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PubMed2002

Strabological results in patients with macular translocation surgery and counterrotation of the globe as a secondary procedure.

INTRODUCTION: Age-related macular degeneration is the most common cause of irreversible loss of visual acuity, including the ability to read, in elderly patients. One of the surgical treatment options is macular translocation with 360 degrees retinotomy. The orthoptic results of torsional muscle surgery as a second procedure are demonstrated. MATERIALS AND METHODS: Between January 1999 and December 2000, the macula was rotated upward by 12-45 degrees in 10 eyes following complete artificial detachment and a 360 degrees retinotomy. In these patients, torsional surgery was carried out as a second procedure. Depending on the resulting cyclotorsion, we performed surgery on the oblique muscles only in four patients with a cyclotropia of 12-20 degrees and a combination of oblique muscle surgery with surgery of two or four rectus muscles in the remaining six eyes (cyclotropia over 21 degrees ). The pre- and postoperative diagnostic techniques included visual acuity, reading vision and the orthoptic status. RESULTS: Due to the unilateral ectopia of the macula, all patients presented postoperative strabismus with a vertical deviation of 2-10 degrees and a subjective cyclotropia between 12 degrees and 40 degrees. After surgery on the oblique muscles, the patients showed a residual cyclotropia of 0-6 degrees. In patients in whom surgery on the oblique muscles was accompanied by rectus muscle surgery, the remaining cyclotorsion was 5-13 degrees. Four patients excluded the non-operated fellow eye, six patients experienced double vision under binocular conditions and thus required prescription of additional prism glasses. CONCLUSION: Macular translocation causes diplopia under binocular conditions because of the unilateral ectopia of the macular region with cyclotropia and vertical deviation. These problems can be resolved or reduced by oblique muscle surgery or in combination with additional surgery on the rectus muscles, depending on the range of the cyclotorsion. Performing the torsional surgery as a second procedure after macular rotation with an exact preoperative measurement of the subjective cyclodeviation appears to be useful.

Aged↗
PubMed2002

Towards identification of genes in regionally accumulated strabismus.

Strabismus, as an inherited disease, is a new challenge to the geneticist. Various forms of strabismus can be found in distantly related members of the same family, who usually report to local ophthalmologists and orthoptic centers very rarely. In addition, local ophthalmologists and orthoptic centers very rarely pay attention to the genetic aspects of strabismus. Therefore, the recruitment of suitable families to identify the underlying genes is the major drawback in this effort. Further problems arise from the mode of inheritance, which can formally be characterized as autosomal dominant with reduced penetrance in most families, but should be considered as multifactorial inheritance with a threshold combination of mutated alleles. The present paper deals with a method for using local accumulations of strabismus patients to circumvent the problems of small families and rare numbers of affected persons. The steps on the way to the identification of strabismus genes will be described.

Chromosome Mapping↗
PubMed2003

Outcome of ocular motility disturbances in orbital injuries.

AIMS: The purpose of this study was to retrospectively address the referral patterns of patients with orbital injuries presenting to the Orthoptic Clinic, to document the types of injury sustained and corresponding ocular motility defects, and to evaluate the eventual ocular motility outcome of these patients. METHODS: This study documented the findings of orthoptic and ophthalmic investigations, history of orbital injury and surgical details where applicable. Case notes of 30 patients were reviewed, of which 22 had an orbital fracture and eight a soft tissue injury. The severity of injury, referral pattern to either maxillofacial or ophthalmology units, and age at time of injury were compared to eventual ocular motility outcome. RESULTS AND CONCLUSION: Despite there being more patients referred initially to the maxillofacial unit, there was no significant difference in outcome regardless of route of referral, type of injury or age at time of injury. The causes of injury included sports, assault, falls and road traffic accidents.

Adolescent↗
PubMed1986

Medical treatment of nystagmus and ocular motor disorders.

An increased compendium of drugs useful in ocular motor system dysfunction has expanded our capacity to treat selected ocular motility disorders. Adjunctive therapeutic modes (e.g., Fresnel prisms and orthoptic exercises) can also be beneficial. PAN and see-saw nystagmus can be treated with baclofen. Downbeat nystagmus may respond to clonazepam therapy, and prisms may help if the nystagmus can be modified with convergence. Congenital nystagmus may respond minimally to drugs (e.g., baclofen), but prisms or surgical procedures, or both, are still the primary treatment modalities. Innovar may be helpful in patients with severe, incapacitating vestibular disorders, and scopolamine alone or in combination with promethazine may be beneficial in patients with milder ambulatory acute peripheral vestibular disorders. Benign positional vertigo is best treated initially with positional exercises before drug therapy is instituted. Opsoclonus and ocular flutter have been treated successfully with corticosteroids, propranolol, and clonazepam, while microflutter, an extremely rare disorder, can resolve with baclofen. Although therapy with carbamazepine, 5-hydroxtryptophan, and scopolamine has been useful in selected patients with ocular palatal myoclonus, most do not respond to drug treatment. It is not usually necessary to treat voluntary nystagmus, but Fresnel prism lenses should be remembered in refractory patients. Potentially reversible and pseudointernuclear ophthalmoplegias also were discussed. Orthoptic exercises can be beneficial in posttraumatic internuclear ophthalmoplegia. Selected supranuclear palsies can be improved completely with the proper drug regimen. Lastly, superior oblique myokymia can be treated successfully with carbamazepine, with tight surveillance for possible adverse side effects. Descriptive phenomenology and pathophysiological localization must be correlated with brain stem neurochemistry and neuropharmacology to medically treat additional ocular motor system disorders.

Adolescent↗
PubMed1983

Analysis of tonic and accommodative vergence disorders of binocular vision.

Tonic and accommodative vergence disorders of binocular vision are analyzed with separate methods. The center of symmetry and the associated phoria of forced duction fixation disparity curves are two criteria used for prismatic correction of tonic vergence disorders. The associated phoria is corrected physiologically when patients who have tonic disorders are able to develop prism adaptation with orthoptic exercises. Graphical methods are used to analyze accommodative disorders resulting from mutual interactions between accommodation and convergence. Graphic analysis illustrates that patients with high AC/A ratios have greater demands upon fusional divergence than other patients with similar ocular deviations who have normal or low AC/A ratios. Prism adaptation, which has no direct influence upon the open-loop accommodative response, replaces corrective fusional vergence innervation and thereby eliminates the main stimulus to convergence accommodation and its exaggeration of accommodative convergence. Because prism adaptation has a response time of 15 to 30 sec, abnormal accommodative convergence interactions exaggerated by convergence accommodation can be transient in patients with normal prism adaptation. Accommodative convergence disorders in patients who lack prism adaptation are classified as sustained. Orthoptic exercises which develop fast fusional vergence are recommended for the transient disorders and additional exercises to develop prism adaptation are recommended for the sustained disorders of accommodative vergence interactions.

Accommodation, Ocular↗
PubMed1983

Static aspects of accommodation in human amblyopia.

Static aspects of accommodation in human amblyopia were investigated. Abnormalities uncovered included decrease in accommodative controller gain, decrease in slope of the accommodative stimulus/response curve, decrease in accommodative amplitude, and increase in depth of focus. Orthoptic therapy improved accommodative function in the amblyopic eye. Similar defects, but of lesser magnitude, were frequently found in the nondominant eyes of subjects in related test groups. This included former amblyopes who had received successful orthoptic therapy in their youth, which suggested lack of complete and/or maintained recovery of accommodative function, and strabismics without amblyopia, which suggested that the effects of strabismic suppression contributed to the accommodative deficits found in some strabismic amblyopes. The accommodative abnormalities found in our amblyopes were attributed to the effects of early, prolonged, abnormal visual experience on the sensory visual system.

Accommodation, Ocular↗
PubMed1991

Comparative study of computer-based and standard clinical accommodative facility testing methods.

Two methods for assessing accommodative facility were compared: the Computer Orthoptics Diagnostic Program and the standard Lens Flipper Method. In random fashion, 40 visually normal [modified clinical technique (MCT) screening] subjects, ages 10 to 18 years, were tested monocularly and binocularly on both methods. Scatter-plot comparisons of the data showed no apparent relation between the two methods, with correlation coefficients close to zero for both monocular (r = 0.0205) and binocular (r = 0.1180) results. In addition, the subject's diagnostic classification (pass or fail) was compared between the two methods. The kappa statistic indicated a low level of agreement between the two methods both monocularly and binocularly. These results suggest that the Computer Orthoptics' diagnostic test is not a valid method for diagnosing accommodative facility deficiencies.

Accommodation, Ocular↗
PubMed2004

Community-based study of the association of high myopia in children with ocular and systemic disease.

PURPOSE: High myopia in childhood is associated with important ocular and systemic conditions. However in the UK, high myopia in early childhood is not specifically identified in current ophthalmology, optometry, or orthoptic protocols for screening, referral, or investigation. An ongoing study in the West Midlands, UK, is investigating high myopia presenting to community health care clinics with the aim of compiling guidelines for assessment and subsequent referral. METHODS: Children with high myopia were identified from community optometric and orthoptic sources and invited for an ophthalmology and optometry examination to ascertain possible ocular or systemic disease. RESULTS: High myopia with no associated ocular or systemic condition was present in 15 (56%) of the children. In seven children (25%), associated ocular problems were found including unrecognized retinal dystrophies and amblyopia. Systemic disorders associated with high myopia were found in five children (19%) and included Sticklers syndrome, Weill-Marchesani syndrome, and homocystinuria. In one child, the diagnosis made before this study was found to be incorrect, and in another child, the results were inconclusive. In two cases, the diagnosis of a systemic condition in the child led to the identification of the disease in at least one relative. CONCLUSIONS: There is a high prevalence of ocular and systemic abnormality in young children seen in the community. Optometric and ophthalmologic assessment of children less than 10 years with myopia > or =5 D is likely to identify significant ocular or systemic disease, a proportion of which will respond to medical intervention. Detection and prompt referral of these cases by community health care services may be expected to prolong vision and possibly life expectancy.

Abnormalities, Multiple↗
PubMed2006

Is the Cardiff Acuity Test effective in detecting refractive errors in children?

PURPOSE: Refractive error is a common cause of reduced visual acuity in young children. This reduced vision should be detected as soon as possible to avoid development of squinting and educational disadvantage. The Bailey-Lovie Chart (BLC) is based on the logarithm of the minimal angle of resolution (logarithm of the minimum angle of resolution logMAR) and is widely accepted as the clinical standard for visual acuity testing. However, most young children are unable to perform this test because of its symbolic level. The Cardiff Acuity Test (CAT) overcomes these symbolic demands and is the test of choice for young children in most U.K. orthoptic departments. The purpose of this study is to determine how effective the CAT is in detecting reduced visual acuity caused by refractive error in young children. METHODS: Visual acuity of the right eye was tested without spectacles in 68 children (mean age, 74 +/- 14.6 months) with known bilateral symmetric refractive error (40 male) using the CAT and the BLC. Subjects were randomized to receive CAT or BLC first in a single assessment using a crossover design. Subjects scoring 0.2 logMAR or better were classified as having passed the test. RESULTS: The CAT correctly identified reduced vision caused by uncorrected refractive error in 25% (17) of the children compared with a detection rate of 97% (66) for the BLC using the specified pass criteria. Further analysis with an adjusted cut point for the CAT (0.0 logMAR), as used to identify abnormal vision in clinical practice, identified a detection rate of 56% (38 of the children). CONCLUSIONS: This study casts doubt on the current clinical practice used in orthoptic clinics by suggesting that assessment of visual acuity with the CAT alone will underdiagnose reduced acuity caused by refractive errors.

Child, Preschool↗
PubMed1985

Photographic screening for strabismus among mentally retarded children.

The prevalence of squint among mentally retarded children is much higher than in the general population. A photographic screening method based on the positioning of the 1st and 4th Purkinje image was applied to 80 mentally retarded children. The method was validated against orthoptic examination of the children. Totally 320 exposures were taken. Fourth Purkinje image was visible on 73% of these. Five children were not evaluable from the 4th Purkinje image. The photographic technique was simple and easy to handle, but comparison between the clinical and photographic diagnoses were inconsistent in 12 out of 80 cases, which made the method unreliable. In some cases the clinical assessments also varied from time to time. A combination of clinical orthoptic assessment and the photographic method is suggested.

Adolescent↗
PubMed1986

Ten years follow-up of surgery for intermittent exotropia.

Ten years post-operative follow-up of 25 consecutive patients with intermittent exotropia have been performed. 13/25 patients are at follow-up fine, that is small and symptom-free exoforia, good sensorial binocular functions of normal type, sufficient although subnormal fusional amplitude and never exotropia. 8/25 patients are fair, that is only occasionally momentary occurrence of exotropia and binocular complaints. 4/25 patients are orthoptically poor (suppression on all tests), but without complaints. Eye position is on a whole unchanged for distance, whereas exodeviation has increased about 10 PD for near during the 10 years post-operative observation time (no orthoptic treatment in this period). 22/25 patients indicated spontaneously at the follow-up examination that they considered their squint cured. None of the patients had cosmetic or functional restrictions in jobs or studies.

Adolescent↗
PubMed2004

A prospective study of the effect of a unilateral macular hole on sensory and motor binocular function and recovery following successful surgery.

AIMS: To examine the effect of a unilateral full thickness macular hole on sensory and motor binocular function and to study recovery after successful surgical closure. METHODS: Twenty eight consecutive patients undergoing surgery for a unilateral macular hole underwent orthoptic examination, including measurements of Titmus and TNO stereoacuity and motor fusion range before surgery. Twenty three patients had successful anatomical closure. Fifteen of these patients, who had both improved acuity in the operated eye following surgery and were available for further testing, underwent repeat orthoptic assessment 2-7 months after surgery. RESULTS: In all patients stereoacuity was reduced before surgery, but few patients were subjectively aware of a deficit of depth perception affecting their everyday life. In those patients with improved Snellen acuity after surgery, stereoacuity measured by the Titmus stereotest also improved significantly, but not that measured by the TNO test. Two patients were aware of a subjective improvement in depth perception. Motor fusion was markedly reduced compared to normal before surgery, with only limited recovery after surgery. CONCLUSION: A unilateral macular hole notably reduced both stereoacuity and motor fusion. Successful closure improved the deficit in stereoacuity associated with the hole when measured by a stereotest using contoured stimuli. The majority of patients were not subjectively aware of the deficit in stereoacuity or its improvement following surgery.

Aged↗
PubMed2002

Amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomised trial.

OBJECTIVE: To assess the effectiveness of early treatment for amblyopia in children. DESIGN: Follow up of outcomes of treatment for amblyopia in a randomised controlled trial comparing intensive orthoptic screening at 8, 12, 18, 25, 31, and 37 months (intensive group) with orthoptic screening at 37 months only (control group). SETTING: Avon, southwest England. PARTICIPANTS: 3490 children who were part of a birth cohort study. MAIN OUTCOME MEASURES: Prevalence of amblyopia and visual acuity of the worse seeing eye at 7.5 years of age. RESULTS: Amblyopia at 7.5 years was less prevalent in the intensive group than in the control group (0.6% v 1.8%; P=0.02). Mean visual acuities in the worse seeing eye were better for children who had been treated for amblyopia in the intensive group than for similar children in the control group (0.15 v 0.26 LogMAR units; P<0.001). A higher proportion of the children who were treated for amblyopia had been seen in a hospital eye clinic before 3 years of age in the intensive group than in the control group (48% v 13%; P=0.0002). CONCLUSIONS: The intensive screening protocol was associated with better acuity in the amblyopic eye and a lower prevalence of amblyopia at 7.5 years of age, in comparison with screening at 37 months only. These data support the hypothesis that early treatment for amblyopia leads to a better outcome than later treatment and may act as a stimulus for research into feasible screening programmes.

Age Factors↗
PubMed1994

Cyclosporin associated headache.

Despite successful orthoptic liver transplantation some patients develop a recurrent headache that interferes with their quality of life. To estimate the frequency of this symptom 34 patients who had undergone orthoptic liver transplantation were questioned about the history and character of any headache. Six patients described a recurrent headache typical of migraine only since transplantation. In two patients the pain improved after reduction of cyclosporin dosage and thereby plasma cyclosporin concentration.

Cyclosporine↗
PubMed1997

The role of plain radiography in the management of suspected orbital blow-out fractures.

We reviewed the indications for radiography and its impact on management in 100 consecutive patients referred to the Radiology Department from the Accident and Emergency Department of a large eye hospital in order to assess the utility of orbital plain radiographs in patients suspected of having blow-out fractures. We assessed whether administration of antibiotics or referral for surgical or orthoptic treatment was influenced by clinical features, radiographic findings or both. Ophthalmologists interpreting the radiographs appeared to be guided by the presence or absence of physical signs. No patient in whom they overlooked a fracture which was not evident clinically was subsequently referred for surgery. All patients who did have surgery for complications of a blow-out fracture underwent pre-operative computed tomography. Neither referral for orthoptic treatment nor administration of systemic antibiotics was consistently influenced by the presence or absence of a fracture. Given these findings, and the observation that the decision to operate was guided exclusively by clinical rather than radiological criteria, we recommend that only patients with well-defined indications for surgery (enophthalmos of more than 2 mm at any time within the first 6 weeks following the injury, and/or diplopia in the primary and/or downgaze reading positions not showing evidence of resolving within 2 weeks of the injury) should undergo radiography.

Adolescent↗
PubMed2006

Refractive surgery in patients with high myopic anisometropia.

PURPOSE: To assess the efficacy and safety of LASIK in patients with high myopic anisometropia and to provide specific screening guidelines for anisometropic patients undergoing refractive surgery. METHODS: Twenty-six eyes of 16 patients with high myopic anisometropia (>3.0 diopters) were enrolled in this study. Complete pre- and postoperative ophthalmologic and orthoptic examinations were performed. The preoperative orthoptic examination was done with glasses and contact lenses. Twenty-two eyes of 13 patients underwent uncomplicated LASIK; the second eye was treated 2 weeks after the first eye. Patients were examined 1 day, 7 days, and 1, 3, 6, and 12 months after surgery. RESULTS: Thirteen patients obtaining good results at red glass bar test (RGB) underwent LASIK without postoperative diplopia; four showed an improvement of the sensorial assessment. Three patients were excluded from surgery because of diplopia with RGB values <4 to 5. LASIK temporarily induced diplopia in the suppressed eye of one patient; however, the diplopia disappeared after surgery of the fixating eye. CONCLUSIONS: Patients with high myopic anisometropia and a weak sensorial state who undergo refractive surgery may be at risk for postoperative diplopia. We suggest clinical guidelines to reduce the occurrence of this complication.

Adult↗
PubMed2001

[Value of the Bébé-Vision test in the screening of strabismus and anisometropic amblyopia in infants].

PURPOSE: To evaluate the accuracy of the Bébé-Vision test for detecting strabismic, ametropic and anisometropic amblyopia in childhood. METHODS: We screened 199 infants under 20 months of age. The screening consisted of a full orthoptic examination by a trained orthopist (cover test, fixation test), a forced choice preferential looking technique (Bébé-Vision test) prior to cycloplegia to test visual acuity, cycloplegic refraction by retinoscopy, and examination of the fundi. RESULTS: Fifteen infants were abnormal on orthoptic examination (clinical evidence of esotropia and/or limitation of abduction and/or amblyopia). The Bébé-Vision test demonstrated a significant interocular difference on the same side of the suspected amblyopic eye in 3 cases and on the opposite side in 3 cases, and no difference in 9 cases. The monocular Bébé-Vision test was abnormal in 51 cases and there was an abnormal cycloplegic refraction in 33 cases. Statistical analysis of these tests demonstrated a very low sensitivity (42%) and a good specificity (90%) for the Bébé-Vision test in detecting amblyopia related to refractive error. CONCLUSION: The Bébé-Vision test does not reliably reveal strabismic or anisometropic amblyopia and is not recommended as a screening test. Diagnosis should continue to be based mainly on the classical clinical methods.

Amblyopia↗
PubMedDate not supplied

Decompensation of exodeviation after corneal refractive surgery for moderate to high myopia.

BACKGROUND AND OBJECTIVE: To evaluate strabismus and binocular decompensation of exodeviation and their surgical treatment following corneal refractive surgery. PATIENTS AND METHODS: A retrospective study of a noncomparative case series was conducted. Seven patients whose strabismus worsened after photorefractive keratectomy or laser in-situ keratomileusis for correction of myopia underwent orthoptic evaluation before and after refractive surgery, as well as after corrective strabismus surgery. The motor alignment and regaining of binocularity after strabismus surgery to correct the misalignment following refractive corneal surgery were evaluated and compared at three time points. RESULTS: After corneal refractive surgery, there was a deterioration in mean distance exodeviation from 7.1 +/- 5.2 to 25.7 +/- 10.1 prism diopters (PD) (P = .028) and in mean near exodeviation from 7.1 +/- 5.1 to 29.7 +/- 8.1 PD (P = .18), with loss of binocular function in 6 of the 7 patients. Following strabismus surgery, the mean distance exodeviation was reduced from 25.7 +/- 10.1 to 2.0 +/- 1.8 PD (P = .027) and the mean near exodeviation from 29.7 +/- 8.1 to 3.7 +/- 1.5 PD (P = .028). Five of the six patients regained binocular function. CONCLUSIONS: All at-risk patients with exophoria and exotropia should undergo a thorough orthoptic evaluation before corneal refractive surgery. Patients with ocular motility and misalignment problems should be warned preoperatively of the risk of decompensation of their strabismus.

Adult↗