Binocular vision & strabology quarterly, Simms-Romano's最新文献

Background and purpose: Two siblings diagnosed with Okihiro Syndrome (also named Duane Radial Ray Syndrome) associated with ophthalmic manifestation including Duane Syndrome and retinal nerve fiber layer (RNFL) hypoplasia were presented.

Methods: The first patient (15-years old female) was diagnosed of Duane Syndrome presenting reduction of visual acuity and pale optic discs. She showed a diffuse decrease in the RNFL thickness, mainly in her left eye, retaining the typical RNFL morphology as double hump, demonstrated by OCT and scanning laser polarimetry. Neurophysiology evaluation found a decrease in visual evoked potentials and pattern electroretinogram amplitudes, and an increase of the latency of P100 component. The second patient (12 year-old female) presented with Duane malformation. Both patients underwent a complete ophthalmic evaluation with best corrected visual acuity, visual field examination, optical coherence tomography (OCT), scanning laser polarimetry, visual evoked potentials, pattern electroretinogram, and genetic study.

Results: The neuro-ophthalmic evaluation showed a subclinical reduction of RNFL average thickness provided by OCT and an increase of P50 and N95 latency by pattern electroretinogram. RNFL average thickness presented a score reduction in both patients, without typical glaucomatous morphology.

Conclusions: Our analyses suggest that Okihiro Syndrome may affect retinal nerve fiber layer development and visual acuity.

Background: To evaluate the outcome achieved by using Bangerter filters in cases of mild to moderate amblyopia associated to strabismus.

Methods: Prospective study comprising 30 children (age range 2-9 years) with unilateral mild to moderate amblyopia associated to esotropia and hyperopia. All patients were treated by prescribing the use of a Bangerter filter in the non-amblyopic eye in combination with the refractive correction. In all cases, the filter selected induced a reduction of the visual acuity of 2 lines below the best spectacle-corrected visual acuity (BSCVA) of the amblyopic eye. A follow-up of 12 months was completed.

Results: A statistically significant improvement in BSCVA was observed at 3 months in amblyopic eyes (p 0.01), with additional significant improvements at 6, 9 and 12 months (p 0.02). The BSCVA in non-amblyopic eyes remained unchanged during the initial 6 months of treatment (p 0.52), with a significant improvement at 9 months (p=0.03). Significant differences between amblyopic and fellow eyes were only detected at 3 months (p 0.01). Filter density had to be changed during the follow-up in 12 eyes (40%). Inverse significant correlations between baseline filter density and BSCVA were found at the end of the follow-up (r -0.35, p 0.01). A significant correlation of the visual acuity with the baseline visual acuity difference among eyes was only present at 3 months (r=-0.55, p 0.01).

Conclusions: Bangerter filters seem to be useful for treating mild or moderate amblyopia due to strabismus, but ocular dominance inversion should be maintained during treatment for obtaining an optimized outcome.

Purpose: To evaluate the safety and efficacy of photorefractive keratectomy (PRK) with Mitomycin C (MMC) for the treatment of severe pediatric anisometropia and amblyopia resistant to more conservative treatment modalities.

Methods: A 3 year-old-child, who at 18 months old underwent unilateral diode laser treatment for threshold ROP, developed 11 diopters of anisometropic myopia and secondary dense amblyopia of the Right Eye. Only after all conservative treatment options failed was he treated with PRK and MMC. Principal outcome measures included cycloplegic refraction, the amount of refractive correction, degree of corneal haze and change in visual acuity.

Results: On presentation: BCVA: 20/CF OD; 20/30 OS. CRNS: -11.50 diopters sphere OD; -0.50 diopters sphere OS. Unilateral PRK followed by application of MMC (0.2 mg/ml) for 1 min was performed under general anesthesia. Three-month postoperative findings include: VA: 20/30 OD; 20/25 OS. CRNS: +0.25 diopters sphere OD. At one year, the BCVA remained equal at the 20/30 level despite mild myopic regression OD. CRNS OD at one year was -1.25 +050 x 116. No corneal haze was appreciated.

Conclusion: In this child, treatment with PRK and MMC safely reduced the anisometropia thus facilitating his visual rehabilitation. While encouraging, further study is required to verify the longer term results of this single case.

Purpose: To evaluate the safety and efficacy of photorefractive keratectomy (PRK) with Mitomycin C (MMC) for the treatment of severe pediatric anisometropia and amblyopia resistant to more conservative treatment modalities.

Methods: A 3 year-old-child, who at 18 months old underwent unilateral diode laser treatment for threshold ROP, developed 11 diopters of anisometropic myopia and secondary dense amblyopia of the Right Eye. Only after all conservative treatment options failed was he treated with PRK and MMC. Principal outcome measures included cycloplegic refraction, the amount of refractive correction, degree of corneal haze and change in visual acuity.

Results: On presentation: BCVA: 20/CF OD; 20/30 OS. CRNS: -11.50 diopters sphere OD; -0.50 diopters sphere OS. Unilateral PRK followed by application of MMC (0.2 mg/ml) for 1 min was performed under general anesthesia. Three-month postoperative findings include: VA: 20/30 OD; 20/25 OS. CRNS: +0.25 diopters sphere OD. At one year, the BCVA remained equal at the 20/30 level despite mild myopic regression OD. CRNS OD at one year was -1.25 +050 x 116. No corneal haze was appreciated.

Conclusion: In this child, treatment with PRK and MMC safely reduced the anisometropia thus facilitating his visual rehabilitation. While encouraging, further study is required to verify the longer term results of this single case.

Cyclovertical muscle palsies are very common. We propose rules that help clinicians and resident physicians diagnose easily the affected muscle. We simplified evaluation of the deviation by measuring it only in the cardinal directions of gaze and omit the oblique fields of gaze. Then the Beilschowsky forced head tilt test is done routinely along with measurement of the cyclotorsion by the double Maddox rod test. In oblique muscle palsy, when the vertical deviation is less than 15 prism diopters (PD), the procedure of choice is weakening of the direct oblique antagonist muscle. When the deviation is over 15 PD, the procedure of choice - unless there is spread of comitance - is to weaken, in addition to the antagonist oblique muscle, the contralateral inferior rectus (IR) muscle in superior oblique palsy (SOP) and the contralateral superior rectus (SR) muscle in inferior oblique palsy (IOP). In vertical rectus muscle palsy, the procedure of choice is to weaken the direct antagonist vertical rectus muscle alone when the vertical deviation does not exceed 15 PD. In case it exceeds 15 PD, a recess/resect procedure is done on the vertical rectus muscles. Horizontal rectus muscle transposition surgery is limited to total paralyses of the SR and IR muscles. Spread of comitance is more common in oblique muscle palsy than in vertical rectus muscle palsy. When it takes place, the incomitant vertical deviation in oblique muscle palsy becomes comitant and the rather comitant vertical deviation in vertical rectus muscle palsy becomes incomitant. When cyclotropia is associated with vertical deviation, proper surgery for the vertical deviation almost always corrects the clyclotropia. Isolated cyclotropia is extremely rare in cyclovertical muscle palsies. Despite careful observation to rule out bilaterality, and despite cautious surgery, an apparent palsy of the contralateral superior oblique (SO) may surprisingly and occasionally appear. Nevertheless, surgical overcorrection is not rare.

Background and purpose: Although horizontal extraocular muscle rectus recession is an accepted treatment for abnormal face turn (AFT) in Duane's Retraction Syndrome (DRS), in some situations it can worsen or reverse the AFT. Patients referred to the author with this complication over a 4 year period (2002-2006) were reviewed to identify potential risk factors.

Methods: Retrospective medical record review of DRS patients referred because of reversal and (or) worsening of the preoperative AFT immediately after technically uncomplicated horizontal rectus eye muscle recession surgery.

Results: All five patients (5-9 years old, all girls) preoperatively had unilateral DRS (four Type I, one Type III), with significant co-contraction during attempted ipsilateral adduction, orthotropia in the preoperative AFT, normal vision in both eyes, and no other ophthalmic findings. Four patients had significant postoperative AFT reversal: three DRS Type I patients with original primary position esotropia of 20 prism diopters or less who developed postoperative primary position exotropia after large ipsilateral medial rectus recession (two bilateral, one unilateral), and one DRS Type III patient whose primary position exotropia persisted after moderate bilateral lateral rectus recessions with a posterior fixation myopexy suture to the the contralateral medial rectus muscle. The fifth patient had postoperative worsening of the original AFT: she was a DRS Type I patient with original primary position esotropia of 40 prism diopters who still had significant undercorrected primary position esotropia after large bilateral medial rectus recessions.

Conclusions: The amount of ipsilateral medial rectus recession for treatment of AFT in esotropic unilateral Type I DRS should be limited if significant preoperative co-contraction is present and the degree of primary position esotropia is small; otherwise, a significant reversal of the AFT may occur. Surgical matching of the DRS eye's duction limitation in the unaffected eye (for example, by posterior fixation suture or large recession) can potentially lead to a compensatory face turn in the direction of the duction limitation in the context of postoperative significant primary position strabismus.

Purpose: To report a patient with medial rectus muscle entrapment as a complication of endoscopic dacryocystorhinostomy (EDCR).

Method: A 34 year old female was referred with diplopia 18 days after EDCR for the treatment of primary nasolacrimal duct obstruction. She had a large angle left exotropia in primary position as well as a complete limitation of adduction and partial limitation of abduction of left eye. CT scan showed large fracture of the medial orbital wall in which the medial rectus muscle was entrapped. She underwent multiple procedures in order to release the entrapped muscle as well as management of the diplopia .

Result: Finally the patient had 10 PD exotropia in primary position but could fuse with a small face turn.

Conclusion: Orbital wall fracture with medial rectus extraocular muscle entrapment as a complication of EDCR should be kept in mind.

Purpose: To report 3 rare cases, seen over 15 years, of isolated superior rectus (SR) palsy in binocularly fusing pediatric patients presenting with appropriate head tilts.

Patients and method: All 3 children, ages 11, 16, and 34 mos, presented with large right head tilts and secondary overactions of the right inferior oblique indicating LSR palsy. All 3 children received recessions of the antagonist left inferior rectus (LIR) 8 to 9 mm with 3 mm of nasal transposition to prevent exotropia in down gaze.

Results: All 3 children had zero head tilt 4 weeks after their LIR recessions of 8 to 9 mm, but all 3 children developed a significant contralateral left head tilt three months after their LIR recessions. Two of the 3 them three-stepped to produce a pattern of (previously occult) SR palsy. These 2 received recessions of the RIR 5.8 to 6.5 mm. One of the 3 had a pattern that indicated LIR weakness; his LIR was advanced 2.5 mm from a 9 mm recession to a 6.5 mm recession. No significant head tilts remained or developed anew after the second surgery, but two of the three cases eventually developed apparent primary overactions of the inferior obliques and received successful weakening procedures of the inferior obliques. Due to inclusion in each case of special handling of the intermuscular septa and Lockwoods ligament (for details see later text), none of the 3 children had lower lid retraction after the large IR recessions.

Conclusions: In view of the fact that the superior division of the Third Cranial Nerve also innervates the adjacent levator and these three cases have had no blepharoptosis suggests that these apparently palsied superior rectus muscles may have been congenitally hypoplastic. Classic MRI (Magnetic Resonance Imaging) of the EOM by the techniques of Demer, to confirm this hypothesis, have not been available in these children, because of the current technical limitations of such diagnostic imaging in the case of young children who cannot maintain steady fixation for the time required.