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PubMed1983

Vision screening and photorefraction - the relation of refractive errors to strabismus and amblyopia.

Isotropic photorefraction is a technique well suited for screening infants and young children for refractive errors. The photorefractive measurements have been empirically calibrated against retinoscopic refractions, so errors exceeding selected criteria can be identified in screening and followed up. Such a screening programme is in progress for the population of 6-9 month infants in the City of Cambridge. In 1096 infants screened 5% have been found to have large hypermetropic errors, 1.3% to show a refractive difference between the eyes (anisometropia) and less than 1% to have significant myopia or manifest strabismus. These findings were generally confirmed on retinoscopic examinations. In subsequent follow up of the large hypermetropic errors, most decline with age but a few show little or no change up to age 2 years and some show more change in one eye than the other leading to anisometropia. A trial is underway to examine whether early correction with spectacles can reduce the later incidence of strabismus and amblyopia in hypermetropic infants. Significant astigmatism is found in a large fraction of the infant population; the predominant axis of this astigmatism shows marked and unexplained variations between different locations in England.

Amblyopia↗

PubMed2004

Late-onset progressive strabismus associated with a hydrogel scleral buckle.

A hydrophilic implant for scleral buckling was developed in 1980. Advantages include softness and elasticity, no dead spaces, ability to gradually absorb and release antibiotics, and stimulating production of a fibrous capsule around the implant. Short-term fellow studies in rabbits showed no clinical or histologic complications. Long-term complications of the hydrogel scleral buckle have emerged in the las 10 years. These included fragmentation, subconjunctival bulging, intraocular erosion, migration, and restriction of extraocular movement. We recently encountered a patient with progressive restrictive strabismus beginning 8 years after retinal detachment repair with a MIRAgel (hydrogel; MIRA, Uxbridge, MA) scleral buckle. Worsening complaints of diplopia and discomfort led to strabismus surgery. Untreatable retinal detachment resulted in enucleation.

Aged↗

PubMed2004

Orbital imaging demonstrates occult blow out fracture in complex strabismus.

BACKGROUND: While strabismologists are familiar with diagnostic evaluation of suspected blow out fractures, unsuspected blow out fractures may further complicate difficult cases of strabismus not clinically supposed to be related to orbital trauma. METHODS: According to a prospective protocol, we studied five adults presenting with diplopia, and one with convergence-related asthenopia. No patient recalled or had any clinical suspicion of orbital fracture at initial evaluation. Surface coil magnetic resonance imaging of the orbits was performed at 312 microm resolution, slice thickness 2 mm. Quasicoronal images in central gaze were supplemented with eccentric gaze positions, and sagittal and axial images as indicated. RESULTS: Five patients had incomitant hypertropia, and one had abducens paralysis. Magnetic resonance imaging disclosed previously unsuspected blow out fractures in all six patients. Three patients had medial wall fracture, one bilaterally. Two patients had inferior wall fractures, and one inferomedial. Although only one patient had an extraocular muscle displaced into a sinus, all had evidence of orbital connective tissue distortion in the region of the rectus extraocular muscle pulleys influencing muscle paths. These effects altered the presentations of more familiar pathologies such as superior oblique palsy. After learning of the MRI findings, most patients then recalled orbital trauma from as early as childhood. CONCLUSION: Unsuspected blow out fractures occur and may confound the usual findings in complex strabismus. High-resolution orbital imaging can detect blow out fractures and clarify the pathophysiology, enabling appropriate surgical management.

Adult↗

PubMed2005

Strabismus in senile cataract patients.

PURPOSE: We sought to determine the prevalence of strabismus among patients with senile cataract. METHODS: Forty-seven consecutive patients who were scheduled for cataract surgery underwent complete eye examinations, including ocular alignment evaluation. Twenty-four normal adults of the same age range underwent also complete eye examinations and were used as a control group. All patients of the cataract group underwent unilateral cataract surgery. The angle of strabismus was measured by the prism and cover test or prism and corneal reflex test. RESULTS: Mean preoperative deviation of the study group was 17.8 +/- 9.7 prism diopters (PD) of exophoria/tropia. In this group, 70.2% had exophoria and 27.7% had exotropia. In the control group exophoria was found in 75% of the persons whereas none of them had any heterotropia. Mean deviation in the control group was 4.7 +/- 5.1 PD of exophoria. Postoperatively, the angle of exophoria/tropia improved to 12.8 +/- 8.5 PD, which was different from the preoperative measurements (P < 0.01). In this group 78.8% had exophoria and 19.1% had exotropia. CONCLUSIONS: Patients with cataract have greater tendency to develop exotropia or exophoria than noncataract persons of the same age. Cataract surgery improves the heterophoric status of these patients.

Aged↗

PubMed2005

Loop myopexy for treatment of myopic strabismus fixus.

In myopic strabismus fixus, there is acquired esotropia and hypotropia associated with restricted elevation and abduction. One possible etiology is an enlarged globe herniating superotemporally through the muscle cone. High-resolution magnetic resonance imaging (MRI) has demonstrated the inferolateral displacement of the lateral rectus (LR) muscle in this restrictive motility disorder. Surgical treatment is difficult. We report two cases of myopic strabismus fixus that were treated with a loop myopexy of the LR and superior rectus (SR) muscles.

Adult↗

PubMed2004

Effects of droperidol dosage on postoperative emetic symptoms following pediatric strabismus surgery.

STUDY OBJECTIVE: To compare the frequency of postoperative emetic symptoms and side effects in pediatric strabismus surgery using four doses of droperidol. DESIGN: Randomized, blinded study. SETTING: University eye institute. PATIENTS: 82 ASA physical status I and II pediatric patients, aged 1 to 16 years, undergoing outpatient strabismus surgery. INTERVENTIONS: Patients were assigned to one of four doses of droperidol (10, 20, 40, or 80 microg.kg(-1)) (Groups 1, 2, 3, and 4, respectively). All patients received the same anesthetic management, with droperidol administered intravenously immediately after induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Postoperatively, patients were evaluated for emetic symptoms (nausea, retching, and/or vomiting) and side effects (postoperative sedation or extrapyramidal symptoms). There was a dose-dependent reduction of emetic symptoms seen with increasing droperidol dose. Predischarge emetic symptoms were 50%, 15%, 15%, and 5% in Groups 1, 2, 3, and 4, respectively (p < 0.009). Peak emetic symptoms were observed after discharge: 75%, 40%, 35%, and 15% in Groups 1, 2, 3, and 4, respectively (p < 0.003). Convalescence times, including awakening, extubation, recovery, and hospitalization, were unaffected by increasing droperidol dose. Sedation was similar in all groups and no patient exhibited any side effects. However, when patients exhibited emetic symptoms, discharge time increased from 207 +/- 57 minutes to 283 +/- 128 minutes (p < 0.001). CONCLUSIONS: Prophylactic administration of droperidol 80 microg.kg(-1) is most effective in reducing postoperative emetic symptoms without increasing time to discharge. In those patients with emetic symptoms who also received prophylactic droperidol, time to discharge was significantly delayed.

Adolescent↗

PubMed2006

A novel scale including strabismus and 'cuspidal ear' for distinguishing schizophrenia patients from controls using minor physical anomalies.

The present study explored minor physical anomaly items relevant to schizophrenia in order to establish a scale that can distinguish schizophrenia from controls using newly identified items along with items from the refined Waldrop scale. Seven items were significantly more frequent among schizophrenia patients (N=218) than controls (N=226). Among these seven items, two novel features, strabismus and 'cuspidal ear' showed markedly different prevalence rates between schizophrenia and control groups. A six-item scale, including the newly identified strabismus and cuspidal ear, was selected for most accurately discriminating patients with schizophrenia from controls. This scale correctly classified 59.6% of patients and 78.9% of control subjects. This new scale is procedurally more exacting and quantitative, and more relevant to schizophrenia than the original Waldrop scale. The validity of this scale should be sound since it was tested on a larger number of cohorts than used in previous research. Our scale can be used as a biomarker for predicting risk for future development of schizophrenia. The scale may also facilitate the identification of schizophrenia susceptibility genetic/environmental factors by stratifying etiologically heterogeneous patients according to physical abnormalities.

Abnormalities, Multiple↗

PubMedDate not supplied

Effects of subtenon anesthesia combined with general anesthesia on perioperative analgesic requirements in pediatric strabismus surgery.

BACKGROUND AND OBJECTIVES: Pediatric strabismus surgery leads to undesirable intraoperative and postoperative side effects that include pain, postoperative nausea and vomiting (PONV), and oculocardiac reflex (OCR). We hypothesized that subtenon anesthesia performed before the start of surgery and combined with general intravenous anesthesia would reduce these adverse effects. METHODS: Forty children (2.5 to 6 years of age, ASA status I to II) were prospectively randomized to receive either subtenon bupivacaine 0.5% or a saline injection before the beginning of surgery in a double-blind manner. Perioperative analgesic requirements, pain scores (CHEOPS scale), hemodynamics, and incidence of OCR and PONV were compared. RESULTS: Postoperative pain scores were lower (P < .001) at removal of the laryngeal mask and 30 minutes later in the bupivacaine group. Intraoperative and postoperative analgesic requirements were significantly reduced in this group (P < .01). The incidence of OCR and PONV were also significantly decreased (P < .01). Intraoperative values of blood pressure were significantly higher in the saline group at 20 minutes (P < .02). CONCLUSION: We conclude that preoperative subtenon bupivacaine 0.5% compared with a saline injection contributed to reduction of perioperative pain and undesirable side effects in pediatric strabismus surgery performed under general anesthesia.

Anesthesia, General↗

PubMed2001

Delayed orbital hemorrhage after routine strabismus surgery.

PURPOSE: To report a case of delayed rectus muscle hemorrhage after strabismus surgery. METHODS: Case report. RESULTS: Rectus muscle hemorrhage occurred 36 hours after strabismus surgery in a 26-year-old man, causing temporary loss of vision and reduced ocular motility. Urgent lateral cantholysis and orbital exploration to restore hemostasis were undertaken. Full recovery of vision occurred and a small residual motility disturbance was present 3 months postoperatively. CONCLUSION: Delayed rectus muscle hemorrhage poststrabismus surgery is rare but can have sight-threatening effects. When vision is threatened because of optic nerve compromise, urgent orbital exploration may allow full recovery of function.

Adult↗

PubMed2002

Rectus extraocular muscle pulley displacement after surgical transposition and posterior fixation for treatment of paralytic strabismus.

PURPOSE: To determine the effect of rectus extraocular muscle (EOM) transposition with posterior fixation (PF), we employed magnetic resonance imaging (MRI) to demonstrate pulley inflections in EOM paths before and after surgery in patients with paralytic strabismus. DESIGN: Consecutive interventional case series. METHODS: Five consecutive patients (three males and two females with a mean age 52 years, range 33 to 77 years) with paralytic strabismus were studied prospectively before and more than 6 weeks after EOM transposition and PF by means of contiguous cross-sectional MRI obtained in planes perpendicular to the long axis of the orbit. Muscle paths were determined in three dimensions (3-D) for each EOM by analysis of cross-sectional area centroids in normalized, oculocentric coordinate systems. RESULTS: Four patients underwent full tendon transposition with PF of the vertical rectus EOMs. One other patient underwent full tendon transposition without PF of the horizontal rectus EOMs superiorly. For transpositions with PF, there was a large displacement of EOM path in central (straight ahead) gaze beginning in the posterior orbit. After surgical transposition, clear inflections representing pulley locations of the superior, medial, and lateral rectus paths occurred in central gaze. There was no clear path inflection for the inferior rectus in central gaze, but there was a small inflection in adduction. After all transpositions, the globe center shifted away from the transposed insertions. CONCLUSIONS: Rectus EOM transpositions with PF shift EOM pulleys posteriorly and in the directions of the transposed EOM tendons, while translating the globe center. These changes may explain the superior effectiveness of PF in increasing duction towards the transposition.

Abducens Nerve Diseases↗

PubMed2002

Rectus eye muscle paths after surgical correction of convergent strabismus fixus.

PURPOSE: To present a new surgical procedure for convergent strabismus fixus. DESIGN: Interventional case report. METHODS: A 69-year-old woman was referred to us because of esotropia of both eyes. Both eyes were fixed in a position of extreme adduction, and ocular motility was severely restricted in all directions. Magnetic resonance imaging demonstrated that the superior rectus (SR) was deviated nasally and the lateral rectus (LR) was deviated inferiorly. We performed operations for both eyes consisting of hemitranspositions of the SR and LR combined with a large recession of the medial rectus. RESULTS: Postoperatively, the patient became able to fixate in primary gaze and ocular motility markedly improved in all directions. Magnetic resonance imaging confirmed that the paths of the SR and LR were corrected. CONCLUSIONS: This surgical procedure appears to be a useful option for treating convergent strabismus fixus.

Aged↗

PubMed1994

Strabismus in the Marfan syndrome.

We studied 573 patients with the Marfan syndrome for the presence of ocular misalignment, refractive errors, and amblyopia. A total of 110 patients (19.2%) had strabismus. Of 573 patients, exotropia occurred in 67 (11.7%), esotropia in 12 (2.1%), vertical deviations in eight (1.4%), and primary inferior oblique muscle overaction in three (0.5%). Of 67 patients with exotropia, 18 had anisometropia and 39 had amblyopia. Of the 12 patients with esotropia, four had amblyopia and none had anisometropia. Exotropia and esotropia are more common in patients with the Marfan syndrome than in the general population of the United States (P < .001 for exotropia and .05 < P < .10 for esotropia). Abnormal afferent visual inputs to cortical centers caused by ectopia lentis, craniofacial abnormalities, and mechanical and genetic factors may all contribute to the higher prevalence of strabismus in this disease.

Adolescent↗

PubMed1992

Vagal responses to adjustable sutures in strabismus correction.

The oculocardiac reflex is a recognized complication of ocular stimulation, precipitated most commonly by traction on the extraocular muscles. To determine the true incidence of occurrence of the oculocardiac reflex during suture adjustments, 20 patients undergoing suture adjustment were monitored for blood pressure, heart rate, and rhythm abnormalities during the suture adjustment. A control group of ten patients with strabismus were studied postoperatively for comparison. Thirteen study patients and two control patients were noted to have a vagal response (P less than .001). The most common response noted was a decrease in heart rate in 15 patients. Only two patients were symptomatic during vagal response (one patient became light-headed and another had an episode of nausea and vomiting). Suture adjustment was found to be the most common triggering event in precipitating vagal responses. Surgeons performing suture adjustment in strabismus correction should be cognizant of vagal responses so that they may properly inform patients of this possibility and take steps to minimize its occurrence.

Adolescent↗

PubMed1990

Peribulbar anesthesia for strabismus surgery.

We prospectively studied 76 patients to analyze the effectiveness of peribulbar anesthesia during strabismus surgery. The patients, ranging in age from 14 to 77 years, were given anesthesia with standard preoperative medication and a peribulbar injection of a mixture of 2% mepivacaine hydrochloride and hyaluronidase. Only one of the 76 patients required an additional injection of anesthetic to achieve adequate anesthesia. No morbidity was associated with the peribulbar anesthesia. Local anesthesia, particularly retrobulbar anesthesia, has been used as an alternative technique in an attempt to reduce the morbidity and mortality associated with general anesthesia in ocular surgery, particularly in those patients with high-risk characteristics. Even with retrobulbar anesthesia, however, there is a risk of morbidity and, in rare cases, mortality. Our results suggest that the use of peribulbar anesthesia is a safe and effective means of anesthesia in strabismus surgery because of minimal associated morbidity.

Adolescent↗

PubMed1995

Change in the cycle of circadian strabismus.

PURPOSE/METHODS: We observed a change in the typical circadian, 24-hour pattern of strabismus (esotropia) in a 2-year-old patient. Methods used include study of the history of the deviation pattern, observation, and measurement of the deviation on the day after travel and six weeks later. RESULTS/CONCLUSIONS: The patient responded to standard recession-resection surgery with a straight eye position daily, through three months of follow-up. Rapid travel over six time zones probably caused the change in the circadian pattern of strabismus.

Child, Preschool↗

PubMedDate not supplied

Accuracy of suture adjustment in adjustable strabismus surgery evaluated at the initial postoperative examination.

PURPOSE: To clarify the efficacy of sliding-noose type adjustable suture strabismus surgery, we evaluated the accuracy of suture adjustment based on data from the initial postoperative examination performed 1-4 weeks after the surgery. METHODS: Thirty-four patients with various types of strabismus participated [age range, 12-79 years; range of far deviation, 4-123 prism diopters (PD)]. Under sub-Tenon anesthesia, a recession (with or without a resection or muscle transposition) was performed with an adjustable suture (Guyton's procedure), and the suture was adjusted 6-24 hours after surgery. RESULTS: Twenty-six (76%) patients required suture adjustment one to eight times. In 50% and 75% of our patients, the errors from individual target angle were within +/- 0.8 and +/- 2.0 PD, respectively, whereas 2 (6%) patients with esotropia showed an undercorrection larger than 10 PD. The error distribution was almost the same throughout the range of preoperative deviation. CONCLUSION: By using an adjustable suture with a sliding noose, pinpoint alignment of the eyes can be achieved in more than half of the cases, at least in the early postoperative period.

Adolescent↗

PubMedDate not supplied

Restrictive strabismus after retrobulbar anesthesia.

Two rare cases of strabismus resulting from contracture of the extraocular rectus muscles after retrobulbar anesthesia for cataract surgery are described. Clinical signs in both cases suggested that the development of the impaired function of the lateral and superior rectus muscles followed the same pattern: initial stimulation followed by paretic and restrictive stages. Abnormal enlargement of the muscles was identified by computed tomography (CT) and magnetic resonance imaging (MRI). The data indicate that the strabismus was the result of direct injection of anesthetics into the rectus muscle.

Anesthesia, Local↗

PubMed1993

Diagnosis and treatment of strabismus disorders.

Strabismus is a common ocular abnormality in children and can have significant effects on visual, physical, and psychological development. The causes of ocular misalignment are numerous. Primary care physicians should be skilled in the evaluation of ocular motility in children. They also should understand the basic pathophysiology of common strabismus disorders and be able to identify those children at risk. This knowledge will aid in making a proper referral to an ophthalmologist when a strabismic disorder is suspected or detected.

Child↗