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PubMed2000

Vertigo is an underestimated symptom of ocular disorders: dizzy children do not always need MRI.

Vertigo, instability, dizziness, or equilibrium disorders are not usually considered as consequences of ophthalmologic problems. We present data indicating that ocular disorders can be responsible for these symptoms in children. In a population of 523 pediatric patients with vertigo or disequilibrium and referred for vestibular testing in our otolaryngology department during a 5-year period, 27 children presented with normal vestibular and somatic neurologic examinations but with ophthalmologic disorders (vergence insufficiency or latent strabismus with binocular vision in 70% and anisometropia in 41%). These patients represented 24% of all vergence insufficiencies detected and 4% of all orthoptic examinations performed in the pediatric ophthalmology department. These ocular abnormalities were considered to be the initial cause of the problems. In two thirds of these patients the symptoms were completely resolved by simple ophthalmologic treatment. No other additional tests, such as magnetic resonance imaging, were required. Therefore we propose that every child complaining of vertigo or dizziness but with normal clinical somatic neurologic and vestibular examinations should have a complete ophthalmologic examination before additional, more costly, investigations. This should lead to better screening and more appropriate care of ocular disorders in children and avoid unnecessary magnetic resonance imaging.

Child↗
PubMed2002

Oculomotor dysfunction in cerebral visual impairment following perinatal hypoxia.

The aim of the study was to describe ocular motility in a sample of 56 patients affected by cerebral visual impairment (CVI) of hypoxic-ischemic origin. The sample consisted of 56 participants (37 males and 19 females), ranging in age from 2 to 16 years. In all cases CVI was associated with MRI-verified damage of the cerebral visual system. A complete ophthalmologic and neurological assessment was performed. Behaviour of gaze was studied in four conditions: during scanning of the surrounding environment, during fixation, execution of saccades, and pursuing. In addition, strabismus, nystagmus, and paroxysmal ocular deviations were evaluated. Ocular motility was studied by video recording the patients' eye motility during orthoptic examination. Each pattern of ocular motility studied revealed profound alterations in all the individuals examined. Typical features of ocular motility in CVI were: paroxysmal ocular deviations (present in 78%); the presence of variable angle strabismus (86%); and defective coordination of saccades (93%). Exploration of the environment and fixation were also impaired (88% and 84%, respectively). Disorders of initiation and performing saccades, absence of smooth pursuit, vergence abnormalities, nystagmus beats, instability of fixation, and difficulty in the systematic exploration of the environment were observed. These abnormalities characterize lack of gaze coordination found in children with brain damage. An early and detailed evaluation of ocular motility in individuals with CVI is important, especially when rehabilitation intervention is intended.

Adolescent↗
PubMed1989

Surgery for otitis media with effusion in children and its relationship to parental smoking.

A study was conducted to ascertain whether there is any relationship between parenteral smoking and various factors in children undergoing surgery for otitis media with effusion. Information was recorded on 115 children admitted to hospital for grommet insertion. Details of parenteral smoking habits, previous surgery for otitis media with effusion and operative findings were noted. A group of 36 children with healthy ears attending an orthoptic clinic were used as controls. Those children with at least one parenteral smoker were found to have a higher change of being admitted to hospital for grommet insertion and were more likely to have had previous surgery for otitis media with effusion.

Child↗
PubMed2003

Influence of axial length of normal eyes on PERG.

The influence of the axial length (AL) of the eye on flash electroretinogram (ERG) responses has been well established in the literature, suggesting an association between ERG abnormalities with myopia (AL > 25 mm). The aim of our present study was to determine whether the AL of normal eyes can also influence the pattern electroretinogram (PERG) on normal subjects. Thirty-nine normal volunteers were subjected to PERG measurements following the standard set by the International Society for Clinical Electrophysiology of Vision (ISCEV). The AL of the eyeball was measured using a TOMEY ultrasonic A scanner. Each volunteer had a complete ophthalmic examination including visual acuity, refraction, intraocular pressure, visual field, colour vision, orthoptic assessment and retinal photographs and had a best corrected visual acuity of 6/9 or better. Only one eye from each of the 39 normal volunteers was included in the statistical analysis of the results. The normal volunteer group had a mean P50 amplitude of 3.8 +/- 1.1 SD microV. The range of AL was between 21.8 and 25.7 mm (mean = 23.8 +/- 1.0 SD mm). Overall findings obtained from this investigation indicate a significant correlation between the AL of normal eyes and the PERG P50 amplitude (Spearman rank correlation coefficient r = -0.413, p < 0.01). The correlation accounts for 17% of the variance observed in the 39 amplitude values. This confirms the current hypothesis that the PERG amplitude is inversely related to axial length and means that AL should be considered when interpreting PERG amplitudes.

Adolescent↗
PubMed2000

Ocular manifestations of incontinentia pigmenti.

PURPOSE: The study aimed to evaluate the ocular manifestations in patients with incontinentia pigmenti (IP). METHODS: Thirty patients from different parts of Sweden participated. Orthoptic and ocular examinations were performed as well as evaluation of refraction and visual acuity. RESULTS: Ocular manifestations, probably associated with IP, were found in 77% (23/30) of the patients. Thirteen had serious or vision-threatening eye manifestations in one eye, of whom 7 were totally blind in that eye from retinal detachments. Ten patients had minor retinal and/or corneal changes. CONCLUSION: Ocular lesions in patients with IP may be serious and lead to blindness because of retinal disease. Ophthalmological follow-up is essential in the neonatal period and such a programme is recommended.

Adolescent↗
PubMed1988

Amblyopia and strabismus in congenital ptosis.

Seventeen per cent of 216 cases of simple congenital ptosis developed amblyopia and 19% had a squint. Of those patients with amblyopia, 14% had amblyopia attributable to stimulus deprivation, 21% had anisometropic amblyopia and 51% had strabismic amblyopia. Early refraction, orthoptic assessment and treatment and, where the pupillary axis is occluded, surgery to prevent stimulus deprivation amblyopia are recommended.

Amblyopia↗
PubMed1989

Chorioretinal scarring following the Faden operation. A retrospective study of 100 procedures.

Following reports of a high incidence of chorioretinal scarring related to the Faden Procedure, a retrospective study was carried out at Moorfields Eye Hospital. One hundred unselected Faden procedures were followed up with orthoptic and fundoscopic examination. Our indications and technique for performing this operation are described. A 7% incidence of chorioretinal scarring was noted; this compares well with previously published figures for conventional squint surgery and this operation should therefore be considered safe.

Adolescent↗
PubMed1994

Persistent binocular diplopia following cataract surgery: aetiology and management.

We studied all patients referred to the orthoptic department with binocular diplopia following cataract surgery between January 1991 and June 1993. Persistence of diplopia for a minimum of 3 months after cataract surgery was required for inclusion in the study. Eighty-one patients (2% of all patients who underwent cataract surgery during this time) satisfied the entry criteria. The patients fell into two groups: non-traumatic and traumatic cataracts. Horizontal deviations were seen in 24 patients. Vertical deviations were seen in 8 patients and a combined horizontal and vertical deviation was seen in 49 patients. Fresnel prisms were used to manage the diplopia in 58 patients. Of these, 48 patients in the non-traumatic group regained binocular single vision with this prism while 10 in the traumatic group benefited. Mechanical and sensory causes are discussed.

Adolescent↗
PubMed1994

The presentation of children with amblyopia.

This study reports the presentation of 961 children who underwent amblyopia treatment at seven orthoptic centres in the United Kingdom. We confirmed previous authors' findings of a small but significant increased incidence of left-sided compared with right-sided amblyopia overall. For pure anisometropic amblyopia this difference was very marked and a possible pathophysiological mechanism is proposed. The mean age of presentation for anismetropic, strabismic and mixed amblyopia was 5.6, 3.3 and 4.4 years, respectively. Neither sex nor race affected the age of presentation. Despite their older age, children with pure anisometropic amblyopia had the best initial visual acuity, with 25% of anisometropes having an initial visual acuity of less than 6/18 compared with 39% of strabismics and 50% of mixed amblyopes. The ages and initial acuities of the strabismic patients in this series are at least as favourable as those of patients reported from outside the UK. There were variations in the age and proportion of patients presenting with anisometropic amblyopia at the different centres, suggesting a failure in the referral of anisometropic amblyopia of importance in interpreting epidemiological studies.

Age Factors↗
PubMed1994

Factors affecting the outcome of children treated for amblyopia.

The outcome of treatment for amblyopia and the factors that affect this are not well understood. A major reason for this has been the exclusion from previous large studies of a sometimes unknown number of patients because of failure to comply with treatment. This paper analyses the outcome of amblyopia treatment in a retrospective review of the orthoptic records of a cohort of 961 children treated for amblyopia at seven centres who first attended in 1983. The final visual acuity was recorded by Snellen or matching methods in 894 children (93%). Of these, 48% achieved 6/9 or better, 35% less than 6/9 but better than or equal to 6/18, and 17% achieved less than 6/18. The outcome was best for pure anisometropic amblyopia, intermediate for pure strabismic amblyopia and least good for mixed strabismic and anisometropic amblyopia with a final visual acuity of 6/10.2, 6/12.8 and 6/14.8 respectively. While the age at start of treatment did not correlate with final visual acuity both poor initial visual acuity and poor compliance were associated with poor outcome. The main factor affecting the outcome of amblyopia treatment is the initial visual acuity. Comparison with the literature suggests that the results of treatment in this country may be falling far short of what would be possible in ideal circumstances with unlimited resources.

Age Factors↗
PubMed1996

Two infant vision screening programmes: prediction and prevention of strabismus and amblyopia from photo- and videorefractive screening.

Two infant vision screening programmes on total populations in the Cambridge Health District have been designed to identify manifest strabismus and strabismogenic and amblyogenic refractive errors at 7-9 months of age. The first, completed, programme used the isotropic photorefractor with cycloplegia together with a standard orthoptic examination. The second, current, programme uses the VRP-1 isotropic videorefractor to identify infants with accommodative lags which are followed up by refraction under cycloplegia. Both programmes show good agreement between infants identified at screening and retinoscopic refractions at follow-up, showing that photo- and videorefraction (with or without cycloplegia) can be effective methods for screening for ametropia in infants and young children. In each programme 5-6% of infants showed abnormal levels of hyperopia (> or = 3.5 D in any meridian), less than 1% showed anisometropia > or = 1.5 D; very few infants (0.25%) showed -3D myopia or greater. Less than 1% showed manifest strabismus. Hyperopic and anisometropic children entered a randomised controlled trial of partial refractive correction. All children identified at screening, alongside appropriate control groups, are extensively followed up to age 4 years. The first programme has found that children who were hyperopic in infancy were 13 times more likely to become strabismic, and 6 times more likely to show measurable acuity deficits by 4 years, compared with controls. Wearing a partial spectacle correction reduced these risk ratios to 4:1 and 2.5:1 respectively. The impaired acuity can be attributed, in part, to meridional amblyopia resulting from persisting astigmatism. Both hyperopic and myopic infants showed refractive changes in the direction of emmetropia between 9 months and 4 years. Wearing a partial spectacle correction did not affect this process of emmetropisation, but does provide the possibility of reducing the incidence of common pre-school vision problems.

Aging↗
PubMed1996

Acquired palsy of the oculomotor, trochlear and abducens nerves.

There have been few studies primarily concerned with the relative frequencies, aetiologies and prognoses of ocular motor palsies. Those published have emanated largely from neurological tertiary referral centres rather than primary ophthalmology departments. We have performed a retrospective study of all patients with acquired III, IV or VI cranial nerve palsy who were seen in the orthoptic department at Ninewells Hospital, Dundee, over the 9 year period from 1984 to 1992. A total of 165 cases were identified. VI nerve palsies accounted for the majority of patients (57%), with IV nerve palsies (21%) occurring more frequently than III nerve palsies (17%) and multiple palsies (5%). Thirty-five per cent of cases were of unknown aetiology and 32% of vascular aetiology. The incidence of sinister pathology-neoplasia (2%) and aneurysm (1%)-was surprisingly low. Fifty-seven per cent of all patients made a total recovery (in a median time of 3 months) and 80% made at least a partial recovery. The results are contrasted with those of previous studies and the value of associated symptoms and of further investigation in the assessment of these patients is discussed.

Abducens Nerve↗
PubMed1998

The incidence of diplopia following coronal and translid orbital decompression in Graves' orbitopathy.

PURPOSE: Firstly, to assess the incidence of induced diplopia following orbital decompression in patients with Graves' orbitopathy. Secondly, to assess patient satisfaction after orbital decompression. Thirdly, to determine the factors that contribute to the variable reported incidence of diplopia complicating decompression surgery. METHODS: We present a retrospective analysis of the alterations of ocular motility in a consecutive series of 81 patients with Graves' orbitopathy who underwent orbital decompression by either a coronal or a translid approach. We assessed patient satisfaction by a telephone survey, and we reviewed the literature. RESULTS: Eleven patients underwent decompressive surgery for dysthyroid optic neuropathy (DON); 5 of them had a three-wall coronal decompression, the other 6 had a two-wall translid decompression. One of the 5 (20%) coronal versus 2 of the 6 (33%) traslid patients experienced worsening of their existing diplopia. Seventy patients underwent surgery for disfiguring proptosis; 41 of them had a coronal decompression and 29 had a translid decompression. Eight of the 41 coronal patients (20%) and 4 of the 29 translid patients (14%) experienced aggravation of their motility impairment. There was no statistically significant difference between these percentages (chi-squared, p > 0.05). Three of 26 coronal patients (12%) without pre-operative motility impairment developed diplopia in all directions. Twenty-five per cent needed strabismus surgery (9% multiple times). High satisfaction scores were noted after both types of orbital decompression. Through a review of the literature, several factors that may add to heterogeneous results were identified, including definition of diplopia, inclusion criteria and type of surgery. CONCLUSIONS: Induced diplopia is seen after any type of orbital decompression (19% overall), and its incidence is determined by various factors. To facilitate comparative studies between decompression techniques, a standardised protocol for orthoptic evaluation should be developed.

Adult↗
PubMed1999

Photoscreening for refractive errors in children and young adults with severe learning disabilities using the MTI photoscreener.

PURPOSE: To test the potential ability of the MTI photoscreener to facilitate screening for significant refractive errors in children and young adults with severe learning disabilities. METHODS: Thirty-eight patients with severe learning disabilities from a special school were examined with the photoscreener, and underwent cycloplegic refraction, an ophthalmological and an orthoptic examination. The age at examination, the cause of learning disability, the pupil size, the number of photographs required for accurate interpretation, the co-operation of the subject and the presence or absence of strabismus were recorded. An educational psychologist had performed a psychological assessment on all the children. The results of the cycloplegic retinoscopy were compared with the photorefraction results. RESULTS: A photorefraction was possible in 37 patients and cycloplegic refraction in all the patients. The patients had severe learning difficulties with an intelligence quotient of less than 50. All the patients had behavioural problems, 9 patients had associated cerebral palsy, 8 had chronic epilepsy, 1 patient was brain damaged from a non-accidental injury and 1 from a road traffic accident. The mean age of the patients was 10.0 +/- 4.9 years (range 3-18 years), the average pupil diameter during photoscreening was 6.1 +/- 0.9 mm (range 4-8 mm) and the average number of photographs required for each subject was 2.1 +/- 0.9 (range 1-4). The photoscreener detected 10 patients with a manifest strabismus. There was one false positive and one false negative result giving a sensitivity of 92.8% and a specificity of 90%. CONCLUSION: The examination of children with severe learning disabilities for refractive errors can be extremely difficult. The MTI photoscreener is an effective means of screening such children and young adults for refractive errors and strabismus so that the children with these abnormalities may be targeted for a more detailed evaluation.

Adolescent↗
PubMed2001

Review of the inverse Knapp procedure: indications, effectiveness and results.

PURPOSE: To evaluate the indications and results of inverse Knapp procedures performed at one institution over a 10 year period between 1987 and 1996. METHODS: The records of patients who had undergone inverse Knapp procedures were retrospectively reviewed. Demographic data were collected, pre- and post-operative orthoptic assessments were evaluated, and pre- and post-operative binocular single vision (BSV) charts and Hess charts were scored. RESULTS: Twenty-one patients were identified and records were available in 17. The main indication for the operation was orbital trauma. The mean vertical deviation in primary position and downgaze improved from 16.06 prism dioptres (PD) to 7.35 PD and 26.45 PD to 6.66 PD respectively. The pre-operative average score for BSV was 42%, increasing to 62% post-operatively. The Hess chart error scores improved on average from 848.8 pre-operatively to 296.4 post-operatively. Further operations were required for 8 patients. CONCLUSIONS: Inverse Knapp procedure is an uncommon strabismus operation but an extremely useful one in selected cases. We recommend it for the treatment of marked inferior rectus weakness, congenital or acquired, for post-traumatic inferior rectus underaction with or without orbital blow-out fracture and for residual large hypertropia in patients with poor binocular functions. The extent of inferior rectus underaction should be assessed very carefully to avoid overcorrecting.

Adolescent↗
PubMed2004

Macular coloboma in siblings affected by different phenotypes of retinitis pigmentosa.

Purpose To report the clinical association between macular coloboma (early-onset macular dystrophies/atrophic changes) and different phenotypes of retinitis pigmentosa (RP). Methods Three young-adult siblings, two males and one female, were retrospectively studied. These patients underwent two complete ophthalmologic examinations (27-month follow-up), including orthoptic evaluation, colour vision test, visual field, corneal topography, electronystagmography, fluorescein angiography, and electroretinography. Eye check, automated visual field test, and complete electroretinographic study were also conducted on other asymptomatic members of the same family. Results All symptomatic siblings were affected by manifest congenital nystagmus, poor visual acuity, and progressive visual field impairment in both eyes, bilaterally presenting macular coloboma associated with three different RP patterns: classic RP; mild dystrophy of the retinal pigment epithelium, associated with subnormal electroretinographic findings (subclinical form of RP); and sector RP. The ophthalmologic reports regarding their deceased father documented that he had suffered from the same alterations of ocular movements and visual performances diagnosing, in both eyes, extensive atrophic changes of the macular area completely surrounded by pigmented bone spicules (RP-type tapeto-retinal dystrophy). The other investigated relatives did not show any specific and/or significant ocular disorder. Conclusions In these three adult members of the same family, the concomitance between macular coloboma and different intrafamilial RP phenotypes is described. This association represents an autosomal dominant clinical entity, hitherto observed only in non familial sporadic cases.Eye (2004) 18, 421-428. doi:10.1038/sj.eye.6700689

Adult↗
PubMed2004

Subnormal visual perception in school-aged ex-preterm patients in a paediatric eye clinic.

PURPOSE: The aim of this study was to assess visual perception at school age of children born preterm with known lesions to the posterior visual pathways or with ophthalmologic signs that might indicate such lesions. METHODS: The study group consisted of 91 patients born before the 37th gestational week. Visual perception was assessed using the TVPS-R (Test of Visual Perceptual Skills - Revised) and a structured interview. In addition, ophthalmologic and orthoptic examinations were performed. RESULTS: On the test of visual perception, 67% of the patients had results below the third percentile of the American reference group. This is to be compared with 10% of Swedish full-term controls. Scores below the third percentile were observed in 87% of the patients with known brain lesions, 48% of those with strabismus without known brain lesion, and 86% of those with reduced visual acuity in the absence of strabismus and known brain lesion. CONCLUSIONS: Reduced visual perception is common among children born preterm who have strabismus and/or reduced visual acuity, as well as in those with known brain lesions. This study emphasises the need to find tools to identify and assess those patients who have visual perceptual problems that may restrict their ability to meet the demands of daily life.

Child↗
PubMed2004

Ophthalmic features of Turner's syndrome.

Turner's syndrome is one of the most common of all chromosomal abnormalities and is associated with significant ophthalmic morbidity. Turner's 1938 account included two patients with strabismus, and hitherto the condition has generated more interest among orthoptists than ophthalmologists. This systematic review of the literature seeks to redress the balance. Based on the pooled data of 274 patients with Turner's syndrome, it is the most complete evaluation so far of the prevalence and severity of ophthalmic problems in this population. This includes both a systematic review of the ophthalmic literature (via Medline) and the much larger body of work available in the orthoptic literature. Finally, we consider recent progress that enables the ophthalmologist to progress from the simple recognition of a phenotype to the correlation of genotypic variations with embryogenesis and consequent features of that phenotype.

Eye Diseases↗