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An apparatus for measuring muscle forces in strabismus has been developed. The globe is fixed with a modified suction cup, force applied is measured by strain gauges, and the excursion of the globe is measured by a light pointer and tangent screen. The values of force generation tests for normal horizontal rectus muscles performing 30 degrees saccades lie mainly within the range of 60 to 80 G.
A 13-year-old white boy developed bilateral polypoid conjunctival masses overlying the lateral rectus muscles six months after surgery for divergent strabismus. Histologic examination confirmed the presence of amyloid in these lesions.
A case of congenital strabismus fixus divergens is described. Other anomalies were vertically oval corneas, high mixed astigmatism, amblyopia, horizontal nystagmus, microcephaly, maxillary hypoplasia, micrognathia, low set large ears, and hyperostosis frontalis interna.
BACKGROUND: Rupture of an inferior rectus muscle is an uncommon problem. The resulting absence of infraduction and large hypertropia that result when the muscle cannot be repaired are challenging to manage surgically. METHODS: We treated 2 patients who had traumatic rupture of the inferior rectus muscle. Both patients underwent an inferior transposition of the inferior halves of the medial and lateral rectus muscles without disinsertion (modified Jensen transposition procedure). RESULTS: Both patients had a persistent small overcorrection in the primary gaze position. One patient was treated with a second strabismus surgery consisting of a recession of the contralateral superior rectus muscle; the other was treated with prism glasses. Both achieved restoration of depression to approximately 40 degrees and single binocular vision in the primary position at distance, near, and in the reading position. CONCLUSION: This modified Jensen transposition procedure of the horizontal rectus muscles appears to be highly effective in the treatment of the hypertropia and infraduction deficit produced by rupture of the inferior rectus muscle. It also appears to be suitable for use in situations when other rectus muscles are absent or unavailable for surgical manipulation.
PURPOSE: To assess frequency of refraction errors, abnormal eye position and binocular vision disorders in children with retinopathy treated with cryotherapy. MATERIAL AND METHODS: Subjects of the study were 67 children, aged 2-7, treated with cryotherapy for active phase retinopathy. RESULTS: The largest group consisted of children with good visual acuity (48%). Refraction error was found in 94% of the examined eyes. Hypermetropia was more common (54%) than myopia (40%). Majority of the examined children had squint, and esotropia was much more frequent (52%). The deviation in 37% of children was over 10 degrees. In the group with birth weight under 1000 grams as well as in those with birth weight 1000-1500 grams the squint occurred in 48%, and in children weighing over 1500 grams in 4.0%. Only 54% of the studied children had normal binocular vision. CONCLUSIONS: Retinopathy of prematurity is a risk factor for development of refraction errors, strabismus and amblyopia. In infants with retinopathy of prematurity treated with cryotherapy it is necessary to have vision check-ups during their early childhood years.
We describe a case of disintegration of the inferior rectus muscle during routine strabismus surgery for restrictive hypotropia after cataract surgery. We used this surgical approach to repair the complete infraduction deficit incurred from the injury.
PURPOSE OF THE STUDY: To evaluate a group of patients with unilateral isometropic amblyopia according to presence of possible amblyogenic factors. MATERIAL AND METHODS: 37 patients (18 girls and 19 boys) with unilateral amblyopia without strabismus and with anisometropia of less than 1 D in any of the meridians were analysed according to such possible risk factors of amblyopia as age of examination, age of mother on delivery, sex, family history, puerperal complications, birth weight, refraction error, left or right eye. Depth of amblyopia, state of binocular vision and results of optical and pleoptical treatment were also evaluated. RESULTS AND DISCUSSION: No significant risks were found regarding the age of patient, sex, left or right eye, birth weight, age of mother on delivery, puerperal complications and family history. Refraction error was not high. Depth of amblyopia did not correlate with amount of refraction error. Central fixation was present only in 50% and stereopsis only in 42% of patients. 10 patients revealed no significant defect of fixation or binocular vision. All patients responded significantly poorly to treatment. CONCLUSIONS: Presence of amblyopia in patients with isometropia cannot be explained by genetic or puerperal risk factors. It might have developed in the period sensitive for amblyopia as a result of anisometropia that was later diminished by the process of emmetropisation or microstrabismus which was spontaneously cured. Some cases can be described as idiopathic because no defect can be detected. Early in life screening is necessary to successfully diagnose and treat amblyopia in childhood.
An ophthalmic survey of 310 school going children in the age group of 4-12 years was done. 41 children (13.2%) were found to have a vision of less than 6/6 in one or both eyes. Myopia of 0.5 D or more and hyperopia of +2 D or more or astigmatism of 1 D or more in one or both eyes were seen in 74 children (22.9%). There was a tendency for a decrease in hyperopia and an increase in myopia with advancing age. Astigmatic error of 1 D or less was seen in 12 eyes (1.93%) and anisometropia of more than 1 D was present in 11 cases (3.5%). Hypertropia was more in female children whereas myopia had a nearly equal distribution in both sexes. There was heterophoria and manifest strabismus which showed a gradual increase with advancing age. This study was compared to few other studies undertaken in the past.
A complex method for examining the function of the upper eyelid and oculomotor system in patients with strabismus concomitant with ptosis is described. Use of this method in 62 patients helped distinguish three clinical forms of this abnormality. It allows detecting important diagnostic criteria and determine the treatment strategy for this patient population.
PURPOSE: The immunotoxin, ricin-mAb 35, composed of ricin conjugated to a monoclonal antibody against the nicotinic acetylcholine receptor of skeletal muscle, has been proposed as a potential new agent for treatment of focal muscle dystonias. It has been demonstrated that direct injection of ricin-mAb 35 into rabbit extraocular muscle (EOM) results in significant muscle loss within 1 week. In this study, the long-term myopathic effects of ricin-mAb 35 on extraocular muscle were investigated. METHODS: Rabbit superior rectus muscles were injected with ricin-mAb 35 at a dose of 0.2 microg/kg, with the contralateral superior rectus muscle serving as the control. After 56 days, 105 days, and 1 year, the superior rectus muscles were removed and prepared for light or electron microscopy. Postinjection changes in muscle fiber morphometry and ultrastructure were examined. Immunohistochemical markers were used to identify inflammatory cellular infiltrate and myosin heavy chain (MHC) isoform expression. RESULTS: Despite evidence of ongoing regeneration, treated muscles continued to show a decrease in both myofiber number and in total cross-sectional area 56 and 105 days after injection. Individual myofiber cross-sectional areas were markedly heterogeneous at 56 days. Myofiber number and muscle cross-sectional area returned to normal 1 year after injection, but pronounced heterogeneity of myofiber size remained. The most significant changes in myosin heavy chain (MHC) isoform expression occurred in the orbital layer, where, at 56 and 105 days, there were increased numbers of fast and neonatal myofibers and decreased numbers of slow myofibers. In the global layer, after both 105 days and 1 year, there was a decrease in myofibers that were positive for slow, neonatal, and developmental MHC expression. CONCLUSIONS: EOM injection with ricin-mAb 35 results in a sustained decrease in muscle mass at 105 days after injection, with subtler morphometric changes persisting even to 1 year. Changes in muscle force development as a result of ricin-mAb 35 injection are currently under investigation. This novel immunotoxin may be useful in the treatment of strabismus if these studies show sustained weakness in treated muscles.
We investigated the cases of 50 non amblyopic children with concomitant convergent strabismus and exuberance of convergence, in which a prolonged prismatic correction was performed. 31 children had a 5 degree higher angle of squint in near vision before the application of prism. In 13 out of 31 the angle of squint, which was measured at the gaze for distance, increased more than 6 degrees. The ratio of normal retinal correspondence (NRC) to abnormal retinal correspondence (ARC) is 14:17. 19 patients developed only after prismatic correction of the angle of squint an exuberance of convergence. This phenomenon we call secundary exuberance of convergence. In this group the angle of squint for distance vision increased in only three children more than 6 degrees, while 6 children had a decrease by up to 11 degrees. The ratio NRC: ARC is 7:12. Postoperativ follow-up of binocular function over 4-5 years showed, that the prognosis in case of primary exuberance of convergence is worse than in secondary.
Strabismus is the lack of binocular vision due to an inability to control one of the eye muscles. Corrective surgery is the most common recourse and consists of adjusting and reattaching the extraocular muscle to the sclera. In approximately 10% of cases involving re-insertment of the extraocular muscle via suture techniques, the needle is inserted too deeply into the eye resulting in perforation of the retina. Fibrin glues and cyanoacrylates have been substituted with unsatisfactory mechanical results. The goal of this study was to maximize the tensile strength of rabbit extraocular muscles repaired using a laser-solder technique developed by McNally et al., Biodegradable polymer membranes of controlled porosity were fabricated with poly(L-lactic-co-glycolic acid) (PLGA) and salt particles using a solvent-casting and particulate-leaching technique. The porous membranes were doped with protein solder composed of 25% and 50% (w/v) serum albumin and 0.5 mg/ml indocyanine green (ICG) dye mixed in deionized water. In vitro tissue specimens were repaired using the solder-doped polymer membranes in conjunction with an 805 nm diode laser. The tensile strength was tested on an MTS machine and results were analyzed with the Student's T-test.
Results following vertical rectus muscle recession and classification of vertical strabismus due to the field of action of the vertical recti. 100 cases of vertical squint underwent surgery of the vertical recti (recession of the superior rectus muscle in 92 cases). One third achieved binocular functions partly based upon microtropia. It may be of special interest that 5 of 19 patients with "dissociated" alternating deviations could be cured by bilateral recession of the superior rectus. The authors try to give their own modification of the difficult classification of the different clinical types of vertical squint, since the results following the treatment of the various types were quite different.
BACKGROUND: Myasthenia gravis is infrequently encountered in pediatric ophthalmology practice. The purpose of this study is to evaluate the clinical spectrum of this condition in children and to identify factors that may aid the clinician in its diagnosis and management. SUBJECTS AND METHODS: A retrospective chart review was performed on all pediatric patients presenting with myasthenia gravis to the Departments of Pediatric Ophthalmology and Neuro- ophthalmology at the Texas Children's Hospital from 1989-1999. Information regarding mode of presentation, myasthenic classification, ocular and systemic involvement, diagnostic investigations, therapy and outcome was collected and evaluated. RESULTS: Fourteen patients were included in the study whose ages ranged from 1-17 years at presentation. One patient had congenital myasthenia gravis and 13 had juvenile myasthenia gravis. Thirteen of 14 (93%) patients presented with ocular findings; two of whom had associated systemic disease at presentation. Six of 14 (43%) patients had systemic involvement during the course of their illness, of whom three (21%) had respiratory compromise requiring assisted ventilation. Thirteen of 14 (93%) patients received pyridostigmine as first line treatment. Ten of 14 (71%) patients had a favorable response. A favorable response was defined as improvement in the extraocular motility to within 10 prism diopters of orthotropia with resolution of the blepharoptosis. Three of 14 patients (21%) received a combination of pyridostigmine and steroids, all of whom had a favorable response. Seven of 14 patients (50%) underwent thymectomy; all had a favorable response. Two of 14 patients (14%) required both blepharoptosis and strabismus surgery. CONCLUSION: Pediatric myasthenia gravis may present initially to the ophthalmologist and should be considered in any pediatric patients with blepharoptosis and an ocular motility disturbance. Prompt diagnosis may be associated with significant reduction in morbidity. A favorable response to medical and surgery therapy was noted in most of our patients.
This paper presents the holistic approach to the care of the pediatric patient with strabismus. It discusses preoperative management, contemporary surgical procedures including postoperative suture adjustments, complications and the care and management of the patient and family on the pediatric unit. It reviews discharge instructions including pain management, postoperative safety and the follow-up appointment with the surgeon. Methods of determining the level of knowledge of the child's primary caregiver are also a major focus.
BACKGROUND: This study evaluated the clinical efficacy and cost-effectiveness of prophylactic ondansetron versus early ondansetron treatment in the management of postoperative nausea and vomiting (PONV) in children undergoing strabismus repair using clinically meaningful outcomes and value-based principles. METHODS: One hundred and fifty children were randomly assigned to either prophylactic (P) or early symptomatic treatment only (T) group (n = 75). Children in group P received ondansetron 100 micrograms kg-1 i.v. and those in group T received placebo at the end of the procedure. After surgery, at the earliest sign of nausea or vomiting, children in both groups received ondansetron 100 micrograms kg-1 i.v. Besides the incidence of PONV, non-surrogate (fast tracking time, duration of stay in the postanaesthesia care unit (PACU) and parental satisfaction scores), therapeutic (numbers needed to prevent and treat) and pharmacoeconomic (cost to benefit a child and cost per PONV-free child) outcome measures were evaluated. RESULTS: The incidences of PONV in the immediate, early, late and first 24-h periods were significantly less in group P (20, 12, 19 and 35% respectively) than in group T (37, 29, 47 and 72%, P < 0.05). Time to achieve fast-track eligibility and duration of PACU stay were significantly shorter in group P (P < 0.001). Children in group P had superior mean (SD) parental satisfaction scores (8.2 (1.8)) compared with those in group T (6.8 (1.7), P < 0.001). The number needed to prevent PONV was 2 and the number needed to treat PONV was 9. The cost to benefit a child was more than fourfold less and the cost per PONV-free child was 35% less in group P. CONCLUSIONS: Compared with early symptomatic treatment with ondansetron, prophylactic ondansetron shortened fast-tracking time and duration of PACU stay and improved parental satisfaction and therapeutic outcomes at a lower direct cost.
The binocular visual field of 100 patients with a variety of manifest strabismus was analysed using a complex visual environment and polaroid dissociation. A significant area of the picture, both nasal and temporal to fixation, was suppressed by all patients. Eighty-nine per cent showed correct localisation and identification in an area which was not suppressed and was approximately 45 prism dioptres peripheral to fixation.
The aim of this paper was to prove by help of questionnaire the psychosocial problems in 26 adult patients operated for strabismus. We stated that the biggest difficulties of patients occurred by work and sport activities. The patients with diplopia also complained of difficulties with uncertain orientation, walking on steps and by locating the objects. The uncertainty by communication was also a great problem. The surgery fulfilled the expectations by 18 patients (69%), 8 patients (31%) were disappointed.