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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↗
PubMed2006

The Pediatric Vision Screener III: detection of strabismus in children.

OBJECTIVE: To evaluate the clinical performance of the Pediatric Vision Screener (PVS) in children in a pediatric ophthalmology office setting. METHODS: Seventy-seven subjects between 2 and 18 years of age received gold-standard orthoptic examinations and were classified as at risk for amblyopia if strabismus or anisometropia (>1.50 diopters) was present. Strabismus was subclassified as variable or constant. The subjects were then tested with the PVS, which produced a pass or refer recommendation based on a binocularity score. The PVS also produced a yield score to indicate the subject's interest in the target. Sensitivity and specificity for amblyopia risk detection were calculated. RESULTS: Binocularity as determined by the PVS was greater than 65% for all controls and less than 20% for all subjects with constant strabismus. Binocularity ranged from 0% to 52% in subjects with variable strabismus. All subjects with anisometropia and no strabismus had binocularity scores less than 10%. CONCLUSIONS: The PVS identified strabismus, when present, in all subjects and identified 3 subjects with anisometropia as well. The PVS shows potential to address a lack of screening instrumentation appropriate for use with preschool-aged children.

Adolescent↗
PubMed1982

Combined use of neostigmine and ocular motility measurements in the diagnosis of myasthenia gravis.

Forty-four patients with diplopia caused by myasthenia gravis, ocular myopathies, and ocular motor nerve palsies underwent complete orthoptic evaluations before and after intramuscular injection of neostigmine (Prostigmin) methylsulfate. A test score combining the results of binocular and uniocular measurements was developed that allowed correct correct classification of 70% (31) of patients studied.

Diagnosis, Differential↗
PubMed2003

Interventions for intermittent distance exotropia.

BACKGROUND: The clinical management of intermittent distance exotropia has been discussed frequently in the literature but there is a lack of clarity regarding the indications for intervention, the most effective type and the optimum age at which it should be carried out. OBJECTIVES: The objective of this review is to assess intervention criteria, the effects of various surgical and non-surgical treatments in people with intermittent distance exotropia and to determine the significance of factors such as age with respect to outcome. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which contains the Cochrane Eyes and Vision Group trials register) on the Cochrane Library (Issue 4 2002), MEDLINE (1966 to November 2002), EMBASE (1980 to November 2002) and LILACS (Latin American and Caribbean Literature on Health Sciences) (1966 to 2002). We manually searched the British Orthoptic Journal, proceedings of the European Strabismological Association (ESA), International Strabismological Association (ISA) and American Academy of Paediatric Ophthalmology and Strabismus meeting (AAPOS). We contacted researchers who are active in the field for information about further published or unpublished studies. There were no language restrictions in the manual or electronic searches. SELECTION CRITERIA: We planned to include randomised controlled trials of any surgical or non-surgical treatment for intermittent distance exotropia. DATA COLLECTION AND ANALYSIS: Each reviewer independently assessed study abstracts identified from database and manual searches. Reviewer analysis was then compared and full papers for appropriate studies were obtained. MAIN RESULTS: No studies were found that met our selection criteria and therefore none were included for analysis. REVIEWER'S CONCLUSIONS: The available literature consists mainly of retrospective case reviews. These are difficult to compare and analyse due to a large variation in the definition of intermittent distance exotropia, intervention criteria and outcome measures. However there seems to be general agreement that non-surgical treatment is most appropriate in small angle deviations or as a supplement to surgery. Studies were found supporting both early and late surgical intervention so the optimal timing of surgical intervention cannot be concluded. Recent work indicates that bilateral surgery may be the most effective surgical procedure in these cases. There is clearly a need for carefully planned clinical trials to be undertaken to improve the evidence base for the management of this condition.

Exotropia↗
PubMed2006

Interventions for intermittent exotropia.

BACKGROUND: The clinical management of intermittent exotropia has been discussed frequently in the literature, but there is a lack of clarity regarding the indications for intervention, the most effective type and if there is a time point at which it should be carried out. OBJECTIVES: The objective of this review was to analyse the effects of various surgical and non-surgical treatments in randomised trials of people with intermittent exotropia, to report intervention criteria and determine the significance of factors such as age with respect to outcome. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (2006, Issue 1), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006) National Research Register (2006, Issue 1), PubMed (searched on 13 March 2006; last 90 days) and LILACS (Latin American and Caribbean Literature on Health Sciences) (1966 to 2002). We manually searched the British Orthoptic Journal, proceedings of the European Strabismological Association (ESA), International Strabismological Association (ISA) and American Academy of Paediatric Ophthalmology and Strabismus meeting (AAPOS). We contacted researchers who are active in the field for information about further published or unpublished studies. There were no language restrictions in the manual or electronic searches. SELECTION CRITERIA: We included randomised controlled trials of any surgical or non-surgical treatment for intermittent exotropia. DATA COLLECTION AND ANALYSIS: Each review author independently assessed study abstracts identified from the database and manual searches. Author analysis was then compared and full papers for appropriate studies were obtained. MAIN RESULTS: We found one randomised trial that was eligible for inclusion. This trial showed that unilateral surgery was more effective than bilateral surgery for correcting basic intermittent exotropia. AUTHORS' CONCLUSIONS: The available literature consists mainly of retrospective case reviews which are difficult to reliably interpret and analyse. The one randomised trial included found unilateral surgery more effective than bilateral for basic intermittent exotropia but there remains a need for more carefully planned clinical trials to be undertaken to improve the evidence base for the management of this condition.

Exotropia↗
PubMed1992

Hemolytic anemia in protoporphyria: possible precipitating role of liver failure and photic stress.

Hemolytic anemia is not a common clinical feature in protoporphyria. In this report, we describe two patients in whom we have encountered severe hemolytic anemia. Both individuals had advanced hepatic disease as a complication of their porphyria and were undergoing orthoptic liver transplantation. The onset of hemolysis appeared to be related to the development of liver disease, and in both cases, the operative procedure acutely exacerbated the red cell destructive process. We suggest that liver involvement in protoporphyria may unmask hemolytic anemia, and that red cells in these individuals are hypersensitive to photooxidative stress, such as might occur during a prolonged operative procedure.

Adolescent↗
PubMed1994

FK506-induced neurotoxicity in liver transplantation.

We report FK506-induced neurotoxicity in 14 of 44 consecutive patients following orthoptic liver transplantation. In 10 of these 14 patients, postural hand tremors were found in the first weeks following surgery, transient apraxia of speech in 3, and generalized tonic-clonic seizures were noted in 2 patients. Other manifestations included nightmares, agitation, and acute delirium. Reduction of the FK506 dose resulted in resolution of symptoms, but in 1 patient mild speech difficulties and in 3 patients a fine tremor remained. Blood and plasma levels of FK506 were similar in patients with and without neurotoxicity. FK506 neurotoxicity in patients with liver transplantation commonly results in transient neurological manifestations. The incidence of neurotoxicity in FK506 is dramatically reduced in maintenance doses of 0.075 mg/kg twice a day.

Adult↗
PubMed1981

[Alternating strabismus--clinical study--treatment].

The author defines motor and sensory alternation: the term "alternation" should not be used in isolation, it should always be accompanied by the name of the parameter concerned. Sensory alternation is always found together with motor alternation but the reverse is not true. The examining criteria for a diagnosis of sensory alternation are given, sensory alternation must not be confused with alternating inhibition. Working from clinical observations of cases of motor alternating strabismus, the author selects 2 types of binocular sensory relations which allow one to differentiate between: - cases of primary alternating strabismus - cases of secondary alternating strabismus. These forms will develop in different ways; in both cases a cure is possible providing that the right treatment is prescribed and once prescribed carefully followed, etc. It is always a case of serious forms of strabismus whose developmental period is spread overall several years. According to the authors, the frequency of cases of true primary strabismus is from 1-3%, the frequency of cases of secondary alternating strabismus varies according to the type of therapy practised on cases of monocular strabismus with amblyopia. These latter will become cases of alternating strabismus under the influence of certain types of therapy carried out over several years (penalization, rocking, alternated occlusion, etc...). Experimental data on kittens confirm clinical data; kittens placed in abnormal environments during the sensitive period will show modification in the distribution of cortical cells and the absence of binocular cells (either because the excitation of the two eyes was not simultaneous, or not identical: artificial strabismus, occlusion, opaque glasses). This disturbances become irreversible after a certain period of exposure (a function of age, length of exposure, etc...). It is thus necessary to bear in mind: 1) the iatrogenic risks of certain orthoptic treatments, 2) the necessity for a binocular form of treatment as soon as possible, as once a certain stage is passed, cortical plasticity diminishes and the elaboration of normal binocular relations becomes impossible.

Animals↗
PubMed1995

Self-assessment of angles of strabismus with photographic Purkinje I and IV reflection pattern evaluation.

BACKGROUND: Accurate assessment of the angle of strabismus, e.g. of variable angles of strabismus, is crucial in preoperative patient management and is usually performed in a clinical environment. Objective assessment by patients themselves, under everyday conditions, could contribute to a better preoperative work-up. A new objective evaluation procedure for the measurement of manifest angles of strabismus for near and distance fixation by the patient himself is presented. METHODS: To account for the modified experimental setup used for the self-assessment, an amended computation procedure of Purkinje reflection pattern evaluation was developed. For measurement, patients and controls placed their head on a head/chin rest and fixated at 33 cm or 4 m distance in primary position. A reflex camera and three photo flash units were positioned on a special frame underneath the visual axis and in front of the subject so that both eyes could be photographed simultaneously. The camera's remote shutter control was released together with the photo flash units by the properly fixating subject. The angles of strabismus were obtained from the series of pictures through later evaluation of the Purkinje I and IV reflection patterns recorded in the photographs of the eyes. RESULTS: Measurements of the ocular alignment in two control groups and in a group of strabismic subjects showed satisfactory accuracy of the "self-assessment" method compared to "standard" Purkinje reflection pattern evaluation and orthoptic measurements of the angle of strabismus. CONCLUSION: The modified "self-assessment" method can be used for the objective recording of angles of strabismus as needed in the preoperative work-up of patients with variable angles of strabismus, over prolonged periods of time, and outside a clinical setting.

Adolescent↗
PubMed1996

Squints and diplopia seen after brain damage.

The aim of this study was to investigate the incidence of squint after brain damage. We performed an observational study on 239 consecutive patients admitted to a specialist neurological rehabilitation unit: 129 with stroke, 84 with head injury and 26 with other conditions. Standard orthoptic measures, including visual acuity, cover test, eye movement recording and tests of binocular function were performed. Of all the patients, 89 (37%), were found to have squints, but only 32 of these (36%) experienced double vision. Brain stem lesions causing peripheral ocular motor impairment were found in a high proportion of patients after head injury (56%). Squints were found in 27 of 95 (28%) patients with cortical strokes, many with no other signs of brain stem involvement. Left was just as likely as right hemisphere damage to be associated with squint, but right-sided lesions seemed to protect against diplopia. We conclude that squint is common after brain damage, even if the brain stem is not obviously affected, but only a minority of these patients with acquired squint suffer diplopia.

Brain Damage, Chronic↗
PubMed1993

Two therapeutic concepts in intermittent divergent squint.

Several therapeutic concepts are in favour of the treatment of intermittent exotropia. The presented paper will try to answer the question, whether this leads to different results, by the review of the 1989 and 1990 cases of two centres. In the Munich Right Isar Eye Hospital (Centre II) during this period 72 patients (already published data) were treated by recession and resection eye muscle surgery against intermittent exotropia or decompensating exophoria. The 111 compared patients of the Department of Orthoptics and Pleoptics at the University Eye Hospital Kiel (Centre I), were mostly treated with bimedial resection procedures. Another difference: diagnostic occlusion and prism correction were done in the Munich patients. There is major evidence that there are two widely different clinical pictures incorporated in the diagnostic frame of the so-called 'Intermittent Exotropia'. In a third prospective group of patients (10/91-3/92), therefore, the prism-acceptance was evaluated.

Adolescent↗
PubMed1994

Mechanisms of rapid bone loss following cardiac transplantation.

Rapid bone loss after orthoptic cardiac transplantation (OHTX) is a major problem; however, the mechanisms are poorly understood. To investigate these mechanisms we measured biochemical and hormonal indices of bone turnover serially in 25 patients (21 men, 4 women) after OHTX. Serum osteocalcin was reduced immediately post-OHTX (2.2 +/- 0.5 ng/ml) but rose significantly by 6 and 12 months (14.1 +/- 2.5 and 15.7 +/- 2.2 respectively). Bone resorption indices (urinary hydroxyproline/creatinine and calcium/creatinine ratios) were increased immediately post-OHTX but fell by 6 months. Serum testosterone was reduced in males but recovered towards normal values by 6-12 months. Regression analysis showed lumbar bone loss was predicted independently by the change in both serum osteocalcin and testosterone. The data suggest that bone loss post-OHTX is due to a combination of accelerated turnover and hypogonadism.

Absorptiometry, Photon↗
PubMed1986

A comparison of the influence of temporary balloon buckles and permanent episcleral silicone sponges on postoperative ocular motility in retinal detachment surgery.

The influence of retinal surgery on ocular motility was examined in 60 patients with rhegmatogenous retinal detachment caused by one tear. Thirty patients were treated with cryotherapy and an episcleral radial silicone sponge explant. The remaining 30 patients were treated with a Lincoff temporary balloon buckle procedure. Extensive pre- and postoperative orthoptic examinations showed the impairment of ocular motility to be significantly less with the balloon-buckle procedure.

Eye↗
PubMed1988

Form-vision deprivation amblyopia and strabismic amblyopia.

The treatment program for form-vision deprivation and strabismic amblyopia currently followed in our orthoptic clinic is presented. In unilateral congenital cataract, a disease that causes form-vision deprivation amblyopia, good vision up to 20/20 can be obtained through surgery performed before the patient reaches 8 weeks of age, employing new surgical techniques such as lentectomy and vitrectomy, combined with early aphakic eye correction and occlusion of the healthy eye. In strabismic amblyopia, prevention and/or early treatment are very important, particularly in cases of unilateral infantile esotropia. Our success rate with occlusion therapy was 84.6% using a patch and 83.3% employing atropine cycloplegia. Occlusion therapy is monitored with the preferential looking technique to prevent the development of occlusion amblyopia. The visual prognosis for amblyopia due to unilateral congenital cataract and infantile strabismic amblyopia has been improved compared with previous reports. The prognosis for binocular function remains poor.

Age Factors↗
PubMed2002

[Does the type of lens influence stereoscopic vision].

PURPOSE: Age and monofocal intraocular lens (IOL) are assumed to reduce the quality of stereopsis, whereas multifocal intraocular lenses (MIOL) are supposed to provide better random dot stereopsis than monofocal IOL. The following study investigates whether and how the different IOL types (including the different existing principles of MIOL) influence stereopsis. PATIENTS AND METHODS: We included 153 persons from six groups (young and elder phakic subjects, patients with bilateral monofocal IOL, with bilateral diffractive MIOL, with bilateral refractive MIOL, and with unilateral diffractive/refractive MIOL). Stereopsis measurements were performed using the Pola test with a two-dimensional and a random dot test for far and near distances and the results for near distance were compared with the Lang random dot, two-dimensional Titmus, and the Monjé real three-dimensional tests. Near and distance monocular and binocular visual acuity and orthoptic examinations had been previously carried out. RESULTS: Of the young phakic subjects, 81-92% correctly perceived the Pola test figures, and 100% did so in the Lang, Titmus, and Monjé tests. Of the elder phakic subjects, 36-73% correctly perceived the Pola test, and 52-88% did so in the Lang, Titmus, and Monjé tests. Of the patients with bilateral monofocal IOL, 19-62% perceived the Pola test figures, as did 30-61% of the patients with bilateral diffractive MIOL, 12-53% of the patients with bilateral refractive MIOL, and 5-29% of the patients with unilateral diffractive/refractive MIOL. CONCLUSION: All patients with bilateral mono- or different multifocal IOL had good binocular vision in far and near distance including random dot stereopsis.

Adolescent↗
PubMed2004

Gene expression of cytochromes P450 in liver transplants over time.

OBJECTIVE: The aim of this study was to (a) quantify the gene expression of some cytochromes P(450) (CYP), especially CYP3A4, in serial biopsies from liver grafts the first year after orthoptic liver transplantation (OLT) and (b) study the relationship between hepatic CYP3A4 gene expression and plasma levels of cyclosporine and tacrolimus. METHODS: Liver tissue was obtained from surplus material of routine liver biopsies performed in 20 patients during the first year after OLT. Real-time reverse-transcription polymerase chain reaction was used for quantitative analyses of mRNA specific for CYP3A4, CYP3A5, CYP2E1 and CYP1A2 cytochromes as well as P-glycoprotein (P-gp). The gene expression of beta-actin was used as an internal standard for comparisons between samples. RESULTS: The median value of the mRNA for all cytochromes, but not for P-gp, was found to increase significantly over time. The gene expression of CYP3A5, CYP2E1 and CYP1A2 was higher than that of CYP3A4. The gene expression of CYP3A4 was related to the plasma concentration of cyclosporine and tacrolimus, i.e. low mRNA concentrations corresponded to high serum concentration levels and vice versa. The serum concentration of bilirubin or the prothrombin index did not correlate with the gene expression level of the cytochromes. CONCLUSION: The hepatic mRNA expression of CYP3A4 and the other investigated cytochromes increased during the first year after OLT. This was not the case with P-gp. Low CYP3A4 gene expression was related to high plasma levels of cyclosporine and tacrolimus and vice versa.

ATP Binding Cassette Transporter, Subfamily B, Mem↗
PubMed2004

[Results of pars plana lensectomy for childhood cataract].

BACKGROUND: Pars plana lensectomy with subsequent fitting of contact lenses is the standard procedure for cataracts occurring within the first 2 years of life. We wanted to assess the outcome and complication rate of this procedure. METHODS: Pars plana lensectomy was performed on 29 eyes of 15 children with bilateral as well as 12 eyes with unilateral cataracts. All children were reexamined at an age of at least 3 years. RESULTS: In bilateral cases the mean age at the time of surgery was 4.0 months and mean resulting visual acuity 0.32. After exclusion of three eyes with complications or bad postoperative compliance, we found a statistically significant correlation between age at surgery and visual acuity (r(2)=0.432, p<0.05). Some form of binocular vision was achieved by 40% of the children; 17% developed ocular hypertension and 7% a secondary cataract. In the unilateral cases the mean age at surgery was 3.9 months and the mean resulting visual acuity 0.14. There was no significant correlation between age and visual acuity; 17% gained binocular function and 5% had ocular hypertension. CONCLUSION: Visual function after lensectomy is better in eyes with bilateral cataracts compared to unilateral cataracts. Early surgery as well as adequate orthoptic therapy and compliance with wearing the contact lens are necessary for good outcome.

Cataract↗
PubMed2005

[Cranial imaging and serology tests are not helpful in tonic pupil. A retrospective study].

BACKGROUND: Tonic pupil (TP) is a common disorder of parasympathetic innervation. In contrast to textbook recommendations, cranial imaging is still being performed in most of the patients with TP. The intention of the present study is to show that cranial imaging is of no benefit. PATIENTS AND METHODS: The medical records of 33 patients with TP were analyzed retrospectively. All patients had undergone a complete ophthalmological, orthoptic, and neurological investigation. Cranial imaging was performed by computed tomography or magnetic resonance imaging. Serology tests were carried out in some of the patients. RESULTS: Diagnostic imaging provided no additional data revealing the underlying cause of TP. CONCLUSIONS: Cranial imaging in isolated tonic pupil is not helpful. Because of therapeutic implications, diagnostic evaluation can be recommended only in patients older than 50 years to exclude giant cell arteritis and syphilis.

Adolescent↗