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PubMed2003

Using diazepam and atropine before strabismus surgery to prevent postoperative nausea and vomiting: a randomized, controlled study.

OBJECTIVE: To evaluate the efficacy of diazepam and atropine sulfate premedication in preventing nausea and vomiting after strabismus surgery under general anesthesia. METHODS: Fifty children age 4 to 15 years who underwent strabismus surgery at Cukurova University Medical Faculty, Department of Ophthalmology, from February 2000 to June 2000 were randomized into 2 groups: 25 children in the control group did not receive premedication, whereas 25 children in the treatment group received premedication with 0.15 mg/kg diazepam and 0.015 mg/kg atropine sulfate. Occurrence of postoperative nausea and vomiting (PONV) was recorded. RESULTS: The incidence of PONV was lower in the premedicated group (P <.018, chi(2) test). CONCLUSIONS: It is concluded that diazepam and atropine sulfate premedication decreases nausea and vomiting after strabismus surgery.

Anti-Anxiety Agents↗

PubMed1998

Results of a combined adjustable recession and posterior fixation suture of the same vertical rectus muscle for incomitant vertical strabismus.

PURPOSE: The posterior fixation suture (fadenoperation) is an effective treatment for complicated incomitant vertical strabismus. Traditional operative methods do not permit the simultaneous use of an adjustable recession of the same muscle. METHODS: Seven patients with incomitant vertical strabismus and diplopia were treated with a combined adjustable recession and posterior fixation suture of the same vertical rectus muscle. Preoperative vertical misalignments in the primary position ranged from 4 to 10 prism diopters. Vertical incomitance from the primary position into the field of action of the recessed vertical rectus muscle ranged from 6 to 30 prism diopters (mean, 17 prism diopters). This was the sole operation in five patients and was combined with other vertical muscle surgery in two others. RESULTS: All seven patients experienced improvement in their diplopia. Five of 7 patients (71%) required postoperative adjustments to achieve orthophoria in the primary position. This combined procedure reduced large deviations in the field of action of the recessed vertical muscle in all cases. Six of 7 patients (86%) did not require prismatic correction after this operation. One patient required prism only in his reading glasses. CONCLUSIONS: A combined adjustable recession and posterior fixation suture of the same vertical rectus muscle was effective in reducing or eliminating vertical incomitant strabismus.

Adult↗

PubMed1999

What is the role of botulinum toxin in the treatment of dysthyroid strabismus?

BACKGROUND: Botulinum toxin A has been used in the treatment of dysthyroid strabismus primarily as a temporary measure during the active phase of the disease. We report on our experience with 65 patients. METHOD: We review the records of 65 patients with dysthyroid strabismus who were treated with botulinum toxin A at Moorfields Eye Hospital between 1984 and 1996. CONCLUSIONS: Patients with a short duration of relatively mild dysthyroid strabismus have a chance of long-term benefit with botulinum toxin A. There is little use for botulinum toxin A in cases of severe dysthyroid disease.

Adult↗

PubMed1999

Developmental delay and poverty in the strabismus clinic.

BACKGROUND: Strabismus and poverty are more common among developmentally delayed children. Poverty is difficult to define, but qualification for Medicaid benefits has been used as an indicator in the past. METHODS: There was a retrospective review of 95 patients with strabismus younger than 7 years who were seen in the Department of Pediatric Ophthalmology at the Albany Medical Center for a 12-month period and were reviewed for the presence or absence of developmental delay. These patients were selected from 2 groups: one with Medicaid coverage and one without. RESULTS: Developmental delays were noted in 13 patients without Medicaid (27.0%) and in 26 patients with Medicaid (55.3%) (P = .0096). Patients with Medicaid were less likely to name Allen pictures by age 3 years (P = .0003). CONCLUSIONS: Poverty is more commonly associated with delays in patients with strabismus, and this should alert ophthalmologists who work with Medicaid patients to seek to identify the presence of developmental delay in managing the care of these patients.

Child↗

PubMed1999

Peroperative treatment with i.v. ketoprofen reduces pain and vomiting in children after strabismus surgery.

BACKGROUND: Strabismus surgery is associated with both pain and vomiting. Ketoprofen is widely used in adults to treat acute pain, but there are only few reports of its use in children. This randomised, double-blind, placebo-controlled, parallel group study was designed to investigate the analgesic effect of i.v. ketoprofen and its effect on the incidence of vomiting in children after day-case strabismus surgery. METHODS: Fifty-nine ASA 1 children, aged 1-12 years, entered the study. After premedication with diazepam and glycopyrronium, anaesthesia was induced with fentanyl and propofol and maintained with isoflurane. After induction the children in the ketoprofen group received 1 mg kg-1 ketoprofen followed by an infusion of 1 mg kg-1 ketoprofen over 2 h. In the placebo group, children received 0.9% saline. The postoperative pain was assessed by the Maunuksela pain score (0 = no pain, 10 = worst possible pain). All children received fentanyl as a rescue analgesic if the Maunuksela score was > or = 3. RESULTS: In the ketoprofen group the number of fentanyl doses was smaller compared to the placebo group (median 1, quartiles (0-2) vs. 2 (1-3), P = 0.047). The children in the ketoprofen group had less pain at 30 min (P = 0.02) and the worst pain observed in the post anaesthesia care unit was lower (3 (0-6) vs. 5 (3-8), P = 0.035). The incidence of vomiting was less in the ketoprofen group compared to the placebo group (17% vs. 41%, P = 0.036). No serious adverse reactions occurred. CONCLUSION: We concluded that ketoprofen administered i.v. during the operation produced analgesia and reduced opioid consumption and the incidence of vomiting in children after strabismus surgery.

Ambulatory Surgical Procedures↗

PubMed2001

Combination of droperidol and ondansetron reduces PONV after pediatric strabismus surgery more than single drug therapy.

BACKGROUND: Pediatric strabismus surgery is associated with a very high incidence of postoperative nausea and vomiting [(PONV) 44-88%]. Droperidol (10-75 microg kg(-1)) and ondansetron (50-150 microg kg(-1)) have shown variable success in reducing the incidence and severity of PONV. Combination of these two drugs has shown promising results. This randomized, double-blind, placebo-controlled clinical trial was conducted to evaluate the efficacy and safety of the combination of these two drugs in reducing the incidence and severity of PONV in pediatric strabismus surgery. METHODS: After institutional approval and parental informed consent, 240 children of ASA physical status I and II of either sex, aged 1-15 years were included in this study. None of the children received any premedication and a standardized anesthesia technique was used for all the children. They were prospectively randomized to one of the four treatment groups. Group PP received normal saline placebo intravenously after induction and at the end of the procedure. Group DP received droperidol 25 microg kg(-1) after induction and normal saline at the end. Group OP received ondansetron 150 microg kg(-1) after induction and saline at the end. Group DO received droperidol 15 microg kg(-1) after induction and ondansetron 100 microg kg(-1) at the end. RESULTS: Combination prophylaxis resulted in a lower incidence of PONV (13%) as compared to placebo (62.5%, P<0.001), ondansetron (37%, P<0.001), or droperidol (32%, P<0.01). CONCLUSION: Droperidol 15 microg kg(-1) in combination with ondansetron 100 microg kg(-1), administered at the induction and end of the operative procedure respectively, is more effective than either drug given individually in reducing the incidence of PONV after strabismus surgery.

Adolescent↗

PubMed2001

Myopexy (Faden) results in more postoperative vomiting after strabismus surgery in children.

BACKGROUND: Strabismus correction in children is associated with a high incidence of postoperative nausea and vomiting. The purpose of this prospective, double-blind study was to examine the influence of the surgical method for correction of squint on the incidence of postoperative vomiting. METHODS: One hundred and twenty consecutive children aged 2-12 years, scheduled for elective strabismus surgery, were enrolled in this prospective, double-blind study. A standardised total intravenous anaesthesia was given to all children. The development of perioperative oculocardiac reflex was noted and the number of episodes of vomiting during the first 48 h postoperatively was recorded. At the completion of the study, the children who were operated with myopexy according to Faden, were allocated to a Faden group, those without a myopexy to the non-Faden group. All the patients included in this study were operated on by the same surgeon with standardised techniques. RESULTS: The Faden group was younger, lighter and the operation time was longer (P<0.05). The incidence of vomiting was greater in the Faden group; 53% versus 12% (P<0.05). The incidence of oculocardiac reflex was similar in both groups; 40% in the Faden versus 28% in the non-Faden group, respectively. The total dose of propofol and alfentanil was similar between the groups. Requirement of analgesics for postoperative pain was similar in both groups. The only independent risk factor for postoperative vomiting was the Faden operation. CONCLUSION: The surgical method used for strabismus correction in children has a great influence on the incidence of postoperative vomiting. The Faden operation is associated with a very high incidence of postoperative vomiting; this particular group of patients has to be considered as a high risk group for postoperative vomiting and deserves an antiemetic prophylaxis.

Alfentanil↗

PubMed2002

Rectally administered diclofenac (Voltaren) reduces vomiting compared with opioid (morphine) after strabismus surgery in children.

BACKGROUND: Nausea, vomiting and pain are common complications after strabismus surgery in children. Diclofenac, a non-steroid anti-inflammatory drug, is widely used to treat acute and chronic pain but there are few reports of its use given rectally in children undergoing strabismus surgery. This open randomised study was designed to investigate the analgesic and anti-emetic properties of rectally administered diclofenac compared with opioid (morphine) given i.v. in connection with strabismus surgery in children. METHODS: After obtaining approval from the local ethics committee and written informed consent from the parents, 50 ASA class I-II children, 4-16 years of age, were randomised to receive either rectally administered diclofenac (Voltaren) 1 mg/kg or i.v. opioid (morphine) 0.05 mg/kg perioperatively. The children were consecutively operated upon from May 1999 to January 2001. Anaesthesia was induced with fentanyl and propofol and maintained with propofol. Nitrous oxide was omitted. The postoperative pain was assessed after arrival at the post anaesthesia care unit (PACU) by using the validated Wong and Baker scale (FACES) Pain Rating Scale. Postoperative nausea and vomiting (PONV) was assessed by measuring the frequency of vomiting and the degree of nausea. RESULTS: In the diclofenac group the incidence of PONV during the first 24 h was 12% (of which one child had severe vomiting). The incidence of PONV was much higher, 72% (P = 0.0000), in the morphine group, where 56% of the children also had severe vomiting. There were no difference in pain score between the two groups. Recovery time at the PACU was longer (P < 0.002) and the postoperative analgesic requirement higher in the morphine group (10 vs. 5 children). No children needed overnight admission to the hospital. CONCLUSION: Diclofenac given rectally is an effective analgesic for this kind of surgery and gives less postoperative nausea than i.v. morphine. No serious adverse events were observed.

Administration, Rectal↗

PubMed2001

Strabismus surgery: fibrin glue versus vicryl for conjunctival closure.

PURPOSE: The aim of present study was to compare the results of conjunctival closure by fibrin glue with vicryl in strabismus surgery. METHODS: 19 patients undergoing bilateral symmetrical strabismus surgery were included in this study. Conjunctival incisions were closed with 6-0 vicryl in the right eye and fibrin glue in the left eye. RESULTS: On first post-operative day 15 out of 19 eyes (78.9%) had well apposed conjunctiva, 3 out of 19 eyes (15.79%) had 1 mm retraction and one out of 19 eyes (5.26%) had 2 mm retraction, which needed suturing, in cases in which fibrin glue was applied. Increased discomfort and excessive watering was noted during the early postoperative period in 8 out of 19 eyes (42.1%), in eyes in which the conjunctiva was closed with 6-0 vicryl, as compared to none in the fibrin glued eyes (p=0.005). However, the difference disappeared after 21 days. CONCLUSION: Fibrin glue can be used as an alternative to suturing for conjunctival closure following strabismus surgery.

Adolescent↗

PubMed2002

Screening for amblyopia and strabismus with the Lang II stereo card.

PURPOSE: To evaluate the effectiveness of the Lang II stereo card as a screening test for amblyopia and/or strabismus. METHODS: A total of 1046 children aged 12-13 years were examined in a field study in the Göteborg area, Sweden. In addition to the Lang II stereo card, the examination included visual acuity, cover testing, cycloplegic refraction, and inspection of the optical media and posterior pole. RESULTS: If every incorrect subject response was considered a reason for referral, the Lang II test would have correctly identified 82% (23 subjects) of the 28 children with manifest strabismus and 38% (11 subjects) of the 29 children with amblyopia. The test failed to refer 45% (21 subjects). Of all subjects referred, 44 (63%) were found to be ophthalmologically normal. CONCLUSIONS: The Lang II stereo card is neither a reliable nor an efficient method of screening for amblyopia and/or strabismus.

Adolescent↗

PubMed2003

Negative social bias against children with strabismus.

PURPOSE: To determine whether the presence of noticeable strabismus creates a negative social bias against children. METHODS: Photographs of two boys and two girls were digitally altered to create photographs of the same child in orthotropic, esotropic and exotropic states. Elementary school teachers rated their perceptions of the children's personal characteristics (using a 10-item list of personal characteristics) based on their responses to these whole-face photographs. The participants were also asked to answer five questions related to the first impressions created by the photographs. RESULTS: Children with esotropia and exotropia were rated more negatively than orthotropic children on all 10 characteristics. Children with esotropia were rated more negatively than those with exotropia on most of these characteristics. CONCLUSIONS: Children with noticeable strabismus are viewed negatively. Hence, correction of strabismus may provide psychosocial benefits even when there is no hope of improving visual function.

Adult↗

PubMed1996

The relationship between infantile strabismus and latent nystagmus.

The so-called infantile strabismus syndrome consists, among other signs, of (1) strabismus, (2) a defect of pursuit and optokinetic tracking with particular involvement of temporally directed responses on monocular viewing, (3) latent nystagmus and (4) adduction preference of the fixating eye. The following causal relationship between these three phenomena is suggested. (1) Binocularity in the visual cortex is impaired, either as a primary defect or as a consequence of misalignment of the eyes. (2) The reduced binocularity prevents maturation of signal transmission from the visual cortex to the brainstem such that slip control is evident in poor pursuit and optokinetic responses, particularly to monocular, temporally directed stimuli. (3) The asymmetry of the pursuit and optokinetic systems is also evident in latent nystagmus which reflects a tonic preponderance, directed nasally with reference to the fixating eye. The directional preponderance drives the slow phases of latent nystagmus if the visual input is unbalanced in favour of one eye. Because of the maldeveloped slip control latent nystagmus is not inhibited by visual contours. When both eyes are open the better-functioning nasally directed pursuit and optokinetic control systems of the two eyes complement each other and largely prevent drifting of the eyes. The defect responsible for the abnormal motor control cannot be located between the retina and the visual cortex because perception of motion is only slightly impaired and a nasal-temporal asymmetry of the motion VEP, typically encountered in infantile strabismus, does not correlate quantitatively with the asymmetry of the motor control. Rather, the defect is located between the cortex and the brainstem. (4) Adduction preference of the fixating eye with a compensatory headturn is due to a gaze-evoked component added to the latent component of the nystagmus. The gaze-evoked component is a purposeful reaction that allows dampening of the nystagmus in adduction at the expense of an increase in abduction.

Electrophysiology↗

PubMed2002

The assessment and management of strabismus and amblyopia: a national audit.

AIMS: To determine what systems are in place within ophthalmic services for the assessment and management of children suspected of having amblyopia and strabismus. To find out what methods are used for the assessment of these children. METHODS: A questionnaire-based study auditing 288 orthoptic departments in the UK. RESULTS: Responses were received from 75% orthoptic departments. Most hospitals employ more than one system for the assessment of strabismus and amblyopia, which is generally dependent on route of referral. These include 'orthoptic assessment without refraction' (66%), 'combined orthoptist and ophthalmologist assessment' (66%), while 22% have an entirely orthoptist/optometric system. Ophthalmologists are involved in the initial assessment in 145 units (67%), whereas some units involve an ophthalmologist only if response to treatment is poor (15%), or if surgery is required (6%). Fourteen per cent of units reviewed all children, with discharge criteria being based on normal visual acuity (52%), accurate visual acuity (39%) and a normal orthoptic assessment (42%). Seventy-six per cent of units review some children, commonly as a result of family history (55%), parental concern (43%), poor co-operation (30%) and young age (72%). In the absence of squint or amblyopia children are discharged at the first visit, in only 8% of units. There is considerable variation in the tests used to assess visual acuity. LogMAR-based tests (eg EDTRS) are not routinely used in 75% of units. CONCLUSION: Different systems exist for the assessment and management of squint and amblyopia across the country. While much of this variation is to be expected given their possible aetiologies, some could be reduced to produce a more cohesive service. There is also considerable scope for rationalising the tests used to screen infants and children for amblyopia and strabismus.

Amblyopia↗

PubMed2003

Strabismus surgery: adjustable sutures-good for all?

AIMS: The role of adjustable sutures in strabismus surgery has mainly been limited to conditions like dysthyroid restrictive myopathy, blow-out fractures of orbit, aberrant regeneration of nerves, and certain other long-standing and complicated squints. In this clinical study, an attempt has been made to analyse the efficacy of adjustable sutures in squint surgery as a routine procedure. We also studied patients' acceptability and satisfaction following this procedure and analysed various factors that may influence the surgical outcome (age, sex, previous surgeries, injections of botulinum toxin, etc). METHODS: A total number of 443 patients, aged between 13 and 78 years, who underwent strabismus surgery in our department, from January 1996 to January 2000, were included in this study. Of these patients, 141 had surgery with adjustable sutures and 302 patients without adjustable sutures. Surgical results were followed up for a period ranging from 12 to 50 months. The main outcome measure was a need for a reoperation in the two groups. In addition, we also studied patients' satisfaction with regard to final cosmetic appearance or relief of diplopia; percentage change in angle of deviation in two groups, and influence of various factors such as age, sex, previous surgeries, and injection of botulinum toxin on the final surgical outcome. The results were statistically analysed using Levene's test for equality of variances, t-test for equality of means, and statistical significance of the results was analysed by calculating P-values. RESULTS: In total, 8.51% of the patients in the adjustable group and 27.15% in the nonadjustable group needed a reoperation. Surgical results were found to be significantly better in patients who had adjustable sutures in comparison to those who did not have adjustable sutures (P<0.005). Patients' satisfaction and percentage change in angle of deviation was also much higher in adjustable sutures group. Age, sex, number of previous surgeries, previous injections of botulinum toxin, and type and amount of deviation had no statistically significant influence on the surgical outcome. CONCLUSIONS: Strabismus surgery with adjustable sutures has a statistically significant better, final result than surgery without adjustable sutures. Patients' satisfaction and percentage change in angle of deviation is also much higher in the adjustable sutures group. As age, sex, number of previous surgeries, previous injections of botulinum toxin, and type and amount of deviation do not influence the final outcome, this type of surgery can be performed in virtually all types of patients.

Adolescent↗

PubMed2006

Combined propofol sedation with sub-Tenon's lidocaine/mercaine infusion for strabismus surgery in adults.

AIMS: To evaluate the safety and efficacy of propofol sedation combined with sub-Tenon's anaesthesia for strabismus surgery in adults. METHODS: Thirty-two consecutive patients aged 31-85 years underwent strabismus surgery under general (n=16) or local (n=16) anaesthesia. In the local anaesthesia (study) group, sedation was induced with a loading dose of midazolam, fentanyl, and propofol, followed by continuous infusion of propofol, 3-6 mg/k/h to deep sedation. A nasal tube was inserted to prevent airway obstruction. Sub-Tenon's anaesthesia included infusion of a 3-4 ml mixture (50 : 50) of lidocaine 2%/mercaine 0.5%. General anaesthesia consisted of premedication with midazolam, followed by fentanyl, esmeron-bromate, propofol, and tracheal intubation. Duration of surgery and anaesthesia, intraoperative oculocardiac reflex and arrhythmias, time to discharge, postoperative pain, nausea and vomiting, and patient and surgeon satisfaction were evaluated. RESULTS: The local anaesthesia group had a significantly shorter operative and anaesthesia time, fewer episodes of oculocardiac reflex or arrythmia/bradycardia requiring treatment, fewer early or late episodes of nausea and vomiting, and less pain. The patients and surgeon in this group reported higher satisfaction. CONCLUSION: Propofol sedation with local sub-Tenon's injection of lidocaine/mercaine is recommended for the induction and maintenance of anaesthesia during unilateral or bilateral strabismus surgery in adults. The method is quick and effective, without systemic or ocular side effects.

Adult↗

PubMed2002

[Congenital ptosis: amblyogenic refractive errors, amblyopia, manifest strabismus and stereopsis related to the types of ptosis. Data on 77 patients and review of the literature].

BACKGROUND: Former reports on amblyogenic refractive errors, amblyopia and binocular vision in congenital ptosis usually comprise all forms of ptosis without any differentiation. This study is an analysis of different kinds of ptosis. PATIENTS AND METHODS: 154 eyes (98 ptotic eyes) of 77 patients with congenital ptosis aged > or = 1 year (56 unilateral ptoses: 45 simple, 1 with rectus superior paresis, 7 with Marcus Gunn's syndrome, 2 congenital oculomotor palsies, 1 unilateral fibrosis syndrome; 21 bilateral ptoses: 10 simple, 2 with bilateral double elevator paresis, 7 blepharophimosis syndromes and 2 bilateral fibrosis syndromes) were investigated concerning visual acuity, refractive error (94 % in cycloplegy), strabismus and stereo acuity. As amblyogenic refractive errors were defined: astigmatism > or = ldpt, anisometropia > or = 1 dpt (spherical equivalent) and hyperopia > or = 3 dpt; amblyopia was defined as visual acuity less than 1.0 or a difference between both eyes of at least 0.2. RESULTS: Altogether were found: Hyperopia > or = 3 dpt in 28.6 % (n = 28); astigmatism > or = 1 dpt in 63.3 % (n = 62), anisometropia in 27.3 % (n = 21), amblyopia in 65.3 % (n = 64), strabismus in 29.9 % (n = 23) and stereopsis in 76.6 % (n = 59). In unilateral simple ptosis, astigmatism of the fellow eye was found in 26.8 % (n = 14). In unilateral ptosis, esotropia was 21.4 % (n = 12), in bilateral ptosis, exotropia 19 % (n = 4), as well as astigmatism > or = 3 dpt 26.2 % (n = 11). As was to be expected, ptosis groups with motility disorders were associated with higher rates of strabismus and amblyopia. The blepharophimosis syndrome could be differentiated by the typical lid anomalies. CONCLUSION: The subgroups of congenital ptosis differ in frequency of amblyogenic factors. In unilateral ptosis these are also frequent in the fellow eye.

Adolescent↗

PubMed1996

[Strabismus and Williams-Beuren syndrome. Presentation of 3 operated cases].

BACKGROUND: Williams-Beuren syndrome (WBS) is a developmental disorder of unknown etiology. The classical features include: 1) a supravalvular aortic stenosis, 2) "elfin" facies and 3) mental deficiency. Ocular findings can be irisabnormalities (stellate, pattern), tortuositas vasorum and, though not essential for diagnosis, strabismus is commonly found. Three cases of WBS with convergent squint which underwent surgical treatment are presented. Biopsy and histological studies were performed in two cases. MATERIAL AND METHODS: Strabismus onset was diagnosed before the second year of life in all three. Pre-operative esotropia (ET) was 45, 40 and 62 delta. Age at operation was respectively 52,67 and 87 months. Surgical treatment consisted in recess-resect procedures on horizontal muscles. Biopsy was performed in two cases. RESULTS: Three months after surgery, angular measurements were respectively: exotropia (XT) 6 delta, ET 2 delta, ET 10 delta. Anatomopathological findings showed normal tendon tissue. DISCUSSION: No particular motility disturbances or pattern have been found in our patients. Amount of surgery has been chosen according to routine. Amblyopia treatment could be performed as usual. Treatment in our patients with WBS has been similar to ordinary cases of strabismus. Medium-term results do not differ from other squinting patients treated with similar procedures.

Child↗

PubMed1995

[Unilateral tucking and advancement of the inferior oblique muscle for treatment of A-pattern strabismus].

PATIENTS: The clinical results of the unilateral tucking and advancement of the inferior oblique base on the retrospective data of 81 patients. METHOD: Tucking and advancement of the inferior oblique was used in A-pattern strabismus, which showed a marked hypofunction of the inferior oblique in relation to hyperfunction of the superior oblique. RESULTS: The unilateral tucking and advancement of the inferior oblique improves the incomitance as well as the elevating deficiency in adduction. The effect of the operation relative to incomitance depends on its preoperative state. With increasing A-pattern strabismus has an increased effect of the advancement and tucking is revealed. CONCLUSION: Unilateral tucking and advancement of the inferior oblique is not a routine procedure in the treatment of A-pattern strabismus, but it is possible to improve the incomitance and the elevating deficiency in adduction.

Adolescent↗