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Biomedical subjects

B J Kushner

Publications and source records attributed to B J Kushner.

At least 37 records · Page 2Linked to original sources
PubMed2000

The usefulness of the cervical range of motion device in the ocular motility examination.

OBJECTIVES: To determine if the cervical range of motion (CROM) device, an instrument designed to assess the range of motion in the cervical spine, may be suited for accurately quantifying the magnitude of a patient's abnormal head posture, limitation of ductions, or range of single binocular vision at distance fixation. METHODS: The CROM device was used to measure abnormal head postures in 10 subjects and limitations of ductions in 12 patients by 2 masked observers. In addition, it was used to test the diplopia field in 17 patients at one third of a meter and 6 m. These findings were compared with a standard diplopia field performed on a Goldmann perimeter. RESULTS: For 10 subjects with abnormal head postures, the findings of the 2 observers had a mean+/-SD difference of 1.0 degrees +/-0.7 degrees (P=.15, paired t test). For the assessment of limitations of ductions, the findings of the 2 observers had a mean+/-SD difference of 1.1 degrees +/-2.6 degrees (P=.17, paired t test). For the 17 patients undergoing diplopia field testing, the results obtained on the Goldmann perimeter and with CROM device at the same test distance were essentially identical (mean+/-SD difference of 1.3 degrees +/-0.95 degrees; P=.88, paired t test); however, there was a significant difference between the results at one third of a meter and 6 m (mean+/-SD difference of 6.0 degrees +/-1.1 degrees for esotropic patients [P=.001]; mean+/-SD difference of 6.0 degrees +/-2.6 degrees for exotropic patients [P=.002]). CONCLUSION: The CROM device seems to be suitable for testing abnormal head postures, limitations of ductions, and the range of single binocular vision. Arch Ophthalmol. 2000;118:946-950

Cervical Vertebrae↗
PubMed1999

Diagnosis and treatment of exotropia with a high accommodation convergence-accommodation ratio.

BACKGROUND: Patients with exotropia often have a slow-to-dissipate fusional mechanism at near, which masks the true near deviation. Consequently, determination of the accommodation convergence-accommodation (AC/A) ratio in patients with exotropia must be based on near measurements obtained after prolonged monocular occlusion (typically 1 hour). When determined in that manner, the presence of a high AC/A ratio before surgery in an exotropic patient has been reported to be predictive of an esotropia at near after surgery. OBJECTIVE: To investigate the diagnosis and management of exotropia with a high AC/A ratio. METHODS: Three hundred four consecutive patients with exotropia were studied. In addition to the usual measurements, measurements were obtained at near after 1 hour of monocular occlusion, with and without additional +3.00-diopter lenses. Also, a gradient AC/A ratio was obtained by using additional minus lenses at distance fixation. RESULTS: One hundred fifty-four (50.7%) of 304 patients would have been thought to have a high AC/A ratio if that diagnosis was based on measurements obtained before prolonged monocular occlusion. In fact, only 22 patients (7.2%) actually had a high AC/A ratio; 132 patients (43.4%) had a pseudo-high AC/A ratio. Six of 22 patients with a high AC/A ratio underwent surgery to correct the exotropia. The presence of a high AC/A ratio before surgery had sensitivity, specificity, and positive and negative predictive values of 100% for predicting a postoperative esotropia at near associated with a high AC/A ratio. The remaining 16 patients with high AC/A ratios were treated with overcorrecting minus lens therapy (including a bifocal). Ten of them have been followed up to at least 18 years of age, by which time 9 have shown normalization of the AC/A ratio. CONCLUSIONS: Near measurements used to calculate the AC/A ratio in exotropic patients must be made after prolonged monocular occlusion. Otherwise, many patients with a pseudo-high AC/A ratio will be thought to have a true high AC/A ratio. The presence of a high AC/A ratio is infrequent in patients with esotropia, but it is highly predictive of a postoperative esotropia at near fixation.

Accommodation, Ocular↗
PubMed1999

Surgical treatment of paralysis of the inferior division of the oculomotor nerve.

BACKGROUND: Paralysis of the inferior division of the oculomotor nerve is relatively rare. Little has been written about its surgical treatment. METHODS: Five patients with paralysis of the inferior division of the oculomotor nerve were treated with transposition of the superior rectus muscle toward the insertion of the medial rectus muscle, transposition of the lateral rectus muscle toward the insertion of the inferior rectus muscle, and tenotomy of the superior oblique tendon in the affected eye. RESULTS: All 5 patients had a satisfactory outcome. They were free of diplopia in the primary position as of their last examination. Follow-up ranged from 3 to 10 years after surgery. CONCLUSION: Paralysis of the inferior division of the oculomotor nerve can be adequately treated by simultaneous transposition of the superior rectus muscle toward the insertion of the medial rectus muscle, transposition of the lateral rectus muscle toward the insertion of the inferior rectus muscle, and tenotomy of the superior oblique tendon in the affected eye.

Adult↗
PubMed1999

Does overcorrecting minus lens therapy for intermittent exotropia cause myopia?

BACKGROUND: Overcorrecting minus lens therapy has been used as a treatment for intermittent exotropia. It is based on the principle that an exotropic deviation will be decreased by stimulating accommodative convergence with additional minus power in spectacles. Because excessive accommodation has been implicated as a cause of myopia, there is theoretical concern that overcorrecting minus lens therapy for exotropia may cause myopia. OBJECTIVE: To investigate the effect of overcorrecting minus lens therapy for exotropia on the progression of myopia. DESIGN: A retrospective chart review. SUBJECTS AND METHODS: Seventy-four patients with intermittent exotropia were treated with overcorrecting minus lens therapy for at least 6 months (6-month treatment group), and a 34-patient subset of them received overcorrecting minus lens therapy for 5 years (5-year treatment group). The mean change in refractive error (spherical equivalent of the fixing eye) of these 2 groups 5 years after initial examination was compared with the mean change in refractive error of a control group of 45 patients with intermittent exotropia who did not receive overcorrecting minus lens therapy. RESULTS: At the time of initial examination, the mean (+/-SD) refractive error was 0.00 +/- 1.40 diopters (D) in the control group, 0.00 +/- 1.50 D in the study group, and -0.10 +/- 1.50 D in the 5-year study group, all of which were essentially identical. Five years after initial examination, the mean change in refractive error was -1.40 +/- 2.80 D in the control group, -1.52 +/- 1.80 D in the 6-month treatment group, and -1.54 +/- 1.80 D in the 5-year treatment group. These differences in the change in refractive error (myopic shift) were not statistically significant (t test), and the differences are clinically unimportant. CONCLUSION: Overcorrecting minus lens therapy for intermittent exotropia does not appear to cause myopia.

Accommodation, Ocular↗
PubMed1999

Diplopia secondary to aniseikonia associated with macular disease.

OBJECTIVE: To provide an explanation for diplopia and the inability to fuse in some patients with macular disease. METHODS: We identified 7 patients from our practices who had binocular diplopia concurrent with epiretinal membranes or vitreomacular traction. A review of the medical records of all patients was performed. In addition to complete ophthalmologic and orthoptic examinations, evaluation of aniseikonia using the Awaya New Aniseikonia Tests (Handaya Co Ltd, Tokyo, Japan) was performed on all patients. RESULTS: All patients were referred for troublesome diplopia. Six of the patients had epiretinal membranes and 1 had vitreomacular traction. All 7 patients had aniseikonia, ranging from 5% to 18%. In 5 of the patients the image in the involved eye was larger, and in the other 2 patients it was smaller than in the fellow eye. All patients had concomitant small-angle strabismus and at least initially did not fuse when the deviation was offset with a prism. Response to optical management and retinal surgery was variable. CONCLUSIONS: Aniseikonia caused by separation or compression of photoreceptors can be a contributing factor to the existence of diplopia and the inability to fuse in patients with macular disease. Concomitant small-angle strabismus and the inability to fuse with prisms may lead the clinician to the incorrect diagnosis of central disruption of fusion. Surgical intervention does not necessarily improve the aniseikonia.

Adult↗
PubMed1999

Ocular torticollis and facial asymmetry.

OBJECTIVE: Ocular torticollis secondary to congenital superior oblique palsy can be associated with facial asymmetry. The purpose of this study was to determine if other ocular causes of head tilting also carry the same association. DESIGN: The study design was clinical evaluation of patients. PARTICIPANTS: Fifteen patients with marked, moderate, or mild head tilts associated with dissociated vertical deviation (DVD), and 3 patients with nystagmus and a torsional null point. A control group was comprised of 3 patients with congenital superior oblique palsy, 3 with traumatic superior oblique palsy, and two normal patients. INTERVENTION: A masked observer analyzed full-face photographs of the subjects. MAIN OUTCOME MEASURE: The presence of facial asymmetry. RESULTS: Facial asymmetry due to bending in/of the sagittal plane of at least two degrees was found in 3 of 4 patients with a marked head tilt from DVD, in 2 of 5 five patients with a moderate head tilt from DVD, in one of 3 patients with a head tilt due to nystagmus, and in one of 3 patients with a head tilt due to congenital superior oblique palsy. None of the patients with a mild head tilt from DVD, traumatic superior oblique palsy, or the normal controls had clinically noticeable facial asymmetry. CONCLUSION: Facial asymmetry can be associated with abnormal head postures, specifically, large head tilts from DVD or nystagmus.

Facial Asymmetry↗
PubMed1998

The distance angle to target in surgery for intermittent exotropia.

BACKGROUND: Patients with intermittent exotropia may have an increase in their angle of strabismus in the distance when the angle is measured either after 1 hour of monocular occlusion or while the patients fixate on a distant target outdoors. The hypothesis that surgery should be performed for this larger deviation has been suggested but not tested. OBJECTIVES: To test the hypothesis that surgery should be performed for the increased angle of strabismus in the distance in patients with intermittent exotropia and to investigate the factors that influence the angle of misalignment. METHODS: A prospective, clinical trial was conducted of patients with intermittent exotropia in whom the angle of misalignment in the distance increased after 1 hour of monocular occlusion or while the patients fixated on an outdoor target. The study group underwent surgery for the largest deviation measured; the control group underwent surgery for the initial angle measured at 6 m. All patients in whom the angle of misalignment increased while the patients were looking at an outdoor target were additionally measured in indoor illumination at 24 m and also at 6 m under floodlights that simulated outdoor illumination. Ninety patients undergoing surgery were randomized. RESULTS: Forty-three (86.0%) of the 50 patients undergoing surgery for the largest angle measured had a satisfactory outcome vs 25 (62.5%) of the 40 patients in the control group (P<.001). The mechanism for the increase in exotropia while fixating on an outdoor target was studied in 76 patients, and the results were variable. CONCLUSIONS: The angle of strabismus in patients with intermittent exotropia undergoing surgery should be measured while the patients fixate on an outdoor target and after 1 hour of monocular occlusion. Surgery should be performed for the largest angle measured.

Accommodation, Ocular↗
PubMed1998

Selective surgery for intermittent exotropia based on distance/near differences.

BACKGROUND: Classic teaching suggests that surgery for intermittent exotropia should be based on distance/near differences. Divergence excess, according to tradition, should be treated with symmetric lateral rectus recessions; simulated divergence excess and basic deviations should be treated with a recess/resect procedure. This teaching, to our knowledge, has not been systematically tested. OBJECTIVES: To evaluate the appropriateness of selective surgery based on distance/near differences and to determine if bilateral lateral rectus recessions affect the distance deviation more than the near deviation. PATIENTS AND METHODS: Patients with basic type intermittent exotropia were randomized to 2 groups, those receiving either unilateral recess/resect procedures or symmetric lateral rectus recessions. Patients with simulated divergence excess intermittent exotropia received symmetric lateral rectus recessions. Outcome was observed 1 year after surgery. RESULTS: Of 19 patients with basic exotropia receiving lateral rectus recessions, 10 patients (52%) had a satisfactory outcome compared with 14 (82%) of the 17 patients who had recess/resect procedures (P<.05). Of the 68 patients with simulated divergence excess, 55 patients (80%) had a satisfactory outcome after bilateral/lateral rectus recessions. This result was significantly better than the outcome for patients with basic exotropia who underwent lateral rectus recessions (P<.05) [corrected]. The decrease in the distance/near difference after surgery was essentially identical for patients with basic exotropia who underwent lateral rectus recessions as for those who received recess/resect procedures (means, 2.4 prism diopters vs 2.1 prism diopters, respectively). CONCLUSIONS: Although this study did not evaluate increasing the amount of symmetric lateral rectus recessions for patients with basic exotropia, these data suggest that patients with basic type intermittent exotropia should be treated with recess/resect procedures. Data also suggest that patients with simulated divergence excess do well with lateral rectus recessions. Recess/resect procedures and symmetric surgery affect distance/near differences equally in patients with basic exotropia.

Adolescent↗
PubMed1998

Distance/near differences in intermittent exotropia.

BACKGROUND: Burian's classification of exotropia based on the difference between the distance deviation and near deviation (distance/near differences) leaves some questions unanswered. Controversy exists concerning whether the divergence excess pattern is caused by an excess of divergence or by excessive accommodative convergence. Much of the literature on this subject has been confusing because investigators did not eliminate tenacious proximal fusion as an artifact in calculating the ratio of accommodative convergence to accommodation (AC/A ratio). Previously, one of us (B.J.K.) proposed a classification system that respected this artifact and subdivided the classification system proposed by Burian. METHODS: A total of 202 consecutive patients with an exotropia underwent a series of measurements to determine the respective role of accommodative convergence and tenacious proximal fusion as a cause for their distance/near differences. In addition, the value obtained by a rapid prism adaptation test as a possible substitute for 1 hour of monocular occlusion was studied. RESULTS: In 98 patients, the initial distance deviation exceeded the near deviation. In 10 patients, the distance/near differences were caused by a high AC/A ratio, which would have been mislabeled by Burian's classification system. Brown's recommendation of using +3.00-diopter lenses at near to diagnose simulated divergence excess would have led to the misdiagnosis of a high AC/A ratio in 61 of these patients. In 26 patients, the near deviation exceeded the distance deviation. Burian's classification would have incorrectly labeled 2 patients as having convergence insufficiency when, in fact, they had pseudoconvergence insufficiency. The new proposed classification system proved 100% sensitive and 100% specific (6 of 6 patients for both parameters) for identifying preoperatively exotropic patients who postoperatively developed an esotropia at near with a high AC/A ratio. Rapid prism adaptation tests at near proved useful for identifying the presence of tenacious proximal fusion, but were not accurate in its quantification. CONCLUSIONS: The validity and utility of the new classification system was confirmed. Identification of exotropic patients with a high AC/A ratio and consideration of nonsurgical treatment is important. The rapid prism adaptation test is qualitatively, but not quantitatively, the same as 1 hour of monocular occlusion.

Accommodation, Ocular↗
PubMed1998

The accuracy of experienced strabismologists using the Hirschberg and Krimsky tests.

OBJECTIVE: The purpose of the study was to assess the accuracy of a group of strabismologists applying the Hirschberg and Krimsky tests. DESIGN: A clinical trial. PARTICIPANTS: Sixteen very experienced strabismologists participated in this study. INTERVENTION: The participants were asked to evaluate slides of four different patients using the Hirschberg method and to evaluate two of the four patients with the Krimsky method. The slides included a patient with 25 delta left esotropia, a patient with 25 delta right exotropia, a patient with 80 delta esotropia with a positive angle kappa, and a patient with 75 delta infantile esotropia. Alternate prism and cover testing was performed immediately after the photograph was taken and considered to be the actual deviation of the patient. MAIN OUTCOME MEASURE: Measured was the accuracy in assessing the angle of strabismus. RESULTS: With the Hirschberg method, each participant underestimated at least one patient by at least 10 delta. In addition, the participants tended to underestimate both large and small angle esotropic and exotropic patients with greater errors of estimation occurring with larger angles of strabismus. With the Krimsky method, a majority of participants overestimated at least one patient by 10 delta and showed difficulty in appreciating differences of 5 delta. In addition, the authors noted inconsistent responses by each participant. CONCLUSION: The Hirschberg and Krimsky methods are substantially less accurate than the alternate prism and cover test.

Adult↗
PubMed1998

The efficacy of SimulVue and Unilens RGP aspheric bifocal contact lenses in the treatment of esotropia associated with a high accommodative convergence/accommodation ratio.

PURPOSE: This was a prospective study assessing the efficacy of the SimulVue bifocal contact lens and the Unilens RGP aspheric multifocal contact lens (Unilens, Largo, Fla.) in the treatment of high accommodative convergence/accommodation (AC/A) esotropia in an adolescent and postadolescent population. METHODS: Those patients meeting the inclusion criteria were fit with contact lenses with use of full cycloplegic refraction and later retested by an examiner masked to the previous binocular status. Particular attention was given to the sensory status and the motor fusion of each patient in their bifocal spectacles and then in their bifocal contact lenses. All patients were followed up for at least 6 months after the contact lenses were fitted. RESULTS: Five of the six patients demonstrated larger angles of esophoria or tropia at near with the contact lenses than with bifocal spectacles. The only patient who maintained excellent stereopsis in bifocal contact lenses was the one who normalized her AC/A ratio during this study and no longer required a bifocal in her spectacle correction for fusion. The two patients who initially had no stereopsis but good alignment in spectacle correction had a large esotropia at near fixation with bifocal contact lenses. CONCLUSIONS: The SimulVue and Unilens RGP aspheric bifocal contact lenses did not adequately treat adolescent patients who had esotropia associated with a high AC/A ratio.

Accommodation, Ocular↗