left recti supraposition left inferior rectus 5 mm adjustable recession
0.2 0.2
1–10°H.
5 Lateral & Superior Gaze Squint Limitation, Left cataract ET (45° Hirschberg) ECCE
Left medial rectus 9 mm recession lateral rectus 9 mm tucking Left inferior rectus 5 mm recession Right faco medial rectus releasing
0.3 0.2
1–35° H.
6 Keratoplasty, ET (45° Hirschberg)
Left medial rectus 10 mm recession Lateral rectus 8 mm tucking; Left inferior rectus recession 6 mm.
0.1 hm
1–25° H.
7 Lateral Gaze Limitation Bilat. ET (30° Hirschberg), ECCE glaucoma, Pseudaphaki Left cataract Squint
Bi medial recti 10 mm recession left Jensen between lateral & superior recti; Lateral rectus 10 mm tucking Right Medial rectus releasing lateral
0.2 0.2
1–10 BO
8 Gaze Limitation, ET (45° Hirschberg)
rectus tucking; Left Medial rectus releasing Lateral rectus tucking; Left inferior rectus recession 8 mm.
0.1
1–10°H.
Bi medial recti 10 mm recession Lateral rectus 9.0 mm tucking
0.2 0.2
1–4 BO, 10 R/L
1 Left cornea out of the rima and change place infero-nasal position (45° Hirschberg)
Recent Findings V/A deviation
Surgery
–
–
(2) ECCE
9 Lateral Gaze Limitation Squint ET (30° Hirschberg)
*1–45° H. *2–30° H.
2–25° H.
2–20° H.
2–8 BO
0.1
1–10°H.
ET – Esotropia; H.– Hirschberg; BO – Base Out; R/L – Right over Left; *1 after first operation * 2 after second operation
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4
DISCUSSION
Kong in his 19 cases in 1993, has used suturing the outer rectus tendon to rima’s outer edge together with medial and inferior rectus tenotomy technique and correction was stable in his long follow-up (Kong 1993). While Bagheri in 2001 was successful in long follow-up of his 2 cases with excessive recession operation (Bagheri 2001), Hayashi recorded fast regression in his 35 cases with the same operation technique (Hayashi 1999). Herzeu and Krzizok have applied horizontal transposition to muscles and in some cases; they fixed muscles to sclera with a silicon tape (Herzau 1996, Krzizok 1997). In contrast to these authors’ successful work, Campos using the same technique states that the results are not sufficient (von Noorden 2002). Hayashi’s approach is towards etiological and is successful in early cases (Hayashi 1999). With the application of same technique 1 of our 2 cases needed additional operations. We think that, long contraction and fibrosis formed due to late treatment of strabismus effect the success of this operation highly negatively. Mansour et al.’s post-mortem study on two eyes found ischemia (Mansour 1987). This shows the importance of early surgical treatment.
5
CONCLUSION
In conclusion, when we evaluate this series, excessive horizontal muscle surgery is not enough in strabismus fixus with high myopia cases and results may change in long term. Patients need more than one operation and one of these includes vertical muscle surgery.
REFERENCES Aoki Y et al. (2003): “Magnetic resonance imaging measurements of extraocular muscle path shift and posterior eyeball prolapse from the muscle cone in acquired esotropia with high myopia.” Am J Ophthalmol. 136(3):482–9 Aydin P, Kansu T, Sanac AS. (1992): “High myopia causing bilateral abduction deficiency” J.Clin.Neuro.Ophthalmol. 12:163 Bagheri A., Adhami F., Repka M. (2001): Bilateral recession-resection surgery for convergent strabismus fixus associated with high myopia. Strabismus. 9(4):225–30 Bagolini B, Tamburelli C, Dichmann A, Colosimo C. (1990): “Convergent strabismus fixus in high myopic patients.” Doc.Ophthalmol. 74 (4), 390–40 Bagshow J. (1966): “Heavy eye phenomenon.” Br.J.Ophthalmol. 23:73 Hayashi T, Maruo T. (1999): “Acquired progressive esotropia and acquired strabismus fixus” Nippon Ganka Gakkai Zasshi 103(8): 604–11 Hayashi T. Iwashige H, Maruo T. (1999): “Clinical features and surgery for acquired progressive esotropia associated with severe myopia” Acta Ophthalmol Scand. 77:66 Herzau V, Ioannakis K. (1996): “Zur Pathogeneses der Eso-und Hypotropie bei hoher Myopie” Klin Monatsbl Augenheilkd. 208(1):33–6 Kong LY, Zhang FH. (1993): “High myopia with esotropia fixus.” Chung Hua Yen Ko Tsa Chih 29(5):274–76 Krzizok T, Kaufmann H, Traupe H. (1997): “New approach to strabismus in high myopia” Br J Ophthalmol. 81:625 Mansour AM, Wang F, el Bobe F, Henkind P. (1987): “Ocular complication in strabismus fixus convergens” Ophthalmologica. 195(3):161–6 Ohta M, Iwashige H, Hayashi T, Maruo T. (1999): “Computed tomography findings in convergent strabismus fixus.” Nippon Ganka Gakkai Zasshi. 99(8):980–5 Toshio M, Nobue K, Hiroyasu I. (1993): “Convergent Strabismus Fixus” Transaction 21st meeting ESA Editor: H.Kaufmann, Salzburg, 259–64* Venkatesh CP, Gayathry N, Murthy KR. (2003): “Myopic strabismus fixus: a mitochondrial myopathy?” Am J Ophthalmol. 135(5):720–2 von Noorden GK, Campos EC. (2002): “Binocular vision and ocular motility,” Theory and Management of strabismus. Sixth edition, Mosby co. St.Louis, 473–74
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Carotid Doppler Ultrasonography in congenital IVth nerve palsy Ylmaz B. Gokyig˘it, S. Akar & O.F. Istanbul Beyoglu Education and Research Hospital, Istanbul, Turkey
ABSTRACT: Purpose: To determine the etiological role of changes in carotid artery blood flow in the facial asymmetry in congenital IVth nerve paralysis. Materials & Method: This study includes 24 patients who had marked facial asymmetry and head position. Patients head position was manually corrected and the colored Doppler Ultrasonography (USG) to bilateral carotid arterial system was applied (Group A). 12 of these patients underwent the same procedure without correcting their head position (Group B). Wilcoxon Signed Ranks test was used for statistical evaluations. Findings: In Group A, a meaningful statistical difference was not found in peak systolic and end diastolic speeds of internal carotid artery (ICA) and common carotid artery (CCA) and between ratio of peak systolic and end diastolic ICA/CCA. When the carotid USGs applied to Group B, peak systolic speed of ICA on the facial hypotrophy side was statistically meaningfully lower than the other side (p 0.05). There were no meaningful statistical differences in other results. Result & Conclusion: This study shows us that in the development of facial asymmetry, besides other factors, vessel restriction may also be responsible.
1
INTRODUCTION
Facial asymmetry develops due to many factors such as trauma, craniosynostosis, facial mikrosomia, phakomatosis, progressive facial atrophy, facial paralysis and cyclovertical muscle paralysis (Bagolini 1982, Hertle 1992, Muchnick 1979, Puttermann 1979). In Congenital cyclovertical extra ocular muscle paralysis, concurrence of head tilt with facial asymmetry was first expressed by Parks in 1958 (Parks 1958). Facial asymmetry is typically described as smaller mid portion of the face on the side of the head tilt and it is generally with the nose plate displaced in the direction of the head tilt (Goodman 1995, Parks 1958, Paysee 1995, Rubin 1986). In congenital superior oblique palsy, facial asymmetry pathogenesis found with the ocular tilt is not yet fully understood and there are different opinions regarding its formation mechanism (Clark 1998, Demer 1995, Goodman 1995, Horton 1967, Paysee 1995, Velez 2000, von Noorden 2002). Colored Doppler investigation is an ultrasonic visualization technique in appraising qualitatively and quantitatively the blood flow velocity and is used in calculating blood flow in clinical and laboratory investigation of different vascular illnesses (Aburn 1993, Eyer 1981, Mitchell 1990). In this study, we aimed to determine the etiological role of changes in carotid artery blood flow in the facial asymmetry in congenital IVth nerve paralysis.
2
MATERIALS AND METHOD
This study covers 24 patients who were not operated and who had an apparent facial asymmetry and head position and were examined and diagnosed with congenital IVth nerve paralysis at the Pediatric Ophthalmology and Strabismus Department of our hospital between 2001–2003. 269
Table I.
Comparison of common internal and external carotid artery flow parameters in Group A cases.
CCA (med ss) n 24 DP
F. Asym. ()
PSV EDV RI PI
F. Asym. ()
85.27 28.20 90.55 30.82 21.82 8.67 25.36 7.89 0.73 0.09 0.71 0.07 1.14 0.29 1.15 0.13
ICA (med ss) n 24
P
F. Asym. ()
ECA (med ss) n 24
F. Asym. ()
0.377 78.55 26.12 81.05 25.32 0.497 27.77 10.11 27.86 11.27 0.627 0.62 0.16 0.65 0.11 0.554 1.02 0.22 1.03 0.20
P
F. Asym. ()
F. Asym. ()
0.253 78.36 22.50 79.91 15.74 0.962 11.36 4.43 15.09 6.01 0.220 0.86 0.05 0.81 0.07 0.863 2.07 0.52 1.90 0.45
P 0.765 0.149 0.124 0.062
DP: Doppler Parameter, ICA: Internal Carotid Artery, ECA: External Carotid Artery, RI: Resistivity index, CCA: Common Carotid Artery, PSV: Peak Systolic Velocity (cm/sec), EDV: End Diastolic Velocity (cm/sec), PI: Pulsatility Index Table II.
Comparison of common internal and external carotid artery flow parameters in Group B cases.
CCA (med ss) n 12
DP
Facial Asym. ()
Facial Asym. ()
PSV 85.64 23.56 88.73 25.31 EDV 23.27 5.44 23.18 5.27 RI 0.73 0.09 0.73 0.06 PI 1.13 0.19 1.19 0.18
ICA (med ss) n 12
P
Facial Asym. ()
ECA (med ss) n 12 Facial Asym. ()
0.657 78.64 14.75 85.00 20.44 1.000 26.18 8.74 25.45 8.18 0.953 0.65 0.14 0.70 0.06 0.356 1.00 0.30 1.09 0.15
P
Facial Asym. ()
FacialAsym. ()
0.050 66.27 16.52 75.27 9.34 1.000 15.36 9.55 12.91 7.22 0.82 + 0.08 0.331 0.77 + 0.11 0.317 1.67 0.58 2.01 0.68
P 0.147 0.514 0.175 0.165
All patients underwent full ophthalmologic and orthoptic examination. The colored Doppler USG to bilateral carotid arterial system was applied to first 12 patients after their head positions were corrected. To the second 12 patients, the colored Doppler USG to bilateral carotid arterial system was applied with head position caused by IVth nerve paralysis in addition to the same investigation made with first 12 patients. The results of investigation with corrected head position are grouped under Group A (n 24 patients) and the results of investigation with uncorrected head position are grouped under Group B (n 12 patients). The colored Doppler studies were done in a private diagnosis center with 6–10 mHz linear and in the cases where position is necessitated with 5–7 mHz endokavier prob and Toshiba (Eccosee) colored Doppler apparatus was used. All measurements were taken by the same radiology doctor. In this study, common carotid artery (CCA), internal carotid artery (ICA) and external carotid artery (ECA) wave form, peak systolic velocity (PSV) (cm/sec), end diastolic velocity (EDV) (cm/sec), median velocity (cm/sec), resistivity indexes (RI), pulsatility indexes (PI), ICA peak systolic velocity/CCA peak systolic velocity ratios, ICA end diastolic velocity/CCA end diastolic velocity ratios were investigated. Resistivity index (RI) was determined by dividing PSV and EDV difference by PSV. Pulsatility index was determined by dividing PSV and EDV difference by mean velocity (Aburn 1993, Zweibel 1987). Data statistical evaluations were made using the Wilcoxon Signed Ranks Test and Paired Samples t–Test. 3
FINDINGS
14 (58%) of the 24 patients who were diagnosed with congenital IVth nerve paralysis were male, 10 (42%) were female. Their median age was 14 7.55(5–32) years. Common artery, internal carotid artery and external carotid artery, peak systolic velocity (PSV), end diastolic velocity (EDV), resistivity index (RI) and pulsatility index (PI) comparison of Group A and Group B cases are given in Table I and Table II. 270
Table III.
Blood flow parameter of ICA/CCA ratios in group A and group B. ICA/CCA (med ss) n 24
Doppler Parameter
Facial Asymmetry ()
PSV(cm/sec) 0.93 0.11 EDV(cm/sec) 1.36 0.46
ICA/CCA (med ss) n 12
Facial Asymmetry ()
P
Facial Asymmetry ()
Facial Asymmetry ()
P
0.93 0.20 1.13 0.37
0.913 0.080
0.94 0.13 1.15 0.40
0.98 0.18 1.15 0.36
1.000 0.894
In Group B cases, the side of facial asymmetry compared to the other side, there was a statistically meaningful decrease in peak systolic velocity (p 0.050). Except for this result, there was not a meaningful difference between Group A and B. There was no statistically meaningful difference between two groups in their internal carotid artery end diastolic velocity/common carotid artery end diastolic velocity ratio as shown in Table III.
4
DISCUSSION
Pathogenesis of facial asymmetry manifested with ocular tilt in congenital IVth nerve palsy is not completely understood and there are different opinions in formation mechanism (Clark 1998, Demer 1995, Horton 1967, Paysee 1995, Velez 2000, von Noorden 2002). According to Goodman, plagiocephaly deformation as a result of abnormal head position while sleeping is the cause of facial asymmetry in IVth nerve paralysis (Goodman 1995) According to another opinion, pathogenesis of facial asymmetry in Congenital IVth nerve paralysis is explained as, due to continuous torticollis starting in childhood, possibly effect of gravity causes nose deviation towards low side and slanted mouth. As a result of this, there will be pinching in veins and decrease in carotid artery blood flow and thus facial asymmetry develops in that side (Duane 1985). As it is well known that cranium, face and brain carotid are replenished by arterial system (Wilson 1993). We have planned this study, thinking that, besides different factors and reasons put forward in facial asymmetry ethiopatogenesis connected to ocular tilt arising in IVth nerve paralysis, carotid arterial system hemodynamic changes and detoriation has also some contribution. In our study, for CCA and ECA, the colored Doppler USG made by correcting the head position caused by congenital IVth nerve paralysis, there was no difference and no decrease in blood flow between the side with facial asymmetry and the other side. For ICA, the colored Doppler USG made without correcting the head position, there was an appreciable decrease in ICA peak systolic velocity on the side with facial asymmetry compared to the other side without facial asymmetry. On the other hand, the colored Doppler USG made by correcting the head position, no difference was observed in peak systolic velocities. It is known that, colored Doppler USG is used in calculating blood flow with an error margin and the systolic flow velocity is an indication of vascular blood flow (Burns 1987, Mittra 1993). Consequently, a decrease in internal carotid artery blood flow on the side with ocular tilt makes us think that there is some contribution of vascular factors in the development of facial asymmetry . Resistivity and pulsatility indexes, which are independent of ultrasonography, are used in comparing flow properties in colored Doppler USG. The reply given in vascular channel to the blood wave originated by heart beat is called pulsatility. Increased resistivity index is inversely proportional with diastolic flow velocity. PI and RI provide the evaluation of vascular resistance in colored Doppler USG. Increase in vascular resistance points to decrease in diastolic blood flow (Mittra 1993). In our series, colored Doppler USG made for CCA, ICA and ECA, with head position or corrected head position, showed no difference between the side with facial asymmetry and the other side in regards to end diastolic velocity, resistivity index and pulsatility index. Consequently, in our study, 271
there were no changes in end diastolic velocity and vascular resistance of carotid artery system on the side with facial asymmetry. In literature, ICA is used in proximal part of stenoz; ICA/CCA peak systolic and end diastolic velocity indexes are used in classification of degree of stenoz. It is considered abnormal when ICA/CCA peak velocity index is above 1.5 and ICA/CCA end diastolic velocity index is above 2.6 (Garth 1983, von Noorden 2002). In our series, colored Doppler USG made with head position or corrected head position, showed no difference between the side with facial asymmetry and the other side in regards to ICA/CCA peak systolic or end diastolic velocity indexes. But, this shows that even though there is no great decrease in blood flow in ICA proximal part connected to torticollis, due to a meaningful peak systolic blood flow difference in Doppler between the side with facial asymmetry and the normal side, we think that, it points to some decrease in blood flow especially in internal carotid artery. In different publications, early surgery treatment of torticollis can prevent or correct the facial asymmetry (Goodman 1995, Rubin 1986). Another reason for early surgery is to prevent secondary scoliosis as a result of abnormal head position and to prevent the formation of contracture in neck muscles (von Noorden 2002, Dietrich 1967). For these reasons, it is stated that children with congenital IVth nerve paralysis should be operated before the age of 6 (Morrison 1982). In spite all of these put forward the relation between torticollis developing in IVth nerve paralysis and facial asymmetry, there is need for many more scientific studies to clarify the facial asymmetry etiology. REFERENCES Aburn NS, Sergott RC. (1993): “Orbital Colour Doppler Imaging”. Eye 7: 639–47. Bagolini B, Campos EC, Chiesi C. (1982); “Plagiocephaly causing superior oblique deficiency and ocular torticollis”. Arch Ophthalmol 100: 1093–6. Burns PN. (1987): “The physical principles of Doppler and spectral analysis”. J Clin Ultrasound 15: 567–90. Clark RA, Miller JM, Rosembaum AL, Demer JL. (1998): “Heterotopic rectus pulleys or oblique muscle dysfunction.” JAAPOS 2: 17–25. Demer JL, Miller JM, Poukens V, Vinters H, Glasgow BJ. (1995): “Evidence for fibro muscular pulleys of the recti extraocular muscles”. Invest Ophthalmol Vis Sci 36: 1125–36. Dietrich DE, Slack WJ. (1967): “Scoliosis secondary to unilateral extraocular muscle paresis (ocular torticollis)”. Radiology 88: 538–40. Duane T.D., Jaeger E.A. (1985): “Clinical Ophthalmology”, Harper & Row Publishers, Philadelphia Vol.1, Chap.19; 4–9. Eyer MK, Brandestini MA, Phillips DJ, Baker DW. (1981): “Color digital echo/Doppler image presentation”. Ultrasound Med Biol 7: 21–31. Garth KE, Carroll BA, Sommer FG, Oppenheimer DA. (1983): “Doplex ultrasound scanning of the carotid arteries with velocity spectrum analysis.” Radiology 147: 823–27. Goodman CR, Chabner E, Guyton D. (1995): “Should early strabismus surgery be performed for ocular torticollis to prevent facial asymmetry?” J Pediatr Ophthalmol Strabismus 32: 162–66. Hertle RW, Quinn GE, Katowitz JA. (1992): “Ocular and adnexal findings in patients with facial microsomias”. Ophthalmology 99: 114–9. Horton CE, Crowford HH, Adamson JE, Ashbell TS. (1967): “Torticollis.” South Med 60: 953–59. Muchnick RS, Aston SJ, Rees TD. (1979): “Ocular manifestations and treatment of hemifacial atrophy”. Am J Ophthalmol 88: 889–97. Morrison JL, MacEwen GD. (1982): “Congenital muscular torticollis: observations regarding clinical findings, associated conditions, and results of treatment.” J Pediatr Orthop 2: 500–505. Mitchell DG.(1990): “Colour Doppler imaging: principles, limitations and artifacts.” Radiology 177: 1–10. Mittra Ra, Sergott RC, Flaharty PM, Lieb WE, et al. (1993): “ Optic nerve decompression improves hemodynamic parameters in papilledema.” Ophthalmology 100: 987–97. Parks MM. (1958): “Isolated cyclovertical muscle palsy.” Arch Ophthalmol 60: 1027–35. Paysee EA, Coats DK, Plager D. (1995): “Facial asymmetry and tendon laxity in superior oblique palsy.” J Pediatr Ophthalmol Strabismus 32: 158–61. Puttermann AM, Chalfin J. (1979): “Ocular asymmetry measuring device.” Ophthalmology 86: 1203–8.
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Rubin SE, Wagner RS. (1986): “Ocular torticollis.” Surv Ophthalmol 30: 366–76. Velez FG, Clark RA, Demer JL. (2000): “Facial asymmetry in superior oblique muscle palsy and pulley heterotopy.” JAAPOS 4: 233–9. Wilson ME, Hoxie J. (1993): “Facial asymmetry in superior oblique muscle palsy.” J Pediatr Ophthalmol Strabismus 30: 315–8. von Noorden GK, Campos EC. (2002): “Paralytic Strabismus,” Binocular Vision and Ocular Motility, 6. Ed, St. Louis, Mosby, Inc. 420–421. Zweibel WJ. (1987): “Spectrum analysis in carotid Doppler sonography.” Ultrasound Med. Biol 13: 625–3.
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Effects of recession strabismus surgery on corneal topography A. Inal, B. Inal, S. Akar, B. Gökyig˘it & Ö.F. Yılmaz Beyogˇlu Educational and Research Eye Hospital, Istanbul, Turkey
ABSTRACT: Purpose: Evaluation of effects of recession strabismus surgery on corneal topography. Methods: In this study, in Istanbul Beyog˘lu Educational and Research Eye hospital, we evaluated the variation of corneal topography after medial or lateral rectus muscle recession by using a computer assisted topographic analysis system. 46 eyes of patients, with only one horizontal rectus recession opreation, were evaluated before and 1 week and 1 month after surgery. Results: One week after the operation, there was a steepness of 0,00–1,75 Diopter (D) in vertical axis (med. 0,35 D) and after the first month the change on average was 0,10 D (p 0,05). Conclusion: We concluded that, since after the first month, the effect of rectus muscle recession operations on corneal astigmatism decrease and return back to the old level, recession operations do not have a practical effect on refractive value of the eye.
1
INTRODUCTION
Changes in corneal curvature have been reported after strabismus surgery (Bagheri, A. 2003, Nardi 1997, Schworm 1996, Mutlu 1999). Reportedly, recession of a single muscle usually causes a decrease in power in the meridian of recessed mucle (Kwitko 1991). We evaluated also the sferical equivalent. Several reports have noted different results in the sferical equivalent. 2
METHODS
In this prospective study a total of 46 eyes of 30 patients were examined. 16 patients (%53,33) were female and 14 patients (%46,66) were male; the average age was 13,47 11,73 (range, 2,5 to 44 years). The patients underwent surgery between 01.2003–10.2003. Eyes that had only one horizontal muscle recessed and no transposition procedures were considered. 26 eyes had medial rectus (MR) muscle recession and 20 eyes had lateral rectus (LR) muscle recession. Patients were examined before, one week after and one month after surgery. Ocular examinations were including; best corrected visual acuity measurment, cycloplegic refraction, prism cover test, biomicroscopy and fundoskopy. Corneal topography was performed using the EyeSys 2000 system. Using this system we evaluated the corneal curvature at the center of the cornea and 1,5 and 3 mm from the corneal meridian, corresponding to the 0°, 90°, 180° and 270°. We determined the spherical equivalent with the formul (Mutlu 1999): SE spherical Dioptry 1⁄2 Cylinderic Dioptry Table 1 shows preoperative mean spherical equivalent and keratometric values of patients and Table 2 shows preoperative corneal curvature values at the center and 1,5 and 3 mm from the corneal meridian, corresponding to the 0°, 90°, 180° and 270°. For the statistical analysis we used Wilcoxon signed rank test. 275
Table 1.
Spherical equivalent and mean keratometric values of patients.
Spherical equivalent Keratometric values
Table 2.
Preoperative
1st week
1st month
0,96 3,44 41,72 2,88
1,17 3,34 41,81 2,88
1,41 3,24 41,76 2,91
Preoperative corneal curvature values.
Central
Periphery
0°
90°
180°
270°
42,21 3,40
1,5 mm 3 mm
41,40 3,36 41,26 2,87
42,15 3,38 42,02 3,10
41,40 3,19 41,26 3,03
42,14 3,36 41,97 3,20
Table 3.
Postoperative (1st week) corneal curvature values.
Central
Periphery
0°
90°
180°
270°
42,16 3,26
1,5 mm 3 mm
41,28 3,30 41,07 2,78
42,50 3,44 42,38 3,21
41,38 3,04 41,35 2,87
42,16 3,27 41,92 2,98
Table 4.
Postoperative (1st month) corneal curvature values.
Central
Periphery
0°
90°
180°
270°
42,23 3,39
1,5 mm 3 mm
41,33 3,11 41,07 2,69
42,25 3,36 42,15 3,12
41,33 3,23 41,30 2,94
42,19 3,49 42,04 3,24
3
RESULTS
Spherical equivalent increased after surgery, but the change was statistically insignificant. Topographic analysis of the cornea revealed a slightly steepening in the 90° meridian and a flattening in the 0° meridian 1 week after surgery. But this effect was statistically insignificant. Postoperative corneal curvature values in 1st week and in 1st month controls are presented in Table 3 and 4.
4
DISCUSSION
Extraocular muscles have some influence on corneal topography. But there has been no consistency in the reported changes in corneal curvaure after strabismus surgery. It has been reported that %60 of patients develop changes in corneal astigmatism in the operated eye after strabismus surgery (Marshall D 1936). On the contrary Fix and Baker reported that only %3 of their patients had changes of at least 1 diopter of astigmatism at one year postoperatively (Fix, A. & Baker, J.D. 1985). Kwitko (Kwitko, S. 1991) suggest that weakening of a muscle lead to a corneal flattening close to the muscle insertion. Schworm reported that corneal topographic changes after strabismus surgery were small and statistically insignificant (Schworm HD. 1996). Our results indicates that the recession of horizontal rectus muscles (ML or LR) causes mild changes in corneal topography which are disappear within 1 months postoperatively. 276
5
CONCLUSION
We concluded that, since after the first month, the effect of rectus muscle recession operations on corneal astigmatism decrease and return back to the old level, recession operations do not have a practical effect on refractive value of the eye.
REFERENCES Bagheri, A., Farahi, A., Guyton, DL. 2003: Astigmatism induced by simultaneous recession of both horizontal rectus muscles. J AAPOS. Feb; 7(1): 42–6. Fix, A., Baker, J.D. 1985: Refractive changes following strabismus surgery. American Orthoptic Journal.; 35: 59–62. Kwitko, S., Sawusch, M.R., Mc Donnell, P.J., Gritz, D.C., Moreira, H., Evensen, D. 1991: Effect of extraocular muscle surgery on corneal topography. Arch. Ophthalmol. 109: 873 –8. Marshall, D. 1936: Changes in refraction following operation for strabismus. Arch. Ophthalmol. 15: 1020–31. Mutlu, M., Tosuncuk, A., Yıldırım, C., Altınsoy, HI. 1999: S ¸ as¸ılık Cerrahisi Sonrası Refraksiyon ve Kornea Topografisi Deg˘is¸iklikleri. MN Oftalmoloji 6(3): 266–9. Nardi, M., Rizzo, S., Pellegrini, G., Lepri, A. 1997: Effects of strabismus surgery on corneal topography. J Pediatr Ophthalmol Strabismus. Jul–Aug; 34(4): 244–6. Schworm, HD., Ullrich, S., Hoing, C., Dittus, C., Boergen, KP. 1996: Effect of strabismus operation of corneal topography. Klin Monatsbl Augenheilkd. Nov; 209(5): 275–82.
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The effectiveness of Faden operation in different types of deviation A. Inal, N. Ünsal, B. Gökyig˘it, S. Akar & Ö.F. Yılmaz Beyogˇ lu Educational and Research Eye Hospital, Istanbul, Turkey
ABSTRACT: In this study 104 patients files, who underwent Faden operation between December 1991–December 2003 in Beyog˘lu Educational and Research Eye Hospital, were evaluated retrospectively. The patients ages were between 1–57 years (mean 14,44 11,52 years). 87 of them esodeviation, 7 of them exodeviation, 5 of them vertical deviation and 5 of them had nystagmus. Their pre-operative near deviation were between 14–60 prism diopter (PD) (39,04 10,52 PD) and distance deviations were between 6–60 PD (34,47 13,35 PD). On 23 eyes operation was applied without recession and whereas on 113 eyes it was applied with recession. Their post operative deviations were found 7,25 8,00 PD at near and 6,20 7,85 PD at distance. The differencess were found statistically significant. Faden operation is an effective procedure when used on appropriate indications.
1
INTRODUCTION
In 1974 Cüppers described the Faden operation which is also known as posterior fixation or retroequatorial myopexy (Cüppers 1974). The Faden operation consists of permanently suturing the posterior extraocular muscle belly to the underlying sclera behind the extraocular muscle insertion, near the equator of the globe (Clark 1999, Yılmaz 1981, Erda 1996). The indications for Faden operation are; changing angels and nonaccomodative convergance excess ET, the paralysis of kontrlateral synergist muscle in monolateral paresia, nystagmus blokage syndrome, head posture in Duane’s syndrome (Yılmaz 1981, Erda 1996, de Decker 1981).
2
MATERIALS AND METHODS
We studied retrospectively 146 eyes of 104 patients in Istanbul Beyog˘lu Eye Research and Education Hospital, during 10.12.1991–14.12.2003 on whom we had performed Faden operation. The ages of patients were between 1–57 (14,44 11,52 years) and 57 of them were female and 47 of them male. We performed on all patients preoperative and postoperative prism cover test for near and distance, Bagolini tests, synopthophor evaluation and fundus examination. 87 patients had esodeviation, 7 had exodeviation, 5 had vertical deviation and 5 had nystagmus (Table 1). Their preoperative near deviations were between 14–60 prism diopter (PD) (39,04 10,52 PD) and distance deviations were between 6–60 PD (34,47 13,35 PD). On 23 eyes operation was applied without recession and whereas on 113 eyes it was applied with recession. The operations of accomodative ET group are shown in Table 2. We considered an optimal squint correction a residual esotropia (ET) or a consecutive exotropia (XT) less than 10 PD. The posterior fixation sutures were placed 11–13,5 mm posterior to the original insertion. In each case, two nonabsorbable sutures (5-0 polyester) were used to incorporate superior and inferior thirds of the extraocular muscle. In combined procedures (Faden recession) posterior fixation sutures were placed through the extraocular muscle after disinsertion where the muscle overlaid the sclera at the appropriate distance from the original insertion. 279
Table 1.
Preoperative diagnosis of patients.
Preoperative diagnosis
Number of patients
Accomodative Esotropia Infantil esotropia Other esotropias* Exotropia Vertical squint Nystagmus Total
18 2 67 7 5 5 104
* Other ET: monoocular ET, alternan ET, residual ET, ET with nystagmus, Et with DVD.
Table 2.
Operations of accomodative ET group.
Bimedial recession faden MR recession faden Bimedial faden MR faden Bimedial Faden MR recession
Patient number
%
4 6 4 2 2
22,2 33,3 22,2 11,1 22,2
The mean postoperative follow-up period was 5,25 10,88 months (between 1–83 months). Postoperative controls were performed at 1 day, 1 week, 1 month, 3 months and then every 3 months. For the statistical analysis we used Wilcoxon Signed Ranks test and p 0,05 is significant. 3
RESULTS
In 79 of 104 patients (76%) we were able to reduce the strabismic angle for distance and near fixation to less than 10 PD. Two cases were undercorrected and after second operation we obtained orthophory at the last visit. Postoperative results of the groups are shown in Table 3 and 4. In this study we had 7 patients with exodeviation. Four patients underwent unilateral 7 mm. LR recession faden and 3 patients underwent bilateral 4 mm. LR recession faden surgery. We had one patient with dissociated vertical deviation. We performed superior rectus 4.5 mm. recession and Faden operation. Preoperative deviation angle of this patient was 30 PD. One month after surgery at near fixation 14 PD and at distance fixation 20 PD deviation.
4
DISCUSSION
Posterior fixation of a muscle creates an artificial palcy and a decrease of torque (Clark 1999, Yılmaz 1981, Erda 1996, de Decker 1981) only in its field of action and has no effect in primary gaze (Clark 1999). Faden operation is more difficult than conventional surgery (Yılmaz 1981, Erda 1996). But especialy if the patient is orthophoric at distance fixation or if the deviation angle is varying, there is a high risk of consecutive XT after bilateral medial rectus recession surgery. In this group Faden operation is a good choice. Erda evaluated 61 esotropic patients who underwent Faden operation. They reported that in none of the patients a residual ET more than 10° or a consecutive XT more than 10° was encountered (Erda 1996). 280
Table 3.
Postoperative results of accomodative ET, infantile ET and other ET groups.
Acomodative ET ET near ET distance Infantile ET ET near ET distance Other ET ET near ET distance XT near*
Preoperative
1st week
PD
PD
p
43,33 10,71 35,77 16,06
4,33 4,76 4,11 7,65
0,00 0,00
6,61 6,18 4,50 6,70
0,00 0,00
5,50 3,81 5,00 4,65
0,01 0,01
16 5,65 15 7,07
0,18 0,18
12,00 2,82 9,00 1,41
0,18 0,18
13,54 3,71 11,20 2,46
0,18 0,18
5,01 6,32 4,08 6,18 0
0,00 0,00
7,24 6,68 5,80 6,79 8,33 3,88 (n 2) 7 4,24 (n 2)
0,00 0,00
8,09 6,65 5,40 5,45 9 1,41 (n 2) 10 (n 1)
0,00 0,00
40 7,07 45 0,00
37,77 10,35 33,75 12,66
XT distance*
1st month
2 (n 1)
PD
3rd month p
PD
p
* Consecutive. Table 4.
Surgical results of exotropia group and vertical squint group.
Exotropia near (n 7) Exotropia distance (n 7) Vertical near (n 5) Vertical distance (n 5)
Preoperative (PD)
Postoperative 3rd month (PD)
p
27,60 13,20 21,30 8,08 21,30 8,08 22,60 6,4
1,00 6,60 0,50 13,80 3,00 0,60 3,00 0,5
0,109 0,109 – –
In this study we had only two consecutive XT out of 87 patients (2,3%). Happe examined consecutive XT after Faden operation. In his study the incidence was 3%. He says that XT appearing immediately after surgery is most likely the result of an individually overdosed operation and motor and sensory instabilities increase the risk of consecutive XT (Happe 1999). In our study Faden operation applied to only two infantile esotropia patients , eventhough it corrected med. 26,46 PD deviation, it was not sufficient by itself. A second resection surgery was needed. 7 XT patients with suture put on their lateral rectus had 79,2 36,1% correction. We did not come across to similar cases in literature. Eventhough DVD is a group where Faden operation is indicative (Kii 1994), because of difficulty in working in this area, superior rectus recession is preferred. We found 53,33% correction in single case in our series. We can conclude that although Faden operation is a more difficult procedure than conventional surgery, it is a usefull method especially in large angle strabismus since it can be more effective by less muscle operation. Safety can be obtained with increasing experience.
REFERENCES Clark, R.A., Isenberg, S.J., Rosenbaum, A.L., Demer, J.L. 1999. Posterior fixation sutures: a revised mechanical explanation for the fadenoperation based on rectus extraocular muscle pulleys. Am J Ophthalmol. Dec; 128(6): 702–14.
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Cüppers, C. 1974. The so-called Faden operation. II. Congress I.S.A. Marseille 1974. Diff Gen Libr ParisMarseille, 395–400. de Decker, W. 1981. The Faden operation. When and how to do it. Trans Ophthalmol Soc U K.; 101 (Pt 2): 264–70. Erda, N., Benian, O. 1996. Ezotropyalarda Faden Ameliyati Sonuclarimiz. MN Oftalmoloji. 3(3): 244–9. Happe, W., Suleiman, Y. 1999. Early and late occurring consecutive exotropia following a medial rectus faden operation. Ophthalmologe. Aug; 96(8): 509–12. Kii, T., Ogasawara, K., Ohba, M., Hotsubo, M., Sakai, N., Nakagawa, T. 1994. The effectiveness of the Faden operation on the superior rectus muscle combined with recession of the muscle for the treatment of dissociated vertical deviation. Nippon Ganka Gakkai Zasshi. Jan; 98(1): 98–102. Yılmaz, Ö.F. 1981. Faden Ameliyati. XV. Ulus. Turk Oft Kong Bult: 336–8.
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The Brückner test as a screening tool for the detection of significant refractive errors J.W.R. Pott1, Y.G.L. Sie-Oh2, M. Broer van Dijk2 & B. de Vries1 1 Department of Ophthalmology, University Hospital Groningen, and 2Department of Youth Health Care, Goningen, The Netherlands
1
INTRODUCTION
The Brückner test can detect amblyogenic conditions, such as unequal or high refractive errors or strabismus. When both eyes are viewed simultaneously through the direct ophthalmoscope in a darkened room from a distance of approximately 2 to 3 feet with the child fixating on the ophthalmoscope light, the red reflexes seen from each eye should be equal in size, brightness, and colour. If one reflex is different from the other, there is a high likelihood that an amblyogenic condition exists. Furthermore, in hypermetropia the light reflex will not fill the entire pupil, but will be darker at the inferior part of the pupil opening. In myopia, the reflex will be darker on the superior side. We retrospectively evaluated the referrals to our paediatric clinic from vision screening based on an abnormal Brückner test during 1997–2003.
2
PATIENTS AND METHODS
In the Netherlands, visual screening is performed by health care workers at different ages. Standard examination at 6–8 weeks include examination of fundus reflex (for cataracts and retinoblastoma). At later age (6–9 months and 14–24 months) eye alignment is also examined. From the age of 3 years monocular visual acuity is examined by means of a picture chart or Landolt C’s. The Brückner test is not included in this protocol, but was routinely performed by 2 screening-physicians (Y.G.L. S-O and M. BvD). Referrals from vision screening with an abnormal Brückner test during 1997–2003 were evaluated. Data on age of referral, cycloplegic refraction, orthoptic examination and visual acuity collected. 3
RESULTS
Medical records of 54 children, who were referred because of an abnormal Brückner test, could be retrieved. Mean age of the children was 2.5 years (see fig.2). The spherical equivalent of the refractive errors found in all these children is shown in fig. 3. Of the 54 children, 21 were under the age of 2.5 years. As visual acuity was never measured in these young children, referral of them
(a)
Figure 1.
(b)
(a) Hypermetropia; (b) Anisometropia.
283
Figure 2.
Age at examination of the 54 referred children.
Figure 3.
Spherical equivalent of the refractive errors found in right and left eyes of the 54 referred children.
Table 1. Diagnosis in the 17 children under the age of 2.5 years correctly referred using the Brückner test. Hypermetropia Anisometropia Myopia Strabismus
11 3 1 2
Criteria: hypermetropia 4D, anisometropia 2D, myopia 2D
284
was solely based on an abnormal Brückner test. In 17 children (81%) referral appeared to be correct and in only 4 children (19%) the referral was incorrect (see table 1).
4
CONCLUSION
In the specific situation described in this poster, the Brückner test seems to have an additive value to the usual visual screening methods. This value is apparent in the young preverbal children. Especially high values of hypermetropia and anisometropia were detected.
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Outcome of surgical management in adults with congenital unilateral superior oblique palsy B. Kaczmarek, E. Wójcik, A. Madroszkiewicz & M. Pociej-z.ero Department of Strabismology, Cracow Eye Hospital, Kraków, Poland
1
INTRODUCTION
Congenital superior oblique palsy (SOP) is usually diagnosed and treated in childhood. However, there is a group of patients in whom SOP becomes symptomatic later in life. We wanted to analize the effectiveness of different surgical methods in adults with SOP.
2
METHODS
A retrospective review of 23 adult patients with congenital superior oblique palsy who underwent surgical correction at our department over a ten year period. Preoperative and postoperative vertical deviations were measured in nine diagnostic positions on a major amblyoscope.
3
RESULTS
There were a total of 29 operations: inferior oblique recession was performed in 21 patients, superior oblique tuck in 7 and a contralateral inferior rectus recession in 1 patient. 17 patients underwent muscle surgery once and 6 were operated twice. An average of 1,3 surgeries were performed per patient. The mean preoperative vertical deviaton was 16 in the primary position and 16 in the reading position. The average final postoperative vertical deviation was 3 in the primary position and 5 in the reading position. The mean reduction of vertical deviation was 13 in the primary position and 11 in the reading position. The mean reduction of vertical deviation in the primary position in the inferior oblique recession group (12 ) was found to be significantly greater than in the superior oblique tuck group (8 ), (p 0,009). Even though the mean reduction of vertical deviation in the reading position in the inferior oblique recession group (9 ) was greater than in the superior oblique tuck group (7 ), no statistically significant difference was found.
4
CONCLUSIONS
1. Successful treatment of adult patients with congenital superior oblique palsy can be accomplished in the majority of cases. 2. Recession of the inferior oblique was found to be more effective than superior oblique tuck in the reduction of primary position hypertropia in adults with congenital superior oblique palsy.
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Inhibitional palsy of the contralateral superior rectus muscle in a patient with superior oblique paresis B. Kaczmarek, E. Wójcik & C. Bilska Department of Strabismology, Cracow Eye Hospital, Kraków, Poland
1
INTRODUCTION
Usually the diagnosis of superior oblique palsy is straightforward. Diagnostic difficulties may sometimes arise when the patient dominantly fixates with the paralyzed eye.
2
CASE REPORT
A 35 year female presented with hypotropia of 40 , marked ptosis and restriction of elevation of her right, amblyopic eye. Careful examination revealed left superior oblique palsy. The Bielschowsky test confirmed the diagnosis. Left inferior oblique recession was performed. Vertical deviation was decreased to 15 and ptosis disappeared. The pre- and postoperative vertical deviation measurements as well as photographic documentation are presented.
3
DISCUSSION
Since the patients right eye is amblopic she habitually fixates with the paralyzed left eye. Left inferior oblique overaction, according to Herring’s law of equal innervation, causes decreased innervation of the right superior rectus causing so-called inhibitional palsy of the contralateral antagonist.
4
CONCLUSION
Trochlear palsy can present in an atypical form and can mimic a contralateral III nerve palsy.
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Surgical treatment of upshoot and downshoots in Duane’s retraction syndrome Ç. Karaca & A.S¸. S¸anaç Hacettepe University Hospital Department of Ophthalmology, Ankara, Turkey
B. Sönmez Military Hospital, Malatya, Turkey
ABSTRACT: Purpose: The purpose of this study is to present our results in treating the upshoot or downshoot of Duane’s retraction syndrome in particular with splitting of the lateral rectus into a Y configuration at its insertion. Methods: Six patients (4 male, 2 female) from our practice at Hacettepe University Hospitals, Ankara were included in this study. Subjects ranged in age from 3 to 21 at the time of surgery and follow up was from ten months to seven years. Three patients showed the motility characteristics of type 2 Duanes retraction syndrome, two patients type 3 and one patient had abduction deficit of the right eye and both abduction and adduction deficit of the left eye. All patients demonstrated a variable face turn and an upshoot was present in all patients. They underwent motility surgery to eliminate the overshoot and the face turn. Results: The right eye was affected in two patients, left eye in two and the other two patients had bilateral involvement. All of them had deviation in the primary position (range: 12–60 pd, mean: 33.67 pd). The method of surgery to treat the upshoot was splitting of the lateral rectus muscle into a Y configuration in five patients and lateral rectus recession only in one patient. To relieve the deviation in primary position, lateral rectus recessions were performed in all patients. The splitting of the ends of the lateral rectus into a Y configuration resulted in improvement of the upshoot in all patients without any complications. Lateral rectus recession only had no effect on the upshoot. Conclusion: The splitting of the ends of the lateral rectus into a Y configuration is an easily performed operation which effectively improves the upshoot in patients with Duanes’ retraction syndrome. Performing simultaneous recession to the lateral rectus muscle combined with the splitting into Y configuration improves the outcome, especially in patients with marked globe retraction.
1 INTRODUCTI ON Duane’s retraction syndrome is a congenital restrictive strabismus disorder that is characterised by a wide spectrum of extraocular muscle motility dysfunction. Heuck was the first to describe retraction of the globe in a patient with severe limitation of ocular motility. Alexander Duane published a 54 cases series in 1905 and described the retraction syndrome in following features: 1) congenital onset (acquired forms are rare), 2) severe limitation of abduction, 3) slight limitation of adduction, 4) globe retraction and narrowing of palpebral fissure on adduction, 5) Commonly associated elevation or depression on adduction. Of special interest is the frequently associated upshoot and downshoot of the adducted eye which at times causes a cosmetic problem of almost grosteque proportions; namely when the cornea of the adducted eye disappears from view. At first glance such patients appear to have increased overaction of the inferior or superior oblique muscles. However surgical weakening 291
procedures on these muscles is entirely ineffectual. Scott pointed out that the high muscle tension caused by the cocontraction of the horizontal rectus muscles or by structural thightness of the lateral rectus muscle when the lateral rectus muscle contracts results in a vertical effect by allowing the muscles slide over the globe when contracting (bridle effect). However it has been shown by CT and MRI scanning that it is actually not the muscles that slide over the surface of the globe but the globe that slips under the muscles. Because the vertical displacement of the horizontal muscles during elevation and depression in relation to the orbital wall is negligible in most but not all cases of Duane syndrome. It is because the horizontal rectus muscles maintain their vertical position with reference to the orbital walls that elevation or depression of the eyes will move the center of rotation above or below the muscle planes. This explains the bridle effect that occurs during co-contraction of these muscles when the eye is slightly elevated or depressed. Therefore the splitting of the lateral rectus muscle into a Y configuration that increases the width of insertion may decrease this briddle effect. The purpose of our study is to present our results in treating the upshoot or downshoot of Duane retraction syndrome in particular with splitting of the lateral rectus into a Y configuration at its insertion. 2
PATI ENTS AND METHODS
Six patients from our practice at Hacettepe University Hospitals, Ankara were included in this study. Subjects ranged in age from 3 to 21 at the time of surgery and follow up was from ten months to seven years. Three patients showed the motility characteristics of type 2 Duane’s retraction syndrome, two patients type 3 and one patient had abduction deficit of the right eye and both abduction and adduction deficit of the left eye. All patients demonstrated a variable face turn and an upshoot was present in all patients. They underwent motility surgery to eliminate the overshoot and the face turn. 3
RESULTS
The right eye was affected in two patients, left eye in two and the other two had bilateral involvement. All of them had deviation in the primary position (range 12–60 pd, mean 33.67 pd) The method of surgery to treat upshoot was splitting of lateral rectus muscle into a Y configuration in five patients and lateral rectus muscle recession only in one patient. The splitting of the ends of the lateral rectus into a Y configuration resulted in improvement of the upshoot in all patients without any complications. Lateral rectus recession only had no effect on the upshoot.
4
DI SCUSSI ON
Different types of surgical techniques are defined for the treatment of upshoot and downshoots in DRS. One of the effective techniques is the recession of the LR muscles. The amount of the
Table 1.
Individual data of 6 patients who had surgery for upshoot and downshoot.
Case
Type
Surgery
Result
1 2 3 4 5 6
2 2 3 3 1, 3 2
Recession to 2LR Y split Recession to 2LR Y split to right LR Recession to 2LR Ysplit to right LR Recession to 2LR Y split to right LR Recession to 2LR Y split to left LR Recession to 2LR resection to right MR
Complete recovery Partial recovery Complete recovery Complete recovery Partial recovery Unchanged
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recession can be defined according to the amount of LR tightness defined preoperatively by the forced duction test. Although a fibrotic LR can be recessed to 7–8 mm for the treatment of vertical deviation, a nonfibrotic LR must be recessed to 10–12 mm. The application of a posterior fixation suture with the recession of the LR also has resulted favourable results for the treatment of the upshoots. Y splitting of the LR muscle is another surgical procedure for the treatment of the vertical deviation. LR recession can be added to splitting if the glob retraction in adduction is high. According to Roger et al Y splitting first defined by Jampolsky in 1980 increases the vertical stabilization effect of the LR muscle over the glob. By application of the Y splitting technique the authors have treated all the head position, esotropia and the abnormal vertical movements in a 5 cases series. In our series Y splitting of the LR was the preferred method for the treatment of the upshoots. 5 cases (83%) had Y splitting of the LR, 1 case (17%) had LR recession only. LR recession was added to four of the cases treated with Y splitting. The upshoot was decreased in all cases with the Y splitting surgery (%40 full correction) but it was unchanged in patients with LR recession surgery only. As Roger stated earlier addition of LR recession to Y splitting results in better outcomes if the presence of enophthalmos in adduction accompanies upshoot and downshoots. Another method of surgery used for the treatment of the vertical movements is the vertical muscle recession. This technique is not favored by some surgeons because of high risk of postoperative iatrogenical vertical deviation. Mohan and Saroha applied SR recession to 10 patients with upshoot. They have observed that the upshoot was recovered in all patiens. Vertical rectus muscle recession was not applied for the treatment of DRS patients with the upshoot and downshoot phenomenon in our clinic. Vertical muscle transposition suggested by Mohan, Saroha and Kraft is also not favored in our clinic for the treatment of upshoot and downshoot in DRS patients. Because the vertical rectus muscles innervated bythe 3rd nerve doesn’t compansate for the lateral rectus muscle innervation, therefore a full version movement is not expected. Vertical muscle transposition is not expected to compansate the real tight medial rectus muscle alone, therefore a MR recession must also be added to the surgery. However this addition may result in an over correction in the primary position and increase the anterior segment ischemia risk as 3 rectus muscles are involved in surgery.
5
CONCLUSI ON
The splitting of the ends of the lateral rectus muscle into a Y configuration is an easily performed operation which effectively improves the upshoot in patients with Duanes’ retraction syndrome. Performing simultaneous recession to the lateral rectus muscle combined with the splitting into Y configuration at its insertion improves the outcome, especially in patients with marked globe retraction.
REFERENCES Bloom, Graviss, Mardelii. A magnetic resonance imaging study of the upshoot – downshoot phenomenon of Duane’s retraction syndrome. Am. J. Ophthalmol. 1972; 88: 635–639 Mohan, Saroha. Vertical rectus recession for the intervention of upshoot and downshoot in Duane’s retraction syndrome. J. Pediatric Ophthalmology and Strabismus 2002; 39: 94–99 Molarte, Rosenbaum. Vertical muscle transposition surgery for Duane’s syndrome. Journal of Pediatric Ophthalmology and Strabismus 1990; 27: 171–177 Rogers, Bremer. Surgical treatment of the upshoot and downshoot in Duane’s retraction syndrome. Ophthalmology 1984; 91: 1380–1382 Von Noorden, Murray. Up and downshoots in Duane’s retraction syndrome. Journal of pediatric ophthalmology and strabismus
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Changes in corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery J.B. Lee, J.H. Chang & S.H. Han Department of Ophthalmology, Yonsei Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
Y.-H. Chang Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
ABSTRACT: We prospectively investigated the changes in corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery. Corneal and conjunctival sensitivity test with Cochet-bonnet esthesiometer, tear film break-up time measurement, and schirmer test were performed prospectively (before operation, 1 week, 1 month and 3 months after operation) in 83 patients (124 eyes) who underwent strabismus surgery in our institution. There were no significant changes in corneal sensitivity, tear film stability, and tear secretion after strabismus surgery (p 0.05). Conjunctival sensitivity decreased significantly after strabismus surgery (p 0.05). The discomfort and dryness after strabismus surgery does not seem to be related with changes in corneal sensitivity, tear film stability, and tear secretion. 1
INTRODUCTION
Some patients complain foreign body sensation, burning sensation, or dryness after strabismus surgery. It is now well recognized that the ocular surface and lacrimal gland function as an integrated unit and that the drive for lacrimal tear production and the blink mechanism that spreads and clears tears from the ocular surface is stimulation of the sensory nerves that innervate the ocular surface (Stern et al. 1998). When the afferent nerves of the ocular surface (trigeminal nerve) are stimulated in a normal individual, a reflex results in immediate blinking and secretion of tears. Sensory loss causes decreased tear secretion and reduces the blink rate (Jordan & Baum 1980). As expected, aqueous tear production and clearance have been reported to decrease in conditions where there is disease, damage, or surgical amputation of the corneal nerves (Heigle & Pflugfelder 1996).Various refractive surgical procedures have been associated with marked postoperative hypesthesia. Corneal sensitivity decreases after laser-assisted in situ keratomileusis (LASIK) because of surgical amputation and laser ablation of the nerve fibers innervating the central corneal surface (Campos et al. 1992, Wilson 1999, Perez-Santoja et al. 1999, Kauffmann et al. 1997). Corneal sensitivity after excimer laser photorefractive keratectomy has been noted to be initially reduced, but it returns to almost normal levels 3 months after surgery (Campos et al. 1992, Ishikawa et al. 1994, Trabucchi et al. 1994). However, little information is available concerning corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery. The purpose of this study was to prospectively evaluate corneal and conjunctival sensitivity, tear film stability, and tear secretion in a series of patients before and after undergoing strabismus surgery. 2
PATIENTS AND METHODS
We prospectively studied 124 eyes of 83 cooperative patients who underwent strabismus surgery in our hospital from October 2001 to March 2003. Those who had general health problems, previous 295
Table 1.
Type of operations.
Type of strabismus surgery
No. of eyes (patients)
Unilateral R & R* Bilateral LR recession Bilateral MR recession Unilateral LR recession Unilateral LR resection Unilateral MR recession Unilateral MR resection Unilateral IR recession Unilateral SR recession
14 (14) 50 (25) 32 (16) 4 (4) 2 (2) 9 (9) 7 (7) 2 (2) 4 (4)
Total
124 (83)
* recession and resection.
ocular surgery, corneal diseases, glaucoma, or history of ocular trauma were excluded. The patients ranged in age from 12 to 61 years (mean 29.4 years). All strabismus surgeries were performed under topical anesthesia by the same surgeon (J.B.Lee) using limbal incision. The type of operation is summarized in Table 1. Cornea and conjunctival sensitivity measurement with the Cochet-Bonnet esthesiometer (Luneau Ophthalmologie, Chartres Cedex, France), tear break-up time, and Schirmer II test (Schirmer test with anesthesia) were documented before and after surgery. The patients were examined at 1 week, 1 month, and 3 months after surgery. To minimize bias in measurement, all measurements were performed by the same observer. Data are presented as means SD. Statistical analysis was carried out by Wilcoxon rank test, and values of P less than 0.05 were considered statistically significant.
3
RESULTS
A total of 83 consecutive patients were enrolled into the study. Thirty-three patients were male and 50 were female. Forty-one patients underwent unilateral strabismus surgery, whereas 42 patients had bilateral strabismus surgery. Results for cornea and conjunctival sensitivity test, Shirmer test, and tear break-up time measurement are shown in Table 2. The preoperative corneal sensitivity was a mean of 58.5 2.7 mm which is similar to that of a previously reported group of noncontact lens wearing subjects (mean 58 mm) (Pflugfelder et al. 1998). Mean corneal sensitivity value was 58.1 3.2 mm at 1 week, 58.1 3.2 mm at 1 month, and 58.0 3.4 mm at 3 months. There were no significant changes in corneal sensitivity at 1 week, 1 month, 3 months postoperatively (p 0.05). Before surgery, the mean conjunctival sensitivity was 27.8 10.6 mm. Mean conjunctival sensitivity value was 22.3 12.1 mm at 1 week, 21.7 10.4 mm at 1 month, and 24.2 12.2 mm at 3 months. Conjunctival sensitivity decreased significantly after strabismus surgery (p 0.05) with slight recovery at 3 months. Patients had mean Schirmer II test scores of 13.41 3.01 mm before surgery. Mean Schimer test with anesthesia value was 13.35 2.98 mm at 1 week, 13.39 3.08 mm at 1 month, and 13.36 3.23 mm at 3 months. There were no significant changes in tear secretion after strabismus surgery (p 0.05). Patients had mean tear break-up time scores of 8.55 2.55 sec before surgery. Mean tear break-up time score was 8.56 2.76 sec at 1 week, 8.51 2.92 sec at 1 month, and 8.53 2.82 sec at 3 months. There were no significant changes in tear break-up time after strabismus surgery (p 0.05). No statistical correlation was found between type of operation (recession or resection, horizontal or vertical) and postoperative corneal and conjunctival sensitivity, Schirmer test, and tear break-up time value at any point of follow-up (p 0.05). There was no relationship between 296
Table 2. Preoperative and postoperative corneal and conjunctival sensitivity, tear film break-up time, and Schirmer test.
Before surgery Postoperative 1 week Postoperative 1 month Postoperative 3 months
Corneal sensitivity (mm)
Conjunctival sensitivity (mm)
Tear film break-up time (sec)
Shirmer test II (mm)
58.5 2.7
27.8 10.6
8.55 2.55
13.4 3.0
58.1 3.2
22.3 12.1*
8.56 2.76
13.4 3.0
58.1 3.2
21.7 10.4*
8.51 2.92
13.4 3.1
58.0 3.4
24.2 12.2*
8.53 2.82
13.4 3.2
* Statistically significant difference (p 0.05).
number of operated muscles and postoperative corneal and conjunctival sensitivity, Schirmer test, and tear break-up time value at any point of follow-up (p 0.05). 4
CONCLUSION
There were no significant changes in corneal sensitivity, tear film stability, and tear secretion after strabismus surgery (p 0.05). Conjunctival sensitivity decreased significantly after strabismus surgery (p 0.05). There was no significant difference in such parameters according to age, the type of surgeries, and number or kind of the operated muscle. The discomfort and dryness after strabismus surgery does not seem to be related with changes in corneal sensitivity, tear film stability, and tear secretion.
REFERENCES Campos, M. et al. 1992. Corneal sensitivity after photorefractive keratectomy. Am J Ophthalmol 114: 51–4. Heigle, T.J. & Pflugfelder, S.C. 1996. Aqueous tear production in patients with neurotrophic keratitis. Cornea 15: 135–8. Ishikawa, T. et al. 1994. Corneal sensation following excimer laser for photorefractive keratectomy in humans. J Refract Corneal Surg 10: 417–22. Jordan, A. & Baum, J. 1980. Basic tear flow. Does it exist? Ophthalmology 87: 920–30. Kauffmann, T. et al. 1997. Corneal reinnervation after photorefractive keratectomy and laser in situ keratomileusis: an in vivo study with a confocal videomicroscope. Ger J Ophthalmol 5: 508–12. Perez-Santoja, J.J. et al. 1999. Corneal sensitivity after photorefractive keratectomy and laser in situ keratomileusis for low myopia. Am J Ophthalmol 127: 497–504. Stern, M.E. et al. 1998. The pathology of dry eye: the interaction between the ocular surface and lacrimal glands [review]. Cornea 17: 584–9. Trabucchi, G. et al. 1994. Corneal nerve damage and regeneration after excimer laser photokeratectomy in rabbit eyes. Invest Ophthalmol Vis Sci 35: 229–35. Wilson, S.E. 1999. Corneal sensitivity after photorefractive keratectomy and laser in situ keratomileusis for low myopia. J Refract Surg 15: 603.
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Surgery of the inferior oblique muscle in bilateral asymmetric paralysis of the superior oblique V. Oguz, M. Yolar, H. Tolun & S. Özkan University of Istanbul, Cerrahpasa Medical Faculty, Istanbul, Turkey
ABSTRACT: The aim of this study is to compare the results of the symmetric surgery and the asymmetric surgery applied in the cases of bilateral asymmetric paralysis of the superior oblique muscle associated with the asymmetric overaction of the inferior oblique. This study includes 24 patients with the bilateral asymmetric paralysis of the superior oblique, who also had a overaction of the inferior oblique less than to for one eye and to for the other. In 11 cases out of 24, a bilateral myectomy of the inferior oblique has been applied not considering the difference of the amount of the overaction of the inferior oblique, while myectomy of the inferior oblique was applied to the eye presenting the greatest overaction of this muscle, and to the eye in which this overaction was less significant a recession of the inferior oblique was applied in the rest of the cases. When these two methods of surgery, asymmetric and symmetric, applied in the bilateral asymmetric paralysis of the superior oblique coexisting with an asymmetric overaction of the inferior oblique, have been compared with respect to the residual overaction of the inferior oblique, the asymmetric surgery has seemed to be more effective than the symmetric surgery. 1
INTRODUCTION
The paralysis of the superior oblique bilateral forms of which represents 11 to 29% of the cases, is the most frequent form of the vertical strabismus (1,2). The form of the paralysis is generally asymmetric and as long as the most affected eye is not operated involvement of the other eye may remain almost masked (almost masked paralysis of the superior oblique). Almost masked bilateral paralysis of the superior oblique is characterized by a strongly unequal overaction of the inferior oblique in almost all of the positions of gaze (3–7). A hypertropia is present in one or two positions of gaze due to the overaction of the inferior oblique muscle. The inversion of the hypertropia is not evident in one or two positions of gaze and in general in the position of oblique gaze to the field of action in which the least overacting effect of the inferior oblique is the most evident and the overaction effect of the inferior oblique may be least pronounced. Almost masked paralysis of the superior oblique has to be suspected in every case of the unilateral apparent paralysis of the superior oblique with overaction of the controlateral inferior oblique and inversion of the hypertropia in the field of action of the overacting oblique (2,8). The unique signs for the suspicion of the bilateral involvement are a right hypertropia at the gaze to the left and left at the gaze to the right and a positive Bielschowsky test in the two positions of gaze, by tilting the head laterally to either sides, and these findings do not exist in the cases of unilateral involvement. However the abscence of these signs do not exclude a bilateral involvement in none of the cases. This study includes the cases with a definite asymmetric paralysis of the superior oblique who have been operated by using two different surgical methods of the inferior oblique muscle. The purpose of this study is to compare the results of these two methods, either the symmetric or the asymmetric surgery, performed in cases of bilateral asymmetric paralysis of almost masked superior oblique, coexisting with the asymmetric overaction of the inferior oblique. 299
2
MATERIALS AND METHODS
Twenty four cases of bilateral asymmetric overaction of the superior oblique superior with a hypertropia between 5 and 20 PD and also a definitely asymmetric overaction of the inferior oblique being / in one eye and / in the other. All of these patients have been showing almost masked bilateral paralysis oblique superior and followed between 1989 and 2002. The criteria of diagnosis of the bilateral paralysis of the oblique superior have been as follows: – An evident paralysis of the oblique superior diagnosed by Parks’ three steps test (9), – Inversion of the hypertropia at the lateral gaze to the left and to the right or at positions of head tilt to either right or left, – Asymmetric overaction of the inferior oblique. Overaction of the inferior oblique has been graded from 1 to 4, and the exyclotorsion has been measured with Maddox double rods. The etiology of the bilateral paralysis of the inferior oblique was either congenital due to the disease history of the patients or was suspected considering the existence of the head-tilt for a long time and or a wide amplitude of vertical fusion. Symmetric surgery as bilateral myectomy of the oblique inferior has been applied in 11 cases and asymmetric surgery as myectomy of the inferior oblique along with a recession of the most overacting muscle due to the amount of the overaction of the less overacting inferior oblique.
3
RESULTS
The cases have been followed for 3 to 72 months, the mean time of follow up being 22,75 20,34 months. The vertical deviations in primary position was measured before the operation between 5 and 20 PD. A residual vertical deviation lower than 5 PD in primary position has been noted among 7 patients in the group of patients who have been treated by symmetric surgery and in 8 patients who have undergone the asymmetric surgery. No significant difference has been observed between these two groups of patients regarding the vertical deviation (p 0,62) while a residual overaction of the inferior oblique has been present in 7 patients of the group of symmetric surgery and 2 patients of the other, and a significant difference existed regarding the overaction of the inferior oblique (p 0,02).
4
DISCUSSION
In this study the procedure of weakening of the inferior oblique has been selected due to the amount of the overaction and recession of the inferior oblique which has been applied in cases presenting a mild () or moderate () overaction, and a myectomy to those with an overaction of the inferior oblique of () or (). It has been reported that the marginal myotomy leads to satisfactory results for unilateral vertical deviations under 6°, and less satisfactory results over it (10). Additionally in a group of 6 patients presenting an asymmetric overaction of the inferior oblique with paralysis of the superior oblique showing a hyperdeviation in primary position, only one sucessful result has been obtained although various procedures have been applied (1). However in a work of Mellott and collaborators, an asymmetric surgery, as the marginal myotomy to the oblique inferior showing a moderate overaction and a myectomy or recession to the most overacting inferior oblique, 9 of 10 cases have resulted satisfactorily with a residual hypertropia of less than 5 PD at primary position (11). As we applied an asymmetric surgery concerning the recession of inferior oblique muscle with a moderate overaction, along with the myectomy of the most overacting, we have also obtained satisfactory results. Only 2 out of 13 cases had a residual hyperdeviation of more than 5 PD in primary position. 300
In the same study of Mellott et al, following an asymmetric surgery, 5 cases out of 10 have presented a residual overaction while we noted a residual overaction in 5 of 13 cases after asymmetric surgery (11). In the two groups of surgery of our study no significant difference with respect to the vertical deviation was present. Many methods with a variable degree of success have been proposed for the treatment of the bilateral paralysis of the superior oblique with unequivalent overaction of the inferior oblique (4,9). The procedures of symmetric weakening of the inferior oblique do not eliminate the vertical deviation in primary position and an intervention on a third vertical muscle may be necessary. Therefore, some authors have proposed an unequivalent recession of the inferior oblique (12). But these experiences have shown that unequivalent recession of the inferior oblique is not sufficient for the elimination of the vertical deviation in primary position. In concordance with with these observations, recession of the controlateral inferior oblique has been carried in two cases along with the symmetric surgery and a postoperatory vertical deviation 10 PD has been obtained. Only one of 13 cases required such an intervention in the group of asymmetric surgery. Among the 11 cases of paralysis of the superior oblique superior showing a overaction of the inferior oblique in whom a symmetric surgery has been realised, 4 showed a residual overaction of the inferior oblique which has also been observed in 2 of 13 cases having undergone an asymmetric surgery. The fact that we obtained better results with the asymmetric surgery appears to be rather sensible due to the fact that we directly aimed at the pathology from which the asymmetry has been originated (4,11). In conclusion in the cases of asymmetric paralysis of the superior oblique showing an asymmetric overaction of the inferior oblique no difference existed in two methods of surgery, as symmetric and asymmetric, regarding the vertical deviation in primary position, whereas in respect with the residual overaction of the inferior oblique the results of the asymmetric surgery were more satisfactory than those of the symmetric one.
REFERENCES 1. Scott WE, Kraft SP. Classification and treatment of superior oblique palsies: II. Bilateral superior oblique palsies. In: Transactions of the New Orleans Academy of Ophthalmology. New York, New York Raven Press; 1986. pp 265–91 2. von Noorden GK. Binocular Vision and Ocular Motility. St.Louis, Mosby, 6th edition. 2002; 434. 3. Urist MJ. Bilateral superior oblique paralysis. Arch ophthalmol 1953; 49: 382 4. Souza Dias C. Surgical management of superior oblique paresis. In: Moore S, Mein J and Stocbridge L(eds). Ortoptics: Past, present and future. Miami, Symposia specialists, 1976, pp: 379–92 5. Hugonnier R. See-saw paralysis of the superior oblique muscle. In: Transactions of the second congress of international Strabismological association. Marseilles, Diffusion Gejal Libraire, 1976. pp. 120–22. 6. Hermann JS. Masked bilateral superior oblique paresis. J Pediatr Ophthalmol Strabismus 1981; 18: 43 7. Kraft SP, Scott WE. Masked bilateral superior oblique palsy. Clinical features and diagnosis. J Pediatr Ophthalmol 1986; 23: 264. 8. Jampolsky A. Vertical strabismus surgery. Trans New Orleans Acad Ophthalmol 1971, p. 366 9. Parks MM. A study of the weakening procedures for eliminating overaction of the inferior oblique muscle. Am J Ophthalmol 1972; 73: 107–22 10. De Decker W, Kueper J. Inferior oblique weakening by marginal myotomy: thermo-electric weakening. Ann Ophthalmol 1973; 5: 605–13. 11. Mellott ML, Scott WE, Ganser GL, Keech RV. Marginal myotomy of the minimally overacing Inferior Oblique Muscle In Asymmetric Biateral Superior Oblique Palsies. JAAPOS 2002; 6: 216–20. 12. Chamberlain W. Inferior oblique recession operation. Int J Ophthalmol Clin 1971; 11: 129–31.
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The oculocardiac reflex in strabismus surgery Asli Özbek, Serpil Akar, Birsen Gökyig˘it, Gulay Eren & Aysenur Öner Beyoglu Eye Education and Research Hospital, Istanbul, Turkey
ABSTRACT: To investigate the incidence of oculocardiac reflex and the differences in the decrease of heart rate according to muscle type, 126 extraocular muscles of 70 patients who underwent strabismus surgery by general anesthesia investigated prospectively. Before and after stretching the extraocular muscles, the heart rates were recorded. Wilcoxon signed ranks and paired t tests were used for statistical analysis. The heart rates before and after stretching 55 medial rectus (MR), 27 lateral rectus (LR), 15 superior rectus (SR), 18 inferior rectus (IR) and 10 inferior obliq (IO) were analysed statistically. The heart rate decreases in all muscle groups were found meaningful by statistical tests. The incidence of positive oculocardiac reflex during strabismus surgery in pediatric age group found significantly high. To determine the affects of anesthetic drug types and doses to oculocardiac reflex needs further studies.
1
INTRODUCTION
The oculocardiac reflex (OCR) (trigeminal – vagal mediated reflex arc) is a well known entity which may result in vagal depression of the heart when pressure is placed on the eyeball or when traction is applied to the extraocular muscles (Gold et al 1988). Bradycardia is by far the most common cardiac response to this stimuli and at least 20% decrease in heart rate from baseline accepted as positive OCR. Dysrhythmias or sinoatrial arrest is also takes place in the defination of OCR. In our study we investigate the incidance of oculocardiac reflex in pediatric age group during strabismus surgery, which is evoked by strecthing of the extraocular muscles, and the differences in the decrease of the heart rate according to muscle type. 2
MATERIALS AND EXPERIMENTAL METHODS
Between June and December 2003, 126 extraocular muscles of 70 pediatric age group patients who underwent strabismus surgery by general anesthesia of propofol, tracrium (or mivacron) and sevoflurane 50% NO2 50% O2, investigated prospectively. We did not use any preanesthetic medication. Heart rates were recorded from the electrocardiography before and after stretching the extraocular muscles. 55 beats per minute heart rate accepted as the critical value to stop stretching the extraocular muscle in order to permit the heart rate to return to normal. 20% or more heart rate decrease from baseline accepted as positive oculocardiac reflex. Wilcoxan signed ranks and paired t tests of SPSS programming were used for statistical analysis. 3
RESULTS
The mean heart rate values before and after streching the muscles that had recorded from 55 (43,65%) MR (Fig. 1), 27 (21,42%) LR (Fig. 2), 15 (11,90%) SR (Fig. 3), 18 (14,28%) IR (Fig. 4), 10 (7,93%) IO (Fig. 5) were analysed statistically. Superior obliq muscle didn’t include in the study because there weren’t enough muscle number for statistical tests. The heart rate decrease from the baseline in MR, 303
300 MRBEFORE MRAFTER
200
100
Mean
0 1,00
7,00
4,00
13,00 19,00 25,00
10,00 16,00 22,00
31,00 37,00 43,00 49,00 55,00
28,00 34,00 40,00 46,00 52,00
NO
Figure 1.
Heart rates before and after stretching the MR.
180 LRBEFORE LRAFTER
160 140 120 100 80
Mean
60 40 20 1,00
5,00 3,00
9,00 7,00
13,00 11,00
17,00
15,00
21,00
19,00
25,00
23,00
27,00
NO
Figure 2.
Heart rates before and after stretching the LR.
160 SRBEFORE SRAFTER 140
120
100
80
60
Mean
40
20 1,00
3,00 2,00
5,00 4,00
7,00 6,00
9,00 8,00
11,00
10,00
13,00
12,00
15,00
14,00
NO
Figure 3.
Heart rates before and after stretching the SR.
LR, SR, IR and IO muscle groups were found significantly meaningful by statistical tests (p 0,05, p 0,05, p 0,05, p 0,05, p 0,05) (Table 1). The positive oculocardiac reflex rates were found 58,18% for MR group, 22,22% for LR group, 53,33% for SR group, 38,88% IR group and 60% for IO group (Table 2). The OCR rate found 46,82% for total group. And 10 (18,18%) patients of MR group, 304
160 IRBEFORE IRAFTER 140
120
100
80
Mean 60
40 1,00
3,00
2,00
5,00
4,00
7,00
6,00
9,00
8,00
11,00
10,00
15,00
13,00
12,00
14,00
17,00
16,00
18,00
NO
Figure 4.
Heart rates before and after stretching the IR. 140 IOBEFORE IOAFTER 120
100
80
Mean 60
40 1,00
2,00
3,00
4,00
5,00
6,00
7,00
8,00
9,00
10,00
NO
Figure 5. Table 1.
Heart rates before and after stretching the IO. Heart rate changes before and after stretching the muscles.
Muscle group
Mean heart rate before stretching
Mean heart rate after stretching
p values for heart rate change
Lateral rectus Superior rectus Inferior rectus Inferior obliq Medial rectus
106,92 24,59 99,26 22,46 96,22 19,24 105 15,84 110,09 27,80
93,25 27,80 75 23,08 83,50 24,66 75,3 19,39 79,50 26,12
p 0,05 p 0,05 p 0,05 p 0,05 p 0,05
Table 2. Rates of positive oculocardiac reflex and reaching to the critical heart rate according to muscle types. Muscle group
20% heart rate decrease from baseline n (%)
Critical heart rate ( 55/min) n (%)
Medial rectus Lateral rectus Superior rectus Inferior rectus Inferior obliq
32 (58,18) 6 (22,22) 8 (53,33) 7 (38,88) 6 (60)
10 (18,18) 2 (7,40) 3 (20) 2 (11,11) 0
305
2 (7,40%) patients of LR group, 3 (20%) patients of SR group and 2 (11,11%) patients of IR group reached to critical point ( 55/minute heart rate).This rate was 13,49% for total group. Critical point didn’t occured in IO group. Life treated dysrhymias or asystole didn’t occured in any of the patients. 4
CONCLUSION
Trigeminovagal bradycardia elicited by tension on an extraocular muscle is a hazard for strabismus patients. In our study the incidence of OCR during strabismus surgery found significantly high. According to our results the OCR was observed more often following traction on the IO muscle group (60%). MR muscle group (58,18%) results were also very high as IO muscle results. We found OCR least for LR group (22,22%). Ohashi et al. studied OCR in 15 patients with strabismus and the reflex observed in all patients when MR and IO muscles were stretched. They also mentioned that as tension was increased, bradycardia occured rapidly and become deep (Ohashi et al 1986). Arnold et al found OCR rate greatest for IR group and least for LR group in their 1275 patients (adults and children) who underwent extraocular muscle surgery (Arnold et al). Tramer et al told that, propofol, the induction agent which we used for lowering the incidance of postoperative nausea and vomiting, associated with an incidence of OCR of about 50% (Tramer et al 1995). Song et al used atropine sulfat or glycopyrrolate premedications in their study and found OCR rate higher in MR group (30,0%) than other muscle groups (Song et al 1987). Mirakhur et al studied the frequency of OCR and its prevention by atropine or glycopyrrolate in 160 children undergoing squint surgery. In their patients 90% of those given no anticholinergic premedication exhibited the reflex. This was decreased to about 50% in those receiving the drugs i.m. glycopyrrolate and i.v. atropine. And they also observed the reflex more often following traction on the MR (Mirakhur et al 1982). Allison et al found OCR rate and dysrhtymias less frequently with sevoflurane than with halothane (Allison et al 2000). Grover et al showed that the overall incidance of OCR was higher with general anesthesia (63,3%) than with local anesthesia (14,4%) (Grover et al 1998). But it is nearly impossible to use local anesthesia in pediatric age group during squint surgery. We think our critical point results and OCR rates for muscle groups can be hepfull to practicans, who are working under insufficent monitorization conditions, to pay attention to critical muscle groups during strabismus surgery under general anesthesia. The carefull monitorization of the patient during strabismus surgery needs more attention to prevent patient from a life treated situation. Gold et al reported two cases of ten second episodes of asystole during traction on the medial rectus (Gold et al 1988). OCR can be reduced by exerting very gentle tension on the extraocular muscles or waiting for return to baseline heart rate before fatiguing the reflex. To determine the differences between the muscle types and affects of anesthetic drug types and doses to OCR needs further studies. REFERENCES 1. Allison CE et al 2000. A comparison of the incidence of the oculocardiac and oculorespiratory reflexes during sevoflurane or halothane anesthesia for strabismus surgery in children. Anesth Analg 2000; (90): 306 2. Arnold RW et al. The profound effect of fast acting narcotics on the oculocardiac reflex. Providence Alaska Medical Centre and Ophtalmic Associates, Anchorage, Alaska 3. Gold RS, Pollard Z, Buchwald IP 1988. Asystole due to the oculocardiac reflex during strabismus surgery: a report of two cases. Ann Ophthalmol 20(12): 473–475 4. Mirakhur RK et al 1982. I.m. or i.v. atropine or glycopyrrolate for the prevention of oculocardiac reflex in children undergoing squint surgery. British Journal of Anaesthesia 1982; 54(10): 1059–1063 5. Ohashi T et al 1986. Quantitative analysis of the oculocardiac reflex by traction on human extraocular muscle. Investigative Ophthalmology & Visual Science 1986; 27(7): 1160–1164 6. Song NW et al 1987. The oculocardiac reflex during strabismus surgery in children. Korean J Anesthesiol 1987 Dec; 20(6): 824–829 7. Tramer M, Moore A, McQuary H 1995. Prevention of vomiting after pediatric strabismus surgery: a systematic review using the numbers needed to treat method. British Journal of Anaesthesia 1995; 75: 556–61
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Globe retraction in a patient with nanophthalmos S. Öner, A.F. Nohutçu & H.N. Ortak Haydarpasa Numune Hospital for Education and Research, Istanbul, Turkey
ABSTRACT: We present a 14 year-old female patient with bilateral nanophthalmos and globe retraction with narrowing of the palpebral fissure on adduction of the left eye. There was ortotropia in primary position, and no restriction of ocular motility. Magnetic resonance imaging showed bilateral normal nervi abducens. One brother of the patient had bilateral nanophthalmos without ocular motility disorder. There is no report of nanophthalmos associated with globe retraction in the literature. Globe retraction on adduction is a typical component of Duane Syndrome Type I, which has not been reported in association with nanophthalmos. We suggest that the phenomenon of globe retraction in this case may be related to mechanical factors rather than innervational abnormalities.
1
INTRODUCTION
The characteristic features of nanophthalmos are narrow palpebral fissures in combination with a deep set globe in a small orbit, hypermetropia, short axial length, reduced volume of the globe with normal lens volume, and normal or reduced corneal diameter. Complications of this disorder are angle closure glaucoma, uveal effusion, choroidal detachment, and non-rhegmatogenous retinal detachment (Singh et al. 1994). Associated strabismus, in most cases nonaccomodative esotropia, and with lower incidence microesotropia and exotropia, can be observed (Sener et al. 2003). Globe retraction and narrowing of the palpebral fissure on adduction are typical components of the Duane retraction syndrome (DRS). Numerous systemic and ocular disorders have been reported in association with DRS (DeRespinis et al. 1993). We report a case of bilateral nanophthalmos with globe retraction and narrowing of the palpebral fissure of the left eye on attempted adduction. To our best knowledge, a similar case has not been described yet.
2
CASE REPORT
The 14 year-old girl presented in our clinic in August 2003 for spectacle renewal. Anamnesis revealed no problem during pregnancy; normal delivery, and no history of disease. She had bilateral narrow palpebral fissures and deeply set globes (Fig. 1). Best corrected visual acuity (BCVA) was 0.4 (13.0) OD, and 0.5 (11.0) OS. She has been wearing spectacles since the age of 1. On biomicroscopic examination, horizontal corneal diameter
Figure 1. Photographs demonstrate bilateral deep set globes with narrow palpebral fissures, and retraction of the left globe with narrowing of the palpebral fissure on right gaze.
307
Table 1.
Orbital B-scan ultrasonography values.
Anteroposterior globe diameter Transvers globe diameter Anterior chamber depth Anteroposterior lens diameter Equatorial lens diameter Skleral thickness
Right eye (mm)
Left eye (mm)
14.4 14.2 1.9 3.5 7.1 1.4
15.1 15.3 1.9 3.5 7.3 1.4
of bilateral 11.0 mm, and thick irises with a convexity towards the cornea were observed. Gonioscopy revealed bilateral Shaffer grade II anterior chamber angle, periferal anterior synechiae and prominent iris convexity. Intraocular pressure was 11 mmHg in both eyes. Visual field testing showed bilateral arcuate scotoma, more extensive in the right eye. On fundoscopy bilateral pseudopapiledema and macular folds were observed. Orbital B-scan ultrasonography values are shown in Table 1. Magnetic resonance imaging of the brain stem showed bilateral normal nervi abducens. There was ortotropia in primary position and no restriction of ductions and versions. Diplopia, head turn or nystagmus were not observed. On attempted adduction of the left eye there was globe retraction and narrowing of the palpebral fissure (Fig. 1). Nanophthalmos was present in 2 of 3 children of this family. The oldest child, a girl, was reported as being healthy and having no ocular problems, the youngest child, an otherwise healthy 11 year-old boy without a history of abnormalities during pregnancy or birth, had bilateral nanophthalmos without ocular motility disorder. Mother and father are secondary degree relatives. Ocular problems have not been reported in any other member of the family.
3
DISCUSSION
Our case showed features of typical nanophthalmos, and globe retraction with narrowing of the palpebral fissure of the left eye on attempted right gaze. Globe retraction and narrowing of the palpebral fissure on adduction are typical components of DRS, and have been related to the paradoxical innervation of the lateral rectus muscle, leading to co-contraction of the horizontal rectus muscles. DRS is more frequently found on the left eye and in females (DeRespinis et al. 1993). Magnetic resonance imaging can show abscence of the nervus abducens (Ozkurt et al. 2003). Gross et al. (Gross et al. 1994) report a case of DRS type II with synchroneous innervation of the ipsilateral horizontal rectus muscles without globe retraction. They propose that in DRS both innervational and mechanical factors are involved. In our case, we propose a mechanical factor for the globe retraction, because neither strabismus, nor restriction of ocular motility was present. REFERENCES DeRespinis, P.A., Caputo, A.R., Wagner, R.S. & Guo, S. 1993. Duane’s Retraction syndrome. Surv Ophthalmol 38(3): 257–288. Gross, S.A., Tien, D.R. & Breinin, G.M. 1994. Aberrant innervational pattern in Duane’s syndrome type II without globe retraction. Am J Ophthalmol 117(3): 348–351. Ozkurt, H., Basak, M., Oral, Y. & Ozkurt, Y. 2003. Magnetic resonance imaging in Duane’s retractionsyndrome. J Pediatr Ophthalmol Strabismus 40(1): 19–22. Sener, E.C., Mocan, M.C., Sarac, O.I., Gedik, S. & Sanac, A.S. 2003. Management of strabismus in nanophthalmic patients. Ophthalmology 110(6): 1230–1236. Singh, O.S. & Sofinski, S.J. 1994. Nanophthalmos: Guidelines for diagnosis and therapy. In: D.M. Albert & F.A. Jacobiec (eds). Principles and Practice of Ophthalmology: 1528–1540. Philadephia: W.B. Saunders.
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Surgical treatment of consecutive exotropia Aslıhan Öztürk, Serpil Akar, Birsen Gökyig˘it, Ömer Faruk Öge, Zerrin Bayraktar Ömer Faruk Yılmaz Beyog˘ lu Eye Research and Education Hospital
ABSTRACT: I⭈ntroduction: Consecutive exotropia (CXT) is a well-known phenomenon found after various surgeries for esotropia (ET). We investigated the characteristics of these patients and the results of the surgery for CXT in this study. Materials and methods: We reviewed the files of patients who underwent surgery for CXT between 1995–2002 at Beyog˘lu Eye Research and Education Hospital. We used Wilcoxon signed Ranks tests as statistical method for evaluation. Results: There was 28 patients who underwent surgery for CXT. Mean age was 18,21 17,07 (range 3–73) years. The average preoperative deviation was (29,29 13,35) prism diopters (pd) (range 10–58 pd XT ) at near fixation and (25,39 15,7) pd (range 0–58 pd XT) at distance fixation. The postoperative average deviation was (1,18 7,11) pd (range 15 ET–18 pd XT) at near fixation and (0,96 7,5) pd (range 25 ET–16 pd XT) at distance fixation. 3 patients had 10 pd of exotropia while 1 had 10 pd of esotropia. One surgery had enough at 24 (85,7%) patients 4 (14,2%) patients required 2 surgeries for CXT. Mean follow up was 9,43 5,6 (range 6–28) months. There are statistically significant difference between preoperative and postoperative near deviations and between preoperative and postoperative distance deviations (p 0.001, p 0.001). Conclusions: Good alignment can be achieved after surgery for CXT.
1
INTRODUCTION
Consecutive exotropia (CXT) is a frequent problem found after varies surgeries for esotropia (ET). Factors of development of CXT in reported series are excessive amount of surgery, amblyopia, high hyperopia and failure to evaluate of patients preoperatively (Cooper EL. 1961, Brown R.M. 1976). In this study, we examined the characteristics of these patients and the factors involved in the development of CXT and the results of the surgical procedures used for its treatment.
2
MATERIALS AND EXPERIMENTAL METHODS
We reviewed the medical records of patients who underwent surgery for CXT between 1995–2002 at strabismus department of Beyog˘lu Eye Research and Education Hospital. Age onset of ET, age at surgery for ET, age CXT noted, age at time of surgery for XT, amount of XT , type of XT surgery, number of XT surgeries, presence of amblyopia, versions, amount of deviation after surgery for CXT were recorded. The surgical technique used was individually considered for each patient. Mean follow up was 9,43 5,6 (range 6–28) months. We used Wilcoxon signed Ranks tests as statistical method for evaluation. 309
Table 1.
Age and time.
Age at ET surgery Age that XT noted Age at CXT surgery Time between ET-XT surgery Table 2.
Mean (years)
Range (years)
6,83 0,77 14,3 2,48 18,21 17,07 7,7
(0,5–17) (0,5–55) (3–73) (0,005–38)
Preoperative findings.
Amblyopia present Presence of A/V/X pattern Table 3.
3
n
%
19 16
63 57
Preoperative and postoperative deviations.
Average deviation
Near fixation
Distance fixation
Preoperative
29,29 13,35 pd (range 10–58 pd XT)
25,39 15,7 pd (range 0–58 pd XT)
Postoperative
1,18 7,11 pd (range 15 pd ET–18 pd XT)
0,96 7,5 pd (range 25 pd ET–16 pd XT)
RESULTS
There was 28 patients who underwent surgery for CXT (11 female and 17 male). Mean age of onset ET was 1,63 years (range 0–6 years). 15 (53.5%) out of 28 patients were younger than 1 year at the onset of the ET. The children with early onset ET are less likely to have stable binocular vision and are more likely to develop CXT. (Eugene R.F. 1983). We research the age of the patient at the time of the ET surgery and the interval between the onset of the CXT. Mean age at ETsurgery was 6,83 0,77 (range 0,5–17) years and mean age that XT noted was 14,3 2,48 (0,5–55) years. Mean age at CXT surgery was 18,21 17,07 (range 3–73) years. The time between surgery for esotropia and exotropia was between 3 days and 38 years (average 7,7 years) (Table 1). Ambliyopia has been identified as one of the factors important in the development of CXT.19 out of 28 patients had ambliyopia and 16 out of 28 patients had A/V/X patterns. (Table 2) Only 5 of 28 patients showed a hyperopia in excess of 2,5 diyoptres and 1 patient showed a myopia in excess of 9,5 diyoptres. The rest of the patients had a refractive error between 2,50 and 1,50. The average preoperative deviation was (29,29 13,35) prism diopters (pd) (range 10–58 pd XT ) at near fixation and (25,39 15,7) pd (range 0–58 pd XT) at distance fixation (Table 3). One surgery had enough at 24 (85,7%) patients , 4 (14,2%) patients required 2 surgeries for CXT. We performed Medial rectus (MR) advancement in 9 patients (MR advancement with infra position in 1 patient), MR advancement LR recession in 13 patients (MR advancement with supra position LR recession in 1 patient), MR resection MR advancement in 2 patients, MR advancement LR myotomi at inferior side in 1 patient, MR advancement bilateral IO recession in 1 patient, MR advancement bilateral LR recession in 2 patients at the first operation. (Table 4) The postoperative average deviation was (1,18 7,11) pd (range 15 ET–18 pd XT) at near fixation and (0,96 7,5) pd (range 25 ET–16 XT) at distance fixation. There are statistically significant difference between preoperative and postoperative near deviations and between preoperative and postoperative distance deviations (p 0.001, p 0.001), 3 patients had 10 prism diopters of exotropia while 1 had 10 PD of esotropia. 310
Table 4.
4
Surgery for XT.
Surgery
n
%
MR advancement MR advancement LR recession MR advancement MR resection MR advancement bilateral IO recession MR advancement bilateral LR recession MR advancement LR myotomi (inferior side)
9 13 2 1 2 1
32 46 7 3,5 7 3,5
DISCUSSION
Consecutive XT is not infrequently confronted after surgery for ET. The incidence in reported series of CXT ranged from 4% to 20% (Bietti GB 1965, Dunnington JH 1950). The incidence was found 2,4% in this study. The time of onset of CXT varies greatly but there has been a noted progression towards exotropic drift in long term follow up of patients in previous studies (Caputo AR 1990). This study indicate that most of the deviations occurred in the immediate postoperative period. But CXT may develop many years later after ET surgery. Therefore, the success of surgery for ET can not be evaluated within a short follow up period. A high degree of hyperopia has been thought to be responsible producing CXT in previous studies (Cooper EL 1961, Brown RM 1976). Our study did not prove this. In our study, only 5 (17%) patient showed a hyperopia in excess of 2,5 dioptres. It is important to properly evaluate the presence of amblyopia and A/V/X patterns (Eugene RF 1983, Bradbury JA 1993). The presence of amblyopia and A/V/X patterns were found to be the most common factors in the development of CXT in our study. These findings may help in the planning of the most appropriate surgery for CXT. Amblyopia must be fully corrected. After surgery patient should continue with amblyopia therapy.
5
CONCLUSION
The final deviation was noted to be closer to orthophoria in our study. Good alignment can be achieved after surgery for CXT.
REFERENCES 1. Cooper EL. The surgical management of secondary exotropia. Trans Am Acad Ophthalmol Otolaryngol, 1961; 65: 595–608. 2. Brown RM, Cooper BM. An assesment of the rule of secondary and consecutive factors in overcorrected esotropia, orthoptics past, present, future. New York: Stratton Intercontinental Medical Book Corporation, 1976: 515–22. 3. Eugene RF. Consecutive exotropia following surgery. British Journal of Ophthalmology, 1983; 67: 546–548. 4. Bradbury JA, et al. Secondary exotropia: a retrospective analysis of matched cases. Journal of Pediatric Ophthalmology and Strabismus, 1993; 30(3): 163–166. 5. Caputo AR, et al. Preferred postoperative alignment after congenital esotropia surgery. Annals of Ophthalmology, 1990; 22(7): 269–272. 6. Bietti GB, Bagloni B. Problems related to surgical overcorrections in strabismus surgery. J Pediatr Ophthalmol, 1965; 2: 11–14. 7. Dunnington JH, Reagan EF. Factors influencing the postoperative result in concomitant convergent strabismus. Arch Ophthalmol, 1950; 33: 380–7.
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Epiblepharon and Mobius syndrome: a rare association Venkateshwar B. Rao & Prashant Sahare Department of Pediatric Ophthalmology and Strabismus, Jasti V Ramanamma Children’s Eye Care Centre, L V Prasad Eye Institute, Hyderabad, India
ABSTRACT: Introduction: Mobius syndrome is a congenital disorder of facial diplegia associated with bilateral lateral rectus paralysis. Clinically it is characterized by a total absence of facial expression and severe esotropia with or without limb abnormalities. The purpose is to report congenital epiblepharon as a new clinical manifestation of Mobius syndrome and present the outcome related to motor alignment after hang back medial rectus recession. Methods: Case report. Results: A 6-month old male infant was referred for ophthalmic evaluation by Pediatrician. The child was a product of a term, uncomplicated pregnancy with a birth weight of 3500 gm. There was no history of alcohol, drug ingestion or any medications taken during pregnancy. Pediatrician evaluation records showed congenital talipes eqinovarus both foot with mild cerebral atrophy in CT scan of brain. Ophthalmic examination showed expression less face, loss of nasolabial folds, marked epicanthal folds, epiblepharon of both lower lids with mild trichiatic lashes and lagophthalmos. No corneal problems were seen. Ocular motility showed large esotropia of 50 to 60 PD by krimsky test with marked limitation of abduction in both eyes (not moving beyond midline). A forced duction test under anaesthesia revealed restriction mild in abduction. A bilateral hang back medial rectus recession of 6.5 mm from insertion was done. One week after surgery the child was orthotropic with stable alignment maintained at 26 months follow-up. Conclusions: This case highlights the association of epiblepharon with Mobius syndrome which to our knowledge is previously unrecognized. Good cosmetic and motor alignment was achieved with hang back recession of medial rectus muscle.
1
INTRODUCTION
Mobius syndrome is a congenital disorder of facial diplegia associated with bilateral sixth nerve paralysis. Neuropathological evidence indicates that Mobius is a more complex syndrome in which palsy of sixth and seventh cranial nerves is the minimum diagnostic feature.1 Clinically, it is characterized by a total absence of facial expression and severe esotropia.2 Generally horizontal eye movements are clearly abnormal and vertical eye movements are preserved. Limb malformations are also common with this syndrome.2,3 The etiology of this syndrome has not been clearly established. A number of investigators have speculated that disruption of the vascular system causes hypoxia of vulnerable tissues between 4 and 7 weeks of gestation.4 It has been proposed that Mobius syndrome, the Poland anomaly and Klippel Feil defect all result from a transient interruption during sixth week of gestation in the development of the subclavian artery and its branches.5 Even though many reports have described the various features of Mobius syndrome, only a few articles have reported the results of strabismus surgery in children.6,7 The purpose is to report congenital epiblepharon as a new clinical manifestation of Mobius syndrome and present the outcome related to motor alignment after hang back medial rectus recession. 313
Figure 1.
Showing esotropia with marked abduction limitation.
(a)
(b)
Figure 2. (a) Showing epiblepharon both lower lids with trichiatic lashes. (b) Lagophthalmos with expressionless face and loss of nasolabial folds.
2
METHODS
CASE REPORT: A 6-month-old infant was referred for ophthalmic evaluation by the pediatrician because of congenital esotropia. The child was a product of a term, uncomplicated pregnancy with a birth weight of 3500 grams. There was no history of any alcohol intake, or drug ingestion or any other medications taken by the mother during pregnancy. His mother was a healthy young woman with no known history of any disease in the family. After delivery an expressionless smooth face, strabismus, and inward turning of both feet were detected (congenital talipes equino varus) and advised for foot surgery by the pediatrician. Patient also had delayed milestones with slowness in general motor progression. Records of evaluation by pediatric neurologist showed mild cerebral atrophy on computed tomography scan of brain. Ultrasonography of abdomen and X-ray chest PA view were normal. Chromosomal analysis showed normal karyotype. Test for human immunodeficiency virus (HIV) and hepatitis surface antigen were negative. The patient was recommended by pediatric neurologist for early congnitive stimulation because of developmental delay. On examination the child was fixing and following the light by moving his head. Ocular motility showed large esotropia of 50 to 60 PD by krimsky test with marked limitation of abduction in both eyes (not moving beyond midline) (Fig 1). Examination showed expressionless face, loss of nasolabial folds, lagophthalmos, epicanthal folds, epiblepharon of both lower lids with trichiatic eye lashes (Fig 2 a & b). Since the child was not co-operative for proper anterior and posterior segment examination, an examination under anaesthesia was advised. Meanwhile patient underwent surgery for congenital talipes equinovarus under general anaesthesia outside and came back for eye examination under anaesthesia. During examination under anaesthesia a forced duction test was carried out which was positive in abduction indicating tight medial recti in both the eyes. Cycloplegic refraction revealed hyperopia of 2.50 Ds in both eyes. Anterior segment and posterior 314
Figure 3.
Post-op photograph showing orthotropic eyes with abduction limitation persisting.
Figure 4.
Pre-op and Post-op appearance.
segment evaluation were normal. A bilateral hang back medial rectus recession of 6.5 mm was performed under general anaesthesia. One week after surgery the child was orthotropic in primary position, still with marked limitation of abduction in both the eyes (Fig 3). This alignment remained stable for two years (Fig 4).
3
DISCUSSION
Mobius syndrome is probably caused by several teratogenic factors that act between the fourth and seventh weeks of the intrauterine life resulting in hypoplasia of sixth and seventh nerve nuclei and 315
atresia of supranuclear pathways. It has been proposed that Mobius syndrome, the Poland anomaly and Klippel-Feil defect all result from a transient interruption during sixth week of gestation in the development of the subclavian artery and its branches, including the basilar, vertebral and internal thoracic arteries which supply the brain, neck, pectoral muscles and upper limbs.5 The congenital paralysis of the lateral rectus muscle and the facial diplegia are the most important clinical manifestations of the syndrome.8 Epiblepharon is the presence of a fold in the skin and orbicularis of the lower lids that may cause trichiasis.9 It is usually self-limited diminishing with facial growth although surgical correction may be required in few cases where corneal problems develop.9 Mobius syndrome must be included in the differential diagnosis of congenital esotropia, as well as in Duane retraction syndrome, early onset accomodative esotropia and other causes of esotropia in infants.10 The few published results of strabismus surgery in these patients advocate surgical options in the form of bilateral medial rectus recession; bilateral medial rectus muscle recession and lateral rectus resection and transposition of vertical rectus muscles.11
4
CONCLUSION
This case highlights the association of epiblepharon with Mobius syndrome which to our knowledge has not been reported previously. Good cosmetic and motor alignment was achieved with hang back recession of medial rectus muscle.
REFERENCES 1. Miller MT, Ray V, Owens P, Chen F. Moebius and Moebius like syndrome. J Pediatr Ophthalmol Strabismus 1989;26:176–88 2. Miller NR. Topical diagnosis of neuropathic ocular motility disorders. In Miller NR, editor: Walsh and Hoyt’s clinical neuro-ophthalmology. Ed 4, vol 2. Baltimore 1985, William and Wilkins. 3. Rogers OL, Hatch GF, Gray I. Mobius syndrome and Limb abnormalities. J Pediatr Ophthalmol 1977;14:134–138 4. Harbord MG, Ginn JP, Ham-Craggs MA et al. Moebius syndrome with unilateral cerebellar hypoplasia. J Med Genet 1989;26:579–582 5. Bavinck JN, Weaver DD. Subclavian artery disruption sequence. Hypothesis of a vascular etiology for Poland, Klipper-Feil and Mobius anomalies. Am J Med Genet 1986;23:903–918 6. Kubatko-Zielinska A, Krzystkowa KM. Congenital syndromes of oculomotor disturbances – diagnosis and results of surgical treatment. Klin Oczna 1995;97: 142–6 7. Abraham Spierer MD, Adiel Barak MD. Strabismus surgery in children with Mobius syndrome. J of AAPOS 2000;4:58–59 8. Cernea P, Grapa C. Congenital bilateral abducen paralysis and facial diplegia: the Moebius syndrome Oftalmologia 1991;35:79–84 9. Hayasaka S, Noda S, Setogawa T. Epiblepharon with inverted eye lashes in Japanese children. II. Surgical repairs. Br J Ophtalmol 1989; 73:128–130 10. Nelson LB, Wagner RS, Simon JW, Harley RD. Congenital esotropia. Surv Ophthalmol 1987;31:363–83. 11. Laby DM, Rosenbaum AL, Isenberg SJ, Fleck BW. Strabismus surgery in patients with Moebius syndrome: update on strabismus and pediatric ophthalmology. Proceedings of the joint ISA and AAPOS Meeting; 1994: Vancouver, Canada p.419–22
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Assessment of the risk of endophthalmitis in accidental globe penetration during strabismus surgery Ali Akbar Saber Moghaddam & Abbas Kargozar Assistant prof. of ophthalmology, Mashhad University of Medical Sciences, Iran
Tahereh Rashed Prof of microbiology, Mashhad University of Medical Sciences, Iran
ABSTRACT: Objective: To asses the risk of endophthalmitis if globe penetrated by suture needle during strabismus surgery. Materials and Methods: Fornix & suture needle culture was performed in 28 eyes of 28 patients. Fornix sampling was performed before and after preparation of the eyes. Fornix samples and suture needle (at the end of operation) cultured in aerobic and anaerobic media. The findings analyzed by SPSS 10.1. Results: Before preparation 25 cases (89.28%) was contaminated by staphylococcus (coagolase positive & negative), peptostreptococcus, gr positive bacillus , and Klebsiella. After preparation, 15 cases (60%) of infected samples change to sterile culture. Also 15 cases (60%) of needle culture were sterile (from 25 primary infected cases). Because close relation between the organisms cultured from pre-preparation samples and needle culture, so we conclude the most probable source of contamination is the normal flora of fornices. There was no evidence of cellulitis or significant conjunctivitis post operatively in our patients. Conclusion: Because of high possibility of needle contamination by lid margin or fornix flora during strabismus surgery, care must be taken to avoid globe penetration and if it was happened, prophylaxis from endophthalmitis seems to be reasonable.
1
INTRODUCTION
There are few reports of endophthalmitis following strabismus surgery. The estimated incidence ranges from 1:3500 to 1:1850001. Despite its major impact on visual outcome, the relative rarity of the event has made it difficult to study definitively. Both the source of the bacteria and the mode of transmission are unknown. Anecdotal reports have speculated on exogenous or endogenous sources, including normal or transient ocular flora2,3. Numerous studies have evaluated methods to decrease preoperative conjunctival bacterial counts in hope of decreasing the risk of infection after strabismus surgery4–6. Currently most pediatric ophthalmologists directly instill 5% povidone-iodine immediately before surgery, but no method completely sterilizes the conjunctiva in all cases7. Even if the host conjunctiva is a major source of infection, the mode of entry to the intraocular space remains unknown. Parks believes that a postoperative cellulitis or abscess precedes and initiates the endophthalmitis. Others suggest that scleral perforation from needles provides a method of access for bacteria2,3. If scleral perforation is involved in the mechanism of endophthalmitis, then needle sterility is an important issue. If needles became contaminated from any source, including conjunctival flora, they could deposit bacteria intrasclerally in the suprachoroidal spaces or in the vitreous cavity. 317
This study was undertaken to determine the sterility of needles that are used during strabismus surgery.
2
METHODS
28 patients undergoing strabismus surgery by the author were eligible for enrollment. After sampling for aerobic and anaerobic cultures patients underwent a standard preoperative preparation in the operating room. No patient received preoperative prophylactic antibiotics. Sampling repeated immediately before operation (post preparation). At the conclusion of the surgery the needles used during the intrascleral pass to secure the muscle to the globe was collected for culture (directly in aerobic and anaerobic culture media). Any bacterial growth from either the aerobic or anaerobic media was considered positive. The results were analyzed by SPSS 10
3
RESULTS
Before preparation 25 cases (89.28%) was contaminated by staphylococcus (coagolase positive & negative), peptostreptococcus, gr positive bacillus , and Klebsiella. After preparation, 15 cases (60%) of infected samples change to sterile culture. Also 15 cases (60%) of needle culture were sterile (from 25 primary infected cases). Because close relation between the organisms cultured from prepreparation samples and needle culture, so we conclude the most probable source of contamination is the normal flora of fornices. There was no evidence of cellulitis or significant conjunctivitis post operatively in our patients.
4
DISCUSSION
Postoperative infection after strabismus surgery is a rare but potentially devastating event2 Estimates in the literature vary widely. Retrospective reviews have documented an incidence of between 1 in 3500 to 1 in 1850001 case. Ing documented an incidence of only 1 per 30000 cases8. Because of this low incidence, the cause and prevention of postoperative endophthalmitis is speculative. Ing found no correlation between infection rate and the use of prophylactic antibiotics8. Most studies of the prevention of postoperative infection have concentrated on reducing the population of the patients own bacterial flora4–6. This philosophy assumes that patients own bacterial flora, either normal low virulent types or transient higher virulent types, is the source of postoperative infection. With use of molecular epidemiology, studies have demonstrated that the pathogens responsible for endophthalmitis after cataract surgery are identical to those residing on the patients own external tissue9,10. Farther more, 43% of patients undergoing uncomplicated cataract surgery demonstrate culture-positive anterior chamber aspirate 11. These studies strongly suggest that bacterial from external ocular structures are often introduced into the eye during cataract surgery and, if the bacterial load is large enough or virulence great enough, an infection may occur. It may be logical to extrapolate these results to strabismus surgery and postulate that the patients own bacterial flora is somehow introduced into the eye and that this may then increase the risk for development of an intraocular infection. Globe perforation during strabismus surgery is not uncommon. It has been estimated to occur in between 1% and 12% of cases 12. Most perforations are not detected during surgery. The intraocular inoculation of exogenous bacterial could occur through the perforation site after surgery or at the time of the surgery if the needle was not sterile. The results of our study show that these needles are not always sterile. In 40% of our cases, the needle was found to be contaminated. As the results indicated, bacteria grown from these needles closely resemble culture results of normal conjunctival flora. Therefore it is logical to hypothesize that the needles used during strabismus surgery may be a method by which resident bacterial are introduced into the eye during surgery. 318
However the introduction of bacteria into the suprachoroidal or deeper spaces of the eye does not equate with clinical infection. If scleral perforation occur at least 1% of the time and these needles are contaminated by conjunctival flora at the rate of about 40%, then bacteria could be introduced 0/40% of the time. This is a rate of 4 per 1000 cases, a number, although low, that is considerably higher than the rate of endophthalmitis. It is however close to the rate of overall periocular infection13. This study was performed to evaluate the incidence of needle contamination during strabismus surgery.
5
CONCLUSION
Because of high possibility of needle contamination by lid margin or fornix flora during strabismus surgery, care must be taken to avoid globe penetration and if it was happened, prophylaxis from endophthalmitis seems to be reasonable.
REFERENCES 1. Weinstein CS, Mondino BJ, Weinberg RJ, Biglan AW. Endophthalmitis in the pediatric population. Ann ophthamol. 1979; 11: 925–943.
2. Salamon SM, Freeberg TR, Luxenberg MN. Endophthalmitis after strabismus surgery. Am J Ophthalmol 1982; 93: 39–41.
3. Thomas JW, Harnill MB, Lambert HM. Streptococcus pneumoniae endophthalmitis following strabismus surgery. Arch Ophthalmol 1993; 111: 1170–1
4. Apt L, Isenberg S, Yoshimori R, Paez JH. Chemical preparation of the eye in Ophthalmic surgery; III; the effect of povidone-iodine on the conjunctiva. Arch Ophthalmol 1984; 102: 728–9.
5. Isenberg SJ, Apt L, Yoshimori R, …, Chemical preparation of the eye in ophthalmic surgery, (IV). Arch Ophthalmol 1985; 103: 1340–3.
6. Apt L, Isenberg SJ, Yoshimori R, …, Out patients topical use of povidone-iodine in preparing the eye for surgery. Ophthalmology 1989; 96: 289–92.
7. Olitsky SE, Awner S, Reynold JD. Perioperative care of strabismus patients, J pediatr Ophthalmol Strabismus 1997; 34: 125–7.
8. Ing MR. Infection following strabismus surgery. Ophthal surg 1991; 22: 41–3. 9. Speaker MG, Milch FA, Shah MK, … Role of external bacterial florain the pathogenesis of acute postoperative endophthalmitis. Ophthalmology 1991; 98: 639–49
10. Bannerman TL, Rhoden DL, McAllister SK, … The source of coagolase-negative staphylococci in endophthalmitis vitrectomy study. Arch Ophthalmol 1997; 115: 357–61.
11. Dieky JB, Thompson KD, Jay WH. Anterior chamber aspirate culture after uncomplicated cataract surgery. Am J Ophthalmol 1991; 112: 278–82.
12. Cibis GW. Incidence of inadvertent perforation in strabismus surgery. J Pediatr Ophthalmol Strabismus 1992; 23: 360–1.
13. Knobloch R, Lotenz A. Uberenste komplikationen nach Scheloperationen. Klin MonatsblAugeheilkd 1962; 141: 348–53.
319
320
male
female
female
female
female female
male
11
12
13
14
15 16
17
female
7
female
female
6
10
male
5
male
female
4
9
female
3
female
female
2
8
male
1
Sex of the patient
Case Summaries
coagulase neg. staphylococcus coagulase neg. staphylococcus sterile coagulase neg. staphylococcus coagulase neg. staphylococcus
coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus sterile
coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus sterile
Preop aerobic culture
sterile
coagulase neg. staphylococcus sterile sterile
9
coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus peptostreptococci
coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus sterile
Preop anaerobic culture
sterile
coagulase neg. staphylococcus sterile sterile
pneumococcus & S.T.N. 9
coagulase neg. staphylococcus sterile
coagulase neg. staphylococcus Gram pos. Bacillus sterile
sterile
klebsiella
sterile
sterile
coagulase neg. staphylococcus sterile
Postop aerobic culture
sterile
coagulase neg. staphylococcus sterile sterile
9
sterile
coagulase neg. staphylococcus sterile
sterile
coagulase neg. staphylococcus 4
sterile
peptostreptococci
sterile
sterile
coagulase neg. staphylococcus sterile
Postop anaerobic culture
coagulase neg. staphylococcus
coagulase neg. staphylococcus coagulase neg. staphylococcus sterile sterile
coagulase neg. staphylococcus sterile
sterile
sterile
coagulase neg. staphylococcus coagulase neg. staphylococcus coagulase neg. staphylococcus sterile
coagulase neg. staphylococcus sterile
sterile
sterile
Postop aerobic culture of needle
sterile
coagulase neg. staphylococcus sterile sterile
coagulase neg. staphylococcus sterile
sterile
sterile
sterile
coagulase neg. staphylococcus sterile
coagulase neg. staphylococcus sterile
coagulase neg. staphylococcus sterile
sterile
sterile
Postop anaerobic culture of needle
321
male
female
female
female male male
female
male
female
20
21
22
23 24 25
26
27
28
Gram pos. Bacillus
sterile coagulase neg. staphylococcus coagulase neg. staphylococcus Gram pos. Bacillus coagulase neg. staphylococcus sterile Gram pos. Bacillus coagulase neg. staphylococcus Gram pos. Bacillus sterile
Total N 28 28 a Limited to first 100 cases.
female male
18 19
28
sterile
sterile
coagulase neg. staphylococcus sterile 4 coagulase neg. staphylococcus 4
4
sterile
sterile sterile
28
coagulase neg. staphylococcus coagulase neg. staphylococcus
sterile sterile coagulase neg. staphylococcus sterile
coagulase neg. staphylococcus sterile
sterile
sterile sterile
28
coagulase neg. staphylococcus
sterile
sterile sterile coagulase neg. staphylococcus sterile
coagulase neg. staphylococcus sterile
sterile
sterile sterile
28
sterile
sterile
sterile
sterile sterile sterile
sterile
coagulase neg. staphylococcus sterile
sterile sterile
28
sterile
sterile
sterile
sterile sterile sterile
sterile
sterile
sterile
sterile sterile
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Assessment of the rate of nausea & vomiting and pain in strabismic patients anesthetized by propofol Ali Akbar Saber Moghaddam Assistant Prof. of ophthalmology, Mashhad University of Medical Sciences, Iran
ABSTRACT: Objective: To asses the rate of nausea & vomiting and pain in strabismic patients anesthetized by propofol Materials & methods: Prospective, non comparative, nonrandomized clinical trial performed on 49 consecutive strabismus surgery. Propofol used for induction and maintenance of anesthesia in all patients. Nausea & vomiting and pain was graded by standard visual analog scale (VAS) in 6 and 24 hours after operation. Other variables was age & sex of patients, duration of operation and recovery, number of muscles operated on and total dose of propofol. The results analyzed by SPSS 10.1. Results: 49 patients [27 (55.1%) female, 22(44.9%) male with mean age of 13.76 years old] included in this study. Mean number of operated muscles in each patient was 2.71 muscles, mean operation time was 46.73 minutes and mean recovery time was 12.08 min. Mean vomiting grade in 6 hrs. after surgery was 2.03 & in 24 hrs. after surgery was 1.31. Statistical correlation was not found between pain & nousea and age, sex, number of muscles operated on , total dose of propofol and duration of anesthesia. Conclusion: It seems that change in anesthesia drug and technique during strabismus surgery (using propofol as main drug) is more safer than use of antiemetic drugs before and after operation
1
INTRODUCTION
Strabismus surgery is mostly carried out as daycase surgery. One study reports postoperative nausea and vomiting (PONV) leading to overnight admission in more than one-third of ambulatory patients1. The incidence of postoperative vomiting or emesis is high, 88%, and up to 50% of the children have severe pain after strabismus surgery2,3. The postoperative pain itself has been considered to be a major cause of the postoperative nausea4. Many factors are known to influence the incidence of vomiting and pain after paediatric strabismus surgery such as the anaesthetic technique, administration of anti-emetics, induction agents such as propofol and use of analgesia intraoperatively and postoperatively2,5–7. Patients find postoperative nausea and vomiting (PONV) most distressing and it is often the worst memory of their hospital stay. The consequences of prolonged PONV range from unexpected admission of day patients, with its economic implications, to physical, metabolic and psychological effects on the patient which slow their recovery and reduce their confidence in future surgery and anaesthesia. The incidence and severity of PONV has been decreasing over the last 10 years, due to the identification of precipitating factors, the use of better anaesthetics and perioperative medications, and improvement in operative techniques8. Despite these changes, there is still an unacceptable frequency of PONV. The cause of PONV is not well defined, but the condition seems to be mediated by various receptors, including dopamine, acetylcholine, histamine, and serotonin. Pharmacologic agents that act as antagonists of these receptors are often used to treat this condition. The three main 323
parameters that are predictive of development of PONV are patient factors, surgical factors (i.e., type of procedure), and anesthetic factors. PONV is more likely in children than adults, in whom its incidence decreases with age. After puberty, females are more likely than males to suffer PONV, especially if they are pregnant or menstruating. Psychological stress and anxiety, obesity and medical conditions, such as diabetes and uraemia, can all increase the risk of PONV. A history of motion sickness or previous PONV is associated with a greater risk of postoperative emesis9. The general effects of the surgical procedure which include metabolic and endocrine changes can contribute to PONV. The duration of a procedure does not always correlate with the degree of postoperative emesis, but there may be a trend towards more prolonged nausea and vomiting with longer operations. Certain procedures, such as dilatation and curettage, laparoscopy, strabismus correction, orchiopexy and abdominal operations are known to be associated with PONV. Volatile agents may alter neurotransmitter release in the area postrema and in certain forebrain sites known to associated with stimulating vomiting8. They also have gastrointestinal effects, leading to reduced motility and relaxation of the pylorus facilitating bile reflux, which is irritant. Hypoperfusion of the gut secondary to the use of volatile agents may sensitize gut afferents directly and lead to the release of serotonin. Numerous peptide hormones can be released by volatile anaesthetics and surgery. These include angiotensin II, ADH, gastrin, insulin, neuropeptide Y, neurotensin, somatostatin, TRH and VIP. Many of these can induce emesis by stimulating the area postrema10,11. Propofol is associated with reduced emesis when compared to other induction agents. and maintenance of anaesthesia with volatile agents is more likely to cause PONV, than anaesthesia with propofol. The mechanism of action of propofol in reducing PONV is not well understood, but there is evidence both for and against anti-D2 and anti-5HT3 effects. 2
MATERIALS & METHODS
Prospective, non comparative, nonrandomized clinical trial performed on 49 consecutive strabismus surgery. Propofol used for induction and maintenance of anesthesia in all patients. In the operating room, patients were hydrated by ringer solution (7 cc/Kg), and then lidocaine (1 mg/kg), fentanyl (2 mic/kg) and dexamethason (0.1 mg/kg) were given intravenously followed by intravenous propofol (2 mg/kg). Following endotracheal intubation, the patients were maintained under a combination of oxygen, nitrous oxide and infusion of propofol (100 mic/kg/min in D/W 5%) during the operation. Nausea & vomiting and pain was graded by standard visual analog scale (VAS) in 6 and 24 hours after operation. Other variables was age & sex of patients, duration of operation and recovery, number of muscles operated on and total dose of propofol. The results analyzed by SPSS 10.1. 3
RESULTS
49 patients [27 (55.1%) female, 22(44.9%) male with mean age of 13.76 years old] included in this study. Mean number of operated muscles in each patient was 2.71 muscles, mean operation time was 46.73 min and mean recovery time was 12.08 min. Mean vomiting grade in 6 hrs after surgery was 2.03 & in 24 hrs after surgery was 1.31. Statistical correlation was not found between pain & nousea and age, sex, number of muscles operated on, total dose of propofol and duration of anesthesia. 4
DISCUSSION
Propofol is an induction agent used intravenously, and it has been suggested that its use is associated with a lower incidence of postoperative nausea and vomiting. In a number of studies in which anaesthesia with propofol was compared with anaesthesia without propofol, the incidence of both 324
early and late vomiting was somewhat less. This beneficial effect of propofol is more prominent when it is used for both induction and maintenance of anesthesia. There are some reports of the use of rectally adminsterd diclofenac12, dexamethasone alone or dexamethasone plus low-dose ondansetron13, oral clonidine14, & i.v. ketoprofen15 to reduce PONV. In this clinical trial, we used the propofol (a lipid soluble substituted isopropyl-phenol, a short acting hypnotic, & sedative that produces rapid induction of anesthesia), as the main anesthetic agent for induction and maintenance of anesthesia and the results indicate significant reduction in PONV. Statistical analysis was shown that this reduction in PONV correlate only with anesthetic agent and there was no correlation between age, sex, number of muscles operated on, time of operation or total dose of propofol (Table 1).
5
CONCLUSION
Present study showed that propofol anaesthesia for strabismus surgery was associated with a major reduction in the frequency of postanaesthetic vomiting, which is the most important factor determining length of stay after ambulatory surgery. Anesthesia with propofol allowed the patient to recover quickly and made earlier adjustment of sutures possible. Induction of anesthesia with propofol, has been found to be superior to halothane. Anesthesia is induced with fewer excitatory effects, recovery is rapid with a shorter interval between awakening and orientation and the incidence of postoperative nausea and vomiting is low.
REFERENCES 1. Isenberg SJ, Apt L, Yamada S. Overnight admission of outpatient strabismus patients. Ophthal Surg 1990; 21:540–3. 2. Lin DM, Furst SR, Rodarte A. A double blinded comparison of metoclorpramide and droperidol for prevention of emesis following strabismus surgery. Anesthesiology 1992; 76:357–361. 3. Finley GA, McGrath PJ, Forward SP, McNeill G, Fitzgerald P. Parents’ management of children’s pain following minor surgery. Pain 1996; 64:83–87. 4. Andersen R, Krogh K. Pain is a major cause of postoperative nausea. Can Anaesthetists Soc J 1976; 23: 366–369. 5. Larsson S, Asgeirson B, Magnusson J. Propofol-fentanyl anaesthesia compared to thiopental-halothane with special reference to recovery and vomiting after paediatric strabismus surgery. Acta Anaesthesiol Scand 1992; 36:182–186. 6. Watcha MF, Simeone RM, White PP, Stevens JP. Effect of propofol on the incidence of postoperative vomiting after strabismus surgery in paediatric outpatients. Anesthesiology 1991; 75:204–209. 7. Weir PM, Munro HM, Reynolds PI, Lewis JH, Wilton NCT. Propofol infusion and the incidence of emesis in paediatric outpatient strabismus surgery. Anesth Analg 1993; 76:760–764. 8. Andrews PLR. Physiology of nausea and vomiting. Brit J Anaesth 1992; 69:2S–19S. 9. Carpenter DO. Neural mechanisms in emesis. Can J Physiol Pharmacol 1990; 68:230–236. 10. Carpenter DO. Neural mechanisms in emesis. Can J Physiol Pharmacol 1990; 68:230–236. 11. Carpenter DO, Briggs DB. Insulin excites neurons of the area postrema and causes emesis. Neuroscience Letters 1986; 68:85–89. 12. Wennstrom B, Reinsfelt B. Rectally administered diclofenac (Voltaren) reduces vomiting compared with opioid (morphine) after strabismus surgery in children. Acta Anaesthesiol Scand 2002 Apr; 46(4):430–4. 13. Splinter WM. Prevention of vomiting after strabismus surgery in children: dexamethasone alone versus dexamethasone plus low-dose ondansetron. Paediatr Anaesth 2001; 11(5):591–5. 14. Handa F, Fujii Y. The efficacy of oral clonidine premedication in the prevention of postoperative vomiting in children following strabismus surgery. Paediatr Anaesth 2001 Jan; 11(1):71–4. 15. Kokki H, Homan E, Tuovinen K, Purhonen S. Peroperative treatment with i.v. ketoprofen reduces pain and vomiting in children after strabismus surgery. Acta Anaesthesiol Scand 1999 Jan; 43(1):13–8.
325
326
1.000 – 49 .104 .265 39 .042 .400 39 .100 .272 39 .239 .071 39 .154 .146 49 .182 .106 49 .323* .012 49 .202 .091 45
AGE .104 .265 39 1.000 – 39 .069 .338 39 .440* .003 39 .152 .178 39 .209 .101 39 .323* .022 39 .294* .034 39 .317* .028 37
PAIN6H
* Correlation is significant at the 0.05 level (1-tailed). ** Correlation is significant at the 0.01 level (1-tailed).
4
REC.TIME
OP.TIME
Pearson Correlation Sig. (1-tailed) N Pearson Correlation Sig. (1-tailed) N Pearson correlation Sig. (1-tailed) N Pearson correlation Sig. (1-tailed) N Pearson Correlation Sig. (1-tailed) N Pearson Correlation Sig. (1-tailed) N Pearson Correlation Sig. (1-tailed) N Pearson Correlation Sig. (1-tailed) N Pearson Correlation Sig. (1-tailed) N
Correlations.
OPERAT.M
N.V. 24H
PAIN24H
N.V.6H
PAIN6H
AGE
Table 1. PAIN24H .100 .272 39 .440* .003 39 .034 .419 39 1000 – 39 .086 .302 39 .120 .234 39 .098 .277 39 .040 .405 39 .576* .000 37
N.V.6H .042 .400 39 .069 .338 39 1.000 – 39 .034 .419 39 .500* .001 39 .149 .183 39 .148 .185 39 .142 .195 39 .188 .133 37 .239 .071 39 .152 .178 39 .500* .001 39 –.086 .302 39 1.000 – 39 .130 .216 39 .156 .171 39 .002 .494 39 .048 .389 37
N.V.24H .154 .146 49 .209 .101 39 .149 .183 39 –.120 .234 39 .130 .216 39 1.000 – 49 .769* .000 49 .015 .458 49 .518* .000 45
OPERAT.M .182 .106 49 .323* .022 39 .148 .185 39 –.098 .277 39 .156 .171 39 .769* .000 49 1.000 – 49 .148 .155 49 .640* .000 45
OP.TIME .323* .012 49 .294* .034 39 .142 .195 39 –.040 .405 39 .002 .494 39 0.15 .458 49 .148 .155 49 1.000 – 49 .062 .343 45
REC.TIME
.202 .091 45 .317* .028 37 .188 .133 37 .576* .000 37 .048 .389 37 .518* .000 45 .640* .000 45 .062 .343 45 1.000 – 45
4
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
The effects of experimentally induced spherical myopic anisometropia on stereoacuity Ali Akbar Saber Moghaddam, Abbas Kargozar & Mohammad Etezad Razavi Assistant Prof. of ophthalmology, Mashhad University of Medical Sciences, Mashhad, Iran
ABSTRACT: Purpose: To determine the effects of experimentally induced anisometropia on stereopsis in healthy adults to assess the potentially detrimental effects of uncorrected anisometropia on the development of stereoacuity during childhood. Materials & Methods: The study performed on 100 healthy adult volunteers, 58 male and 42 female (ranging in age from 20–30 years). 3 type of myopic anisometropia were induced in all 100 patients in their left eyes (by plus lenses 0.75 to 2.25 diopter in 0.75 diopter increment). Then stereoacuity was measured by Titmus stereotest. Each patient’s highest level of stereoacuity was recorded (in each step of anisometropia induction). The statistical analysis performed by paired t-test. Conclusion: Producing of anisometropia to 1.25 dipter does not significantly affects stereopsis, but anisometropia more than 1.75 diopter can significantly reduce stereoacuity. Also reduction of visual acuity to 20/40 doesn’t create statistically significant decrease in stereopsis but reduction of visual acuity to 2/100 or less, significantly effects stereopsis.
1
INTRODUCTION
Anisometropia is considered a causal factor in the pathogenesis of amblyopia and strabismus in the developing human eye. It is estimated that as many as 6%–38% of all cases of amblyopia are caused by anisometropia without strabismus, whereas approximately 12%–18% of children with strabismus also have anisometropia (1,2). However, data on the prevalence of anisometropia and its complications in children are rare and conflicting. Although is generally agreed that anisometropic refractive errors should be corrected in patients with established amblyopia or strabismus to ensure optimal visual development and maturation, the exact levels of anisometropia and age at which corrections should be undertaken in otherwise healthy children remain to be determined. Amblyopia may be defined as a unilateral or bilateral decrease in visual acuity caused by deprivation of form vision, abnormal binocular interaction, or both, for which no organic cause can be detected(3). This definition clearly implicates amblyopia as the functional consequence during early developmental plasticity; it does not encompass any abnormalities in binocular vision that also may exist. Normal neural development of binocular cortical cells requires clear and equal retinal images during the critical period of visual development. Research shows that unilateral image blur during the early period of visual development results in loss of binocular function such as fusion and stereopsis (4). Thus, it is important to consider the associated effects on binocular vision when establishing guidelines for the empiric management of potentially amblyogenic problems. Stereopsis is the unique quality or binocular vision that enables depth perception in visual space. It arises from the horizontal retinal image disparity between the two foveas or other corresponding retinal points; differing amounts of such disparity give rise to differing sensations of depth (5). It has been suggested (5,6) that empiric correction should be considered for the following anisometropic refractive errors: astigmatism 1.5 diopters (D), hyperopia of 1.5 D, and myopia 327
of 3D. Due to a lack of clinical evidence in support of these recommendations, the potential effects of uncorrected anisometropia on stereopsis were investigated. In this prospective study, the stereoacuity levels of experimentally induced anisometropia in binocularly healthy adults were measured. We speculated that the sensory consequences induced by monocular blur in this group might mimic those experienced by the anisometropic young child with an equivalent amount of monocular blur. Although these two populations clearly are not identical, this approach may yield insights into the relationship between anisometropia and stereopsis, as well as identify levels of stereopsis possible in individuals affected by various degrees of anisometropia. 2
MATERIALS & METHODS
100 health adult volunteers (58 male and 42 female) ranging in age from 20–30 years and free of ocular disease participated in the study. Eligibility criteria for participation was 20/20 snellen visual acuity without correction in each eye in both distance and near, no significant refractive error, normal ocular alignment, and normal stereoacuity (40 second of arc or better measured by Titmus fly test). 3 different type of myopic anisometropia were induced in all 100 patients in their left eyes by 0.75, 1.50 and 2.25 diopter lenses (in 0.75 diopter increment). So there were 3 types of unilateral myopia (0.75, 1.50 and 2.25). Testing was carried out under normal room lighting condition. Stereoacuity was measured using the Titmus stereotest with patients placing the cross-polarizing stereoacuity glass over their trial frame. Each patient’s highest level of stereoacuity was recorded. The statistical analysis was performed using paired t-test to evaluate the differences in stereopsis test results between different levels of anisometropia, P equal or less than 0.05 was considered statistically significant.
3
RESULTS
Levels of stereoacuity were measured in each step of anisometropia. When 0.75 diopter anisometropia induced, mean visual acuity decreased to 20/30 and mean stereoacuity decreased to 60 second of arc (stage 1). This decrease was not statistically significant (p 0.5). With 1.50 diopter anisometropia induction, visual acuity decreased to 20/40 and stereoacuity decreased to 200 40 second of arc (stage 2). This difference also was not statistically significant (P 0.1). In third step, anisometropia produced by 2.25 diopter lens. Mean visual acuity decreased to 20/100 and stereopsis decreased to 900 100 second of arc (P 0.0001) which is statistically significant
Stage
Sphere
Mean stereopsis (second of arc)
Range of Stereopsis (Second of arc, percent)
I
Plano
40
40 (100%)
10/10
10/10
100
II
0.75
60 10
50–60 (55%) 81–100 (39%) 111–140 (6%)
10/10
7/10
100
III
1.50
200 40
100–200 (62%) 201–300 (–) 301–400 (38%)
10/10
5/10
100
IV
2.25
900 100
800 (82%) Worth than 800 (18%)
10/10
2/10
100
328
Patients number
VA
4
DISCUSSION
The visual acuity and stereoscopic acuity depends on many factors and is influenced greatly by the method used in determining it, (in refined laboratory examination and with highly trained subjects, stereoscopic acuities as low as 2 to 7 seconds of arc have been found (7)). It is clear that visual acuity has some relation to stereoscopic acuity. Stereoscopic acuity decrease (as doe’s visual acuity), from the center to the periphery of the retina(8). However, despite this relationship, stereopsis is a function not linearly correlated with visual acuity, so that reduction of visual acuity with neutral density filter over one eye does not rise the stereoscopic threshold, even if the acuity was lowered to as low as 20/70. Further decreases in vision to 20/100 greatly increase the threshold and with a decrease in acuity of the covered eye to 20/200, stereopsis will be absent(9). Poor visual acuity was generally accompanied by reduced stereoscopic acuity but that there were no correlation between these two functions and of special clinical interest is the fact that stereoacuity in patients with amblyopia may be better than what one would expect from their visual acuity (10, 11). Anisometropia and also anisokonia have been seen to affect stereoscopic acuity as well. For this, we study the effects of induced anisometropia by glass lenses on stereopsis, as well as visual acuity. As shown by our study the induced anisometropia also affects stereoscopic acuity in nonlinear method. Anisometropia equal or less than 1.50 diopter have not significant effect on stereoscopic view, but increase in anisometropia (to 2.25 diopter or more) will affect stereopsis significantly (P 0001). Oguzh(12) had been indicated such relationship but in lesser number of patients. Weakly(13) studied the effect of innate (natural) anisometropia on stereoscopic vision and found that spherical myopic anisometropia greater than 2 diopter and spherical hyperopic anisometropia greater than 1 diopter results in statistically significant decrease in binocular function. White(14) studied the effect of post eximer laser photorefractive keratectomy (PRK) anisometropia on binocular function and concluded that anisometropia greater than 2.5 diopter can affect the stereoacuity. Brooke(15) studied binocular function in similar to our study method in 19 adults and founds that stereoacuity was significantly decreased with as little as one diopter of spherical anisometropia. The Titmus stereotest was used due to its ease of presentation, with the understanding that it may not be sensitive enough to make quantitative measurements of stereoacuity or sufficient to detect small differences in stereoacuity. The test can not completely exclude monocular clues or the use of memory to identify correct targets, which can result in falsely high measured stereoacuity levels. As described above, we attempted to minimize this problem by carefully instructing patients to identify axially displaced circle only. Data from other investigators show similar reductions in stereopsis using random dot stereograms (16); the reduction in stereoacuity in our study was highly significant for some increase in anisometropia, suggesting the use of Titmus stereotest did not bias the results of our study. Although, the precise mechanisms by which anisometropia leads a decrease in stereoacuity are not clear, it has been suggested foveal suppression in the defocused eye is the cause of decreased stereopsis.
5
CONCLUSION
Anisometropia can have a significant adverse effect on high-grade binocular function. The mechanisms underlying the loss of stereopsis seem to involve foveal suppression, the extent of which is directly related to the degree of anisometropia. Also we concluded that relation between decrease in visual acuity and stereopsis is not linear. Our results the effects of anisometropia on stereopsis should be considered in the empiric correction of anisometropic refractive errors in children. This study may help the development of guidelines in the future.
329
REFERENCES 1. Phelps WL, Muir V. Anisometropia and strabismus. Am Orthop J. 1977; 27:131–133. 2. Vreis de J. Anisometropia in children: analysis of a hospital population. Br J. Ophthalmol. 1985; 69: 504–507. 3. Von Noorden GK. Mechanisms of amblyopia. Doc Ophthalmol. 1977; 34:39. 4. Wright KW, Matsumato E, Edelman PM. Binocular Fusion and stereopsis associated with early surgery for monocular congenital cataracts. Arch Ophthalmol, 1992; 110:1607–1609. 5. Goodwin RT, Romano PE. Stereoacuity degradation by experimental and real monocular and binocular amblyopia. Invest Ophthalmol Vis Sci. 1985; 26:917–923. 6. American Academy of Ophthalmology. Amblyopia preferred Practice Pattern. San Francisco, Calif: American Academy of Ophthalmology, 1992; 1. 7. Von Noorden GK. Binocular Vision and Ocular Motility.6th ed. St Louis.Mo:CV Mosby:2002; 25. 8. Burian HM. Stereopsis. Doc Ophthamol 5–6:169,1951. 9. Matsubayashi A: Visual space perception. In Graham CH. Ed: Vision and visual perception. New york, John Wiley& sons, 1965; p527 10. Avilla C. Noorden GK von. Limitation of TNO random dot stereo test for visual screening. Am Orthopt J 81;87, 1981. 11. Campos EC. Enoch JM. Amount of aniseikonia compatible with fine binocular vision: some old and new concepts. J Pediatr Ophthalmol Strabismus 17:44, 1980. 12. Oguz H, Ogus V. The effects of experimentally induced anisometropia on stereopsis. J Pediater Ophthalmol Strabismus 2000 Jul–Aug; 37(4): 214–8. 13. Weakly DR. The association between anisometropia, amblyopia, and binocularity in the absence of strabismus. Ophthalmology 1996 Jul; 103(7):1139–43 14. Jie E White DBO. T, Julian Stevens. The effects on Binocular Function of Anisometropia Induced by Excimer Laser Photorefractive Keratectomy. AApos 1997. 15. Brooks SE, Johnson D, Fischer N. Anisometropia and binocularity. Ophthalmology, 1996 Jul; 103 (7): 1139–43. 16. Lovasik JV, Szymkiw M. Effects of aniseikonia, anisometropia, accommodation, retinal illuminance, and pupil size on stereopsis. Invest Ophthalmol Vis Sci.1985; 26:741–750.
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Refractive surgery: strabologic patients management L. Sabetti, L.D’Alessandri, A. Fiasca & K. Salvatori L’Aquila University, City of L’Aquila, Italy
ABSTRACT: 84 patients (35 M and 49 F; mean age 35,19 / 8,03) with refractive errors and ocular motility disorders (ET, XT, convergence defects) underwent refractive surgery. Only patients with a valid binocular function were selected for this study. 65 patients underwent PRK and 19 underwent LASIK. At two years follow up have been evaluated. Results: only 1 patient (0.01%) manifested diplopia post- surgery. Conclusions: ocular motility disorders are not absolute contra-indication to refractive surgery.
1
INTRODUCTION
In last years many patients having refractive surgery reported a decompensated strabismus and binocular diplopia (Kim 2000; Holland 2000). It should be caused by the monovision during the period between the treatment of the first and the second eye (Schuler 1999). The preoperative evaluation for refractive surgery with excimer laser has always been based on a complete ophthalmologic examination that included: careful refraction with and without cycloplegia, contact lens use, presence of corneal disease and dry eye syndrome, pupil size, corneal topography and corneal thickness. It is still not clear the importance of preoperative orthoptic evaluation (Godts 2004). The aim of this study is to evaluate the binocular function in patients with ocular motility defects before and after refractive surgery in order to identify risk groups for post treatment diplopia. 2
MATERIALS AND METHODS
Eighty four patients (35 M and 49 F, mean age 35,19 / 8,03) that presented refractive errors (32 hyperopic, 52 myopic) with ocular motility disorders (18 accommodative strabismus: 6 myopic XT and 12 hyperopic ET; 52 no accommodative: 20 myopic XT, 12 myopic ET, 10 hyperopic ET and 10 hyperopic XT; 14 convergence defects) underwent a complete ophthalmologic visit and orthoptic evaluation. Ophthalmologic examination included refraction with and without cycloplegia, Goldman tonometry, biomicroscopy of the anterior segment, funduscopic examination, pupil size, corneal thickness, corneal topography and endothelial microscopy. Orthoptic examination evaluated the ocular motility in the nine gaze positions, the presence of anomalous head positions, objective and fusional convergence, Bagolini’s red filter, Worth and Micro-Worth, 4-dot test, Lang test (I,II), Titmus, red filter test. Before refractive surgery the angle of deviation was evaluated with prism cover test at near and at distance after a continuous use of a corneal lens for thirty days. After surgery it was measured without correction. Only patients with a valid binocular function were selected for this study. 4 patients with profound suppression have been included. Exclusion criterion was diplopia in primary position. Six myopic patients with accommodative exotropia underwent PRK. Preoperative mean angle deviation was 4 at near and 4.3 at distance; the mean spherical equivalent was 2.38 /2.9D; the mean UCVA was 20/200; the mean BCVA was 20/22; Lang test mean value was 240 / 79; the Wirt test mean value was 51.20 / 21; the red filter test was negative in all cases. 331
5 hyperopic patients with accommodative esotropia underwent PRK. Preoperative mean angle deviation was 5 at near and 2.4 at distance; the mean spherical equivalent was 4.6 / 0.8D; the mean UCVA was 20/30; the BCVA was 20/20; Lang test mean value was 280 / 156; the Wirt test mean value was 43 / 67.6; the red filter test was negative in all cases. 7 hyperopic patients with accommodative esotropia underwent LASIK. Preoperative mean angle deviation was 5.4 at near and 2.8 at distance; the mean spherical equivalent was 6.46 / 1.1D; the mean UCVA was 20/30; the mean BCVA was 20/20; the Lang test mean value was 520 / 109.5; the Wirt test mean value was 600 / 299.8; the red filter test was negative in all cases. 20 myopic patients with no accommodative exotropia underwent refractive surgery (16 PRK and 4 LASIK). Preoperative mean angle deviation was 6.13 / 3.66 at near and 1.5 / 3.2 at distance; the mean spherical equivalent was 4.86 / 2.24D; the mean UCVA was 20/400; the mean BCVA was 20/20; the Lang test mean value was 250 / 89.44; the Wirt test mean value was 53.79 / 23.09; the red filter test was negative in all cases. 12 myopic patients with no accommodative esotropia underwent PRK. Preoperative mean angle deviation was 4.6 / 3.05 at near and 2 / 2.8 at distance; the mean spherical equivalent was 3.33 / 1.32D; the mean UCVA was 20/160; the mean BCVA was 20/20; the Lang test mean value was 300 / 167; the Wirt test mean value was 45 / 70.7; the red filter test was negative in all cases. 10 hyperopic patients with no accommodative esotropia underwent refractive surgery (6 PRK and 4 LASIK). Preoperative mean angle deviation was 9 / 6.83 at near and 7 / 7.39 at distance; the mean spherical equivalent was 4.42 / 2.80D; the mean UCVA was 20/200; the mean BCVA was 20/20; the Lang test mean value was 520 / 109.5; the Wirt test mean value was 652 / 330.9; the red filter test was negative in 6 cases.4 patients presented profound suppression. 10 hyperopic patients with no accommodative exotropia underwent refractive surgery (8 PRK and 2 LASIK). Preoperative mean angle deviation was 9.5 / 6.40 at near and 3.5 / 4.72 at distance; the mean spherical equivalent was 4.25 / 3.02D; the mean UCVA was 20/60; the mean BCVA was 20/22; the Lang test mean value was 280 / 109.5; the Wirt test mean value was 204 /333.5; the red filter test was negative in all cases. 14 myopic patients with convergence defects undervent refractive surgery (12 PRK and 2 LASIK). Preoperative mean angle deviation was 8.8fr / 6.6 at near and 4.66fr / 3.2 at distance; the spherical equivalent mean was 4.41 / 2.69D; the mean UCVA was 20/360; the mean BCVA was 20/20; the Lang test mean value was 200; the Wirt test mean value was 64 / 32.86; the red filter test was negative in all cases.
3
RESULTS
6 myopic patients with accommodative exotropia that underwent PRK presented postoperative mean angle deviation 0 at near and 0.6 at distance; the mean spherical equivalent was plano; the mean UCVA was 20/20; the mean BCVA was 20/20; Lang test mean value was 236 / 96; the Wirt test mean value was 50.3 / 26.5; the red filter test was negative in all cases. 5 hyperopic patients with accommodative esotropia that underwent PRK presented postoperative mean angle deviation 2 at near and 0.4 at distance; the mean spherical equivalent was 0.17D; the mean UCVA was 20/25; the mean BCVA was 20/20; the Lang test mean value was 278 / 150; the Wirt test mean value was 43 / 67.6; the red filter test was negative in all cases. 7 hyperopic patients with accommodative esotropia that underwent LASIK showed postoperative mean angle deviation 1.7fr at near and 0.2fr at distance; the mean spherical equivalent was plano; the mean UCVA was 20/25; the mean BCVA was 20/20; the Lang test mean value was 520 / 109.5; the Wirt test mean value was 572 / 300; the red filter test was negative in all cases. 20 myopic patients with no accommodative exotropia that underwent refractive surgery (16 PRK and 4 LASIK).showed postoperative mean angle deviation 4 / 2.8 at near and 0.5 / 1.2
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at distance; the mean spherical equivalent was plano; the mean UCVA was 20/25; the mean BCVA was 20/20; the Lang test mean value was 257 / 94.24; the Wirt test mean value was 54.3 / 26.5; the red filter test was negative in all cases. 12 myopic patients with no accommodative esotropia that underwent PRK presented postoperative mean angle deviation 4 / 2.8 at near and 0.5 at distance; the mean spherical equivalent was plano; the mean UCVA was 20/25; the mean BCVA was 20/20; the Lang test mean value was 300 /167; the Wirt test mean value was 48 / 70.5; the red filter test was negative in all cases. 10 hyperopic patients with no accommodative esotropia that underwent refractive surgery (6 PRK and 4 LASIK) presented postoperative mean angle deviation 7 / 4.2 at near and 4 / 4.24 at distance; the mean spherical equivalent was plano; the mean UCVA was 20/25; the mean BCVA was 20/20; the Lang test mean value was 550 / 100; the Wirt test mean value was 572 / 334.54; the red filter test was negative in 6 cases.4 patients presented profound suppression. 10 hyperopic patients with no accommodative exotropia that underwent refractive surgery (8 PRK and 2 LASIK)showed postoperative mean angle deviation 6.4 / 5.17 at near and 3.5 / 4.24 at distance; the mean spherical equivalent was plano; the mean UCVA was 20/20; the mean BCVA was 20/20; the Lang test mean value was 240 / 89.4; the Wirt test mean value was 204 / 333.5; the red filter test was negative in all cases. 14 myopic patients with convergence defects that underwent refractive surgery (12 PRK and 2 LASIK) presented postoperative mean angle deviation 10.6fr / 4.24 at near and 5.5fr / 3.41 at distance; the mean spherical equivalent was plano; the mean UCVA was 20/20; the mean BCVA was 20/20; the Lang test mean value was 200 / 0.0; the Wirt test mean value was 64 / 32.86; the red filter test was positive for diplopia in one case.
4
DISCUSSION
Laser in situ keratomileusis (LASIK) and Photorefractive keratectomy (PRK) are widely used for the correction or myopia hyperopia and astigmatism (Hersh 1998). Few reports of binocular vision impairment and diplopia after refractive surgery have been published (Mandava 1996; Marmer 1987; Schuler 1999; Holland 2000), and there are few reports of the importance of a preoperative orthoptic evaluation (Godts 2004). In this study we emphasize the importance of a detailed orthoptic examination before refractive surgery to exclude risk groups for binocular vision impairment. Pre-existent strabismus and convergence defect should alert the surgeon to possible postoperative binocular problems. So, in our study, an orthopitic evaluation after a continuous use of a corneal lens for thirty days was an invaluable tool to identify risk groups for post treatment diplopia. The only one case of postoperative binocular vision impairment belonged to convergence defects group. This result can be by mere chance, but we suggest that further studies should be done to confirm it.
5
CONCLUSIONS
The presence of ocular motility disorders is not an absolute contra-indication to refractive surgery but it must be carefully evaluated every time. In our study only one patient (0.01%) showed worsening of deviation angle and of binocular fusion manifesting diplopia post surgery.
REFERENCES Gods D, Tassignon MJ, Gobin L. 2004. Binocular visual impairment after refractive surgery. J Cataract Refract Surg. 30:101–109. Hersh PS, Brint SF, Maloney RK. 1998. Photorefractive keratectomy versus laser in situ keratomileusis for moderate to high myopia; a randomized prospective study. Ophthalmology 105:1522–1523.
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Holland D, Amm M, De Decker W. 2000. Persisting diplopia after bilateral laser in situ keratomileusis. J Cataract Refract Surg. 26:1555–1557. Kim SK, Lee JB, Han SH, Kim EK. 2000. Ocular deviation after unilateral laser in situ keratomileusis. Yonsei Med J 41:404–406. Mandava N, Donnenfeld ED, Owens PL. 1996. Ocular deviation following excimer laser photorefractive keratectomy. J Cataract Refract Surg. 22:504–505. Marmer RH. 1987. Ocular deviation induced by radial keratotomy. Ann Ophthalmol 19:451–452. Schuler E, Silverberg M, Beade P, Moadel K. 1999. Decompensate strabismus after laser in situ keratomileusis. J Cataract Refract Surg. 25:1552–1553.
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Glomus jugulare tumour presenting with VIth nerve palsy A.G. Sainani, E. Dawson & J.P. Lee Moorfields eye hospital, London, UK
ABSTRACT: Introduction: Tumours of the glomus jugulare are a rare entity. The typical presentation is with middle ear symptoms or dysfunction of cranial nerves VIIth, VIIIth, Xth, XIIth, and IXth. We report two cases of glomus jugulare tumour with diplopia secondary to VIth nerve palsy as the presenting feature. Methods: Patients included were, one female with an age of presentation of 52 years and one male of 55 years. Both patients underwent resection surgery for the tumour. Both patients were managed initially with Botulinum toxin followed by appropriate squint surgery for the ocular motility problem. One patient regained binocular vision with stereopsis of 240. Conclusion: This case report is to highlight the rare presentation of sixth nerve palsy as a result of glomus jugulare tumour. To our knowledge, VIth nerve palsy as the presenting feature of glomus jugulare tumour has not been reported before.
1
INTRODUCTION
The glomus jugulare is a chemoreceptor located in the adventitia of the superior bulb of the internal jugular vein. Tumours of the glomus jugulare are a rare entity. It is a slow growing tumour, which initially presents with middle ear symptoms. Depending on location and tumour growth, it can cause dysfunction of the VII, IX, X, XI and XII cranial nerves. We report two cases of glomus jugulare tumour with associated VIth nerve palsies.
2 2.1
CASE REPORTS Case No. 1
A 52 year old lady presented with a 3-year history of double vision and difficulty in swallowing. She initially had left sensorineural deafness 5 years ago. She was then diagnosed to have a left glomus jugulare tumour with IX and Xth nerve palsies 2 years ago. She underwent embolization of tumour followed by excision 1 year ago. She also had external beam radiation therapy at the time. After the surgery the double vision worsened and XIIth nerve was paralysed. On cover test, she had a left convergent squint measuring 70PD. On examining the ocular movements she had grossly limited abduction beyond midline in the left eye indicating a total VIth nerve palsy. The patient initially had botulinum toxin A injected into her left medial rectus, which was followed by a lateral transposition of the superior and inferior recti, to the upper and lower borders of the lateral rectus. She was overcorrected to a 45PD exotropia in primary position on her first post-operative visit. In the next 4 years she slowly drifted back to a 25PD esotropia with diplopia in primary gaze. She then underwent left medial rectus recession on adjustable sutures and a right lateral rectus faden at 7 mm for the residual esotropia. Post operatively she was left with a 4PD esotropia for near and 6PD exotropia for distance with diplopia only on laevoversion. 335
2.2
Case No. 2
A 55 years old gentleman presented with a 6-month history of double vision in left gaze. Past medical history revealed that he was diagnosed with a left glomus jugulare tumour 13 years ago. He had undergone 6 excision operations for the tumour. His last operation was 2 years ago. He also developed a left facial paresis after the 3rd operation. On examination he had a left sided face turn. On cover test he had an esophoria. Prism bar cover test revealed a primary deviation of 14PD esotropia and a secondary deviation of 25PD esotropia. Ocular movements suggested a partial VIth nerve palsy. He was initially managed with prisms and also had botulinium toxin A injected into the ipsilateral medial rectus as a postoperative diplopia test. He then underwent a left medial rectus recession and lateral recession on adjustable sutures. Post operatively he corrected to a 2PD exotropia in primary gaze. Although he was asymptomatic in primary gaze, he had double vision on both lateral gazes. This incomitancy worsened in the subsequent years. Neurological assessment revealed that VII, IX and XII nerves were also affected now. Repeat substraction MRI did not show any recurrence, although revealed a significant amount of fibrosis at the apex of the temporal bone in the region of the excised tumour. He subsequently underwent Scott procedures on the medial and lateral rectii of the fellow eye. This operation involves the resection followed by recession of a muscle by the same amount to effectively weaken the action of the muscle and was placed on an adjustable suture with the aim to match the eye movements on lateral gaze. Post operatively the diplopia improved on lateral gaze and he regained binocular vision with stereopsis of 240.
3
DISCUSSION
In 1941, Stacy Guildi (Guild 1941), of Johns Hopkins Medical School, described an anatomical structure he called a glomus body. The glomus jugularis also known as a jugulotympanic paraganglionii (Glenner 1974) occurs in the jugular bulb of the internal jugular vein. It is a chemoreceptor and when stimulated by hypoxia elicits a reflex increase in ventilation via its connections with the brainstem respiratory centres. Rossenwasseriii (Rossenwasser 1945) was the first to realize the origins of a vascular tumour of the glomus body in the middle ear. Most paragangliomas arise from the paraganglion situated in the wall of the jugular bulb; these are the so-called jugular paragangliomas. A minority of the tumours arise from the paraganglion situated near the middle ear surface of the promontory; these are called tympanic paragangliomas. The glomus jugulare tumour is the most common tumour of the middle eariv (Spector 1979) and is the second most common tumour of the temporal bonev(Spector 1980). Females are 4 to 6 times more commonly affected than males vi(Alford 1962). Patients generally present in the 5th and 6th decades of life. The progression of manifest symptomatology depends on the tumour location and local growth, which commonly progresses as follows. Growth in the middle ear can cause pulsatile tinnitusvii (House 1968) and conductive hearing lossviii,ix (Spector 1975, Brown 1967). The tumour can simulate an aural polyp that can haemorrhage spontaneouslyix (Brown 1967). Medial extension of the tumour disrupts the facial nervex (Spector 1975). Invasion of the labyrinth causes a sensorineural hearing lossvi,ix(Alford 1962, Brown 1967). It has been reported that 1–3% of paragangliomas secrete clinically significant levels of catecholaminesxi (Schwaber 1984). The overall incidencex (Spector 1975) of cranial nerve palsy with glomus jugulare tumour is reported to be 35%. The IX, X, XI, XII nerves and sympathetic chain are more commonly involved at the level of the neck as they enter the brain through their respective foramina in the skull. Thus the patient may present with hoarseness of voice, difficulty in swallowing, tongue atrophy or Horners syndrome depending on the nerves affected. It is very uncommon for VIth nerve to be affected in a case of glomus jugulare tumourxii (Gulia 1993). It is distantly related to the jugular foramen lying medial to it as it ascends anterior to the brainstem in the posterior cranial fossa. 336
We propose the following theories for the possible cause of VIth nerve palsy in a case of Glomus jugulare tumour: The sixth nerve has been reported to be affected post surgically, after excision of the tumour. It can be affected directly during the excision of a large tumour with intracranial extension or due to post surgical fibrous tissue formation in the area of the VIth nerve. The later is the most probable cause in our second patient who had undergone multiple surgical procedures for the tumour prior to the VIth nerve palsy and a subsequent MRI showed scarring over the petrous part of the temporal bone. Large tumours have been known to spread to the posterior cranial fossax (Spector 1975) through the jugular and hypoglossal foramina. Access to the middle cranial fossa is provided by the carotid artery through the foramen lacerum. Intracranial extension pressing on the VIth nerve directly can thus be a cause of the palsy. Raised intracranial pressure may result in papilloedemavi (Alford 1962) with VIth nerve palsy as a false localising sign. Distant metastasis is reported to occur only in 4% of casesxiii (Borsanyi 1962). The sites of metastasis in decreasing order are lungs, lymph nodes, liver and bonexiv. A small metastatic lesion near the intracranial part of VIth nerve can be a theoretically rare possibility. Jugulotympanic tumours have a tendency towards multicentricityxv, xvi(Rossenwasser 1968, Spector 1973). Multicentricity is the simultaneous occurrence of synchronous tumours in the different craniocervical paraganglia. These synchronous lesions may arise as a carotid body tumour, a glomus intravagalexvii (Ervin 1984) or another jugulotympanic paraganglioma. Although a synchronous tumour has been reported to affect the Xth nerve, it has not yet been found in the area of the VIth nerve. The management of the ocular motility problems and the diplopia due to VIth nerve palsy secondary to this tumour is not considered to be any different from that, of any other VIth nerve palsy.
4
CONCLUSION
This case report highlights the rare presentation of sixth nerve palsy as a result of glomus jugulare tumour. VIth nerve palsy has been reported to occur secondary to neurosurgery for the tumour, as was the case in our second patient. In our first patient although, VIth nerve palsy was a presenting feature. To our knowledge, VIth nerve palsy as the presenting feature of glomus jugulare tumour has not been reported before.
REFERENCES i Guild, S.R. 1941. A Hitherto Unrecognised Structure, the Glomus Jugularis, in Man, Anat Rec, 79 (Suppl 1): 28, Abstract. ii Glenner, G. G. and Grimley, P.M. 1974. Tumours of the extra adrenal paraganglion system. In: Atlas of tumour Pathology (2nd series) (fascicle 9). Armed Forces Institute of Pathology, Washington DC. pp 1–90. iii Rossenwasser, H. 1945. Carotid body tumour of the middle ear and mastoid. Arch Otolaryngology, 41: 64–67. iv Spector, G.J., Sobol, S., Thawley, S.E. et al. 1979. Glomus jugulare tumours of the temporal bone. Laryngoscope 89:1628–1639. v Spector, G.J., Gada, M., Ciralsky, R. et al. 1980. Neurologic Implications of Glomus Tumours in the Head. Neck Surgery, 88: 531–535. vi Alford B.R and Guilford, F.R. 1962. A Compressive Study of Tumours of the Glomus Jugulare. Laryngoscope 72:765–787. vii House, W.F and Glasscock, M.E III. 1968. Glomus Tymoanicum Tumours. Arch Otolaryngol 87: 550–554 viii Spector, C.J.,Ciralsky, R.H. and Ogura, J.H. 1975.Glomus Tumours in the head and neck: III. Analysis of Clinical Manifestations. Ann Otol Rhinol Laryngol, 84: 73–79. ix Brown J.S. 1967. Glomus jugulare tumours. Methods and Difficulties of Diagnosis and Surgical treatment. Laryngoscope 77: 26–67.
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x Spector, G.J., Gado, M., Ciralsky, R., et al. 1975. Neurologic Implications of Glomus Tumours in the Head and Neck. Laryngoscope, 85:1387–1395. xi Schwaber, M.K., Glasscock, M.E., Jackson, C.G. et al. 1984. Diagnosis and Management of Catecholamine secreting tumours. Laryngoscope 94:1008–1015 xii Julianna Gulya. 1993. Section II, The glomus Tumour and its Biology. Laryngoscope 103: 7–15. xiii Borsanyi, S.J. 1962. Glomus Jugulare Tumours. Laryngoscope, 72:1336–1345 xiv Ficky, E.L. F.M and Paparella, M.M. 1984. A Metastatic glomus Jugulare Tumour. A Temporal bone report. Amm J of Otol, 5: 197–200 xv Rossenwasser, H. 1968. monograph on Glomus Jugulare Tumors. Arch Otolaryngol, 88:3–40. xvi Spector, G.J., Maisel, R.H and Ogura, J.H. 1973. Glomus Tumours in the Middle Ear. Laryngoscope 83:1652–1672. xvii Ervin, D.M. and Osguthorpe, J.D. 1984. X ray Study of the Month. Multicentric Paragangliomas.Ann Otol Rhinol Laryngol, 93: 96–97,
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Influence of near correction on visual perception and perceptional organization skills in Down Syndrome children G. S atırtav, E.C. S ener & A.S . Sanaç Hacettepe University School of Medicine, Department of Ophthalmology, Ankara, Turkey
E. Erdog˘an Bakar Hacettepe University School of Medicine, Department of Neurology, Ankara, Turkey
ABSTRACT: To determine the effect of near spectacle correction on visual perception and perceptional organization skills in children with Down Syndrome, full ophthalmologic examination including dynamic retinoscopy were performed on 11 children with Down Syndrome and the children were grouped according to their accommodation capacity. To determine the visual perception and perceptional organisation skills, Bender Gestalt Motor Perception Test was carried out on two occasions two weeks apart with distant refractive correction on first visit and with 3.0 add on the second visit. When the scores of the first and second performances in the BGMPT are compared within each group; in the children with defective accommodation, the total BGMPT score means in the second performances are found to be significantly lower than the first test score means and in children without defective accommodation, the difference between the mean scores of the first and second performances were found to be statistically insignificant.
1
INTRODUCTION
Poor accommodation has been reported to be a common feature of Down Syndrome. It has been first reported by Linstedt who has used a comparison of distance and near visual acuities to evaluate accommodation and has shown that children with visual impairment and children with Down Syndrome frequently have reduced accommodation. Since then this has been supported by several authors. Woodhouse has reported that accommodation in these children is not dependent on the refractive error present and the spectacles to correct the distant refractive error do not improve the accommodative response. Furthermore age, angular subtense of the target used for the fixation and cognitive factors could not fully account for the poor accommodation in these children. To the best of our knowledge, there has not been any study done concerning the effect of near refractive correction, to compensate for the defective accommodation, on the child’s visual perception. The aim of the present investigation is to determine the effect of near spectacle correction on visual perception and perceptional organizational skills in children with Down Syndrome. 2 2.1
SUBJECTS AND METHODS Participants
Thirteen individuals with a primary diagnosis of Down Syndrome were the subjects in this study. Two children were recruited but excluded from the final sample for failure to complete the testing. There were four females and seven males and the ages ranged from 80 months to 158 months with a mean age of 130,36 months at the time of testing. Permission to their ophthalmologic examination and application of the tests was obtained from each subject’s parent or guardian. 339
2.2
Procedures
All children with Down Syndrome underwent full ophthalmologic examination. Visual acuity was measured using the Lea and the Snellen chart according to the child’s cooperation. Strabismus was identified with the cover test. Dynamic retinoscopy and cycloplegic refraction were performed on each child. Dynamic retinoscopy is done sitting about 50 cm in front of the child observing the retinoscopic streak light movement while the child is looking straight ahead at distance with both eyes open. A small picture that attracts interest is then introduced 20–30 cm in front of the child. The child is then encouraged to fixate the near target constantly. If normal accommodation is present, the examiner observes a very distinct shift from “with” movements to “against” movements. If, when presenting the target, this shift did not take place in spite of a cooperative child, the accommodation response was classified as accommodation weakness. In most cases the accommodative state of the right eye was assessed. However, in one child with strabismus and a fixating left eye accommodation was assessed from the left eye. Children were grouped according to their accommodative responses as “children with accommodative weakness” and “children without accommodative weakness”. To determine the visual perception and perceptional organization skills, Bender Gestalt Motor Perception Test (BGMPT) was carried out on each child by one of the authors (EEB). The test was done on two occasions two weeks apart, with best corrected vision for distance on first visit and with 3.0 additions on the second visit. The BGMPT is a psychological assessment used to evaluate visual motor functioning, visual perceptual skills in children and adults ages 3 and older. The original BGMPT was developed in 1938 by psychiatrist Lauretta Bender. The standard BGMPT consists of 9 figures of geometric designs (numbered A and 1–8) each on its own 3 5 inches card. An examiner presents each figure to the test subject one at a time and asks the subject to copy it on to a single piece of blank paper. The only instruction given to the subject is that he or she should make the best reproduction of the figure possible. The test is not timed; results are scored based on accuracy and organization. Common features considered in evaluating the drawings are attachment, rotation, distortion, symmetry and perseveration. Each mistake done while drawing each figure is scored as “1” and the maximum score that can be obtained is “30”.(Koppitz, 1964). The majority of more than 20 different reliability studies reported by Koppitz reveals correlation coefficients in the .80 range and suggests that normal elementary school children show relatively stable patterns of BGMPT scores from one administration to the next. 2.3
Statistics
The data was analyzed statistically in the Statistical Package for Social Sciences (SPSS, 11.5). The score differences obtained from the BGMPT in the first and second visits for the two groups of children were compared using Mann Whitney Test. P 0.05 was chosen as the level of significance. 3
RESULTS
The visual acuities of the children ranged from 0.4 to 1.0 (mean 0.52) (Table 1) Only one of the subjects (%9.1) had strabismus (right esotropia) and others did not have any eye movement disorder (Table 1). Seven of the children (%63.6) had low grade hypermetropia (spherical equivalent right eye 2.0), one (%9.1) had high grade hypermetropia (spherical equivalent of the right eye 4.0 D), one (%9.1) had myopia and two (%18.2) were emmetropes (Table 1). When the total score and subscores of the first and second performances in the BGMPT are compared within each group; – In the children with defective accommodation, the total BGMPT score means in the second performances (X 11,67) are found to be significantly lower than the first test score means (X 9,00) (P 0,034). 340
Table 1.
Individual cross-sectional data on 11 children on the first examination.
Group*
Subject
Age (months)
Visual acuity
Refractive error
1
FK
80
20/63 OD 20/63 OS
1.50 80 OD 1.25 110 OS
1
EU
151
20/50 OD 20/50 OS
0.50 OD 0.50 OS
1
MC
151
20/40 OD 20/50 OS
1.75, 0.75 150 OD 1.25, 1.00 30 OS
1
PK
147
20/40 OD 20/40 OS
1.75, 1.00 167 OD 2.00, 0,75 175 OS
1
CD
158
20/40 OD 20/32 OS
1.50, 1.00 85 OD 1.00, 1.00 100 OS
2
TD
143
20/63 OD 20/63 OS
1.00, 1.00 5 OD 1.00, 1.00 170 OS
2
EA
108
20/25 OD 20/25 OS
0.50 10 OD 0.50 170 OS
2
MD
96
20/25 OD 20/32 OS
0.50, 0.75 45 OD 0.50, 0.50 110 OS
2
EE
148
20/40 OD 20/40 OS
1.50, 2.00 80 OD 0.50, 1.00 120 OS
2
BG
132
20/80 OD 20/80 OS
0,75 OD 0.50 OS
2
AT
120
20/80 OD 20/80 OS
6,75 OD 6,50 OS
Other ocular defects
Lenticular opacities
Right esotropia
* Group 1: children without defective accommodation. Group 2: children with defective accommodation.
– In the children without defective accommodation, the difference between the mean scores of the first (X 13,00) and second performances (X 13,40) were found to be statistically insignificant (P 0,715). – In the children with defective accommodation, the total BGMPT attachment subscore means in the second performances (X 2,00) are found to be significantly lower than the first test subscore means (X 3,67) (P 0,039). – In the children without defective accommodation, the difference between the mean attachment subscores of the first (X 4,40) and second performances (X 4,60) were found to be statistically insignificant (P 0,564). When the total and subtotal Bender score differences of the two performances are compared between each group; – The mean difference of the total Bender scores in the group with defective accommodation (X 7,75) is found to be higher than the mean difference of the total Bender scores in the group without defective accommodation (X 3,90) and the difference was found to be statistically significant (P 0,05). – The mean difference of the attachment subscore in the group with defective accommodation (X 1,67) is found to be higher than the mean difference of the attachment subscores in the group without defective accommodation (X 0,20) and the difference was found to be statistically significant (P 0,01). 341
4
CONCLUSION
The majority of children with Down Syndrome are probably visually impaired at near distances. Uncorrected refractive errors and poor accommodation might be a factor in the educational achievements of children with Down Syndrome. The learning ability of these children might be hampered by the inability to see near objects clearly or comfortably especially in a learning environment and it is imperative that clinicians and educators are made aware of this. In this study we have shown that near correction may have an impact on their near work. Therefore, the ophthalmologic examination of these children should include dynamic retinoscopy to see their accommodation abilities and near correction for the children with accommodation deficit can be considered in the visual rehabilitation.
REFERENCES Cregg, et al. (2001) Accommodation and refractive error in children with Down Syndrome: cross-sectional and longitudinal studies. Invest Ophthalmol Vis Sci 2001;42:55–63. Linstedt (1983) Failing Accommodation in cases of Down Syndrome; Ophthalmic Paediatr Genet. 1983;3:191. Mitchell-Burns (2000) Performance of children with and without learning disabilities on Canter’s Background Interference Procedure and Koppitz’s scoring system for the Bender test. Percept Mot Skills. 2000 Jun;90(3 Pt 1):875–82. Pires da Cunha et al. (1996) Ocular Findings in Downs Syndrome. Am J Ophthalmol. 122:236–244. Woodhouse et al. (1993) Reduced Accommodation in children with Down Syndrome; Invest Ophthalmol Vis Sci 34:2382–2387. Woodhouse, et al. (1996) Visual acuity and accommodation in infants and young children with Down Syndrome. J Int Dis Res.;40:49–55. Woodhouse, et al. (2000) The effect of age, size of target and cognitive factors on accommodative responses of children with Down Syndrome. Invest Ophthalmol Vis Sci;41:2479–2485.
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Surgical management of complete oculomotor nerve palsy N. Sefi Yurdakul, S. Ugurlu & A. Maden .
Atatürk Education and Research Hospital, I zmir, Turkey
ABSTRACT: Purpose: To assess the effectiveness of horizontal muscle surgery in association with adducting traction suture in the management of complete oculomotor nerve palsy. Methods: Large recession of the lateral rectus muscle with hemi-hangback suture, large resection of the medial rectus muscle and adducting traction suture were applied to all patients. For vertical deviation, insertions of the medial and lateral rectus muscles were transposed superiorly. The resultant deviation at primary position was evaluated. Results: Five patients with a median age of 12 years (6–25 years) were evaluated. The median preoperative horizontal deviation was 65 prism diopters (PD), and vertical deviation was 10 PD. At the last visit, median horizontal deviation was 10 PD, and vertical deviation was 4 PD. Conclusion: Large recession with loop suture and resection of horizontal muscles combined with adducting traction sutures is a safe and effective procedure in the management of complete oculomotor nerve palsy.
1
INTRODUCTION
In complete oculomotor nerve palsy, the eye becomes fixed in a position of abduction, slight depression and intorsion because of unopposed action of the lateral recti and superior oblique muscles. The palsy of the levator palpebrae muscle results in ptosis. The palsy of intrinsic muscles of the eye causes dilatation of the pupil and a palsy of accomodation. The surgical management of this condition presents a formidable challenge and the therapeutic possibilities are limited. The goal of surgery in complete third nerve palsy is to align the paralytic eye in primary gaze (von Noorden & Campos 2002). Various surgical procedures have been described to achieved this goal (Scott 1977, Sato et al. 2000, Kose et al. 2001). In the current study, the effectiveness of horizontal muscle surgery in association with adducting traction suture in the management of complete oculomotor nerve palsy was assessed.
2
MATERIAL AND METHODS
Consecutive patients with complete oculomotor nerve palsy who presented to the division of Strabismus and Neuroophthalmology between April 2001 and June 2003 were included in the study. After a complete ophthalmic examination preoperative ocular motility was evaluated. The degree of ocular deviation was assessed by means of the prism cover test. The functions of the ciliary muscle, spinchter pupilla and levator palpebrae were established. Surgery was performed under general anesthesia. All of the surgical procedures were done on the muscles of the paralytic eye. Limbal conjunctival incision was used for all patients. The lateral rectus muscles were recessed 10 mm from the original insertion with a 4 mm hemi-hangback loop suture. Large resection of the medial rectus muscle (8 mm) was performed. For vertical deviation correction, insertions of the medial and lateral rectus muscles were transposed superiorly according to 343
Figure 1. Preoperative appearance of a patient with congenital oculomotor nerve palsy at primary position (left), immediate postoperative appearance after simultaneous strabismus and ptosis surgery with adducting traction suture in place (middle) and postoperative 6th month appearance (right).
amount of deviation. At the completion of the surgery, traction sutures (5-0 Dacron) were passed through limbal scleral tissue and then passed through the extreme medial canthal area. Sutures were tied over tarsorrhaphy bolsters and left in place for at least four weeks (Figure 1). All patients underwent frontalis suspension surgery either simultaneously or following strabismus surgery. Prospective analysis of the resultant deviation at primary position and patient satisfaction were evaluated at 1st, 3rd, 6th, 12th and 24th months.
3
RESULTS
Five patients with a median age of 12 years (range, 6–25 years) were evaluated. Two patients were female, three patients were male. Four patients had unilateral congenital palsy, and one patient had acquired unilateral palsy secondary to an intracranial mass. No patient demonstrated apparent medial rectus muscle function. All five patients had functioning superior oblique and lateral recti muscles, and had ptosis in the involved eyes. The pupils of the patients were dilated and unresponsive to light. The median preoperative horizontal deviation was 65 prism diopters (PD) (range, 50–85 PD), and vertical deviation was 10 PD (range, 6–18 PD). Median time of limbal traction suture application was 5 week (range, 4–6 weeks). The median follow-up period was 12 months (range, 6–24 months). At the last visit, median horizontal deviation was 10 PD (range, 6–16 PD), and vertical deviation was 4 PD (range, 0–8 PD). Satisfaction with final outcome was rated to be excellent by all patients. None of the patients complained and demanded removal of traction sutures.
4
DISCUSSION
Surgical management of complete third nerve palsy is difficult and multiple procedures are often needed to maintain good ocular alignment (Schumacher-Feero et al. 1999). Most authors advocate superior oblique tenotomy and transposition procedures combined with a horizontal recession and resection in the treatment of complete third nerve palsy (Scott 1977, Gottlob et al. 1991, Lee et al. 2001), and report cosmetically satisfactory long term results. Athough superior oblique tendon transposition may be helpful in complete oculomotor nerve palsy with no residual medial rectus function (Gottlob et al. 1991), the procedure is technically difficult and inadequate horizontal alignment, hypertropias or paradoxic ocular movements are possible. The concept of use of traction sutures in management of oculomotor palsy is not new. Daniell et al. (1996) reported satisfactory results using adducting traction sutures in 24 patients with fixed divergent squint secondary to long-standing oculomotor nerve palsy. They combined a supramaximal horizontal resection/recession procedure, and left the sutures in situ for 6 weeks. They achieved good cosmetic position in all but two patients. Lee et al. (2001) performed horizontal recti resection/recession, supra-placement of the insertions, superior oblique weakening and traction sutures in 7 congenital third nerve palsy patients, and reported reasonable cosmesis. The current study involved a similar 344
approach with the above studies with the exception of combined use of the loop suture technique and the traction sutures. The median preoperative horizontal deviation of 65 PD (range, 50–85 PD) was reduced to 10 PD (range, 6–16 PD) at the last follow-up visit. We believe the combined use of traction suture along with loop suture technique might have promoted the effect of supramaximal recession by preventing the re-attachment of lateral rectus anteriorly. Although this concept needs to be validated, Sato et al. (2000) was able to demonstrate the re-attachment of lateral rectus muscle through a fibrous tissue after complete myectomy (without suturing to the globe) in a patient with complete third nerve palsy by magnetic resonance imaging. Hence, it is reasonable to assume that one may achieve a more controlled attachment of lateral rectus muscle by allowing the rectus muscle to hang back in a controlled fashion and applying traction to keep the eye in adduction so as to obtain a new insertion behind the equator. Correction of vertical deviation secondary to oculomotor palsy may be achieved by the use of superior oblique transposition, inferior rectus recession or transposition of insertions of horizontal recti superiorly. In the current study, surgery of superior oblique muscle was avoided. Insertions of the medial and lateral rectus muscles were transposed superiorly according to amount of deviation, and the median vertical deviation was 4 PD (range, 0–8 PD) at the last visit. With this approach normal function of the superior oblique muscle was preserved and the option of transposition of superior oblique muscle in case of a failed surgical result was kept possible. Overall satisfaction with final outcome was rated to be excellent by all patients, and no patient was willing to be reoperated for the residual deviation. None of our patients complained of intractable diplopia.
5
CONCLUSION
Establishment of ocular alignment in complete oculomotor nerve palsy is a challenging task. Large recession with loop suture and resection of horizontal muscles combined with adducting traction sutures appears to be a safe and effective procedure in reaching this goal.
REFERENCES Daniell MD, Gregson RM & Lee JP. 1996. Management of fixed divergent squint in third nerve palsy using traction sutures. Aust N Z J Ophthalmol 24: 261–265. Gottlob I, Catalano RA & Reinecke RD. 1991. Surgical management of oculomotor nerve palsy. Am J Ophthalmol 111: 71–76. Kose S, Uretmen O & Pamukcu K. 2001. An approach to the surgical management of total oculomotor nerve palsy. Strabismus 9: 1–8. Lee V, Bentley CR & Lee JP. 2001. Strabismus surgery in congenital third nerve palsy. Strabismus 9: 91–99. Noorden GK von & Campos EC. 2002. Paralytic strabismus. In Binocular vision and ocular motility. Theory and management of strabismus. 6th ed. St. Louis: Mosby: 414–457. Scott AB. 1977. Transposition of the superior oblique. Am J Orthop 27: 11–14. Schumacher-Feero LA, Yoo KW, Solari FM & Biglan AW. 1999. Third cranial nerve palsy in children. Am J Ophthalmol 128: 216–221. Sato M, Maeda M, Ohmura T & Miyazaki Y. 2000. Myectomy of lateral rectus muscle for third nerve palsy. Jpn J Ophthalmol 44: 555–558.
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Etiology of paralytic strabismus N. Sefi Yurdakul, S. Ugurlu, G. Aydeniz . & A. Maden Atatürk Education and Research Hospital, I zmir, Turkey
ABSTRACT: Purpose: To evaluate the etiologies and clinical features of patients with paralytic strabismus. Methods: The records of the patients followed with the diagnosis of paralytic strabismus were studied retrospectively. Results: Of 122 patients, 53 were women (43%), 69 were men (57%), and the average age was 32.1 23.8 years (range, 1–80 years). Abducens nerve palsy was determined in 47 (38.5%), trochlear in 36 (29.5%), oculomotor in 31 (25.4%) and multiple nerve palsies in 8 patients (6.6%). Etiologies were congenital in 39 (31.9%), trauma in 34 (27.9%), vascular in 20 (16.4%), undetermined in 13 (10.7%) and other causes in 16 cases (13.1%). The most commonly affected nerve was trochlear (p 0.000) in the pediatric group and abducens (p 0.006) in the adult group. Conclusion: Congenital and vascular diseases are the major causes of paralytic strabismus in childhood and adulthood, respectively. Each patient with paralytic strabismus should undergo appropriate investigation after a complete neuro-ophthalmologic examination.
1
INTRODUCTION
Paralytic strabismus appears secondary to lesions that involve the muscle, neuromuscular junction, peripheral nerve, nuclear or supranuclear pathways (von Noorden & Campos 2002). Information regarding the etiology is of utmost importance in acquired paralytic strabismus as it will aid both diagnosis and management. In the current study, we have evaluated patients with paralytic strabismus retrospectively, and analyzed the findings in the adult and the pediatric population. 2
MATERIAL AND METHODS
The records of patients followed with the diagnosis of paralytic strabismus between August 1999–December 2003 were studied retrospectively. Patients with strabismus secondary to restrictive or myopathic causes were not included in the study. Patient charts were reviewed to identify features of orthophtic, neuroophthalmologic and systemic evaluations as well as imaging studies. Patients were classified according to the type of nerve palsies and the etiology. Time of detection of motor nerve palsy was used to describe patients with pediatric onset (age 18 years) and with adult onset (age 18 years). If paralytic strabismus was noted since birth, it was classified as congenital; those with no clear etiologic reason were grouped as undetermined. Statistical analysis was carried out by SPSS version 10.0 (SPSS Inc., Chicago, IL) using chi-square test. P value below 0.05 was considered significant. 3
RESULTS
Of the 122 patients with paralytic strabismus 53 were women (43%), 69 were men (57%), and the average age of was 32.1 23.8 years (range, 1–80 years). Abducens nerve palsy was determined 347
Table 1.
Distribution of etiology of paralytic strabismus in the pediatric group.
Congenital Trauma Others Undetermined Total
Table 2.
Oculomotor n (%)
Trochlear n (%)
Abducens n (%)
Multiple n (%)
Total n (%)
7 (63.6) 3 (27.3) 1 (9.1) – 11
27 (84.4) 3 (9.4) 1 (3.1) 1 (3.1) 32
4 (25) 9 (56.3) 2 (12.5) 1 (6.3) 16
1 (33.3) 2 (66.7) – – 3
39 (62.9) 17 (27.4) 4 (6.5) 2 (3.2) 62
Distribution of etiology of paralytic strabismus in the adult group.
Vascular Trauma Others Undetermined Total
Oculomotor n (%)
Trochlear n (%)
Abducens n (%)
Multiple n (%)
Total n (%)
7 (35) 6 (30) 6 (30) 1 (5) 20
– – 1 (25) 3 (75) 4
13 (41.9) 8 (25.8) 3 (9.7) 7 (22.6) 31
– 3 (60) 2 (40) – 5
20 (33.3) 17 (28.3) 12 (20) 11 (18.3) 60
in 47 (38.5%), trochlear in 36 (29.5%), oculomotor in 31 (25.4%), and multiple nerve palsies in 8 patients (6.6%). Etiologies were congenital in 39 cases (31.9%), trauma in 34 cases (27.9%), vascular in 20 cases (16.4%), and undetermined reasons in 13 cases (10.7%). Other causes such as meningitis-encephalitis (n 4), intracranial intervention (n 3), cavernous sinus lesions (n 2), multiple sclerosis (n 2), intracranial neoplasm (n 3), aneurysm (n 1) and arachnoid cyst (n 1) were noted in 16 cases (13.1%). Distribution of etiologies are given in Tables 1 and 2 for pediatric and adult patients, respectively. Trochlear nerve palsy and congenital palsies were more frequent in the pediatric population (p 0.000). Abducens nerve palsy (p 0.006) and vascular factors (p 0.000) were more prevalent in the adult patient.
4
DISCUSSION
Despite ample data, there is no consensus on frequencies of cranial nerve palsies leading to paralytic strabismus. In several studies, abducens nerve palsy was reported to be the most frequently observed palsy, followed by oculomotor and trochlear nerve palsy. The convoluted, lengthy course of abducens nerve was felt to be the reason of frequent involvement (Rucker 1966, Rush & Young 1981, Richards et al. 1992). On the other hand, von Noorden et al. (1986) reported that trochlear nerve palsy was the most frequent cranial nerve palsy, followed in decreasing order of frequency by abducens and oculomotor nerve palsies. In the current study, abducens nerve palsy was the leading palsy followed trochlear, oculomotor and multiple nerve palsies in decreasing order of frequency when all the patients were considered. Comparison of frequencies of cranial nerve palsies according to the age of presentation has shown conflicting results. Kodsi & Young (1992) reported acquired abducens cranial nerve palsies significantly more often in the pediatric population and acquired trochlear cranial nerve palsies in the adult population. The proportions of cases involving acquired oculomotor cranial nerve palsies in the pediatric group were similar to those in the adult population. In contrast, in the current study, comparison of pediatric and adult groups yielded trochlear nerve palsy and abducens nerve palsy as the major causes of paralytic strabismus, respectively. With elimination of the congenital strabismus cases, abducens nerve palsy became the most frequent palsy in both groups. 348
Previous studies have revealed different etiology as the major causes of paralytic strabismus in pediatric and adult populations. The microvascular diseases like hypertension, diabetes mellitus and atherosclerosis are known to be more prevalent in the elderly patients (Rush & Younge 1981). Berlit (1991) reported microvascular diseases to be the most frequent cause in patients older than 14 years. Similar results were observed in the current study. Patients above 18 years suffered from microvascular diseases; patients below 18 years had congenital nerve palsies and palsies secondary to trauma. Trauma was reported to be the most frequent reason for acquired cranial nerve palsy in the pediatric patients (Kodsi & Young 1992). In the current study exclusion of cases with congenital origin resulted in a similar outcome; acquired palsies were of traumatic origin in the majority of the pediatric patients. It was the second commonest reason in adult patients, too. In our study group, trauma appears to play a significant role which may be attributed to high prevalence of both traffic and occupational accidents in Turkey. Undetermined reasons have been reported to be the leading reason in paralytic strabismus in some studies among adult patients (Rush & Young 1981, Richards et al. 1992). This was not the finding in the current study, yet, this group was statistically significantly more prevalent in the adult group compared to the pediatric group. Undetermined reasons are felt to be composed of diseases associated with microvascular diseases that cannot be diagnosed with certainity. With progress in the currently available diagnostic methods, those that have been described as undetermined would probably decrease over the years. In this study several other intracranial diseases were observed to cause cranial nerve palsy both in the adult and the pediatric patients which were classified as ‘others’. Advanced imaging techniques and detailed neurologic examination are to be performed depending on the clinical features of acquired paralytic strabismus so as to identify the specific intracranial diseases.
5
CONCLUSION
Different outcomes regarding frequencies and etiology of paralytic strabismus in various studies are reported. The variable outcome might be attributed to different patient populations that have been studied, and to different study settings. Regardless of the relative frequency of any cranial nerve palsy, each patient with paralytic strabismus should undergo appropriate investigations including a complete neuro-ophthalmologic examination.
REFERENCES Berlit P. 1991. Isolated and combined pareses of cranial nerves III, IV and VI. A retrospective study of 412 patients. J Neurol Sci 103: 10–15. Noorden GK von, Murray E & Wong SY. 1986. Superior oblique paralysis. A review of 270 cases. Arch Ophthalmol 104: 1771–1776. Noorden GK von & Campos EC. 2002. Paralytic strabismus. In Binocular vision and ocular motility. Theory and management of strabismus. 6th ed. St. Louis: Mosby: 414–457. Kodsi SR & Younge BR. 1992. Acquired oculomotor, trochlear, and abducent cranial nerve palsies in pediatric patients. Am J Ophthalmol 114: 568–574. Rucker CW. 1966. The causes of paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol 61: 1293–1298. Rush JA & Younge BR. 1981. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases. Arch Ophthalmol 99: 76–79. Richards BW, Jones FR Jr & Younge BR. 1992. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol 113: 489–496.
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Clinical, pedigree and genetic analysis of congenital fibrosis of extraocular muscles B.T. Öztürk*, E.C. Sener ¸ & A.¸S. Sanaç ¸ Hacettepe University, Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey * Currently assigned at the Ankara Güven Hospital
N. Akarsu Pediatrics, Hacettepe University Medical Faculty, Ankara, Turkey
K. Yamada & E.C. Engle Division of Genetics, Children’s Hospital Boston and Harvard Medical School, Boston, MA, USA
ABSTRACT: Our study aimed to investigate the clinical characteristics and genotyping of CFEOM in the Turkish population. During a period of 10 years (1993–2003) 56 cases with CFEOM were followed at one university hospital setting. Three of these families and 4 of the sporadic cases were genetically analysed. We demonstrated that a CFEOM2 individual reduced to homozygosity across the CFEOM2 locus and harbored a homozygous mutation in PHOX2A. One CFEOM1 family was consistent with linkage to both CFEOM1 and CFEOM3 loci and the affected individuals had a pathogenic heterozygous mutation in KIF21A. In addition, we identified that one CFEOM3 pedigree was linked to the CFEOM1 locus and the affected individuals harbored another KIF21A mutation. The clinical and genetical analysis of the CFEOM patients reveals a complex disease condition in which further information may bring better treatment hope for the severely affected individuals.
1
OBJECTIVE
CFEOM is an ocular motility disorder characterized by ptosis and restrictive ophthalmoplegia in the oculomotor and trochlear nerve distribution. Three genetic loci for CFEOM have been identified (CFEOM1–3) already which lead to a new classification of the disease which combines both genetic etiology and clinical presentation (Engle, 1995; Wang, 1998; Doberty, 1999; Engle, 2002). Our study aimed to investigate the clinical characteristics and genotyping of CFEOM in the turkish population. 2
MATERIAL AND METHOD
During a period of 10 years (1993–2003) 56 cases (29 male, 27 female) with CFEOM were followed at one university hospital setting. The age of the patients at the time of the study ranged between 6 months and 74 years. Following the selection of the index cases from the charts, pedigree analysis and sample collection were prospectively carried out in the field. Genetic analysis was completed when possible. 3 3.1
RESULTS Clinical Findings
In primary position, the affected eye was hypotropic in 69.6% of cases, associated with esotropia in 25% and exotropia in 19.6%. Clinical findings of 46.4% of participants were consistent with 351
Figure 1.
Photographs of a classic CFEOM case from pedigree 1.
Figure 2.
Photographs of an individual from pedigree 1 showing variations from classical CFEOM.
that described for classic CFEOM (Figure 1). The restrictive strabismus can be very mild to very severe in the same family (Figures 1, 2). Amblyopia was noted in 95% and ptosis in 83.9% of the CFEOM cases. Associated ocular anomalies included nystagmus, microcoria, situs inversus, tilted disc, increased cupping and systemic anomalies included corpus callosum agenesis, sensorineural hearing deficit and facial paralysis. 3.2
Pedigree analysis
Thirteen of the CFEOM cases were sporadic and the remaining 43 belonged to 6 families. Pedigree 1 (Figure 1) consists of 94 individuals 29 of which were affected by the disease. This pedigree presents autosomal dominant trait with variable expressivity (S ¸ ener, 2000). In 18 of affected members the phenotypic expression of the disorder is consistent with that described for classic CFEOM. The remaining 11 affected members had more variable clinical phenotypes that did not meet CFEOM1 criteria and so the pedigree was classified as CFEOM3. Pedigree 2 and 4 showed autosomal dominant trait with classic CFEOM1 patients. Pedigree 3, 5 and 6 presents features of CFEOM3 as the affected members presents findings variable from classic CFEOM. 3.3
Genetic Analysis
Three of these families and 4 of the sporadic cases were genetically analysed (Table 1). We demonstrated that one of our sporadic CFEOM2 individual (Case1) reduced to homozygosity across the CFEOM2 locus and harbored a homozygous mutation in ARIX (PHOX2A) (Nakano, 2001). The CFEOM1 family (Pedigree 2) was consistent with linkage to both CFEOM1 and CFEOM3 loci and the affected individuals had a pathogenic heterozygous mutation in KIF21A (Yamada, 2003). In addition, we identified that the CFEOM3 family in pedigree 1 was linked to the CFEOM1 locus and the affected individuals harbored another KIF21A mutation (¸Sener, 2000; Yamada, 2004). 352
Figure 3. Table 1.
Pedigrees of Turkish CFEOM families. Results of genetic analysis. Genotype CFEOM1
CFEOM2
CFEOM3
KIF21A mutation analysis
Haplotype analysis (11q13)
ARIX (PHOX2A) mutation analysis
Haplotype analysis (16q24)
Pedigrees
Phenotype
Haplotype analysis (12p11.2-q12)
Pedigree 1 Pedigree 2 Pedigree 3 Sporadic cases Case 1
CFEOM3 CFEOM1 CFEOM3
Lrp cw cw rp
cw cw
CFEOM2
Case 2 Case 3 Case 4
CFEOM3 CFEOM2 CFEOM3
Reduce to homozygosity
L: linked; cw: consistent with linkage; rp: reduced penetrance.
4
CONCLUSIONS
CFEOM is one of the rare inherited ocular motility disorders. As the genetic basis of the disease becomes known the way it is being classified is changing. Studies led to definiton of three genetic loci (CFEOM1-3) and three phenotypes arranged according to these genetic loci (Engle, 2002). The 353
findings that CFEOM1 results from a primary absence of the superior division of the oculomotor nerve and that affected patients harbor mutations in KIF21A and that CFEOM2 results from absence of the oculomotor and trochlear nuclei and that affected patients harbor mutations in ARIX ( PHOX2A) provide insight that has allowed these disorder to be classified as neurogenic rather than myopathic (Yamada, 2004). Genetic analysis of several of the Turkish CFEOM pedigrees revealed mutations both of these genes and supports this hypothesis (Nakano, 2001; Yamada, 2003). The clinical and genetical analysis of the CFEOM patients reveals a complex disease condition in which further information may bring better treatment hope for the severely affected individuals.
REFERENCES Doberty E.J. 1999. CFEOM 3: A new extraocular congenital fibrosis syndrome that maps to 16q24.2–24.3. Inves Ophthalmol Vis Sci 40(8):1691–4. Engle E.C. 1995. Congenital fibrosis of the extraocular muscles (Autosomal dominant congenital external ophthalmolplegia): Genetic homogeneity, linkage refinement and physical mapping on chromosome 12. Am J Hum Genet 57:1086–94. Engle E.C. 1997. Oculomotor nerve and muscle abnormalities in congenital fibrosis of the extraocular muscles. Ann Neurol 41:314–25. Engle E. 2002. The molecular basis of the congenital fibrosis syndrome. Strabismus 10(2): 125–8. Nakano M. 2001. Homozygous Mutations in ARIX(PHOX2A) result in congenital fibrosis of the extraocular muscles type 2. Nat Genet 29:315–20 S¸ ener E.C. 2000 A Clinically Variant Fibrosis Syndrome in a Turkish Family Maps to the CFEOM1 Locus on Chromosome 12. Arch Ophthalmol 118:1090–97. Wang S.M. 1998. Congenital fibrosis of the extraocular muscles type 2, an inherited exotropic strabismus fixus, maps to distal 11q13. Am J Hum Genet 63:517–25. Yamada K. 2003. Heterozygous mutations of the kinesin KIF21A in congenital fibrosis of the extraocular muscles type 1 (CFEOM1). Nat Genet. 35:318–21. Yamada K., 2004. KIF21A mutations are a rare cause of congenital fibrosis of the extraocular muscles Type 3 (CFEOM3). Invest Ophthalmol Vis Sci. [in press]
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Abnormal lateral rectus insertion associated with V-pattern exotropia and up-shoot . Y. Uysal, F.M. Mutlu, C. Erdurman, H.I Altınsoy S.M.Z. Bayraktar GATA Department of Ophthalmology, Ankara, Turkey
D. Ceyhan Gendarmerie Military Hospital, Ankara, Turkey
ABSTRACT: Purpose: To report the clinical characteristics, preoperative, intraoperative, postoperative, anatomic findings of four cases of V-pattern exotropia, with up-shoot in one eye and inferior oblique over-action in the other eye. Materials and Methods: We reviewed retrospectively the data of four patients who had V-pattern exotropia and up-shoot with abnormal lateral rectus insertion. All four patients underwent strabismus surgery and inferior oblique myectomy and lateral rectus recession procedures were performed. Results: Mean age was 22.2 (ranged from 21 to 23) years. There was exotropia and up-shoot in all patients. During the operation, we observed that lateral rectus muscles inserted posterior and inferior of the expected insertion site of the eye with up-shoot and also extended from posterior and inferior part of the orbit. After the operation in all patients, substantial decrease in up-shoot was obtained and exotropia was decreased to less than 10 prism diopter. Conclusion: In cases with both V-pattern and up-shoot, the abnormal insertion of the lateral rectus muscles should be considered during the operation planning phase. MRI scan focusing on the extraocular muscles may be beneficiary.
1
INTRODUCTION
Up-shoot is the elevation of the eye during adduction (strabismus sursoadductorius). Patients with up-shoot complain about the disappearance of the eye during inward movement. There is also loss of fusion during side gaze, which may cause functional impairment. This clinical entity is mostly seen with Duane’s syndrome. It is also seen with exotropia (XT), esotropia (ET) and as an isolated clinical picture. If it is with exotropia, there is usually V-pattern strabismus (von Norden, 1996a). V-pattern XT constitutes 23–30% of all A- and V-pattern strabismus cases (Rosenbaum). It is not usual to see cases with both up-shoot and V-pattern. The co-existance of V-pattern and up-shoot is a challenging problem to the clinician, regarding the etiology and treatment of these cases, and the existance of abnormal muscle insertions have been rarely reported (Lee, 1996). We present clinical, preoperative, operative, and post-operative findings of 4 cases of V-pattern XT, with up-shoot in one eye, and propose a possible embryologic explanation to these cases.
2
REPORT OF CASES
Case 1: 23 years old male patient complains about outward turning of his eyes. In examination visual acuity was 20/20 in both eyes and there was an XT of 40 prism diopter (pD) with V-pattern. Although he was not much concerned, his right eye (RE) was up-shooting during left gaze. Also 355
there was a slight up-shoot of his left eye. We thought that IO (inferior oblique) OA (over acting) contributes to the up-shoot of the eye. Bilateral IO myectomy and bilateral lateral rectus (LR) 7 mm recession, RE adjustable, was planned. First, LE was operated. After, IO myectomy of the right eye was completed, and we observed that the lateral rectus of the RE (the eye with more up-shoot) inserted posterior and inferior of the expected insertion site. Also the LR muscle was extending from the posterior inferior part of the orbit. The insertions of inferior and superior rectus were normal. Lateral rectus was supraplaced and sutured beyond the expected insertion site, measuring from limbus. During the first postoperative day there was an 18 pD of XT and no up-shoot and IOOA. After 6 weeks the XT became an XT of 20 pD. The patient has undergone resection of 5.5 mm of both medial recti. After this operation patient has an XT of 8 pD and no up-shoot or IO OA. Case 2: The second case had almost the same findings preoperatively. A V-pattern XT of 35 pD and up-shoot of the right and a slight up-shoot of the left eye. The operation plan was bilateral inferior oblique myectomy and bilateral lateral rectus recessions of 6.5 mm. During the operation it was observed that, the lateral rectus of the right eye inserted posterior and inferior of the expected insertion site. Like previous case the muscle was also extending from inferior and posterior of the orbit. Other operated muscles and the inferior rectus insertion site were normal. The LR was reattached beyond the expected insertion site, measuring from the limbus. After the operation there was an XT of 10 pD and, a substantial decrease in up-shoot and IO OA Case 3: This case is 23 years old and complains about the outward turning of his eyes. He had an alternating XT of 20 pD and a V-pattern strabismus. His left eye was elevating during inward movement; also right eye was elevating slightly during adduction. First, IO muscle of both eyes were disinserted, and the LR of the left eye planned to be recessed 6 mm. During the operation LR was seen to insert inferior and posterior of expected insertion site. This muscle was supraplaced and reattached behind the expected insertion site. Also this muscle was stitched to sclera 4 mm posterior of new insertion site. After the operation there was a 5 pD of XT and there was a decrease of the up-shoot of both eyes. Case 4: 21 years old male patient complains about outward turning of his eyes. A V-pattern XT of 20 pD, dissociated vertical deviation (DVD) of the left eye together with up-shoot and () 4 IO OA, and () 1 OA of the right IO muscle. First, anterior transposition of the left IO muscle was performed then LR was seen to insert inferior and posterior of expected insertion site. This muscle was supraplaced and reattached 7 mm behind the expected insertion site. Also this muscle was stitched to sclera 4 mm posterior of new insertion site. After the operation there was a 5 pD of XT and there was a decrease of the up-shoot of left eye, and a significant decrease of V-pattern and DVD. 3
DISCUSSION
Regarding the etiology of V-pattern strabismus, there are excellent reviews discussing the possible effects of horizontal, vertical, oblique muscles or anomalies of muscle insertions and orbital structural differences (Von Norden, 1996b; Von Norden, 1986; Kushner, 1991). There should be no single etiologic factor causing these complex clinical pictures. In our cases, it is hard to propose a relationship between abnormal insertion of lateral rectus in one eye and the existence of V-pattern. We did not see an abnormal insertion of the lateral rectus of the eye without up-shoot. So, abnormal lateral rectus insertion may be only a contributing factor to V-pattern, not the major cause of the entity. The abnormal insertion may be the only detectable part of a more generalized sub-clinical abnormality of orbital contents, resulting both V-pattern exotropia and the elevation during inward gaze. Up-shoot is mostly studied with Duane’s Syndrome. The possible etiologic factors are reviewed in some reports (Von Norden,1986). It is usually believed to be the result of the: a) Spasmodic contraction of the inferior oblique; b) Paradoxical synergistic innervations between medial and superior rectus muscles; 356
c) A bridle effect of two horizontal muscles; proposing that as the muscle planes change, the horizontal muscles become elevators, and up-shoots the eye. Regarding the findings of versions; in the cases with up-shoot, the effect of inferior oblique muscles is the first to be considered. The unsuccessful results of inferior oblique surgery with upshoot in Duane’s syndrome showed the need for another explanation. In our cases we observed that the IO surgery together with LR recession decreased the up-shoot of in both eyes. IO muscle maybe caused at least a limited effect on elevation during adduction (up-shoot) of eyes, but it is speculative without any evidence except abnormal LR insertion. Kuschner (1991) reported that in V- and Y-pattern strabismus, some hypertropia during adduction might be confused with IO OA. He proposes that IO OA appears during whole adduction, pseudo IO OA occurs only when the eye goes up over the horizontal level. He also proposes that this kind of movement may be a form of co-contraction abnormality. Although there should be some effect of IO on the over elevation of our cases, supraplacing the lateral rectus, that inferiorly located, has a relieving effect for up-shoot too. We believe that the abnormal insertion of LR has more effect on up-shoot of these eyes, because over elevation of the eyes with abnormal insertion was marked. Jampolsky reported that the all the knife-edge up-shoot was always related to abnormal mechanics or structure of lateral rectus muscle (Jampolsky, 1999). We think the up-shoot of the eyes of our cases should be the result of the abnormal insertion of the lateral rectus. There was not any other anatomic finding that explain the up-shoot of the eye, nor an abnormal insertion of the lateral rectus in eyes without up-shoot. We could not recognize abnormal lateral rectus insertion in eyes with slighter up-shoot. There may be an undetectable insertion abnormality of the lateral rectus of these eyes. More recently, “muscle pulleys” and extraocular muscles’ relation with these pulleys and the effect of these structures on strabismus have been studied (Demer, 2002b). Heterotopy of rectus pulleys was reported to be the cause of some incomitant cases. Demer (2002a) reports that the inferior location of lateral, relative to medial rectus pulley causes the medial rectus act as a relative elevator in adduction. The “heterotopy” of LR of our cases may cause over-elevation in adduction. According to our findings, this, like bridle theory, accounts to be the most relevant explanation of the up-shoot of the cases (Von Norden,1986). This muscle should become an elevator, when the muscle planes change during inward movement. We used a posteior fixation suture to pull the muscle horizontal plane but we could not observed clinically significant difference with respect to the cases without posterior fixation suture. Also the effect of over-acting IO may augment the elevator effect of the abnormally inserted LR. It is hard to predict the total effect of the abnormal insertion site of LR about the etiology of V-pattern and up-shoot according to our findings. We believe that, the abnormal insertion of lateral rectus should be the only visually detectable pathology in orbital contents, causing this clinical picture. Some sub-clinical differences should contribute to the existence of the whole findings. Embryologically, the extraocular muscles develops as condensations in the paraxial mesoderm surrounding the optic vesicle (Mann,1964). While the muscles differentiate from the apex of the orbit forward, the sclera simultaneously differentiates in the opposite direction (Jacobiec, 1982). The muscles that innervated by different nerves have different embryological origins. The muscles innervated by III nerve derives from premandibular condensations; and the lateral rectus derive from the tissues adjacent to maxillomandibular mesoderm. The nerves of these muscles develop at different weeks of fetal development. Also the collagen fibers enveloping muscles and connective tissue septa develop after the muscles. The abnormal insertion of these muscles may be the result of an embryological insult during development of these particular parts, at their particular development time. The co-existence of craniofacial dysostosis and extraocular muscle insertion abnormalities are reported; and also coexistence of heterotopias of extraocular muscles with facial asymmetry is reported (Coats, 2000). We propose that, cases like ours are a slight form of the cases with craniofacial anomalies, which frequently co-exist with muscle abnormalities. The existence of facial asymmetry should be a warning sign for the clinician, for muscle abnormalities, during treatment planning phase. 357
Although a detailed oculomotor evaluation is performed, the exact cause of up-shoot and V-pattern could not be understood clearly. Before deciding to operate on certain muscles, all possible etiologic factors should be thought and the surgeon should be ready to change the operation plan. In cases with both V-pattern and up- shoot, the abnormal insertion of the lateral rectus muscles should be considered, during the operation-planning phase. If it is possible an MRI scan focusing on the extraocular muscles may be beneficiary.
REFERENCES Coats D.K. et al. 2000. Surgical management of V-pattern strabismus and oblique dysfunction in craniofacial dysostosis, JAAPOS 4:338–421. Demer J.L.2002. Behind the insertions: New concepts of extraocular muscles for orbital and strabismus surgeons, AAO/PAAO joint Meeting Orlando. Demer J.L. et al. 2002. A 12-year, prospective study of extraocular muscle imaging in complex strabismus. JAAPOS 6:337–347. Jacobiec F.A. 1982. Ocular anatomy embryology and teratology, Philadelphia, Harper & Row Publishers. p. 783. Jampolsky A. 1999. Duane syndrome In A.L. Rosenbaum & A.P. Santiago (eds), Clinical strabismus management: 326–344. Philadelphia, W.B. Saunders Co. p.335. Kushner B.J.1991. Pseudo inferior overaction associated with Y- and V-patterns Ophthalmol. Oct 98: 10: 1500–1505. Lee J.P. 1992. Congenital extraocular muscle defects, Eye 6: 181–183. Mann I. 1964. The development of the human eye, New York, Grune & Stratton Inc. p.256. Von Noorden G.K & Murray E.1986 Up- and downshoot in Duane’s retraction syndrome JPOS 23: 212–215. Von Noorden Gunter K. Up-shoot in adduction 1996a. Binocular Vision and Ocular Motility 5th Ed. Mosby Year Book Inc. p.367–368. Von Noorden Gunter K Binocular Vision and Ocular Motility 5th Ed. Mosby-Year Book Inc. 1996 A- and V-patterns p.376–391.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Transposition procedure for abducens palsy: 10 year-results ehu˚rek R. Autrata, K. Vodic ková, J. R Department of Pediatric Ophthalmology, Faculty of Medicine, Masaryk University Hospital, Czech Republic
ABSTRACT: Authors evaluated a long-term outcomes of two surgical methods for the treatment of six nerve palsy. Eighty nine patients with paralytic strabismus secondary to sixth nerve palsy undergone surgery in the period from January 1993 to October 2003. Group A included 46 patients, who were treated using a large recession of the medial rectus combined with a supramaximal resection of the lateral rectus. Group B comprised 43 patients in whom were performed the Hummelsheim transposition procedure with or without resection of transposed half-tendon vertical muscles, always combined with recession of medial rectus. The modified split-tendon Hummelsheim procedure involves half-tendon transpositions of the adjacent rectus muscles to the insertion of the paralyzed muscle, coupled with resection of the transposed halves. The mean follow-up was 34.6 months (range, 6 to 114 months). The primary position deviation and the occurence of diplopia after one surgical procedures were compared in the both groups preoperatively and postoperatively. For statistical analysis was used the Student-t test. The mean preoperative primary position deviation in the Group A and B was 56 prism diopters (PD), (range: 28 to 80 PD), and 59 PD (range: 30 to 90 PD), respectively. Diplopia was present in 78% of Group A patients, and 89% of Group B patients. At last visit postoperatively, the mean primary deviation decreased to 27 PD (range: 6 to 40 PD) in A group, and 8 PD (range: –8 to 26 PD), (P 0.038). Diplopia postoperatively was present in 28 % of A group, and 9% of B group (P 0.029). No cases of anterior segment ischemia or induced vertical deviation were found. In summary, the use of the augmented half-tendon transposition procedure resulted in a significantly better primary position of eyes postoperatively, than only the graded recession-resection procedure of the horizontal muscles.
1
INTRODUCTION
Six nerve palsy is the most common of the acquired palsies, occuring less commonly on a congenital basis. After diagnosis and treatment for any underlying conditions, management of the strabismus resulting from the sixth nerve palsy includes observation of signs of contracture of the antagonist medial rectus or of recovery of the paretic lateral rectus. During the waiting period of at least 6 months, alternate patching may help to prevent contracture of the medial rectus of the involved eye. Alternatively, botulinum toxin may be injected into the medial rectus to prevent contracture, but it cloudes the clinical picture when neurological examination may change. After 6 months of waiting for possible return of sixth nerve function, surgical treatment is considered. A graded medial rectus recession and lateral rectus resection for the appropriate amount of esotropia can be performed. In an eye with a totally paralyzed lateral rectus and esotropia in the range of 50 prism diopters(PD), the medial rectus should be recessed more than 8 mm. Little is gained from only resecting the lateral rectus if it is totally paralyzed. A muscle transfer procedure may be necessary to keep the eye in the straight position and also to obtain some abducting force. The Hummelsheim procedure consists of transposing the lateral halves of the vertical recti to the lateral rectus. It is relatively tissue- and vessel-sparing compared with other procedures. To augment 359
the effect of the procedure, and possibly improve abduction and the field of single binocular vision, the ipsilateral medial rectus also may be recessed (l,2) or injected with botulinum toxin (3). The modified Hummelsheim procedure with augmentation achieved by resection of the transposed halves is capable to correct a very large angles of deviation associated with abducens palsy of various etiologies. (7) Our study evaluated the efficacy of the horizontal muscle surgery and the Hummelsheim trans-position procedure with or without augmentation in long term follow-up.
2
PATIENTS AND METHODS
A retrospective review analyzed 89 patients (42 children, 47 adults) with paralytic strabismus secondary to sixth nerve palsy, who undergone surgery in the period from January 1993 to October 2003. The mean follow-up was 34.6 months (range, 6 to 121 months). The sixth nerve palsy is refered whether it was a complete palsy or an incomplete paresis. The abduction deficit and angle of deviation were measured in prism diopters (PD) by simultaneous prism and cover test in the primary position at distance fixation. The etiology of the palsy were: congenital, traumatic, neoplastic, vascular, diabetic, hydrocephalus or unknown. A complete palsy was defined as an inability to abduct the eye to the midline or limitited abduction only to the midline. The inclusion criteria: more than six months from onset, inability to abduct 1 or both eyes, distance esotropia more than 25 PD, diplopia in primary position at distance fixation, visual acuity at least 6/60 in each eye, no previous treatment with botox or surgery. The following data from each patient were recorded: diagnosis and duration of palsy, prism-cover measurements in the primary position at distance, presence of diplopia, qualitative assessment of ductions, coexisting ocular disease, details of surgical procedure and intraoperative passive forced ductions and complications (anterior segment ischemia or induced vertical deviation). Group A included 46 patients treated using a large recession of the medial rectus combined with a supramaximal resection of the lateral rectus. Group B comprised 43 patients in whom were performed the Hummelsheim transposition procedure with (34 patients) or without resection of transposed half-tendon vertical muscles, always combined with recession of medial rectus. The modified split-tendon Hummelsheim procedure involved half-tendon transpositions of the adjacent vertical rectus muscles to the insertion of the paralyzed muscle, coupled with resection of the transposed halves. The superior and inferior rectus muscles were carefully divided in half in a longitudinal fashion for approximately 15 mm using a muscle hooks. Care also was taken to avoid injury to the anterior ciliary vessels in the portions of muscle not used for transposition. Doublearmed 6-0 vicryl suture was placed at a predetermined distance posterior to the muscle insertion (in the cases with resection of the transposed muscles: the amount of 5–8 mm of muscle was resected). The primary position deviation and the occurence of diplopia after one surgical procedures were compared in the both groups preoperatively and postoperatively. For statistical analysis was used the Student-t test.
3
RESULTS
Data and results of all patients included in the both study groups are summarized in Table 1. The mean preoperative primary position deviation in the Group A and B was 56 prism diopters (PD), (range: 28 to 80 PD), and 59 PD (range: 30 to 90 PD), respectively. Diplopia was present in 78% of Group A patients, and 89% of Group B patients. At last visit postoperatively, the mean primary deviation decreased to 27 PD (range: 6 to 40 PD) in A group, and 8 PD (range: 8 to 26 PD), (P 0.038). Diplopia postoperatively was present in 28% of A group, and 9% of B group (P 0.029). No complications in terms of anterior segment ischemia or induced vertical deviation were found. 360
Table 1.
Data for all patients, preoperative and postoperative status.
Number of patients The mean age SD (range, years) Etiology (number of patients): Congenital Traumatic Neoplastic Vascular Hydrocephalus Undetermined Bilateral (number of patients) Unilateral (number of patients) The mean deviation SD (range,PD) PREOP. The mean deviation SD (range,PD) POSTOP. Diplopia in primary position (%) PREOP. Diplopia in primary position (%) POSTOP.
4
Group A (46)
Group B (43)
21.3 17.6 (2 to 67)
19.7 20.4 (1 to 65)
11 9 7 5 3 11 19 27 56 37 PD (28 to 80) 27 22 PD (6 to 40) 78% 28%
9 12 8 4 5 5 15 28 59 28 PD (30 to 90) 8 37 11 (28 to 80) 89% 9%
DISCUSSION
The management of the sixth nerve palsy depends on the underlying cause. If recovery of the chronic palsy does not occur, surgery is necessary. Few studies have been conducted on the outcome of patients with chronic sixth nerve palsy and paresis. Chronic is defined, for the present study, as longer than 6 months in duration since onset. There is controversy about the optimum timing and mode of treatment for these patients. In a survey of 201 pediatric ophthalmologists and neuro-ophthalmologists regarding the timing of strabismus surgery in acute traumatic sixth nerve palsy, 26% would wait more than 6 months from onset before performing surgery, expecting further recovery (8). Although some physicians advocate continued conservative management at 6 months from onset, others advocate botulinum toxin (botox) injection to the ipsilateral medial rectus (9) or strabismus surgery with or without botox (10). Muscle transposition surgery often is required in those cases in which the degree of muscle palsy is severe and agonist action is negligible. Numerous procedures to accomplish this purpose and subsequent modifications have been described over the years. (11) The goals of the surgical procedure are to improve the range of single binocular vision, restore ocular alignment in the primary position, and improve cosmesis, while minimizing the risk of ocular complications. A variety of transposition procedures have been promoted for the treatment of abducens palsy and other complex paralytic ocular motility abnormalities (3,12,13,14,15). Full tendon transposition procedures, although reasonably effective when severe duction deficits are present, often result in undercorrection, necessitating recession of the ipsilateral antagonist rectus muscle to achieve successful alignment (2). This method carries a significant risk of anterior segment ischemia. In 1997, Foster (16) described a new procedure consisted of a full tendon rectus muscle transposition of the vertical rectus muscles to the lateral rectus muscle insertion, augmented with a posterior fixation fixation suture in each of the transposed muscles. The posterior fixation suture used in this technique further directed vector forces of the transposed muscles laterally. Paysse (17) reported that use of the vessel-sparing three fourths partial tendon transposition modification of this technique is effective for the treatment of a variety of complex vertical and horizontal paralytic ocular motility disorders. In this modification, only 75% of the width of the muscles was transposed, taking care to leave one intact anterior ciliary artery in each nontransposed segment of the muscle. Posterior fixation suture was placed on each of the transposed muscles on the side adjacent to the paralyzed muscle 12 to 15 mm posterior to the limbus to augment the effect of the transposition. Mean distance deviation in primary position improved from 48 PD preoperatively to 6 PD after surgery. In our study, the similar improvement in horizontal deviation was achieved 361
by the resection 5 to 8 mm of the half-tendon vertical transposed muscle. The mean deviation 59 PD preoperatively changed to 8 PD post-operatively. Even if the ipsilateral medial rectus muscle was recessed, in no patient the anterior ischemia has been developed. The wide range of corrections achieved for primary position deviation is comparable to that reported in other studies (7,8,16–19). Our results in patients with only the resection-recession procedures of the horizontal muscles demonstrated a low ability to correct medium to large large angles of deviation compared to augmented transposition procedures. The data of our study suggest the augmented Hummelsheim procedure may not have significant limitations with regard to preoperative angle. Botulinum toxin injected into the ipsilateral medial rectus has been advocated, in selected patients, for treating chronic sixth nerve palsy (9). Results in another study (8) provide little support for this botox treatment, because in only 1 (10%) of 10 patients was successful. Repka et al (9) reported success in 9 (41%) of 22 patients with chronic sixth nerve palsy of 5 or more months duration, but defined success somewhat differently; they included patients who had 50% improvement in their esotropia. Even excluding these cases, the same author reported a 32% success rate in restoring single binocular vision in primary position. Their patients received 1 to 5 injections of botox and were followed for an unspecified time. Taken together, the results of botox injection alone for chronic sixth nerve palsy are less than encouraging. In conclusion, our results confirm the effectivenes of the augmented rectus muscle transposition procedure in abducens palsy. The procedure resulted in marked improvement in head posture and ocular alignment in the primary position, with partial restoration of abduction. Additionally, the procedure was safe without complications in terms of anterior segment ischemia or induced vertical deviation.
REFERENCES 1. Uribe LE. Muscle transplantation in ocular paralysis. Am J Ophthalmol 1968;65:601–607. 2. Rosenbaum AL, Foster RS, et al. Complete superior and inferior rectus transposition with adjustable medial rectus recession for abducens palsy. Strabismus 1984;2:599–605. 3. Rosenbaum AL, Kushner BJ, Kirschen D. Vertical recrus muscle transposition and botulinum toxin(Oculinum) to medial recrus for abducens palsy. Arch Ophthalmol 1989;107:820–823. 4. Saunders RA, Phillips MS. Anterior segment ischemia after three rectus muscle surgery. Ophthalmology 1988; 95:533–537. 5. Saunders RA, Sandall GS. Anterior segment ischemia syndrome following rectus muscle transposition. Am J Ophthalmol 1982;93:34–38. 6. Saunders RA, Bluestein EC, Wilson ME, et al. Anterior segment ischemia after strabismus surgery. Surv Ophthamol 1994;38:456–466. 7. Brooks SE, Olitsky SE, et al. Augmented Hummelsheim Procedure for Paralytic Strabismus. J Pediatric Ophthalmol Strabismus 2000, 37:189–195s. 8. Holmes JM, Leske DA et al. Initial treatment outcomes in chronic sixth nerve palsy. J AAPOS 2001;5:370–376. 9. Repka MX, Lam GC, Morrison NA. The efficacy of botulinum neurotoxin A for the treatment of complete and partially recovered chronic sixth nerve palsy. J Pediatr Ophthalmol Strabismus 1994;31:79–83. 10. Rosenbaum AL, Kushner BJ, Kirschen D. Vertical rectus muscle transposition and botulinum toxin (Oculinum) to medial rectus for abducens palsy. Arch Ophthalmol 1989;107:820–823. 11. Helveston EM. Muscle transposition procedures. Surv Ophthamol 1971;16:92–97. 12. Mc Manaway J.W., Buckley E.G., Brodsky M.C. Vertical rectus muscle transpostion with intraoperative botulinum injection for chronic sixth nerve palsy. Graefes Arch Clin Exp Ophthalmol 1990;228:401–406. 13. Hiatt RL. Transposition procedures in strabismus. Ann Ophthalmol 1986;18:332–336. 14. Cline RA., Scott WE. Long-term follow-up of Jensen procedures. J Pediatr Ophthalmol Strabismus 1988; 25:264–269. 15. Maruo T., Iwahige H. et al. Results of surgery for paralytic esotropia. Jpn J Ophthalmol 1996;40:229–234. 16. Foster RS. Vertical muscle transposition augmented with lateral fixation. J AAPOS 1997;1: 20–30. 17. Paysse EA, Mc Creery KMB, et al. Use of augmented rectus muscle transposition surgery for complex strabismus. Ophthalmology 2002;109:1309–1314.
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18. Burke JP, Ruben JB, Scort WE. Vertical transposition of the horizontal recti (Knapp procedure) for the treatment of double elevator palsy: effectiveness and long-term stability. Br J Ophthalmol 1992;76: 734–737. 19. Burke JP, Keech RV: Effectiveness of inferior transposition of the horizontal rectus muscles for acquired inferior rectus paresis. J Pediatr Ophthalmol Strabismus. 1995;32:172–177. 20. King AJ, Stacey E, Stephenson G. Spontaneous recovery rates for unilateral sixth nerve palsies Eye 1995;9:476–478. 21. Savino PJ, Hilliker JK, Casell GH, Schatz NJ. Chronic sixth nerve palsies: are they really harbingers of serious intracranial disease? Arch Ophthalmol 1982;100:1442–1444. 22. Golnik KC, Miller NR. Late recovery of function after oculomotor nerve palsy. Am J Ophthalmol 1991;111:566–570.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Inferior oblique muscle surgery for dissociated vertical deviation eh˚uˇrek R. Autrata, K. Vodicková & J. R Department of Pediatric Ophthalmology, Faculty of Medicine, Masaryk University Hospital, Brno, Czech Republic
ABSTRACT: Purpose: Anterior transposition of the inferior oblique muscle (ATIO) and myectomy of the inferior oblique muscle (MIO) are a popular surgical methods for dissociated vertical deviation (DVD), also in patients with coexisting inferior oblique muscle overaction (IOOA). We evaluated whether anterior transposition improves the outcome compared with myectomy of the inferior oblique muscle. Methods: We undertook a prospective, comparative, randomized evaluation of ATIO and MIO, in patients with DVD of at least 5 PD in one eye. We included 82 eyes of 46 patients, 44 eyes treated with ATIO and 38 treated with MIO. We recorded the size of the preoperative and final DVD, grade of the preoperative and final IOOA, rates of reoperation, and complications. Mean followup was 29.6 months in the ATIO group and 36.5 months in the MIO group, with a minimum of 12 months for all cases. Results: The mean preoperative and postoperative DVD was 13 PD and 4 PD in the ATIO group, respectively. This compared with 15 PD and 3 PD, respectively, in the MIO group, representing no statistically significant difference in outcome. The presence or absence of IOOA did not influence the result of ATIO and MIO for both groups. No significant complications of surgery occurred in either group. Conclusions: ATIO is an effective treatment for DVD and can be used to treat DVD in patients with or without IOOA, with no adverse effects. Our study revealed no statistically significant difference in outcome between anterior transpositon and myectomy of the inferior oblique muscle.
1
INTRODUCTION
Dissociated vertical deviation (DVD) is characterized by elevation, abduction and excyclotorsion of the nonfixing eye without corresponding hypotropia of the contralateral eye. On alternate cover test, the occluded eye will spontaneously “float up” and outward, and, when fixation recurs, there is no redress movement of the other eye. DVD is usually, but not always, bilateral but asymmetrical. DVD and inferior oblique overaction (IOOA) may occur simultaneously. The deviation is greatest in adduction for overaction of the inferior oblique and concomitant for DVD. Procedures on every vertically acting muscle have been tried in order to treat DVD. Most recently, several authors have advocated variations on anterior transposition of the inferior oblique muscle (ATIO) or myectomy of the inferior oblique muscle (MIO) for the treatment of DVD, particularly when it occurs in conjunction with inferior oblique muscle overaction (IOOA). (1,2,3,4,5,6,7,8,9,10,11,12) Inferior oblique overaction is most commonly associated with infantile esotropia. (10,11) Our goals in undertaking this study were to prospectively analyze the results of ATIO for DVD and compare this with myectomy of the inferior oblique muscle. 365
2
SUBJECTS AND METHODS
We included all patients treated at our Department of Pediatric Ophthalmology, Masaryk University Brno, from 1995 to 2002, who were aged 6 months to 15 years and who had DVD of 5 PD or greater in at least one eye that required surgery. We used a paired (ie, before vs after surgery) comparison that included a 2-sided 5% significance level, in which effect size equals the mean difference between the 2 groups, divided by the standard error of the difference. Before the operation, all patients received correction of their refractive errors and occlusion for any associated amblyopia. Patients were excluded if they had paretic or restrictive strabismus, prior oblique muscle or vertical rectus muscle surgery, prior or planned concurrent vertical offsetting of horizontal rectus muscles, or any systemic disorder or syndrome that could affect extraocular muscle. Factors that did not affect inclusion or exclusion included whether the DVD was manifest or latent, previous or planned recession or resection of the horizontal rectus muscles, and the amount of preoperative IOOA. DVD was measured in a fashion described by Burke et al (1) by using the prism and alternate cover test with the eyes in the primary position, fixating on an accommodative target at 6 m with full refractive correction, if worn. Any concurrent horizontal deviation was initially neutralized with horizontal prism over the contralateral eye and the DVD measured in the ipsilateral eye. Prisms were then switched to measure DVD in the other eye. We measured any true hypertropia in primary position and side gazes to distinguish between IOOA and DVD. DVD was measured in infants and very young patients by the Krimsky test once the DVD in a given eye had been uncovered to its maximal extent by several seconds of occlusion, either with a black paddle or a Spielmann occluder. Oblique muscle function was graded on a scale of 4 to 4 (1 to 4 representing underaction and 1 to 4 representing overaction) by observing eye movement in the lateral and upper tertiary positions of gaze. Each unit represents an approximate 1-mm height difference between the inferior limbus of each eye. Patients were randomized to receive ATIO to the lateral border of the insertion of the inferior rectus muscle or myectomy of the inferior oblique muscle. When possible, in addition to those measurements taken by the surgeon, preoperative and postoperative measurements were taken by one orthoptist who was masked to the procedure that was performed. The inferior oblique muscle was approached by using an inferior-temporal fornix incision, through conjunctiva and Tenon’s capsule. The lateral rectus muscle was isolated with a 4-0 silk bridle suture or with a muscle hook during the procedure. After the inferior oblique muscle was isolated on muscle hooks, its fascial attachments were lysed both anteriorly and posteriorly, for the distal 10 to 12 mm of the muscle. In our study, 46 patients met the inclusion criteria, including 82 eyes. There were 44 eyes in the ATIO group and 38 eyes in the MIO group. The outcomes of the patients from the anterior transposition and myectomy groups were compared for both DVD and IOOA. We also noted any complications of the procedures. The data were analyzed by using nonparametric statistics (Mann-Whitney U, Wilcoxon, and Fischer exact tests of statistical significance). Statistical significance was taken at the P value 0.05 or lower. 3
RESULTS
Patient data and postoperative complications for each group are summarized in Table 1. Table 2 summarizes the results of ATIO and MIO on DVD in the anterior transposition and rmyectomy groups, and Table 3 summarizes the overall results of ATIO and MIO on IOOA in the anterior transposition and rmyectomy groups. Both procedures are shown to be effective at treating DVD, with no statistically significant difference between them. For IOOA, the anterior transposition group had a statistically significant reduction between preoperative IOOA and postoperative IOOA, whereas the myectomy group failed to show a difference. However, no statistically significant difference in postoperative median IOOA existed between the 2 groups. 366
Table 1.
Patients and complications.
No. of patients No. of eyes Mean age, years (range) Mean follow-up, months (range) Patients needing reoperation for DVD (% of eyes) Patients with limitation of elevation in abduction (% of eyes)
ATIO group
MIO group
27 44 5.4 (1.1–13.7) 29.6 (7–53) 3/35 (8.6) 1/35 (2.8)
19 38 6.1 (1.6–14.8) 36.5 (8–72) 5/38 (13.2) 5/38 (13.2)
ATIO anterior transposition of the inferior oblique muscle. MIO myectomy of the inferior oblique muscle. Table 2. Results of ATIO and MIO on DVD in the anterior transposition and myectomy groups, including those with less than 1 inferior oblique overaction, and those with 1 to 4 inferior oblique overaction. Median DVD magnitude, PD (range) Group All Cases ATIO MIO IOOA grade 1 ATIO MIO IOOA grade 1 to 4 ATIO MIO
No. of eyes
Presurgery
Postsurgery
44 38
13.0ns (6–19) 15.0 (7–22)
4.0ns* (0–14) 3.0ns† (0–13)
16 15
11 (6–15) 10 (7–14)
4 (2–9) 3 (0–8)
19 23
12 (6–18)ns 16 (10–22)ns
4 (0–13)ns 3 (2–9)ns
ns, No significant difference between standard and resection (Mann-Whitney U test); PD, prism diopters. * Significant difference from presurgery to postsurgery, P .05. † Significant difference from presurgery to postsurgery, P .02 (Wilcoxon test). Table 3.
Results of ATIO and MIO on IOOA in the anterior transposition and rmyectomy groups.
Group
No. of eyes
Presurgery, MIOG (range)
Postsurgery, MIOG (range)
ATIO MIO
44 38
1.0 (0 to 4) 1.0ns (0 to 3)
0.0* (1 to 2) 0.5ns† (1 to 2)
MIOG, Median inferior oblique grading; ns, no significant difference between standard and resection groups (Mann-Whitney U test). * Significant difference from presurgery to postsurgery, P .05 (Wilcoxon test). † No significant difference from presurgery to postsurgery.
We were interested to know if ATIO and MIO surgery, could be performed to treat DVD in patients who had little or no preoperative IOOA. Table 3 also shows a comparison within the anterior transposition and myectomy groups of those patients with minimal or no preoperative IOOA (less than 1) and those with preoperative IOOA of 1 or more. No statistically significant differences in effect were found between the both operations on DVD in the groups with no IOOA or with IOOA of 1 or more. That is, the 2 variations on ATIO work well, with or without preoperative IOOA. We also analyzed the data to see how effective the 2 procedures were in treating large angle DVD (DVD of at least 15 PD). Results are presented in Table 4. 367
Table 4.
Results of ATIO and MIO surgery in eyes with DVD of 15 PD or more. Results of surgery No. of eyes*
ATIO† MIO†
17 15
Excellent (0–4 PD)
Good (5–9 PD)
Fair (10–14 PD)
Poor (14 PD)
2 2
1 3
1 1
10 9
* None of these eyes were in the same patient. † No significant difference, Fischer exact test (P .76)
Fischer exact test reveals that the difference between the 2 groups is not significant (P .76). Five of the 9 “excellent” eyes in the myectomy group had mild (grade 1 of 4) limitation of elevation in abduction, compared with one eye in the anterior transposition group.
4
DISCUSSION
Several different procedures have gone in and out of fashion to best surgically manage DVD. In the past, bilateral large (symmetrical or asymmetrical) inferior rectus resections had been advocated, but in recent years this procedure has fallen into disfavor with many surgeons. Today, most surgeons prefer either large superior rectus recessions or small superior rectus recessions with posterior fixation suture or anterior transposition of the inferior oblique muscles. However, superior rectus muscle recession and inferior rectus muscle resection can alter lid position. Large, supramaximal, superior rectus muscle recessions and inferior rectus muscle resections can result in postoperative vertical tropia and/or limitation of upgaze. Inferior oblique muscle weakening, in the form of a myectomy may be effective at controlling DVD (9,10,11). ATIO can solve the frequently coexisting problems of DVD and IOOA or DVD alone (11). It also poses no risk of compromising the blood supply of the anterior segment of the globe. Evidence exists that ATIO adjacent or anterior to the inferior rectus muscle insertion reduces excyclotorsion. (12) Elliott and Nankin, (13) in 1981, published the first, retrospective series comparing ATIO as it is performed today with standard inferior oblique muscle recession in the treatment of IOOA and proposed that this operation may convert the inferior oblique muscle from an elevator to a depressor. It was noted an improvement in DVD in patients with both DVD and IOOA when evaluating bilateral ATIO in the treatment of children with IOOA. (3,5) Several authors have evaluated the effectiveness of ATIO with or without a graded anteriorization of the inferior oblique muscle position in relation to the inferior rectus muscle insertion in the treatment of DVD. (1–11) These studies have shown the technique to be effective in controlling both DVD and IOOA in the majority of cases. We analyzed our data to see if ATIO or myectomy was a more effective procedure for the treatment of DVD in the presence of IOOA. This analysis of subgroups with and without IOOA did not show any difference in outcome for DVD between those with significant IOOA and those without it, for either ATIO or myectomy groups. Nor was there significant inferior oblique muscle underaction produced in either group in those with no or minimal preoperative IOOA. Our results suggest that ATIO can be used to treat DVD, even if the patient has little or no IOOA. The procedures both work reasonably well for large DVD angles, and results compare favorably with other procedures. (14,15) Kushner (16 ) has shown that a complication of ATIO, limitation of elevation in abduction, occurs with ATIO greater than 1 mm anterior to the inferior rectus muscle insertion. (16) This complication, which results in a Y or V pattern, may be more likely if the inferior oblique insertion is spread out when the muscle is reattached to the globe. A result of limitation of elevation in abduction can also be pseudo-IOOA in the contralateral eye. However, in a retrospective study of 368
myectomy and ATIO, Gonzalez and Klein (7) noted only a transient limitation of upgaze in adduction (not abduction) in 49 eyes of 29 patients. They placed the inferior oblique muscle to a point 3 mm posterior to the limbus, anterior to the lateral border of the inferior rectus insertion. In our study (Table 1), no patient in the ATIO group developed limitation of elevation in abduction after the operation. When we compared ATIO and myectomy groups, we found no significant difference in outcome of surgery on IOOA between these techniques. We did not specifically search for presence of A or V patterns in our patients. In conclusion, we compared anterior transposition to myectomy of the inferior oblique muscle to establish if there was any benefit between these surgical methods.. Our results show a statistically significant improvement in DVD in both groups but no statistically significant difference between the 2 groups for effectiveness of treating DVD or concurrent IOOA. The anterior transposition of the inferior oblique muscle is now our preferred technique and can be used to treat DVD, with or without IOOA.
REFERENCES 1. Burke JP, Scott WE, Kutschke PJ. Anterior transposition of the inferior oblique muscle for dissociated vertical deviation. Ophthalmology 1993; 100: 245–50. 2. Caputo AR, Santiago AP. Bilateral anterior transposition of the inferior oblique for dissociated vertical deviation in congenital esotropia. Am Orthoptic J 1996; 46: 133–42. 3. Bacal DA, Nelson LB. Anterior transposition of the inferior oblique muscle for both dissociated vertical deviation and/or inferior oblique overaction: results of 94 procedures in 55 patients. Binoc Vis Eye Muscle Surgery Qtrly 1992; 7: 219–25. 4. Weakly DR, Stager DR. A new surgical procedure: nasal myectomy of the inferior oblique muscle combined with anterior transposition of the insertion; results in 10 cases. Binoc Vis Eye Muscle Surgery Qtrly 1992; 7: 215–8. 5. Seawright AA, Gole GA. Results of anterior transposition of the inferior oblique. Aust NZ J Ophthalmol 1996; 24: 39–345. 6. Black BC. Results of anterior transposition of the inferior oblique muscle in incomitant dissociated vertical deviation. J AAPOS 1997; 1: 83–7. 7. Gonzalez C, Klein B. Myectomy and anterior transposition of the inferior oblique: a new surgical procedure and its results in 49 operations. Binoc Vis Eye Muscle Surgery Qtrly 1993; 8: 249–58. 8. Milot JM, Tremblay C, Ouellette C. Anterior transposition of the inferior oblique for dissociated vertical deviation with inferior obliqueoveraction. Can J Ophthalmol 1994; 29: 284–7. . ehuˇrek J. Strabismus surgery in the past and in the present. Folia strabolog9. Hromádková L, Autrata R, R ica et neuroophthalmologica 2000; 2: 51–54. . ehuˇrek J. . Efficacy of early surgery of infantile esotropia on binocular 10. Autrata R, Hromádková L, R vision outcome. Cesk a Slov Oftalmol 2002; 58: 36–42. . ehuˇrek J. Vertical deviations in children. Folia strabologica et 11. Autrata R, Unc ovská E, Hromádková L, R neuroophthalmologica. 2002; Suppl. 5: 39–44. 12. Santiago AP, Isenberg SJ, Apt L, Roh YB. The effect of anterior transposition of the inferior oblique muscle on ocular torsion. J AAPOS 1997; 1: 191–6. 13. Elliott RL, Nankin SJ. Anterior transposition of the inferior oblique. J Pediatr Ophthalmol Strabismus 1981; 18: 35–8. 14. Stager DR, Weakly DR, Stager D. Anterior transposition of the inferior oblique. Anatomic assessment of the neurovascular bundle. Arch Ophthalmol 1992; 110: 360–2. 15. Esswein MB, von Noorden GK, Coburn A. Comparison of surgical methods in the treatment of dissociated vertical deviation. Am J Ophthalmol 1992; 113: 287–90. 16. Kushner BJ. Restriction of elevation in abduction after inferior oblique anteriorization. J AAPOS 1997; 1: 55–62.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Congenital fibrosis of extraocular (CFEOM) muscles associated with musculoskeletal abnormalities Cem Yıldırım*, Sinan Tatlipinar*, Esat Kiter**, Fusun Duzcan***, Volkan Yaylali* & Serap Özden* Department of Ophthalmology *, Department of Orthopedics ** and Department of Genetics ***, Pamukkale University School of Medicine, Denizli, Turkey
Two families with CFEOM associated with musculoskeletal abnormalities were studied. Pedigree of the first family demonstrated autosomal recessive penetrance of CFEOM. Two members of the first family were affected. One affected member had restrictive exotropia with the globes frozen in abduction, and a normal levator function. The other subject demonstrated unilateral ptosis with contralateral loss of ocular movements. Both patients had extension and flexion contractures of extremities, pes cavus, patellar hypoplasia, and scoliosis. Electroneuromyographic (ENMG) studies revealed normal neural motor and sensorial conduction velocities. Pedigree of the second family demonstrated autosomal dominant penetrance of synpolydactyly with a sporadic CFEOM case. Both eyes of the sibling were fixed in downward position with absent upgaze and aberrant horizontal gaze. The association of CFEOM with musculoskeletal diseases with normal ENMG studies raises the idea that some forms of ocular fibrosis cases might be a part of a more generalized skeletal muscle disorder. CFEOM is characterized by several different inherited restrictive strabismus syndromes that had been classified under five clinical entities: (1) general fibrosis syndrome; (2) congenital fibrosis of the inferior rectus with blepharoptosis; (3) strabismus fixus; (4) congenital enophthalmos with ocular muscle fibrosis and blepharoptosis; and (5) vertical retraction syndrome (Harley et al. 1978). CFEOM has been traditionally regarded to result from primary extraocular muscle (EOM) fibrosis. In addition, fibrosis of the Tenon capsule and adhesions between EOMs, Tenon capsule and globe were found (Hansen 1968). Recent studies, however, suggest that these disorders result from primarily developmental defects of the oculomotor, trochlear and abducens nerves and corresponding nuclei with secondary myopathic EOM changes (Engle et al. 1997; Wang et al. 1998; Mackey et al. 2002). Three inherited CFEOM phenotypes (CFEOM1, CFEOM2 and CFEOM3) and related genetic loci (FEOM1, FEOM2 and FEOM3) were defined. However, it has been established that much more heterogeneity at the CFEOM1 locus than previously reported exists and to distinguish the different CFEOM loci based solely on clinical presentation was questionable (Sener et al. 2000). In this present study two Turkish families with CFEOM associated with generalized musculoskeletal abnormalities were reported. The coexistence of these abnormalities with CFEOM arise the possibility that the disease might be a part of a more widespread myopathy affecting the skeletal muscles.
1
CLINICAL REPORTS
Pedigree of the first family demonstrated autosomal recessive penetrance of CFEOM. Two members of the first family were affected. There was one unaffected sibling and the parents were first-degree consanguineous. The unaffected sibling, a 26 year-old girl, and the parents were normal in all respects. The antenatal of all probands records were normal. No other relatives were known to be affected. 371
Figure 1. Left: The sibling shows a typical appearance of exotropic strabismus fixus with no ptosis. Right: hands of the sibling showing metatarsal and interphalangeal hyperextension and flexion contractures along with prominent hypothenar and intrinsic muscle atrophies.
Figure 2.
Radiograph showing, Left: patellar hypoplasia. Right: major thoracal scoliosis.
Case 1: The 20 year-old sibling had restrictive exotropia with the globes frozen in extreme abduction. No vertical or horizontal eye movements could be elicited and forced duction testing was positive for restriction. He used to fixate with either eye in abduction and had no ptosis. The rest of the ocular examination including pupils was normal. The physical examination of Case 1 revealed normal height, weight and intelligence. He had low-set ears, micrognathia, bilateral metatarsal and interphalangeal hyperextension and flexion contractures along with prominent hypothenar and intrinsic muscle atrophies in his hands, thoracolumbar scoliosis, bilateral patellar hypoplasia, flexion contractures at knees, severe bilateral hallux valgus and pes cavus deformities in lower extremities. Biopsy specimens from Tenon’s capsule-conjunctiva and the lateral rectus showed bundles of striated muscles surrounded by loose connective tissue containing curly filaments. Fibrovascular tissue and curly filaments contained bundles of collagen. The MRI of the brain and orbits showed no structural abnormalities. ENMG studies of the upper and the lower extremities including median, ulnar, tibial and perioneal nerves revealed normal neural motor and sensorial conduction velocities. No pathological findings were detected with needle EMG studies of tenar, hypotenar, gastrocnemieus and quadriceps muscles. Case 2: The 22 year-old sibling had mild ptosis with normal ductions in her right eye. There was no ptosis in the left eye and Bell phenomenon was absent. Horizontal and vertical eye movements were restricted in the left eye. She had a severe left adduction deficiency and was unable to rotate the eye to the midline in the horizontal plane. She also showed mild to moderate vertical and abduction limitations in the left eye. Prominent glob retraction and down-shoot while looking to the right were also observed in the left eye. She had left exotropia of 20° with left 5° of hypotropia. She had a face turn to the right with head tilt to the left shoulder. The rest of the ocular examination including pupils was normal. The physical examination of Case 2 revealed short stature with normal intelligence. She had high forehead, low-set ears, micrognathia, bilateral metatharsal and interphalangial hyperextension and flexion contractures along with prominent hypothenar and intrinsic muscle atrophies in her hands, left-sided scoliosis, bilateral patellar hypoplasia and pes cavus. ENMG results were normal. 372
Figure 3. Case 2 shows limited vertical and horizontal ductions with no ptosis in the left eye and moderate ptosis with normal ductions in the right eye. Top view, attempted upgaze. Center view, straight ahead position. Bottom view, attempted downgaze.
Figure 4. Case 3 shows Left: limited vertical and horizontal ductions with no ptosis in both eyes; Right: synpolydactyly in the third and fourth fingers.
Pedigree of the second family demonstrated autosomal dominant penetrance of synpolydactyly with a sporadic CFEOM case. Parents were non-consanguineous and father and three male siblings had synpolydactyly. There were four unaffected siblings. Case 3: 22-year-old male proband had congenital bilateral ophthalmoplegia. Both eyes were fixed in downward position with absent upgaze and aberrant horizontal gaze. Forced duction testing was positive for restriction. He showed exotropia of 20° with left 10° of hypotropia. He had a backward head tilt and ptosis was absent. The rest of the ocular examination including pupils was normal. There was bilateral syndactyly of the third and fourth fingers. He was otherwise healthy.
2
DISCUSSION
Both families described here include individuals who do not have classical findings of CFEOM thus the phenotypes could be classified as FEOM3. In families with CFEOM3, one or more affected individuals do not have classic findings of the disorder. Their eyes may not be infraducted or may elevate above the midline, or the individual may be unilaterally affected, or ptosis may be absent. This autosomal dominant disorder maps to the FEOM3 locus on chromosome 16q24 373
(Mackey et al. 2002). The unusual features observed in our patients were absence of ptosis in cases 1 and 3, and only unilateral ptosis with normal ductions in case 2. CFEOM might be associated rarely with other ocular defects such as microphthalmia (Arruga et al. 1978), congenital cataract superficial keratopathy (Gilles et al. 1995) and Marcus-Gunn jaw winking phenomenon (Brodsky et al. 1989). Remaining ocular examinations were normal in our cases. Systemic abnormalities occurring in association with CFEOM are also rare. Facial palsy (Krüger & Friedrich 1963), craniofacial dysmorphism (Arruga et al. 1978), dental anomalies (Arruga et al. 1978), inguinal hernias and cryptorchidism (Apt & Axelrod 1978), congenital facial hemiatrophy (Schimidt & Feicht 1989), congenital heart diseases (Hansen 1968), oculucutaneous albinism (Brodsky et al. 1989), scoliosis (Kishore & Kumar 1991) and flexion contractures at elbows and knees (Kishore & Kumar 1991) have been reported. Facial anomalies, campatodactyly, syndactyly, joint contractures and scoliosis seen in our cases do extend the spectrum of systemic abnormalities observed in association with CFEOM disease. Recent studies suggest that CFEOM results from primarily developmental defects of the oculomotor, trochlear and abducens nerves, rather than an EOM myopathy (Engle et al. 1997; Wang et al. 1998; Mackey et al. 2002). However, the association of CFEOM with widespread musculoskeletal disorders with normal ENMG and EMG studies makes difficult to explain the primary defect solely on a neuropathic basis. A myopathy could possibly produce abnormalities involving both the extraocular and other skeletal muscles. However, our cases might resemble a new syndrome and the assumption that the abnormalities observed in our cases were caused by a single disease remains speculative. In conclusion, the association of coexistence of CFEOM with musculoskeletal diseases with normal ENMG studies raises the idea that some forms of ocular fibrosis cases might be a part of a more generalized skeletal muscle disorder.
REFERENCES: Apt L. & Axelrod. R.N, 1978. Generalized fibrosis of the extraocular muscles. Am J Ophthalmol 85:822–829. Arruga, A., Henriquez, A.S. & Delachaux, A. 1978. Congenital frozen eyes with other mesodermal abnormalities. Report of a case. Adv Ophthalmol 36:1007–1117. Brodsky, M.C., Pollock, S.C. & Buckley E.G. 1989. Neural misdirection in congenital ocular fibrosis syndrome: implications and pathogenesis. J Pediatr Ophthalmol Strabismus 26:159–161. Engle, E.C., Goumnerov B., McKeown C.A., Schatz M., Johns D.R., Porter J.D. & Beggs A.H. 1997. Oculomotor nerve and muscle abnormalities in congenital fibrosis of the extraocular muscles. Ann Neurol 41:314–25. Gillies, W.E., Harris, A.J., Brooks, A.V.M., Rivers, M.R. & Wolfe, R.J.B. 1995. Congenital fibrosis of the vertically acting extraocular muscles: a new group of dominantly inherited ocular fibrosis with radiologic findings. Ophthalmology 102:607–612. Hansen, E. 1968. Congenital general fibrosis of the extraocular muscles. Acta Ophthalmol 46:469–476. Harley, R.D., Rodrigues, M.M. & Crawford, J.S. 1978. Congenital fibrosis of the extraocular muscles. J Pediatr Ophthalmol Strabismus 15:346–358. Kishore, K. & Kumar, H. 1991. Congenital ocular fibrosis with musculoskeletal abnormality: A new association. J Pediatr Ophthalmol Strab 28:283–286. Krüger, K.E. & Friedrich, D. 1963. Familiare kongenitale Motilitatsstörungen der Augen. Klin Monatsbl Augenheilkd 142:101–117. Mackey, D.A., Chan, W.M., Chan, C., Gillies, W.E., Brooks, A.M.V., O’Day, J. & Engle, E.C. 2002. Congenital fibrosis of the vertically acting extraocular muscles maps to the FEOM3 locus. Hum Genet 110:510–512. Schmidt, T. & Feicht, B. 1989. Facial hemiatrophy with monolateral fibrosis of all extraocular muscles. Klin Monatsbl Augenheilkd 194:117–119. Sener, E.C., Lee, B.A., Turgut, B., Akarsu, A.N. & Engle, E.C. 2000. A clinically variant fibrosis syndrome in a Turkish family maps to the CFEOM1 locus on chromosome 12. Arch Ophthalmol 118:1090–1097. Wang, S.M., Zwaan, J., Mullaney, P.B., Jabak, M.H., Al-Awad, A., Beggs, A.H. & Engle, E.C. 1998. Congenital fibrosis of the extraocular muscles type 2, an inherited exotropic strabismus fixus, maps to distal 11q13. Am J Hum Genet 63:517–525.
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Hiper maximum lateral rectus recession operation of adults with large angle exotropia M.D. Basak Yılmaz, Birsen Gökyig˘it, Serpil Akar & Ömer Faruk Yılmaz Beyog˘lu Kuledibi Eye Education and Research Hospital, Istanbu, Turkey
ABSTRACT: Purpose: To introduce and evaluate the effect of a new adjustable suture technique in hiper maximum lateral rectus recession operation added to medial rectus resection in adults with large angle exotropia. Materials and Method: This study was done in 8 adult patients who had very large angle exotropia. Six of the patients were female and 2 were male. Their ages ranged between 21 and 64. These patients only one eye was operated which included medial rectus resection and new technique hyper maximum lateral rectus recession. In new technique we use 2 scleral passes, one of which is passed through insertion. The muscle was released 12 mm behind insertion. The operation continued as usual. Mean follow-up was 6 months. Findings: While the patient’s pre-operative deviations were between 60 and 90 prism diopter (PD), their post-operative deviations were between 2 and 12 PD. Only one patient needed adjustment for over correction. None of the patients had limitation of ocular motility. Conclusion: 8 mm behind the insertion adjustable suture technique is a practical method which gives patients recession up to 12 mm.
1
INTRODUCTION
Strabismus surgery with adjustable suture technique which is first described by Mc Mullen was popularized in early 1970’s by Jampolsky. Adjustable sutures were introduced as an adjunct to traditional surgery to allow the surgeon to place the eyes in the desired alignment in the immediate postoperative period (within 24–48 hours ), with the goal of promoting the best possible long-term alignment once postoperative drift, if any, occured. Especially the cases in which we can not predict amount of deviation correction with conventional surgery due to contracture or scarring of extraocular muscles are the most important advantages of this technique. (Howard, C.W. 1986) Other indications are reoperations, large angle deviations, thyroid ophthalmopathy, blow out fracture, paralytic strabismus, combined horizontal and vertical muscle surgery. (Jampolsky, A.J. 1975, Jampolsky, A.J. 1979, Franklin, S.R. 1989) In this study we aimed to investigate the efficiacy and effectiveness of the hypermaximum lateral rectus muscle recession surgery with the adjustable suture technique in the large angle exotropia patients.
2
MATERIAL AND METHODS
10 (Ten) patients who were operated with adjustable suture hipermaximum lateral rectus recession technique in addition to medial rectus resection of one eye and followed in the strabismus department of the Beyog˘lu Eye Education Hospital between 20.02.2003–29.03.2004 were included in our study. Mean follow up time was 6,80 3,55 month and preoperative deviations were 60 PD (Prism Diopter) or bigger in 4 (four) of the our patients at near and distance as seen in table 1. In table 1 375
Table 1. Near and distance deviation measurements of all patients. Preop
Postop
No
Sex
Age
ND
DD
ND
DD
1 2 3 4 5 6 7 8 9 10
M F M F M F F F M F
42 39 72 64 56 54 21 34 51 32
70 60 90 90 50 50 60 30 80 30
40 60 90 90 70 40 60 18 35 25
6 25 20 30 14 10 14 14 10 10
6 30 16 35 8 10 12 14 8 0
DD: Distance deviation (Prism deviation) ND: Near deviation (Prism deviation) 100
ND (XT)
80 60 40 20 0 1
2
3
4
5
6
7
8
9
10
-20 Patient No
Figure 1.
Change in prism deviation at near after adjustable surgery.
100
DD (XT)
80 60 40 20 0 -20
1
2
3
4
5
6
7
8
9
10
Patient No
Figure 2.
Change in prism deviation at distances after adjustable surgery.
our patient’s preoperative and postoperative prism deviation measurements have been shown. We made complete ophthalmological and orthoptic examinations to all the patients. Distance vision examination with Snellen chart; anterior segment examination with biomicroscopy and then posterior segment examination with indirect ophtalmoscopy were made to all the patients. Their deviations at near and distance were measured with alternan cover test, cover test, prism cover test. The prism deviations of the patients with low vision were measured with Krimsky test. Ocular ductions and versions were evaluated. 376
Table 2.
Average deviations and correction rate of prism deviations. Preop
Average Median S.Deviation Minimum Maximum
Postop
Correction
ND
DD
ND
DD
NPD
DPD
61,0 60,0 21,833 30 90
52,80 50,0 25,376 18 90
12,50 12,0 11,956 14 3
11,10 9,0 13,956 14 35
48,50 12,0 16,821 20 70
41,70 9,0 16,977 70 74
Complete orthoptic and ophthalmological examinations were made preoperatively, first day after adjustment, postoperative 1st–2nd week, postoperative 4–6th Week, postoperative 3rd–4th month, postoperative 6th month. We evaluated the operation as successful if the postoperative prism deviation value was 10 PD (Prism Diopter) or less during at least 2 months postoperative follow up examinations. In our study Wilcoxon Signed Ranks test was used statistically. 3
SURGICAL TECHNIQUE
After standart limbal conjunctival peritomy, lateral rectus muscle is hooked and released from peripheral attachments. After placing the pole suture by passing through muscles recessed with double armed 6-0 vicryl, the both ends of the suture are tied at the two edges of the muscle and the muscle separated from its original insertion. First vicryl suture passed through the sclera that is 6–8 mm behind muscle insertion; then after, with the condition of the muscle being 10 mm behind, one needle passed through musle insertion site and near half of the muscle shaft in the form of the Z shape. Same procedure is repeated with other needle. The suture is tied as knot first and then tied as bowknot. Conjunctiva is sutured with the 8-0 vicryl suture. If the patient has no complaint and diplopia, and if deviation measured with prism cover test is appropriate for our target success criteria during the examination which is made 24 hours after operation; by using topical anesthesia (Benoxinate, Alcaine) bowknot is opened and is tied as second knot. Depending on the results, suture is either tightened to reduce the amount of recession, or slackened to increase it. The latter is done by fixing the globe by means of the Vicryl handle, and asking the patient to look in the direction of action of the muscle. The process is repeated until the optimum cosmetic and functional alignment is achieved, following which a permanent knot is made, and the trimmed ends tucked under the edge of conjunctival flap. 4
FINDINGS
Ten eyes of 10 patients ranging in age from 21 to 72 years underwent adjustable lateral rectus recession. Prism deviation measurements at near and distance were 60 PD (Prism Diopter) or bigger in 4 (Four) of the 10 (ten) patients. 6 (six) of the patients were female and 4 of the patients were male in our study. Mean age was 46,5 15,69 years (21–72). Mean follow up time was 6,80 3,55 month. In our study 90% of all adjustable suture lateral rectus recession operations we made were primary, other 10% of operations we made was reoperation. Table 1 shows the preoperative and postoperative deviation values measured (PD). Considering surgical alignment to be “successful”, when there is less than 10 prism diopters (PD) deviation. (Metz, H.S. 1988, Lee, J. 1992, Gunton, K.B. 2002). We had success rates of 70% for surgery of adjustable lateral rectus recession according to this criteria in our study. Overall correction rate of prism deviation after operation with adjustable suture technique was 79% as seen in table 2. In our study Wilcoxon Signed Ranks test was used statistically. Difference 377
90 80 70 60 50 40 30 20 10 0 -10
Figure 3.
PrND
PoND
PrDD
PoDD
Change of average deviations at near and distance after adjustable surgery.
between postoperative and preoperative prism deviations for both near and distance fixation was statistically significant. (p 0,005 for near deviation and p 0,005 for distance deviation). 5
CONCLUSIONS
Adjustable suture modifications to traditional strabismus surgery were introduced to increase the rate of surgical successes and to reduce the frequency of reoperations by eliminating undesirable early postoperative under or over corrections. (Agnello, R. 1986, Fells, P. 1987, Keech, R.V. 1987, Franklin, S.R. 1989, Lee, J. 1992, Currie, Z.I. 2003) This procedure permits the surgeon to enhance or diminish the amount of muscle recession on the evening after surgery or the first postoperative day if cover testing indicates an inapropriate amount of under correction or over correction so these advantages increase success of surgery and decrease the need for reoperation in early postoperative period. Preoperative evaluation including measurement of the deviation, forced ductions, rotations, and active force generated and variables such as the age of patient and cause of strabismus are all included in the process of deciding on the amount of surgery. It is generally accepted that adjustable suture surgery requires cooperation and is very difficult under the age of 14. (Fells, P. 1988, Guyton, D.L. 1988, Gunton, K.B. 2002) Our youngest patient was 21 years old. Surgery of horizontal muscle deviation was considered successful by most authors if there was less than 10 prism deviation. (Lee, J. 1992, Gunton, K.B. 2002, Metz, H.S. 1988). Some authors reported success rate as 67–91,7% in horizontal muscle surgery with adjustable suture procedure; (Smith, A.G. 1986, Fells, P. 1988, Pratt-Johnson, J.A. 1988), some other authors suggested that rate as 80–85% after primary surgery. (Jampolsky, A.J. 1975, Rosenbaum, 1977, Rosenbaum, 1978). The frequency of need for reoperation was proposed as 4–11% in most studies. (Jampolsky, A.J. 1975, Fells, P. 1988, Metz, H.S. 1988, Morris, R.J. 1992). Kraft recorded this rate as 5% (Jampolsky, A.J. 1975), in our study one of ten patients needed reoperation (10%). There are different ideas about suture adjustment time, adjustment must be done 5–24 hours after surgery according to some authors (Jampolsky, A.J. 1975, Smith, A.G. 1986,) maximum in 2 weeks after surgery according to Cleve. (Guyton, D.L. 1988) Haward and Simith suggested adjustment 3–4 day after operation. (Guyton, D.L. 1988) In our study we preferred making adjustment 24 hours after operation because we think that if we wait much more time, the risk of hemorrhage and suture break increases.In our study there was no postoperative complication such as suture granulma or conjunctival reaction seen especially in Cinch method. In large angle exotropia successful alignment was achieved in 71–76% of cases with conventional lateral rectus recession and/or medial rectus resection operation according to various studies. (Kraft, S. 1991) Successful alignment was reported in average 77% of cases with adjustable suture technique lateral rectus recession operation in various studies. (Scott, W.E. 1977). In our 378
study successful alignment was achieved in 70% of cases with large angle exotropia. As a result lateral rectus recession operation with adjustable suture procedure gives satisfactory results with one operation, so is effective and efficient technique for large angle exotropia.
REFERENCES 1. Agnello, R. Adjustable sutures in strabismus surgery: a personal series of cases. Aust NZJ Ophthalmol 1986; 14: 143–53. 2. Currie, Z.I., Shipman, T. Surgical correction of large angle exotropia in adults. Eye 2003 Apr; 17(3): 334–9. 3. Fells, P. Techniques and applications of adjustable sutures. Aust NZJ Ophthalmol 1987; 15: 35–41. 4. Fells P. Adjustable sutures. Eye 1988; 2: 33–35. 5. Franklin, S.R. Adjustable sutures in strabismus surgery. Ann Ophthalmol 1989; 21: 285–89. 6. Howard, C.W., Smith, A.G. Use of adjustable sutures: A helpful modification. Ann Ophthalmol 1986; 18: 70–3. 7. Jampolsky, A.J. Strabismus reoperation techniques. Trans Am Acad Ophthalmol Otolaryngol. 1975; 79: 704–717. 8. Jampolsky, A.J. Current techniques of adjustable strabismus surgery. Am J Ophthalmol.1979; 88: 406–418. 9. Kraft, S. Postoperative drifts after adjustable suture strabismus surgery. Can J Ophthalmol 1997; 32: 163–169. 10. Keech, R.V., Scott, W.E. Adjustable suture strabismus surgery. J Pediatr Ophthalmol Strabismus 1987; 24: 97–102. 11. Kraft, S.P., Jacobson, M.E. Techniques adjustable suture strabismus surgery. Ophthalmic Surgery 1990; 21: 633–640. 12. Lee, J. Modern management of sixth nerve palsy. Aust NZJ Ophthalmol 1992; 20(1): 41–7. 13. Livir-Rallatos, G., Gunton, K.B. Surgical results in large angle exotropia. Jaapos 2002 apr; 6(2): 77–80. 14. Metz, H.S. Motor alignment following traditional surgery versus adjustable suture strabismus surgery. Transactions of the sixth International Orthoptic Congress. Horrogate, England, 1988; 454–59. 15. Morris, R.J. Adjustable sutures in squint surgery. Br J Ophthalmol. 1992; 76: 560–62. 16. Pratt-Johnson, J.A. Complicated strabismus and adjustable sutures. Aust NZJ Ophthalmol 1988; 16: 87–92. 17. Rosenbaum, A.L., Metz, H.S. Adjustable rectus muscle recession surgery. Arch Ophthalmol 1977; 95: 817–820. 18. Rosenbaum, A.L. The use of adjustable suture procedures in strabismus surgery. Am Orthopt J. 1978; 28: 88–94.
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Surgical outcome in superior oblique muscle palsy S. Zıylan, A. Yigit, Ö. Yabas, D. Serin, S. Hoca & I. Daruga Sisli Etfal Education and Research Hospital, Istanbul, Turkey
ABSTRACT: 25 patients who underwent surgical correction for unilateral superior oblique palsy were enrolled in the study. Inferior oblique recession was performed to treat the cases with hypertropia of 15 prism diopters or less. In cases with more than 15 prism diopters hypertropia, inferior oblique recession was combined with contralateral inferior rectus recession. Cases with marked laxity of the superior oblique muscle were treated with superior oblique tendon tuck. A patient was considered to have successful outcome if the abnormal head posture and diplopia were relieved and the postoperative hyperdeviation was 5 prism diopters or less in primary position and 10 prism diopters or less in oblique gaze positions. Our overall success rate was %84. In the treatment of superior oblique palsy favorable results can be achieved with careful clinical assessment and appropriate surgical intervention.
1
INTRODUCTION
Superior oblique muscle palsy is the most common form of paralytic strabismus. Congenital superior oblique palsy is encountered more often than the acquired form. The etiologic factors in the congenital form are laxity, abnormal insertion or the absence of the superior oblique tendon. Trauma, intracranial pathologies and microvascular disorders can lead to acquired paralysis. Abnormal head posture, facial asymmetry, high vertical fusion amplitudes are seen more frequently in patients with congenital palsy. Complaints of image tilt, excyclotropia and diplopia are characteristics of acquired superior oblique palsy. (Dale 1982, Von Noorden 1996). There are various surgical techniques and different results in the treatment of superior oblique palsy. In the current study we reviewed 25 cases with unilateral superior oblique palsy and evaluated the outcome of their surgical treatment.
2
METHODS
The subjects of this study consisted of 25 patients with unilateral superior oblique palsy followed in the ophthalmology clinic of Sisli Etfal Hospital between 1997 and 2003. Each patient underwent complete ophthalmologic examination. Abnormal head posture and facial asymmetry was noted if present. The angle of deviation was measured with the prism and alternate cover test in 9 diagnostic gaze positions. Bielschowsky head tilt test was considered positive if the hyper deviation on the palsied side was at least greater by 5 prism diopters. Binocular status was assessed with the Titmus and Worth 4 dot test. Torsion was measured with the double Maddox rod. Extraocular muscle functions on versions were graded from 0 to 4 for under actions and 0 to 4 for over actions. The diagnosis of superior oblique palsy was based on the Parks’ 3 step test. Surgical intervention was planned according to the classification of Knapp and Moore (Knapp 1971, Knapp & Moore 1976). Cases with primary position hypertropia of 15 prism diopters or less underwent ipsilateral inferior oblique recession and those with primary position hypertropia of more than 15 prism diopters underwent ipsilateral inferior oblique recession and contralateral inferior rectus 381
recession. Patients with advanced laxity of the superior oblique muscle on the forced duction test were treated with superior oblique tendon tuck. A patient was considered to have successful outcome if the abnormal head posture and diplopia were relieved and the postoperative hyper deviation was 5 prism diopters or less in primary position and 10 prism diopters or less in oblique gaze positions.
3
RESULTS
15 female and 10 male patients with an average age of 13, 5 years (range: 4–40 years) were enrolled in the study. The average follow up time was 18 months (range: 4–32 months). 18 patients had their palsy from birth or early infancy. In 3 cases the palsy was considered traumatic in origin and in 4 cases the cause was unknown. The presenting symptoms included abnormal head posture (n: 3), diplopia (n: 3) and cosmetically unacceptable ocular alignment (n: 19). Facial asymmetry was present in 10 patients. 22 patients had some degree of binocularity. 15 of the 22 had stereoacuity ranging from 3000 to 40 arc/sec and the remaining 7 had peripheral fusion. Extorsion could be measured in 19 patients. The average amount of excyclotorsion was 3.5° (range: 0–8°). All of the patients had overaction of the ipsilateral inferior oblique muscle varying from 1 to 4. The average distance hyperdeviation in primary position was 17.6 prism diopters (range: 10–30 prism diopters). Types of palsy and the preoperative hyperdeviations in primary position is shown in Table 1. 9 patients had an associated esodeviation of 8 prism diopters or more, and 4 had an associated exodeviation of 12 prism diopters or more. 7 of these 13 patients underwent concomitant horizontal rectus surgery. 11 patients with type I palsy and primary position hyperdeviation of 15 prism diopters or less underwent solitary inferior oblique recession. Among the patients with 16 to 30 prism diopters of primary position hypertropia, 8 with type III palsy and 4 with type IV palsy underwent inferior oblique recession and contralateral inferior rectus recession. Two patients with type II palsy had superior oblique tendon tuck. Our mean correction of hyperdeviation in all positions of gaze was 11.1 prism diopters with inferior oblique recession, 19.5 prism diopters with combined inferior oblique and contralateral inferior rectus recession. With superior oblique tendon tuck 16 prism diopters of hypertropia were corrected in the field of the palsied muscle. Our overall success rate was 84%. Table 1.
Table 2.
Types of palsy.
n (total: 25)
Knapp’s class
11 2 8 4
I II III IV
Postoperative results. Average hypertropia Prism diopters
Gaze position
Preoperative
Postoperative
Primary Oblique up Oblique down
15.3 16.8 17.1
3.7 3.5 3.5
382
Residual primary position hypertropia more than 5 prism diopters was present in 4 patients at the end of the follow up period. 2 of these patients still had abnormal head posture. A mild Brown syndrome with 1 limitation developed in one of the patients who had superior oblique tendon tuck.
4
DISCUSSION
In the treatment of superior oblique palsy choice of surgical technique varies among different authors. Knapp and Moore classified superior oblique palsy according to the angle of deviations in primary and oblique gaze positions and recommended surgical guidelines (Knapp 1971, Knapp & Moore 1976). This classification provides appropriate surgical orientation in most cases. In superior oblique muscle palsy, the response to surgery is strongly related to the amount of preoperative deviation. Weakening of the overacting inferior oblique muscle is generally the preferred operation for treatment of most patients with unilateral superior oblique palsy (Dyer & Duke 1976, Helveston & Haldi 1976, Toosi & Von Noorden 1979, Katz 1984). However, patients with large angle deviations often require two muscle operations. Toosi & Von Noorden reported favorable results with isolated inferior oblique myectomy in their series of unilateral superior oblique palsy with small angle deviations. The mean preoperative deviation in primary position was 15.1 prism diopters in this series (Toosi & Von Noorden 1979). Farvardin & Nazarpoor reported an average reduction of 14.52 prism diopters with anterior transposition of the inferior oblique muscle (Farvardin & Nazarpoor 2002). Flanders & Draper preferred to perform disinsertion or myectomy in type I palsy with a primary position hypertropia of 15 prism diopters or less (Flanders & Draper 1990). Our choice of surgery was similar for small angle superior oblique palsy. We performed inferior oblique recession in cases with 15 prism diopters or less hypertropia in primary position, and our success rate was 82% with this technique. Many authors recommend two muscle operations for patients with large angle vertical deviations as single muscle operations may cause undercorrections (Jampolsky 1971, Mittelman & Folk 1976, Saunders 1986, Flanders & Draper 1990). In this study we combined inferior oblique muscle recession with contralateral inferior rectus muscle recession for more than 15 prism diopters of primary position hypertropia in type III and IV palsy. With this surgical approach our success rate was 83%. Lower eyelid deformity is one of the complications of inferior rectus recession. To avoid this adverse event, we limited the amount of recession to 4 mm. None of our patients showed lower eyelid deformity. In type III palsy another choice of surgery is combining ipsilateral superior oblique tendon tuck with inferior oblique muscle recession. Saunders reported favorable results with this technique (Saunders 1986). Knapp recommends superior oblique tendon tuck for superior oblique palsy in which the angle of deviation is greater in the field of the paretic muscle (Knapp 1971, Knapp & Moore 1976). This technique can lead to iatrogenic Brown syndrome. In the retrospective study of Simons et al., postoperative Brown syndrome rate was 60% with superior oblique tendon tuck (Simons et al. 1998). Helveston et al. reported a rate of 17% for mild Brown syndrome following and resection (Helveston et al. 1996). In our study a mild Brown syndrome of 1 limitation occurred in one of the two patients that underwent superior oblique tendon tuck.
5
CONCLUSION
In our study we achieved satisfactory results with isolated inferior oblique muscle recession in the treatment of unilateral superior oblique palsy with primary position hypertropia of 15 prism diopters or less. For larger angle deviations, combining contralateral inferior rectus recession is with inferior oblique recession is an effective option. Superior oblique tendon tuck is also a satisfactory method for cases with laxity of the superior oblique tendon. 383
With careful clinical assesment, superior oblique palsy can be diagnosed without difficulty. If the deviation patterns are carefully determined, appropriate surgery can be performed with a high degree of success.
REFERENCES Dale R.T. 1982. Fundementals of ocular motility and strabismus: 10–25, 245–52, 268. New York: Grune & Stratton Dyer J.A. & Duke D.G. 1976. Inferior oblique weakening procedures. Int Ophthalmol Clin 16(3): 103–12 Farvardin M & Nazarpoor S. 2002. Anterior transposition of the inferior oblique muscle for treatment of superior oblique palsy. J Pediatr Ophthalmol Strabismus 39(2): 100–104 Flanders M. & Draper J. 2000. Superior oblique palsy: diagnosis and treatment Helveston E.M et al. 1996. Surgical treatment of superior oblique palsy. Trans Am Ophthalmol Soc 94: 315–28 Helveston E.M & Haldi B.A. 1976. Surgical weakening of the inferior oblique. Int Ophthalmol Clin 16(3): 113–26 Jampolsky A. 1971. Vertical strabismus surgery. In: symposium on Strabismus; Transactions of the New Orleans Acedemy of Ophtalmology. St Louis: CV Mosby 382–4 Katz N.N.K. 1984. Denervation and extirpation of the inferior oblique muscle as the primary surgical procedure in the treatment of superior oblique palsy. In: Reinecke R.D. (ed.), Strabismus II; Proceeings of the Forth Meeting of the international strabismological association October 25–29, 1982 Aslomar, California: 821–7. Orlando FL: Grune & Stratton Knapp P. 1971. Diagnosis and surgical treatment of hypertropia. Am Orthopt J 21: 29–37 Knapp P. & Moore S. 1976. Diagnosis and surgical options in superior oblique surgery. Int Ophtalmol Clin. 16(3): 137–49 Mittelman D. & Folk E.R. 1976. The evaluation and treatment of superior oblique muscle palsy. Trans Am Acad Ophtalmol Otolaryngol 81: 893–8 Saunders R.A. 1986. Treatment of superior oblique palsy with superior oblique tendon tuck and inferior oblique myectomy. Ophtalmology 93(8): 1023–7 Simons B.D. et al. 1998. Outcome of surgical management of superior oblique palsy: a study of 123 cases. Binocul Vis Strabismus 13(4): 273–82 Toosy S.H. & von Noorden G.K 1979. Effect of isolated inferior oblique muscle myectomy in the management of superior oblique muscle palsy. Am J Ophthalmol 88: 602–8 von Noorden G.K. et al. 1986. Superior oblique paralysis A review of 270 cases. Arch Ophthalmol 104: 1771–6 von Noorden G.K. 1996. Binocular vision and ocular motility: 41–57, 392–429. St Louis: CV Mosby
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Medical detective W. Duifhuizen–Visscher, W.J. van der Linden, M. Tjon Fo Sang & M. Wefers Bettink–Remeijer Orthoptic Department Rotterdam Eye Hospital, The Netherlands
ABSTRACT: Introduction: A male patient, age 73, with changing diplopia visited our orthoptic department. Upon each visit the ocular motility pattern suggested a different diagnosis. Methods: Full ophthalmologic and orthoptic examination were performed. Several blood tests and CT-scan of the orbit were performed. Results: In three years the ocular motility changed every orthoptic visit. Further examination did not lead to a clear diagnosis. Conclusion: Sometimes the orthoptic patient is a puzzle. In this case the diagnosis is most likely ocular Myastenia Gravis.
1
INTRODUCTION
We present a patient with variable diplopia during a course of 3 years. Upon each visit to our orthoptic department, he showed a totally different pattern of ocular motility.
2
CASE
The patient presented in 2001 with a sudden onset of binocular diplopia. Medical history: – Prolonged deafness – Hypertension – Hypothyroidism Medication: – – – – –
Meto prololtertraat Levothyroxine Isosorbidemononitraat Lisinoprlil Carbasalaatcalcium
Full ophthalmic examination was performed. Except for nuclear cataract there were no abnormalities. Before the first orthoptic examination could be performed, the diplopia disappeared spontaneously. One and a half year later the patient presented again with binocular diplopia. Although during each orthoptic examination the eye position and motility were found to be stable, between subsequent orthoptic visits the eye position and motility kept changing. (fig. 1) However, the subjective diplopia corresponded with the orthoptic findings. 385
Figure 1.
3
METHODS
Differential diagnosis – – – – – –
Ocular Myasthenia Gravis Lyme disease Cavernous sinus syndrome Graves’orbitopathy Micro vascular problem Neurolues
Further examination – – – – – – – – – – –
4
Antibodies against acetylcholine receptors: negative C-reactive proteine: normal ESR: normal Glucose: normal Hemoglobine: normal TSH-FT4: normal Borrelia: the result is still unknown VDRL/TPHA: the result is still unknown CT-scan of the orbit: no abnormalities Forced Duction Test: negative Ice compress test: negative
DISCUSSION
The diagnosis is not confirmed. The most likely diagnosis is ocular Myasthenia Gravis. Myasthenia gravis is the most common myogenic palsy seen in ophthalmic departments. Although the exact aetiology is still not entirely clear, the defect lies at the level of the neuromuscular end-plate, where acetylcholine is normally stored in the nerve terminals for release when muscle contraction is required. In myasthenia, the disease process results in failure to release or produce acetylcholine, so that the muscle does not contract sufficiently and its action is weakened. Mein. J. & Harcourt. B. 1986. 386
Ptosis is the most consistent sign of myasthenia; it may be unilateral of bilateral and usually remains partial for a long time. It is often associated with weakness of the orbicularis and with diplopia. The latter is difficult to identify and takes diverse forms, as more than one muscle is variously affected at a time. Usually there is a vertical imbalance, either isolated or associated with a horizontal deviation. Upon superficial examination, paretic phenomena may sometimes be taken for a paralysis of convergence or even for a paralysis of conjugate lateral movements. Al these signs are less pronounced in the morning and increase with fatigue; they may vary considerably from one day, and even from one minute, to the next. Hugonnier, R. Clayette – Hugonnier, S. 1969. Presently, the patient has a straight eye position and no limitations of ocular movements. When diplopia re-occurs, further neurological examination will be recommended.
5
CONCLUSION
This is an example of a case with probably a-typical ocular Myasthenia Gravis. Sometimes the diagnosis is a puzzle. The ophthalmologist or orthoptist can be medical detectives.
REFERENCES 1. Schmidt, D. Signs in Ocular Myasthenia and Pseudomyasthenia. Differential diagnostic criteria, a clinical review, Neuro ophthalmology 1995 vol. 15, no. 1. 21–58 2. Lesser, R.L. MD, Kornmehl, E.W. MD, Pachner, A.R. MD e.a. Neuro-Ophthalmologic Manifestations of Lyme Disease, Ophthalmology 1990; 97: 699–706 3. Mein, J. & Harcourt, B. 1986. Diagnosis and Management of Ocular Motility Disorders. Oxford: Blackwell Scientific Publications 4. Hugonnier, R. Clayette – Hugonnier, S. 1969. Strabismus, heterophoria, ocular motor paralysis. Saint Louis: The C.V. Mosby Company
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Minutes of the general business meeting Izmir – June 4, 2004
1
OPENING REMARKS FROM THE PRESIDENT
The President of the ESA, Professor Micheline Spiritus, opened the General Business Meeting at 13:30 and thanked all participants for their attendance of the ESA Congress. She informs the audience that her term of office ends in 2004 and no re-election is possible. She apologizes for not having the Editor included the Minutes of the General Business Meeting in Bergen and the Membership Roster in the Proceedings Volume.
2
SECRETARY/TREASURER’S REPORT
The minutes of the General Business Meeting in Bergen have been included in the letter/call for membership that has been sent to all members. No objections were received. The minutes are therefore approved. The financial report was checked and approved by the account auditors, Prof. V. Herzau and Prof. E. Campos. The report was circulated among the members of the Executive Committee and was explained at the General Business Meeting. It was approved without objections. The balance of the ESA account in Bologna in may 2004 was 38.523,12 EURO. Prof. V. Herzau and Prof. E. Campos were confirmed as account auditors of the next period by acclamation of the audience. The membership fee for the next year will be unchanged (50 EURO for Ordinary and Associate Members). The following applicants were accepted as new members of the ESA by the Executive Committee:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
Dr. A. Broniarczyk-Loba (Poland) Dr. E. van der Marel (The Netherlands) Dr. C. Speeg-Schatz (France) Mrs. M. Gutter (The Netherlands) Mrs. J. van Nouhuys (The Netherlands) Dr. H. Or (Turkey) Dr. E. Yalgin (Turkey) Dr. H. Tolun (Turkey) Dr. O. Yabas (Turkey) Dr. K. Keshinbora (Turkey) Dr. A. Nohutcu (Turkey) Dr. H. Hasiripi (Turkey) Dr. I. Gokcen (Turkey) Dr. S. Kargi (Turkey) Dr. H. Bayramlar (Turkey) Dr. S. Kutluk (Turkey) Dr. F. Feray Koc (Turkey) Dr.D. Erkan (Turkey) Dr. S. Sumru Onal (Turkey)
20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 389
Dr. Y. Ozkm (Turkey) Dr. C. Bellusci (Italy) Dr. M. Fresina (Italy) Dr. A. Alavi (Iran) Dr. A. Attarzadeh (Iran) Dr. A. Bates (United Kingdom) Dr. S. Celebi (Turkey) Prof. Y. Duranoglu (Turkey) Dr. A. Faraht (Turkey) Dr. D. Fernandez-Agrafojo (Spain) Dr. O. Hakim (Saudi Arabia) Dr. M. Hok Wikstrand (Sweden) Dr. D. Kenal (Turkey) Dr. A. Inal (Turkey) Dr. S. Moguel (Mexico) Dr. A. Ozbek (Turkey) Dr. A. Ozturk (Turkey) Prof. N. Reza (Iran) Dr. H. Salama (Saudi Arabia)
39. Dr. K. Slanjankic (Bosna) 40. Dr. M.R. Talebnejad (Iran) 41. Mrs. C. Timms (United Kingdom)
3
42. Dr. A. Vanheesbeke (Belgium) 43. Dr. B. Yılmaz (Turkey)
ELECTION OF NEW HONORARY MEMBERS
The Executive Committee proposes four new Honorary Members: Dr Annette Spielmann (France), Prof. Gunnar Lennestrand (Sweden), Prof. Guntram Kommerell (Germany), and Prof. Wilfried de Decker (Germany). The Assembly agreed unanimously to this proposal by acclamation. No objection was made.
4
ESA WEB-SITE
The responsibility of the ESA web-site will stay in the hands of the Secretary/Treasurer who proposes a new installing person. The audience approves.
5
ESA FELLOWSHIP
The President proposes that the requirements for application of the candidate will include his/her clinical and research qualifications, a curriculum vitae and list of publications, evidence of completion of training in ophthalmology such as the certificate of the European Board in Ophthalmology (EUBO) (Goldstandard) or equivalent qualification. The trainer will also be invited to deliver a report in connection with his/her work and/or research during his/her fellowship. A Fellowship Committee consisting of 3 ESA members, including the Secretary/Treasurer, will be established. After a brief discussion, the audience approves.
6
TRANSACTIONS ESA MEETING 2004
The President announces that Dr. J.-T. de Faber will be the Editor of the transaction book of the ESA Meeting 2004. The President underlines that the ESA by-laws updated, the Minutes of the General Business Meeting in Izmir and the Membership roster updated have to be included in the transaction book. The audience approves.
7
ELECTION OF NEW COUNCIL MEMBERS
The President announces that the term of office of the actual members of the Executive Committee ends this year for three Council members. Re-election is possible in two cases. Prof. Spiritus is not re-eligible. Prof. Pechereau is re-eligible for two years. Prof. Haugen is re-eligible for a second term of four years. The President gives the following proposals and asks for further candidates: Seyan Ozkan as President, Alain Pechereau and Olav Haugen as Vice-Presidents, Alexandros G. Damanakis as new Councillor. Dr. Damanakis should be co-opted because he will organize the ESA Meeting 2007. According to the actual by-laws, the Secretary asks the audience if a secret election with a written ballot is wished. Because no vote for a secret election was obtained and no further candidates were received from the audience, the proposals of the Council 390
were voted by show of hands. They were approved without contrary votes. The actual Executive Committee is therefore: President Vice-Presidents
Councillors
Secretary/Treasurer
S.B. Ozkan J. Lee A. Pechereau O. Haugen R. Gomez de Liano H.D. Schworm A. Damanakis C. Schiavi
Since the term of office of six Council Members will end in 2006 and since in that year the ESA Meeting will not be held, the President proposes to anticipate elections in 2005. To do this, an amendment of the by-laws should be done. According to the by-laws, the proposal of amendment must be sent to the Secretary/Treasurer six months before the next ESA Meeting. 8
FUTURE ESA MEETINGS
30th ESA Meeting Date: Location: Local organizer:
Abstract submission: 31st ESA Meeting Date: Location: Local organizer:
9
8th–11th June 2005 Killarney, County Kerry, Ireland John Lee (United Kingdom) e-mail:
[email protected] ESA web-site: www.esa-strabismology.com Congress web-site: www.esa2005.org
[email protected] By e-mail only, details will be provided on the congress web-site. Dead line: January 15, 2005. May–June 2007 Myconos or Athens (Greece) Alexandros G. Damanakis (Greece) e-mail:
[email protected]
ESA LECTURER
The President proposes Prof. V. Herzau as the next ESA Lecturer. The assembly approves unanimously. 10
VARIA
No other matters were brought to attention. The President closed the General Business Meeting at 14.30. The Assembly appreciated with a standing ovation the great care and ability in holding her office. Respectfully submitted Dr. Costantino Schiavi (Secretary/Treasurer) 391
Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
ESA EUROPEAN STRABISMOLOGICAL ASSOCIATION Founded 1982 former Consilium Europaeum Strabismi Studio Deditum (CESSD)
BY-LAWS
Article 1: The European Strabismological Association (ESA) derives from the CESSD founded in Paris in May 1962. The new association was founded with the aim of opening the former CESSD to all persons, who have a special interest in eye motility problems and disturbances of binocular vision. Article 2: The aims of the European Strabismological Association are: a) to disseminate knowledge of all sensory and motor aspects of strabismus and other disorders of ocular motility, b) to diffuse knowledge of diagnostic and therapeutic procedures, c) to foster clinical and experimental research, d) to create as far as possible a common global terminology in spire of the differences of language. Article 3: The ESA is autonomous and administers itself within the European Ophthalmological Society. It has its administrative seat in the city of the Secretary’s residence. Article 4: There shall be the following classes of membership: Ordinary Members, Associate Members, Honorary Members and Senior Members. Any physician with a special interest in strabismology, who is duly proposed in writing by two Ordinary Members or Honorary Members, shall become an Ordinary Member by decision of the Executive Committee. Any non-physician with a special interest in strabismology, who is duly proposed in writing by two Ordinary Members or Honorary Members, shall become an Associate Member by decision of the Executive Committee. The Executive Committee can transform an associate membership to ordinary membership. Any person, who has performed particularly meritorious work in strabismology may become an Honorary Member by a majority vote of Ordinary Members at the General Business Meeting. Any Ordinary or Associate Member who is no more professionally active can be considered as Senior Member and does not need to pay membership fees. A Senior Member can be classified as such by written request. Ordinary, Honorary and Senior Members have a voting right. 393
The qualification of membership is lost by resignation. Failure to pay dues by the last day of the calendar year shall automatically disqualify membership until the dues have been paid.
Article 5: The annual membership fee will be fixed by the General Business Meeting. The money has to be paid in the currency of the location of the society. In the case of members from countries where currency restrictions limit the transfer of funds, it shall be possible to have this membership fee waived upon written request to the Secretary/Treasurer. Honorary members do not pay any fee.
Article 6: Administration of the association: The association is managed by an Executive Committee consisting of: l President 3 Vice-Presidents l Secretary/Treasurer 3 Councillors Each member of the Executive Committee is elected at the General Business Meeting from among the ordinary members, for a period of 4 years. Re-election is possible only for one additional term. For the election representation of regions, languages and of the next meeting place should be taken into due consideration. In the event of vacancy of one member of the Executive Committee substitution will be performed by election at the following General Business Meeting. After nominations by ordinary members present the vote shall be taken by a show of hands or if requested by means of a secret written ballot. The election shall be made by a simple majority of votes. If no candidate reaches the majority of votes, the election shall be repeated by reducing the number of candidates to the two candidates, who obtained the most votes. In the case of a tie of votes the President shall have the casting vote. The Executive Committee fixes the date and place of the meetings and determines the program of the sessions. The President presides at meetings of the Executive Committee, the General Business Meeting and all other meetings of the association. He may temporarily delegate his functions to one of the VicePresidents or to another member of the Executive Committee. The Vice-President shall assume the duties of the President in the event of the President being unable to perform any of his duties. The duties of the Secretary / Treasurer shall include a) b) c) d)
the collection of membership fees, the recording of minutes of the meetings, the presentation of the Secretary’s/Treasurer’s report at the General Business Meeting, the correspondence concering the ESA as necessary. The function of the Secretary and the Treasurer bearing in mind the local conditions of some European countries can be performed by one or two members of the Executive Committee.
Two of the Councillors shall organize the next meetings of the ESA.
Article 7: A Meeting of the association shall take place at least every two years, in case of a congress of the European Ophthalmological Society as a satellit-meeting. 394
A Program Committee of three persons shall be appointed by the Executive Committee for the selection of papers to be presented at the meeting and the appointment of the authors for the reports. The proceedings volume will be edited by a member appointed by the Executive Committee as Editor and will be send to all the members of the association. The General Business Meeting shall be held on the occasion of the meeting of the association with a quorum of not less than thirty (30) ordinary members. A vote shall be taken by a show of hands or by a simple majority vote of ordinary members present and voting. In the case of a tie of votes the President shall have the casting vote. There shall be no voting by proxy. Proposed changes of the by-laws shall be submitted to the Secretary not less than 6 months and shall be communicated to all ordinary members not less than 3 months prior to the General Business Meeting for a vote at that meeting.
Article 8: The official languages of the ESA are English, French, German and occasionally the language of the meeting place. (Amended and adopted at the General Business Meeting, Krakow, October 21, 1989)
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Membership roster
Dr. Gill Adams Moorfields Eye Hospital City Road London ECIV 2 PD ENGLAND UK
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Dr. J. Asproudis Ch. Tzicoupi 4 45332 Ioannina GREECE
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Dr. K. Agopsonicz 2 Truskawkowa Str. 53-007 Wroclaw POLAND
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Dr. A. Assaf Milton Keynes NHS Trust Hospital Milton Keynes, MK6 5LD ENGLAND UK
Dr. Alireza Alavi Baghe Nari Ave. Susanst. N. 83 71447 Shiraz IRAN
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Prof. H. Atilla Mahatma Gandi cad 51/17 06700 GOP Ankara TURKEY
Prof. H. Ibrahim Altinsoy Gulhane Military Medical Academy Dept. of Ophthalmology 06010 Ankara TURKEY
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Dr. P. J. Alves do Vale Rua da Azenha de Cima N°157 4460-260 Senhora da Hona PORTUGAL
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Dr. W. Andrzejewska Str. Grzegorza z Sanoka 60 71-278 Stettin POLAND
Prof. Abbas Attarzadeh OM Khalili Hospital Department of Pediatric Ophthalmology 711 Shiraz IRAN Prof. Shinobu Awaya Kariya General Hospital 5-15 Sumiyoshi-cho, Kariya City Aichi 448-8505 JAPAN
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Prof. B. Bagolini Clinica Oculistica dell´ Università Largo A. Gemelli, 8 00168 Roma ITALY
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Dr. A. Arruga Santa Teresa, 15, 08960 Sant Just Desvern SPAIN
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Dr. John Baker 2355 Monroe Dearborn, MI 48124 USA
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Dr. S. Arsene rue d´Entraignes 224 37000 Tours FRANCE
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Dr. T. Baranowska-George Katedra i Klinika Okulistyki z Zakladem Patofizjologii Narzadu Wzroku PAM, al Powstancow Wlkp. 72 70-111 Stettin POLAND 397
Dr. Margriet Bartier H. Consciencestraat 11 2800 Mechelen BELGIUM
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Prof. Emel Basar Cemil Aslan Gudersok Sahinler Apt. N.10 D13 Gayrettepe-Istanbul TURKEY
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Dr. Hikmet Basmak Sumer Mah. Giftlikhisan Sok. N.4/1 26140 Eskisehir TURKEY
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Dr. Adam Bates 26 Sumburgh Road SW12 8AJ London ENGLAND UK
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Prof. Huseyin Bayramlar Cosnuk Mh. Mehmet Buyruk CD. Turay Ap. 74/4 Malatya TURKEY
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Dr. Costantino Bellusci University Eye Clinic via Massarenti 9 40138 Bologna ITALY
Dr. B. Biedner Dept. of Ophthalmology Soroka Medical Center, Ben-Gurion Univ. of the Negev 84101 Beer-Sheva ISRAEL
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Prof. K.P. Boergen Universitäts-Augenklinik Mathildenstraße 8 80336 München GERMANY
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Dr. C. Bosshard Zuchwilerstr. 43 Box 205 4501 Solothurn SWITZERLAND
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Dr. M. Bourron-Madignier 70, avenue Maréchal de Saxe 69003 Lyon FRANCE
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Dr. I. Boychuk Frantzusky Boulevard, 49/51 270061 Odessa UKRAINE
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Mr. J. Bradbury Lindley House Lindley N. Yorks LS21 2QP ENGLAND UK
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Dr. J. Bendoriene Goduliu 8 LT 3018 Kaunas LITHUANIA
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Prof. M. Brodsky Arcansas Childrens Hospital 800 Marshall Street Little Rock, Arkansa 72202 USA
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Dr. R. Benhamou Chits-Hospital de la Seynes/Mer 83500 La Seynes/Mer FRANCE
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Dr. Anna Broniarczyk-Loba Department of Ophthalmology Medical University Ul. Sienkiewicza 59 90 009 Lodz POLAND
Prof. P.V. Bérard Villa “Atalante” 397, Corniche J.-F. Kennedy 13007 Marseille FRANCE
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Dr. R.M. Brown 17 B Deanfield Limavady Road Londonderry BT 47 1 HY ENGLAND UK
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Prof. E.C. Campos Clinica Oculistica dell´ Università Via Massarenti 9 40138 Bologna ITALY
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Dr. C. Chiesi Clinica Oculistica dell´ Università Via del Pozzo 71 41100 Modena ITALY
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Dr. R. Caputo Via Martiri della Libertà 56020 Orentano (Pisa) ITALY
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Prof. E. Chipont Benavent Pintor Cabrera 27, 3°zda 03003 Alicante SPAIN
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Dr. A.J. Carvalho de Freitas OM Avenida Dr. Antunes Guimaraes 1120 1 4100 Porto PORTUGAL
Dr. D.E. Cioplean B-OUL Constructorilor 14, AP. 56 Bucharest ROMANIA
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Dr. A.R. Castanera de Molina Instituto Castanera Via Augusta 20, 2 08006 Barcelona SPAIN
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Dr. M. Clarke Department of Ophthalmology, RVI Newcastle upon Tyne NE1 4 LP ENGLAND UK
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Dr. D. K. Coats 1102 Bates, #300 (MC 3-2700) Houston, Texas 77030 USA
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Dr. A.M. Castanera de Molina Instituto Castanera Freixa 5-9, bajos 08021 Barcelona SPAIN
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Dr. J.C. Castiella Acha Gardoqui 1 48008 Bilbao SPAIN
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Dr. J. Coimbra de Matos Rua de Alcantara 221 4350-025 Porto PORTUGAL
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Mrs. Giovanna Cattini Via Amundsen 6 20148 Milano ITALY
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Dr. M. Cordonnier Hospital Erasme-U.L.B. 808 Route de Lennik 1070 Bruxelles BELGIUM
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Dr. N.R. Cota St. Helens Hospital Department of Ophthalmology Marshalls Cross Road Merseyside WA9 3DA ENGLAND UK
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Prof. Serdal Celebi Abant Izzet Baysal University Izzet Baysal Medical Faculty Golkoy/Bolu TURKEY Prof. Dr. Maria Celic ul. V. Vidrica 31/III. HR-10000 Zagreb KROATIEN
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Dr. M. Couderc-Devaux 9, Rue de Civry 75016 Paris FRANCE
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Prof. R.A. Crone Reguliersgracht 1 1017 LJ Amsterdam THE NETHERLANDS
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Dr. I. de Veuster Berentrodedreef 33 2820 Bonheiden BELGIUM
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Prof. M. D’Esposito Clinica Oculistica Il Facoltà di Medicina Via Capella Cangiani 5 80131 Napoli ITALY
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Dr. A. Debackere Alfred Nichelsstraat 4 9300 Aalst BELGIUM
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Dr. M. Da Conceição Neves Rua Sousa Lopes, Lote P. Q. 161 1600-207 Lisboa PORTUGAL
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Prof. M. Deller Montbenon 2 1003 Lausanne SWITZERLAND
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Dr. A. Damanakis 119 Vas. Sofias Ave. 115 21 Athens GREECE
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Prof. D.L.G. Denis Hospital Nord Chemin des Bourrely 13015 Marseille FRANCE
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Dr. E. Danieliene Kregzdziu 30 Vilnius 2040 LITHUANIA
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Dr. Susana Di Pierro Avda Italia 2565 11600 Montevideo
Dr. C. Daunius Kasenallén 8 B 46260 Vänersborg SWEDEN
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Mrs. Helen Davis University Department of Ophthalmol. Royal Hallamshire Hospital Glossop Road Sheffield S10 2JF ENGLAND UK
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Prof. W. de Decker Universitäts-Augenklinik Hegewischstraße 2 24105 Kiel GERMANY
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Dr. J.H.N. de Faber Eye Hospital Rotterdam Schiedamsevest 180 3011 BH Rotterdam THE NETHERLANDS
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URUGUAY
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Dr. M. Di Pietro Via Casare Vivante, 9 95124 Catania ITALY
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Dr. A. Dickmann Via Vittorio Montiglio, 7 00168 Roma ITALY
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Dr. M. Dostalek Hrbitouni 1026 560 02 Czeska Trzebova CZECH REPUBLIC
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Dr. E. Dreisler Laegehuset Vognporten 6 2620 Albertslund DENMARK
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Dr. Ulla Dreisler Laegehuset Vognporten 6 2620 Albertslund DENMARK
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Dr. C. Duncombe-Poulet 18 Rue Constant Forget 14000 Caen FRANCE
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Dr. P.A. Evens Lakenslaan 36 1090 Brussels BELGIUM
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Prof. Yasar Duranoglu Akdemiz Universitesi Tip Fakultesi 602 Hastaliklari Anabilim Dali TURKEY
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Dr. G. Fabian Floragatan 11 A 72461 Vasteras SWEDEN
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Dr. O. Ehrt Kranzhornstraße 19 81825 München GERMANY
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DR. Azadeh Farahi 139 Fathi Shaghaghi St. Tehran IRAN
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Mr. John Elston The Oxford Eye Hospital Radcliffe Infirmary Woodstock Road Oxford OX2 6HE ENGLAND UK
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Mr. P. Fells Hill View, 67 North Road Southwold IP18 6BH ENGLAND UK
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Prof. Dr. Nazan Erda Trakya Üniversitesi Talatpasa c. 118/8 22100 Edirne TURKEY
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Dr. Feray Feray Koc Kuzgun Sok. 4813 A.Ayranci 06540 Ankara TURKEY
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Dr. Dilek Erkan Ondokuz Mayis University School of Medicine Department of Ophthalmology 55139 Samsun TURKEY
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Dr. Dora Fernandez-Agrafojo Consultorios 156-157 Teknon Vilana n.12 08022 Barcelona SPAIN Dr. D. Ferraretti Via Roma 32 40017 S. Giovanni in Persiceto ITALY
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Dr. Heikki Erkkilä Helsinki University Eye Hospital PB 220 00290 Helsinki FINLAND
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Dr. J. Esser Goldfinkstraße 20 45134 Essen GERMANY
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Dr. U. Flüeler Asylstraße 81 8032 Zürich SWITZERLAND
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Dr. C. Estivin rue de la Dolve 17 37000 Tours FRANCE
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Prof. M.M. Fodor Maria Utca 39 1085 Budapest HUNGARY
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Dr. Birsen Gökyig˘it Tekfen Sitesi Yagmur Apt. DS, Ulus Etiler 80600 Istanbul TURKEY
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Dr. P. Gomez de Liaño Nunez de Balboa 81, 2° A 28006 Madrid SPAIN
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Dr. R. Gomez de Liaño Fortuny 51 28010 Madrid SPAIN
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Prof. R. Frosini Clinica Oculistica dell´ Università Viale Morgagni 85 50134 Firenze ITALY
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Dr. F. Gomez Villaescusa Artes Graficas 10 46010 Valencia SPAIN
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Dr. S. Frosini 90/5 Via Simone Martini 50142 Firenze ITALY
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Dr. J. Gonzalez-Martin 202 c Waterloo Warghouse Waterloo Rd Liverpool L30BH ENGLAND UK
Dr. J. Garcia de Oteyza C/Dr. Carulla 31-33 08017 Barcelona SPAIN
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Dr. G.P. Gracis Via Cernaia, 22 10122 Torino ITALY
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Dr. Ch. Gerard 25 Rue Voltaire 42100 St. Etienne FRANCE
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Dr. M. Gräf Roonstraße 29 35390 Giessen GERMANY
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Dr. M. Goberville 61, rue de Rennes 75006 Paris FRANCE
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Dr. M.A. Granate Rua Jorge Pasticho 6, 3° 1900-272 Lisboa PORTUGAL
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Mrs. D. Godts Dodoensstraat 31 2140 Antwerp BELGIUM
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Dr. N. Gravier 10 rue Sarrazin 44000 Nantes FRANCE
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Dr. Ibrahim Gokcen 36 ADA ATA 2/2 Daire:92 Atasehir Kadikoy Istanbul TURKEY
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Dr. Brian Greaves Swan House 15 Church Street WIE TH 25 5BM Amsford Kent ENGLAND UK
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Dr. A. Franceschetti 1, J.-D. Maillard 1217 Meyrin SWITZERLAND
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Dr. Michela Fresina University Eye Clinic via Massarenti 9 40138 Bologna ITALY
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Dr. R. Friling 2 Ben-Chaim St. Ramat-Hasaron 47261 ISRAEL
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Dr. Brian Greaves Swan House 15 Church Street WIE TH 25 5BM Amsford Kent ENGLAND UK
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Dr. Paul I. Grecu Spitalul Clinic de Oftalmologie Piata Lahovari Nr. 1 Sectorul 1 Bucharest ROMANIA
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Prof. E. Gregersen Langs Hegnet 22 B 2800 KGS. LYNGBY DENMARK
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Miss H. Griffiths 12 Nethergreen Road Sheffield, South Yorkshire S11 7EJ ENGLAND UK
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Mrs. Mari Gutter Hoqeschool v Utrecht Fac. Gezandheidzaky afd. Orthoptie Bdagnalaas 101 3584 CJ Utrecht THE NETHERLANDS
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Prof. W. Haase Bramkoppel 1 c 22395 Hamburg GERMANY
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Dr. C.A. Habault 70, avenue de Saxe 69003 Lyon FRANCE
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Dr. E. Hadjadj Hospital Nord Chemin des Bourrelys 13015 Marseille FRANCE
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Dr. Marianne Haim Holmegaardsvej 20 8270 Hoejbjerg DENMARK
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Dr. Ossama Hakim Department of Pediatric Ophthalmology and Strabismus El Maghaty Eye Center P.O Box 655 Madina Munawara K. SAUDI ARABIA
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Dr. Hikmet Hasiripi Ataturk Bulvari n. 169/30 06680 Bakanliklar Ankara TURKEY
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Dr. W. Hassan Hassan 187 Rue El Guish Cairo EGYPT
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Dr. O.H. Haugen Department of Ophthalmology Haukeland University Hospital 5021 Bergen NORWAY
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Mrs. W. Hentschel-Beilner Av Independencia, 172 s/1201 Porto Alegre, RS 90035-070 BRAZIL
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Prof. V. Herzau Universitäts-Augenklinik Schleichstraße 12 72076 Tübingen GERMANY
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Dr. Margareta Hok Wikstrand The Eye Department Sanlgrenska University Hospital 43180 Molndal SWEDEN
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Dr. Jonathan M. Holmes MAYO CLINIC 200 First Street Southwest Rochester, Minnesota, 55905 USA
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Dr. G. Holmström Department of Ophthalmology Uppsala University S-75185 Uppsala SWEDEN
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Dr. J. Holst Pilestredet 15 0164 Oslo NORWAY
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Mrs. J. Hoole 22 Friar Close Stannington Sheffield 56 GEP ENGLAND UK
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Dr. S. Hortensia University Clinical of Navarra PIO XII, 35 31080 Pamplona Navarra SPAIN
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Dr. W.A. Houtmann Rijksstraatweg 106 9756 AJ Glimmen THE NETHERLANDS
Dr. P. Jakobsson Department of Ophthalmology University Hospital 58185 Linkoping SWEDEN
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Dr. A. Jampolsky The Smith-Kettlewell Eye Research Institute 2318 Fillmore Street San Francisco, CA 94115-1813 USA
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Dr. V. Jonsson Fannborg 7-9 IS-200 Kópavogur ICELAND
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Dr. Bernadette Hutsebaut Frans Reinemundlei 14 2900 Schoten BELGIUM
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Dr. B. Kaczmarek Ul. Radzikowskiego 77/51 31-315 Krakow POLAND
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Dr. S. Ignotiene Rudens 2-21 Vilnius 2055 LITHUANIA
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Dr. H.J. Kaiser Universitäts-Augenklinik Mittlere Straße 91 CH-4012 Basel SWITZERLAND
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Dr. N. Ikonomopoulos Solonos Str. 129 Athens GREECE
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Dr. Sebnem Kargi Karaelmas Universitesi Tip Facultesi Goz Hastaliklari Ad. Zonguldak TURKEY
Dr. Asli Inal Emichan cad. Seher ap. N.127/16 Dikilitas-Besiktas Istanbul TURKEY
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Prof. H. Kaufmann Universitäts-Augenklinik Friedrichstr. 18 35385 Giessen GERMANY
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Dr. K. Ioannakis Argyrokastrou 12 68100 Alexandroupolis GREECE
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Dr. H. Keller Elfenaustraße 35 3074 Muri/Bern SWITZERLAND
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Dr. S. Isenberg Jules Stein Eye Institute /Ucla 100 Stein Plaza Los Angeles, CA 90095 USA
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Prof. Dikici Kemal Darussafaka Yolu Cankent Sitesi B Blok Drive 10 80670 Maslak/Istanbul TURKEY
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Dr. E. Lala Gitteau 130 Rue Salangro 3700 Tours FRANCE
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Dr. K. Landau Augenklinik Universitätsspital Zürich 8091 Zürich SWITZERLAND
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Prof. J. Lang Höhenstraße 24 8127 Forch SWITZERLAND
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Prof. G. Kommerell Kandelstraße 4 79211 Denzlingen GERMANY
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Prof. A. Langmann University of Graz Dept. of Ophthalmology Auenbruggerplatz 4 8036 Graz AUSTRIA
Dr. A. Kostakis 17 B Eslington Terrale Newcastle Upon Tyne NE2 4RL ENGLAND UK
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Mrs. V. K. Lantau Velazquezstraat 5 1077 NG Amsterdam THE NETHERLANDS
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Dr. L. Kowal 19 Simpson Street East Melbourne, Victoria, 3002 AUSTRALIA
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Dr. G. Lasorella Via De Gasperi 12 53100 Siena ITALY
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Dr. A. Kubatko Zielinska Ostatnia 2D/68 31-444 Krakow POLAND
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Dr. Francoise Lavenant-Oger Rue Dobree 2 BIS 44100 Nantes FRANCE
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Dr. Sedef Kutluk Ahmet Rasim Sokak n. 10/9 Cankaya/Ankara TURKEY
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Mr. J.P. Lee 165 Camberwell Grove London SE 5 8 JS ENGLAND UK
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Dr. G. Robert La Roche 5850 University Avenue B3J 3 G9 Halifax CANADA
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Dr. D. Lengyel Dept. of Strabology Kantonsspital St. Gallen SWITZERLAND
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Dr. G. Ladenvall Ögonkliniken Södra Älvsborgs Sjukhus Boras Iasarett 501 82 Boras SWEDEN
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Dr. Kadircan H. Keskinbora Incirli Cad. 43-5 Bakirkoy 34740 Istanbul TURKEY
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Dr. G. Klainguti Hopital Ophtalmique Universitaire Avenue de France 15 1004 Lausanne SWITZERLAND
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Prof. G. Kolling Universitäts-Augenklinik Im Neuenheimer Feld 400 69120 Heidelberg GERMANY
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Prof. E. Leonardi Via E. Ximenes 3 00197 Roma ITALY
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Dr. I.B. Marsh 86 Rodney Street Liverpool, L1 9AR ENGLAND UK
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Dr. Magda Lena Leys J. Hendrickxstraat 57 2900 Schoten BELGIUM
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Dr. L. Lindberg Dept. of Ophthalmology Helsinki University Central Hospital 00029 HUS FINLAND
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Dr. Wendy Marshman 320 Victoria Parade, Suite 113 East Melbourne 3002 Victoria AUSTRALIA
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Dr. S. Lindner Universitätsaugenklinik Graz Auenbruggerplatz 4 A-8036 Graz AUSTRIA
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Dr. A. Mataftsi Hopital Ophtalmique Jules Gonin Av. de France 15 1044 Lausanne SWITZERLAND
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Dr. J.-L. Llamas Clinique Sourdille 8, Rue Camille Flammarion 44000 Nantes FRANCE
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Mrs. Ann McIntyre Moorfields Eye Hospital City Road London, ECV 2PD ENGLAND UK
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Prof. B. Lorenz Universitäts-Augenklinik Franz-Josef-Strauß-Allee 11 93053 Regensburg GERMANY
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Dr. E. Milan S. S. Padana Sup. 160 36100 Vicenza ITALY
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Dr. Igor Loskoutov 111 116 PO Box 5 Moscow RUSSIA
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Dr. Silvia Moguel G. Mancera 1023 Col. Del Valle Mexico D.F. 03100 MEXICO
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Dr. A. Magalhaes R. António Praca 42-50/Canidelo 4400-366 Vila Nova de Gaia PORTUGAL
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Dr. N. Morelle Ophtalasne SPRL Route D´Ottignies 40 1380 Lasne BELGIUM
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Prof. A. Magli Via Mergellina 44 Napoli ITALY
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Prof. H. Mühlendyck Universitäts-Augenklinik Robert-Koch-Str. 40 37075 Göttingen GERMANY Dr. M. Nardi Piazza Varanini 2 55100 Lucca ITALY
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Dr. G.B. Marcon OM Via Bortolo Zonta 14 36061 Bassano del Grappa (VICENZA) ITALY 406
Dr. Meir Neufeld 49 Hagefen Str., P.O.B. 1539 Efrat-90435 ISRAEL
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Dr. Meir Neufeld 49 Hagefenstr. P.O Box 1539 90435 Efrat ISRAEL
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Dr. Ahmet F. Nohutcu Rumeli Cad. Itir Sokak Kristal Han 2/15 Nisantasi-Istanbul TURKEY
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Prof. G.K. von Noorden 3040 Grand Bay Blvd. 263 Longboat Key, FL 34228 USA
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Dr. Mehdi Suha Ogut Acibadem PK 226 81020 Istanbul TURKEY
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Prof. Dr. Velittin Oguz Polat T.R. Yesil Gimen Sok N. 4 D 324 Fulya Sisli, Istanbul TURKEY
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Dr. Sumru Sumru Onal Marmara Universitesi Tip Fakultesi Hastanesi Goz Hastaliklari A.D. Tophanelioglu Cad. n.13/15 34660 Altunizade Istanbul TURKEY
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Dr. Himli Or Valikonagi Cad. Sinoplu Sehit Cemal Sok. Ege Apt. B Blok. 7/5 TR-34365 Nisantasi-Istanbul TURKEY
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Dr. Sibel Oto OM Baskent University School of Medicine Department of Ophthalmology Fevzi Cakmak Blv. 10. sok. No: 45 Bahcelievler, Ankara TURKEY 407
Dr. Asli Ozbek Zuhuratbaba Mah. Hudaverdi Sok. Super Apt. N.35/8 Bailirkoy-Istanbul TURKEY
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Dr. S.B. Özkan Adnan Menderes Üniversitesi Tip Fakültesi Göz Hastaliklari A. D. 09010 Aydin TURKEY
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Dr. Y enice Ozkm Aucilar cod Eser Apt. N. 27/10 Ideakpe-Istanbul TURKEY
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Dr. Aslihan Ozturk Semsettin Gunaltay cod. N. 78/8 Sungun Apt. N. 78/8 Erenkoy-Istanbul TURKEY
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Prof. G.P. Paliaga Viale Masia 97 22100 Como ITALY
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Dr. V. Paris La Campagnette 1 6900 Marche-en-Famenne BELGIUM
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Dr. S. Paruliene 8, Avenue Victor Hugo L-1750 Luxembourg G.D. of LUXEMBOURG
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Mrs. F. Passador Valério Rua Maestro Francisco Fortunato, 52 Presidente Prudente Sao Paulo BRAZIL
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Dr. T.O. Paul 135 Marina Blvd San Francisco, CA 94123-1202 USA
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Prof. E. Paysse 6621 Fannin CCC 640.00 Houston, Texas 77030 USA
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Prof. A. Pechereau Service d’Ophtalmologie Hotel Dieu 44035 Nantes Cedex FRANCE
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Dr. S. Pelle Pandy Kalman Hospital Semmelweis u. 1 5700 Gyula HUNGARY
Prof. M.A. Quére Centre Hospitalier Régional 44035 Nantes Cedex FRANCE
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Dr. C. Rechichi Parco Fiamma, 14 891126 Reggio Calabria ITALY
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Dr. Andrea Piantanida Via Baragiola 5 22012 Cernobbio/Como ITALY
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Mrs. Isabel Maria Reich-d´Almeida Rua Frei Amader Arrais Rua Castilho 167-5-D 1070-050 Lisbon PORTUGAL
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Dr. F. Pincon 23, Rue Montbazon 3300 Bordeaux FRANCE
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Prof. F. Reich-d’Almeida Rua Frei Amader Arrais Rua Castilho, 167-5-D 1070-050 Lisbon PORTUGAL
Dr. J.W. Pott Dept. of Ophthalmology University Hospital Groningen P.O box 30001 9700 Groningen THE NETHERLANDS
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Dr. R. Reydy 45, Boulevard André Aune 13006 Marseille FRANCE
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Dr. S. Prinsen Dascottelei 5 2100 Deurne BELGIUM
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Prof. Nabie Reza Abassi Avenue Nikookari Eye Hospital Tabriz IRAN
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Dr. Lidia Puchalska-Niedbal Al. Wojska Polskiego 147 70-490 Stettin POLAND
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Dr. J.F. Ribeiro Breda R. Agostinho de Campos 351-6 D 4200-018 Porto PORTUGAL
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Dr. D. Puertas Bordallo C/Condado De Trevino 2 PTDL 2 5° G 28033 Madrid SPAIN
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Dr. J.M. Rodriguez el Sotillo n° 37 28043 Madrid SPAIN
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Mrs. C. Puga R. Luis de Camoes, 36 2000-116 Santarém PORTUGAL
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Prof. P. Roggenkämper Universitäts-Augenklinik Sigmund-Freud-Straße 25 53105 Bonn GERMANY
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Dr. P.E. Romano Post Office Box 3727 740 Piney Acres Circle Dillon, CO 80435-3727 USA
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Dr. Torleif Pugesgaard Snekkerupvej 40 4140 Borup DENMARK
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Dr. M. Roosdorp 376 Channing Way Alameda, Ca 94501 USA
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Dr. Kamoun Samira Marrakchi 11 Rue Limam Ibn Arafa El Menzah 8 1004 Tunis TUNESIA
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Prof. A. Roth Universitäts-Augenklinik 25, Chemin de Grand Donzel 1234 Vessy SWITZERLAND
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Dr. B. Samuelsson V. Kyrkogatan 2 B 262 OO Angelholm SWEDEN
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Dr. F. Roulez-Iven 144 Rue de la Lasne 1380 Lasne BELGIUM
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Dr. H. Sanchez Tocino Hospital Rio Hortega Adva Santa Tetesa 47006 Valladolid SPAIN
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Dr. F. Rowe 2 Bollin Close, Lymm Cheshire WAI3 9PZ ENGLAND UK
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Dr. A. Sansonetti Ferrario 2 Quai-du-Cheval-Blanc 1227 Carouge SWITZERLAND
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Prof. W. Rüssmann Universitäts-Augenklinik Joseph-Stelzmann-Str. 9 50937 Köln GERMANY
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Dr. R. Sargent 6/52 E. Princeton Circle Englewood, Colorado 80111 USA
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Dr. Agneta Rydberg Karolinska Institutet St. Eriks Eye Hospital 11282 Stockholm SWEDEN
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Dr. G. Savino C 8° F. Vito 1 00168 Rome ITALY
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Dr. L. Sabetti Via Amelia 24 00181 Roma ITALY
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Dr. C. Schiavi Clinica Oculistica dell´ Università Via Massarenti 9 40138 Bologna ITALY
Prof. R. Sachsenweger Heinzelmannweg 12 04277 Leipzig GERMANY
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Dr. Hesham Salama Madina Road P.O Box 20377 21455 Jeddah K. SAUDI ARABIA
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Prof. Elisabeth Schulz Universitäts-Augenklinik Martinistr. 52 20251 Hamburg GERMANY Dr. E.C. Schwarz Kieler Str. 1 10115 Berlin GERMANY
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Prof. Dr. H. D. Schworm Thuillestraße 45 81247 München GERMANY
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Dr. A. Salerni OM Catholic University of the Sacred Heart L.GO A. Gemelli S-00168 Rome ITALY 409
Dr. N. Sefi Yurdakul Cetas 2 Sitesi A Blok N° 12 Narlidere-Izmir TURKEY
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Dr. A. Soproni Sarköz U. 7/C 1142 Budapest HUNGARY
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Dr. F. Seiwerth-Feric Klinika za ocne Bolesti Medicinskog Fakulteta Svencilista Zagreb YUGOSLAVIA
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Prof. Claude Speeg-Schatz Rue Imlin 3 67100 Strasbourg FRANCE
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Dr. L. Sellami 7 Rue du Doctore Denoyelle 37000 Tours FRANCE
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Dr. Annette Spielmann 11, Rue de la Ravinelle 54000 Nancy FRANCE
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Dr. E. C. Sener Dept. of Ophthalmology Hacettepe University Hospitals 06100 Ankara TURKEY
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Dr. Alain Spielmann 11, Rue de la Ravinelle 54000 Nancy FRANCE
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Dr. D. A. Shawki Prof. of Ophthalmology Alexandria University 9, Ramleh Square Alexandria EGYPT
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Prof. M. Spiritus Ophthalmology Cliniques Universitaires St Luc 10, Hippocrate Avenue 1200 Brussels BELGIUM
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Dr. H.J. Simonsz Legmeerstraat 27 NL 1058 NA Amsterdam THE NETHERLANDS
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Dr. Derek Sprunger Midwest Eye Institute 201 Pennsylvania Parkway Indianapolis IN 46280 USA
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Prof. J. Sjostrand Göteborg University Institute of Clincal Neuroscience SU/Mölndal 413 80 Mölndal SWEDEN
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Dr. O.A. Standal Førde Sentralsiuketus Hospital 6807 Førde NORWAY
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Dr. E. Stangler-Zuschrott Hintzerstr. 2/1 1030 Wien AUSTRIA
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Dr. Kemija Slanjankic Rudolfa Vikica L III/I 75000 Tuzla BOSNA-HERCEGOVINA
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Dr. B. Stankovic Institute of Ophthalmology Clinical Centre of Serbia Pasterova 2 11000 Beograd YUGOSLAVIA
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Mr. J. Sloper Moorfields Eye Hospital City Road London EC IV 2PD ENGLAND UK
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Dr. M. I. Stavis 909 Frostwood Suite #334 Houston, Texas 77024 USA
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Mr. I. Strachan 287 Glossop Road Sheffield ENGLAND UK
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Mrs. Chris Timms Eye Department Hospital for Children Great Ormond Street WCIN 3JH London ENGLAND
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Prof. K. Süheyla EGE Univ. School of Medicine Dept. of Ophthalmology Bornova-Izmir TURKEY
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Dr. M. Tjon-Fo-Sang Schiedamse Vest 180 3011 BH Rotterdam THE NETHERLANDS
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Dr. R.J. Szpytma 1/6 Targowa str. 30 529 Krakow POLAND
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Dr. Hayati Tolun Dunia Goz Hastanesi Aydin Sok. N. 1 Levent-Istanbul TURKEY
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Prof. Mohamed Reza Talebnejad Khalili Hospital Department of Ophthalmology Shiraz IRAN
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Dr. B. Trigaux Rue des Remparts, 2-25 B-4500 HUY BELGIUM
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Dr. Bernard Tapiero 68 Rue du Palais Gallien 33000 Bordeaux FRANCE
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Dr. Gregorios Tsopakis 25, Averof Street 71201 Iraklion-Crete GREECE
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Dr. R. Taylor York District Hospital Wigginton Road York YO31 8HE ENGLAND UK
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Dr. L. Tychsen Washington University Eye Center Campus Box 8096, 660 S. Euclid Ave. St. Louis, MO 63110-1093 USA
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Dr. Luminita Anamaria Teodorescu Pache Protopopesu B-dv N. 56, Sect II, Bucharest ROMANIA
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Dr. Heleen van der Marel Vijverweg 10 6133 AN Sittard THE NETHERLANDS Mrs. Josè van Nouhuys Carisini-Wilhelmina Hospital P.O. Box 9015 6500 G.S. Nymegen THE NETHERLANDS
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Dr. Anne Vanheesbeke 4 Chemin de Baudemont 1400 Nivelles BELGIUM
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Dr. D. Thouvenin 76, Allée Jean Taurés 31071 Toulouse Cedex FRANCE
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Dr. V. Tilleul-Hatwell 31 Avenue Jean Lolive 93500 Pantin FRANCE
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Dr. S. Verhulst Sierkerslaan 44 2940 Stabroek BELGIUM
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Dr. M. Lourdes Vieira de Freitas Estrada do Calhariz de Benfica, Lote 1-5° Esq 1500 Lisbon PORTUGAL
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Mrs. Jane Walker Hospital for Sick Children Great Ormond Street London WC1N 3JH ENGLAND UK
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Dr. O. Wennhall Ogonkliniken Centrallasarettet 721 89 Vasteras SWEDEN
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Mrs. Joy White Moorfields Eye Hospital City Road London EC 1V2PD ENGLAND UK
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Dr. P.D. Wieser Burgunderstraße 40 4051 Basel SWITZERLAND
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Dr. G. Wirth Barben Augenklinik Universitätsspital Zürich Frauenklinikstrasse 24 CH 8091 Zürich SWITZERLAND
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Dr. E. Wojcik 7/49 Zakatek str. Krakow POLAND
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Dr. Ozge Yabas Sezai Bey Cad. Haydar Rifat Sok. N. 3/4 Baltalimani Istanbul TURKEY
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Dr. Elvan Yilgin Karadeniz Cad. Aquacity 2 Etap 83 Parsel Meridyen 4. D.4 A. Dudullu Istanbul TURKEY
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Dr. Basak Yılmaz Deli Huseym Pasa Cad. Bingaller Apt. N. 17/3 Bancelievler Istanbul TURKEY
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Dr. Demel Yuksel Au. General Lobau, 30 1380 Lasne BELGIUM
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Dr. N. Ziakas 93 Metropoleos Str. 54622 Thessaloniki GREECE
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Dr. Zibrandtsen Vilhelsaebsvej 5 2920 Charlottenlund DENMARK
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Dr. S. Ziylan Halaskargazi cd. Muruvvet apt. 323-325/3 sisli 80860 Istanbul TURKEY
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Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9
Author Index
Aasuri, M.K. 165 Acheson, J.F. 117 Adams, G.G.W. 117 Addison, P. 61 Agrafojo, D.F. 255 Akar, S. 121, 125, 147, 177, 251, 265, 269, 275, 279, 303, 309, 375 Akarsu, N. 351 Akyol-Salman, I. 29 Alavi, A. 45, 143, 155 Altıeri, M. 61 . Altinsoy, H.I . 185, 355 Altintas¸, Ö. 195, 199, 247 Aras, T. 217 Arslan, U. 15, 203 Arslankurt, M. 29 Assaf, A. 61 Atarzadeh, A. 45, 155 Atilla, H. 15, 203, 207 Attarzadeh, A. 45, 155 Autrata, R. 359, 365 Aydeniz, G. 347 Aydın, S. 49 Aykol-Salman, I. 191
Çag˘lar, Y. 195, 199, 247 Campos, E.C. 35, 173 Can, E. 207 Çelebi, S. 185 Ceyhan, D. 355 Chang, J.H. 295 Chang, Y.-H. 295 Chatterjee, S. 61 Cho, Y.A. 231 Cioplean, D. 105, 153 Claeys, J. 95
Balcı, Ö. 213 Banihashemi, A. 159 Barrio, M. 261 . Bartz¯ -Schmidt, K.V. XXIX Bas¸ar, E. 217 Basoglu, A. 265 Bates, A.C. 117, 169 Batiog˘lu, F. 207 Baykal, O. 29, 191 Bayraktar, S.M.Z. 355 Bayraktar, Z. 309 Bellusci, C. 35, 173 Benassi, M.G. 35 Bilska, C. 289 Bolzani, R. 35 Boychuk, I.M. 227 Bruenech, J.R. 91 Broek, van den, P.Ph. 237 Broer van Dijk, M. 283
Ehrt, O. 243 Eldem, T. 113 El-Hag, Y.G. 71 Eliaçik, M. 251 Elibol, O. 247 Engle, E.C. 351 Enrile, P.M. 255 Erdog˘an Bakar, E. 339 Erdurman, C. 355 Eren, G. 303 Erkam, N. 15, 203, 207
D’Alessandri, L. 331 Daruga, I. 381 Davis, A. 3 Dawson, E. 53, 235, 335 dell’Omo, R. 181 Demirci, G. 199 Dickmann, A. 181 Dinçer, G. 7 Dogan, M. 177 Duifhuizen–Visscher, W. 385 Dursun, O. 29 Durukan, H. 7 Duzcan, F. 371
Fabré, J.P. 255 Farvardin, M. 143, 155, 159 Faber, de, J.T. H.H. XIII, 237 Fernandez, Y. 261 Fiasca, A. 331 Franco Iglesias, G. 99 Fresina, M. 173 413
Garnham, L. 33 Gedık, s¸. 113 Genol, I. 261 Gezer, A. 137, 213 Gibson, A. 61 Godts, D.J.M. 95 Gök, K. 121 Gökyig˘it, B. 121, 125, 147, 177, 251, 265, 269, 275, 279, 303, 309, 375 Gomez de Liaño, P. 99 Gomez de Liaño, R. 99, 261 Guccione, L. 181 Guyton, D.L. 81 Hakim, O.M. 21, 71 Han, S.H. 295 Hayden, C. 169 Hekimhan, P.K. 147 Herzau, V. XXIX Hoca, S. 381 Hogg, C. 3 Holder, G. 3 . I.brahim Altinsoy, H. 7 Idil, A. 15 Iglesias, I. 261 Inal, A. 275, 279 Inal, B. 275 . Ipek Akyüz Ünsal, A. 57 Kaczmarek, B. 287, 289 Karabas¸, L. 247 Karabas¸, V.L. 199 Karabela, Y. 191 Karaman, C.Z. 57 Kargozar, A. 317, 327 Keskinbora, H.K. 131 Kim, S. 231 Kiter, E. 371 Kjellevold Haugen, I-B. 91 Kliffen, M. 237 Kunert, K.S. 239 Karaca, Ç. 113, 291
Lee, J.B. 295 Lee, J.P. 53, 117, 169, 235, 335 Linder, van der, W.J. 385
Petroni, S. 181 . Pociej-z¯ ero, M. 287 Pott, J.W.R. 283 Pulur, N.K. 131
Ma˛ droszkiewicz, A. 287 Maden, A. 343, 347 Mehmet Mutlu, F. 7 Mielke, J. XXIX Moghaddam, A.A.S. 317, 323, 327 Moguel, S. 41, 87 Morgan, M. 3 Mumcuog˘lu, T. 7 Mutlu, F.M. 185, 355
Rashed, T. 317 Ravazi, M.E. 327 ˇ eh˚uˇrek, J. 359, 365 R Roth, A. 77
Neveu, M. 3 Newman, H. 169 Nohutçu, A.F. 307 Noorden, von, G.K. XXIII Öge, Ö.F. 309 Oguz, V. 299 Öner, A. 303 Öner, S. . 307 Onur, I . 199 Oral, O. 265 Orozco, L. 87 Ortak, H.N. 307 Özbek, A. 303 Özden, S. 371 Özkan, B. 195 Özkan, S. 299 Özkan, S.B. 49, 57 Öztürk, A. 309 Öztürk, B.T. 135, 351 Paridaens, A.D.A. 237 Paris, V. 109 Parsa, C.F. 81
Saadat, M. 159 Sabetti, L. 331 Sahare, P. 221, 313 Sainani, A.G. 335 Sainari, A. 53 Salerni, A. 181 Salvatori, K. 331 S¸anaç, A. S¸. 113, 135, 291, 339, 351 S¸atirtav, G. 339 Savino, G. 181 Schiavi, C. 35, 173 Schraepen, P. 95 Schwarz, E.Ch. 239 Sefi Yurdakul, N. 343, 347 Serin, D. 11, 381 S¸ener, E.C. 113, 135, 339, 351 Sezen, F. 213 Sie-Oh, Y.G.L. 283 Singh, J. 165 Sloper, J. 3, 33 Soltan-Sanjari, M. 81 Sönmez, B. 113, 291 Speeg-Schatz, C. 77 Spielmann, A.C. 65 Spiritus, M. XXI Talebnejad, M.R. 45 Tassignon, M.J. 95
414
Tatlipinar, S. 371 Teodorescu, L. 105, 153 Tjon Fo Sang, M. 385 Tolun, H. 299 Topalog˘lu, A.S. 49 Tükel, T. 137 Ugurlu, S. 343, 347 Ünal, N. 279 Ünsal, A. 57 Uysal, Y. 185, 355 Venkateshwar Rao, B. 221, 313 Venkateshwar Rao, R. 165 Vodicˇková, K. 359, 365 Vries, de, B. 211, 283 Walter, H-S. XXIX Wefers Bettink–Remeijer, M. 385 Wójcik, E. 287, 289 Wright, K.W. 21 Wunsch, G. 239 Yıldırım, C. 371 Yabas, Ö. 11, 381 Yamada, K. 351 Yaylali, V. 371 Yazıcı, A. 29 Yi, S. 231 Yigit, A. 381 Yilmaz, B. 251, 375 Yılmaz, Ö.F. 121, 125, 147, 177, 251, 265, 269, 275, 279, 309, 375 Yolar, M. 299 Yüksel, N. 195 Zappe, H. 239 Zıylan, S. 11, 381
