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[Clinical aspects of strabismus with insufficiency of the superior oblique muscle].

Clinical features of vertical strabismus with superior oblique muscle insufficiency were studied in 123 patients. A complex of clinical methods was used and clinical evaluation of these methods made. Various forms of strabismus with superior oblique muscle insufficiency were detected. Four degrees of superior oblique muscle weakness were distinguished corresponding to four degrees of inferior oblique muscle hyperfunction.

Adolescent↗

PubMed1993

[Surgical treatment of A-pattern strabismus with over-acting superior oblique muscles].

13 cases of A-pattern strabismus with overacting superior oblique muscles were treated with Berke's procedure. Depending on the severity of superior oblique muscle overaction, simple tenotomy or partial tenectomy of the superior obliques was performed. For cases of A-pattern strabismus < 30 prism diopters, bilateral superior oblique muscle weakening might result in overcorrection, and for cases > 40 prism diopters, bilateral superior oblique weakening should be accompanied with vertical displacement of the horizontal muscles. For patients with stereoacuity of 40 arc seconds, surgery should be refrained from in order to avoid post-operative cyclodeviation.

Adolescent↗

PubMed1993

Open placebo controlled comparison of the antiemetic effect of droperidol, metoclopramide or a combination of both in pediatric strabismus surgery.

In children, strabismus surgery is frequently followed by vomiting. The present study compares the antiemetic effects of droperidol (10 micrograms/kg) and/or metoclopramide (0.1 mg/kg) in 104 children undergoing strabismus surgery. The patients were randomly divided into four groups. Group I (n = 28) received placebo (saline), Group II (n = 26) droperidol 10 micrograms/kg, Group III (n = 25) metoclopramide 0.1 mg/kg and Group IV (n = 25) droperidol 10 micrograms/kg and metoclopramide 0.1 mg/kg. Droperidol was given just after induction and metoclopramide at the end of surgery, just before recovery. The technique of anesthesia involved an anticholinergic premedication, IV fentanyl (2 micrograms/kg), controlled ventilation using isoflurance and N2O in oxygen and systematic gastric emptying before extubation. Vomiting, retching and nausea were noted at 5 different moments: in the Post Anesthetic Care Unit, when arriving on the ward (= after carriage by lift), during the first hour following the return in the ward, from the 6th to the 12th postoperative hour and on the morning of day 1. There was no statistically significant difference in the incidence of vomiting among these four groups. Moreover, the incidence of vomiting in the placebo group was much lower (17.9% in the recovery room, 3.6% at return in the ward, 25% during the first hour, 7.1% from 6 to 12 hours and 3.6% the next day) than that reported in previous studies. We think that this could result from the additive effects of some aspects of the technique of anesthesia described and discussed in this paper.

Antiemetics↗

PubMed1996

Amblyopia & strabismus.

Amblyopia and strabismus are the most common ocular conditions occurring during childhood. Amblyopia is the leading cause of vision loss in childhood. Strabismus is a significant cause of ocular morbidity leading to amblyopia and psychosocial distress in childhood and into adulthood.

Amblyopia↗

PubMed1996

Practical approach to diagnosis of strabismus.

Jampolsky's approach to the diagnosis of strabismus is simple. Certain tests are to be performed in sequence to determine 1) the presence of fusion in the habitual head position under normal viewing conditions and in the primary position at near and distance; 2) the presence and characteristics of fusion vergences and 3) the deviations that exist at distance and near. These are established by the cover tests and the prism cover test. 4) Incomitance of the strabismus, A-V phenomena and mechanical weaknesses and restrictions are assessed by observations of eye movements and the forceps tests. Finally, 5) inferences about the state of the sensory system are made based on the history, vision and clinical examination. Additional tests performed on indication are the 4 diopter prism test, the prism adaptation test and the forceps muscle tests. This approach allows an accurate and reproducible examination to be performed in an objective manner making it possible to compare clinical findings over time and allow a rational plan of management to be evolved. Errors in examination arise from poor control of three factors, accommodation, fixation and fusion vergence. These can be controlled by careful attention to the test conditions. This system of diagnosis is simple to follow and understand, economic on time and altogether less of a strain to examiner (and patient) than the traditional system.

Child↗

PubMed1995

[Benefits of total hypermetropia correction in patients with strabismus].

This study compared the sensory status of 23 patients (19 children and 4 adults) before and after treatment with total hypermetropic correction. We have shown that binocular improvement can be obtained in every category of strabismological pathology, including exotropia, with the exception of early onset micro-strabismus. Three cases of late onset micro-strabismus (one divergent and two convergent) where total sensory cure was obtained are also described. We confirm the slow clinical progression of hypermetropia in the strabismic patient provided with total optical correction. The two examples reported, as well as our cursory review of recent literature, provide justification for the early, systematic prescription of total optical correction for strongly hypermetropic children (> 4 D).

Adolescent↗

PubMed1998

A muscle-clamping system with an absorbable jaw clip to reduce suturing in strabismus surgery.

Most of the ocular complications of strabismus surgery are related to needle trauma during the suturing of muscles. The authors have developed a muscle-clamping system with an absorbable jaw clip to facilitate exact techniques of eye muscle surgery and to reduce the risk of complications. The absorbable jaw clip is composed of a lower fixing body with three jaws and an upper supporting body. The clip is used to tie an extraocular muscle (which is moved and reattached with the membrane) with a single scleral bite. Using the absorbable jaw clip, the authors performed superior rectus recession on 16 eyes of eight rabbits. The authors examined the conjunctival injection, muscle adhesion power, and light microscopic findings at 1, 2, 4, and 8 weeks postoperatively. The conjunctival injection diminished with time. Bond strengths ranged from 380 to 620 gram gravity, which is sufficient to withstand the normal pull of human extraocular muscles. Some inflammatory cells were found microscopically, and fibrosis increased with time. The muscle-clamping method with the newly invented clip was technically easy, fast, and exact, and it may reduce suturing and complications during strabismus surgery.

Animals↗

PubMed1998

Prophylactic metoclopramide administered immediately after the induction of anesthesia has no effect on the incidence of postoperative emesis after strabismus surgery.

OBJECTIVE: To evaluate the efficacy of metoclopramide (0.25 mg/kg) administered IV immediately after induction of general anesthesia for the prevention of postoperative emesis in children undergoing, elective strabismus surgery. DESIGN: Double blind, randomized. SETTING: Operation-theater. SUBJECTS AND INTERVENTIONS: Seventy six non premedicated children of ASA class 1 and 2 were randomly allocated to receive either normal saline or metoclopramide immediately after the induction of general anesthesia. All children received a standardized similar anesthetic technique. Postoperative analgesia consisted of oral indomethacin. RESULTS: The incidence of postoperative emesis in the metoclopramide group was 60% versus 71% in a placebo group (p < 0.05). The incidence of severe emesis (2 or > 2 vomiting) was similar in the placebo group (34.20%) and metoclopramide group (21.05%). There were no adverse reactions like excessive sedation, extrapyramidal signs and hemodynamic depression in either placebo or metoclopramide group. CONCLUSIONS: Metoclopramide in a dose of 0.25 mg/kg administered intravenously prior to manipulation of eyeball is devoid of the effects but is not effective in preventing postoperative emesis in children undergoing strabismus surgery.

Anesthesia, General↗

PubMed1976

Special considerations and techniques in strabismus surgery.

Strabismus surgery continues to present a challenge to the ophthalmologist who evaluates results critically. Precise diagnoses and expert surgical judgment never will be supplanted by tools and techniques. Nevertheless, by remaining aware of newer surgical procedures and improved instrumentation, the strabismus surgeon will continue to increase the probability of achieving desirable surgical results.

Humans↗

PubMed1998

[Use of botulinum toxin in the treatment of strabismus].

The authors present their two years experience with the administration of botulotoxin, the first observations in this country in connection with treatment of strabismus. Botulotoxin was injected by the i.m. route to 26 children mostly with residual deviations above 20 PD in concomitant strabismus. After a single injection the deviation declined to less than 20 PD in all patients. However persistence of deviations under 10 PD was not permanent and after reappearance of the deviation the administration of botulotoxin had to be repeated. The authors consider the therapeutic results satisfactory and draw attention to advantages and disadvantages of this method. They discuss in particular problems of the long-term effect of treatment.

Adolescent↗

PubMed1998

Downshoot in infra-adduction following selected superior oblique surgical weakening procedures for A-pattern strabismus.

PURPOSE: To determine the incidence of postoperative persistent or recurrent, true or pseudo, superior oblique muscle overaction (SOOA) following treatment of A-pattern strabismus by a selective surgical approach; and to seek its cause. SUBJECTS AND METHODS: Retrospective analysis of the records of 104 consecutive patients with A-pattern strabismus and SOOA treated, with 4 different superior oblique (SO) weakening procedures, selected according to the amount of preoperative anisotropia (in order, smallest to largest): posterior (partial) tenectomy, scleral disinsertion, tenectomy at the insertion and recession with posterior transposition. After exclusions for cause, there were 93 patients who received the same procedure in both eyes. The mean preoperative A anisotropia was 18.30delta+/-8.05delta (range 8delta to 50delta). The mean preoperative SOOA was +2.06 (range +1 to +4). RESULTS: The mean correction obtained by surgery was 16.20delta+/-8.7delta (88.5% of the preoperative deviation). The mean reduction of SOOA was -1.89 (-91. 7% of the preoperative SOOA, range -75.8% to - 103.1%). During postoperative followup, a pattern of persistence of downshoot in the infra-adducted position of gaze (true/pseudo SOOA) was found in 37. 6% of the cases (28% following tenectomy, 30.7% after recession, 40. 4% after posterior tenectomy and 62.5% after disinsertion). A complication, Superior Oblique Inclusion Syndrome was discovered in two cases. CONCLUSIONS: Persistence or recurrence of postoperative downshoot in the infra-adducted position is a common finding following any of the SO weakening procedures analyzed in this study. Its occurrence does not seem to be related either to the amount of preoperative SOOA and/or A anisotropia, nor to the amount of A anisotropia correction obtained. Relatively uncontrolled procedures, such as disinsertion, showed the highest incidence of this sequel of surgery.

Adolescent↗

PubMed1989

The influence of axial length on the response to strabismus surgery.

We performed axial length determinations preoperatively on a series of patients undergoing strabismus surgery. A statistically significant inverse correlation was found between axial length and the response (prism diopters per millimeter of medial rectus recession) for esotropic patients. The data suggest that a surgical formula designed to take axial length into account would decrease the variability in response to strabismus surgery in esotropic patients. Poor correlation was found between axial length and response to surgery in exotropic patients. We feel this poor correlation was due, in part, to the postoperative drift rate in exotropic patients as well as inaccuracies with the standard techniques used to determine the basic deviation on which surgery in exotropic patients is based.

Adolescent↗

PubMed1989

Effects of convergent strabismus on the development of physiologically identified retinogeniculate axons in cats.

We have studied the effects of surgically induced convergent strabismus (esotropia) on the morphological development of retinogeniculate X and Y axon arbors in cats. Single axons were recorded in the lateral geniculate nucleus or in the optic tract adjacent to the nucleus, classified physiologically, and injected intracellularly with horseradish peroxidase. The arbors of recovered axons were compared with X and Y axon arbors from normally reared adult cats. Our data demonstrate that while X axon arbors are relatively normal, the arbors of Y axons are profoundly affected by rearing with strabismus. Y axons, whether originating from the deviated or the nondeviated eye, have substantially smaller arbors and fewer boutons in the A-laminae of the lateral geniculate nucleus compared to Y axons in normal cats. The C-lamina terminations of contralaterally projecting Y axons in the strabismic cats are unaffected. These results suggest that the postnatal development of retinogeniculate Y axon arbors in the A-laminae is strongly influenced by abnormalities in postnatal visual experience. Furthermore, the present data suggest that, in addition to intraocular competitive interactions between X and Y axons previously proposed to account for the effects of other rearing conditions, interactions between afferents from the two eyes must also be involved in the development of at least Y axons.

Action Potentials↗

PubMed2002

Cortical binocularity in convergent strabismus after section of the optic chiasm.

In convergent strabismus (esotropia) the spatial asynchrony of the two eye inputs unbalances the interocular interactions, leading to the functional advantage of the nondeviated eye and the inhibition of the esotropic eye. It may be argued that the strabismic suppression, if it is the effect of inhibitory interactions between the eyes, could be removed by interrupting the interocular pathways at the optic chiasm. After chiasmatic section, each eye is connected only to the ipsilateral cortex through the uncrossed retinal projections and so the functionality of each eye's input is no longer interfered with by interocular mechanisms. In strabismic cats submitted, as adults, to section of the optic chiasm, we performed electrophysiological recordings from the striate cortex. Results show that in these animals: (1) the cortical responsiveness to the strabismic eye is strikingly higher than in esotropes with an intact optic chiasm; (2) the effectiveness of stimulation of the deviated eye is not different from that of the nondeviated eye in driving neurons of corresponding cortex; (3) surprisingly, a high degree of binocular activation is present in the cortex ipsilateral to the deviated eye, while in the cortex connected to the nondeviated eye the greatest majority of neurons are monocularly driven. Cortical binocularity depends on the corpus callosum, which conveys the input from the nondeviated eye to the opposite cortex (which receives the direct strabismic input), but not vice versa. The asymmetry of callosal transmission parallels the morphological asymmetry of callosal connections that occur in convergent strabismus. All together the findings indicate that the impaired effectiveness of esotropic input does not result from developmental deficit of the strabismic afferents but, rather, from inhibitory influences that are actively exerted through the interocular pathways. Strabismic suppression may be accomplished by the same interocular mechanisms underlying binocular rivalry.

Animals↗

PubMed2005

Orbital cellulitis after strabismus surgery.

Serious infection is uncommon after eye muscle surgery. Orbital cellulitis is a rarely reported but is potentially vision- and life-threatening complication after strabismus surgery. In this report, we describe a case of unilateral orbital cellulitis after strabismus surgery for sensory exotropia in a healthy adolescent boy.

Adolescent↗

PubMed2006

Retrobulbar hemorrhage following strabismus surgery.

Retrobulbar hemorrhage, although a well-known complication of retrobulbar injection, periocular injections, and periocular surgeries, is not routinely associated with strabismus surgery. We present a case of delayed orbital hemorrhage occurring in a young boy 2 days after strabismus surgery.

Child, Preschool↗

PubMed2006

Effect of adult strabismus on ratings of official U.S. Army photographs.

PURPOSE: To determine if strabismus affects the ratings of official U.S. Army photographs. METHODS: Photographs of seven women and seven men officers (subjects) were digitally altered to give the impression of strabismus. Four photographs of each subject were obtained: two in an orthotropic state; one in a left exotropic state; and one in a left esotropic state. The photographs were presented randomly to a panel of 38 raters. Masked to the study design, the raters rated every photograph on a 1 to 10 Likert scale. The results were grouped according to eye alignment: two orthotropic groups, one exotropic group, and one esotropic group. Comparisons of the mean ratings were made between each eye alignment group and based on the subject's gender. RESULTS: The mean rating for each orthotropic group was 5.4 and 5.5 Likert scale units with a SD of 0.8 and 0.9, respectively (group 1 and group 2). The mean rating for the exotropic group was 5.4 Likert scale units with a SD of 0.7. The mean rating for the esotropic group was 5.1 Likert scale units with a SD of 0.8. Significantly lower ratings were obtained for the esotropic group compared with the orthotropic group (p=0.028). Women received significantly lower ratings regardless of eye alignment (p=0.044). CONCLUSIONS: This study indicates that the presence of esotropia negatively affects the rating of an official U.S. Army photograph; furthermore, female gender negatively affects ratings.

Adult↗

PubMed1993

Fusion after surgical alignment of longstanding strabismus in adults.

BACKGROUND: Fusion and the development of the monofixation syndrome are well recognized after surgical alignment of congenital esotropia to within 8 delta of orthotropia. However, in adults with longstanding strabismus and a history of congenital esotropia who are not surgically aligned within the first few years of life, the prognosis for the development of fusion is believed to be poor. METHODS AND RESULTS: Twenty-four adults, 12 with a history of congenital esotropia (onset before 6 months age), 1 of congenital exotropia, and 11 with the onset of esotropia between 6 months and 2 years, were included in this study. All patients had longstanding strabismus, and none had been surgically aligned within the first 2 years of life. No patient had visual acuity worse than 20/30 in the worse eye. Preoperatively, no patient demonstrated fusion with the red glass test, Worth four-dot, or Titmus test. Postoperatively, all were aligned to within 8 delta of orthotropia, and all demonstrated peripheral fusion with the Worth four-dot at near. Twelve patients (50%), 8 of whom were in the congenital group, achieved stereopsis of 200 seconds of arc or better using the Titmus stereo test. CONCLUSION: These findings suggest that surgery in this group of patients not only eliminates the ocular alignment deformity but can confer the functional benefits of fusion and increased field of binocular vision.

Adolescent↗