DOCSLIB.ORG

Botulinum Toxin in the Treatment of Strabismus. a Review of Its Use and Effects

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Botulinum Toxin in the Treatment of Strabismus. a Review of Its Use and Effects Disability and Rehabilitation, December 2007; 29(23): 1823 – 1831 Botulinum Toxin in the treatment of strabismus. A review of its use and effects LIONEL KOWAL1,2, ELAINE WONG1,2 & CLAUDIA YAHALOM3 1Ocular Motility Unit, Royal Victorian Eye and Ear Hospital, Melbourne, 2Centre for Eye Research, Australia, and 3Ophthalmology, Hadassah Hospital, Jerusalem, Israel Abstract Botulinum Toxin as a medical therapy was introduced by Dr Alan Scott more than 20 years ago. The first clinical applications of Botulinum Toxin type A (BT-A) were for the treatment of strabismus and for periocular spasms. Botulinum Toxin type A is often effective in small to moderate angle convergent strabismus (esotropia) of any cause, and may be an alternative to surgery in these cases. Botulinum Toxin type A may have a role in acute or chronic fourth and sixth nerve palsy, childhood strabismus and thyroid eye disease. The use of BT-A for strabismus varies enormously in different cities and countries for no apparent reason. Botulinum Toxin type A may be particularly useful in situations where strabismus surgery is undesirable. This may be in elderly patients unfit for general anaesthesia, when the clinical condition is evolving or unstable, or if surgery has not been successful. Botulinum Toxin type A can give temporary symptomatic relief in many instances of bothersome diplopia irrespective of the cause. Ptosis and acquired vertical deviations are the commonest complications encountered. Vision-threatening complications are rare. Repeated use of BT-A is safe. Keywords: Strabismus, Botulinum Toxin type A, ocular Motility disorders There are a small number of centres where BT-A is Introduction used frequently in the treatment of strabismus. The The use of Botulinum Toxin type A (BT-A) for Toxin Clinic at the Moorfields Eye Hospital in strabismus was first described and developed by the London had given 18,000 BT-A injections for stra- American ophthalmologist Dr Alan Scott in the early bismus by the end of 2005. The Gomez family of 1980s [1,2]. He personally trained hundreds of ophthalmologists in Madrid have given 7,000 BT-A ophthalmologist collaborators in its use (including injections for strabismus until 2005. These two groups, the author LK) and carefully collated data from his and that of the developer Alan Scott in San Francisco, own and their work over some years to demonstrate stand out as the most experienced centres inter- the effects of BT-A. Botulinum Toxin type A was nationally in the use of BT-A in strabismus. subsequently approved by the Food and Drug In Australia, there are about 10 ophthalmologists Authority [USA] for both adult strabismus and who have been trained in the use of BT-A for blepharospasm in 1989. Since then, BT-A has been strabismus, usually in London or San Francisco. used by a small number of ophthalmologists (usually Statistics on the use of BT-A in strabismus in strabismus specialists) as an easier and less invasive Australia are available from the Medicare Australia alternative to strabismus surgery in selected cases. website. The data does not include patients who are Regrettably, prospective randomized controlled trials treated in public hospitals or whose treatment is not on the use of BT-A in different strabismus entities billed through Medicare Australia, e.g., those paid by comparing the effect of BT-A to that of surgery have Workcover companies. Only 70 – 80 BT-A treat- yet to be performed. ments for strabismus a year are recorded on the Correspondence: Dr Lionel Kowal, The Private Eye Clinic, Level 3, 182 Victoria Parade, East Melbourne VIC 3002, Australia. E-mail: [email protected] ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd. DOI: 10.1080/09638280701568189 1824 L. Kowal et al. Medicare Australia website (www.medicareaustra- rein sets are not ‘pure’ and there is some overlap. lia.gov.au) throughout the country. The primarily torsional muscles have a secondary Botulinum Toxin type A is usually injected directly vertical effect, and the primarily vertical muscles sets into the selected extraocular muscle in the ophthal- have a secondary torsional effect. In upgaze and mologists’ office under topical anaesthesia, usually downgaze the horizontal muscles may have a vertical with electromyographic (EMG) guidance. Patient effect, and the vertical muscles have a horizontal cooperation is required. The ‘chair time’ is typically effect. Fortunately most cases of strabismus are not 10 – 15 min, and time lost from work is typically of the highest degrees of complexity! 2 – 3 h. The effect of BT-A will start to be seen within Treating an imbalance surgically usually involves 2 – 4 days of the injection, it then causes an over- changing the length and tension of one or both correction for some weeks (‘the effect’), which then muscles of an agonist/antagonist set. Typically the wears off after 6 – 8 weeks leaving a permanent re- muscle that is pulling the eye out of alignment is alignment (‘the after-effect’) in many cases. repositioned (recessed) by effectively lengthening it Botulinum Toxin type A may be particularly (this changes the eye position) and changing the useful in situations where strabismus surgery is amount of torque it can generate (the change in undesirable. This may be in elderly patients unfit torque affects the medium – long-term stability of the for general anaesthesia, when the clinical condition is new eye position). The ‘pair’ of the weakened muscle evolving or unstable, or if surgery has not been is usually shortened (resected) to pull the eye away successful. Botulinum Toxin type A can give from its misaligned position to a more correct one. temporary symptomatic relief in many instances of bothersome diplopia irrespective of the cause. How BT-A works in strabismus Botulinum Toxin type A works by paralyzing the Strabismus extraocular muscle that is pulling the eye out of Strabismus arises when there is imbalance in alignment. In the initial period of paralysis, there will extraocular muscle function resulting in misalign- be an overcorrection of strabismus as the normally ment of the eye or eyes. The foveas will not both be functioning antagonist overpowers the paralysed directed at the same object and (if both eyes see well) muscle (‘the effect’). With this overcorrection there there will be diplopia and confusion. will be contraction of the antagonist and stretching of The muscular control of eye movements can be the paralysed muscle. During this time the lengths of likened to the reins of a horse – when one muscle the paralyzed muscle and its antagonist will change, contracts (agonist), the other relaxes (antagonist). and the length-tension curves within these muscles Both reins do not contract at the same time unless will also change. Histology shows a change in innervation is anomalous. There are 3 different sets sarcomere density. When the effect of BT-A wears of reins for each eye, for horizontal, vertical and off, some of these changes will persist, and a resultant torsional movements. The actions of the 3 sets of net change to the alignment of the eyes occurs (‘the muscle in one eye are intricately linked to the actions after-effect’). of the 3 sets of the other eye. Each rein forms part of For example, in the correction of small angle left one of 3 pairs of agonist and antagonist extraocular convergent strabismus, BT-A is injected into the left muscles, the primary actions of which are: medial rectus (LMR). This will paralyze the LMR for some weeks. During that time, the unopposed left (1) Horizontal movement: lateral rectus (LLR), will abduct the eye, and the eye (a) Medial rectus (MR) – adduction (mov- will be divergent (‘the effect’). Whilst the eye is ing the eye towards the nose) divergent the following changes are likely to occur: (b) Lateral rectus (LR) – abduction (towards the ear) (1) The LMR will be stretched and will lengthen; (2) Vertical movement: (2) The length-tension curve of the LMR will (a) Superior rectus (SR) – elevation change; (b) Inferior rectus (IR) – depression (3) The length-tension curve of the LLR will also (3) Torsional movement: change; (a) Superior oblique (SO) – intorsion (4) The LLR will shorten; and (clockwise rotation of the right eye, (5) Sarcomere density in both these muscles will anti- clockwise of the left eye) gradually change. (b) Inferior oblique (IO) – extorsion. When the LMR paralysis from the BT-A wears off, When there is an imbalance of one or more of these some of the changes in the lengths and length- muscles sets, strabismus results. The actions of the tension ratios in both the recently paralyzed and Botulinum toxin in the treatment of strabismus 1825 stretched LMR and the recently contracted LLR will (3) Injection under direct vision through a be retained and result in lessened misalignment, ‘the conjunctival incision prepared just for the after-effect’. BT-A injection; It is important to note that, in this LMR example, (4) Injection via subconjunctival lacrimal BT-A will not have an after-effect if the LLR is not cannula alongside a muscle [3]; or active – a functioning LLR is needed to pull the (5) Transconjunctival injection after grasping the LMR out and stretch it causing some temporary muscle with forceps and bunching it up [4]. overcorrection of the misalignment in order to have an after-effect. In one series, injection without EMG guidance in 40 The amount of after-effect (change in alignment) children with different types of convergent strabis- will be dependent on the final changes in the lengths mus has been shown to be reasonably successful with of the muscles after the stretching and contraction. a complication rate comparable to that incurred with The duration of the after-effect (stability of the new EMG guidance [5].
Load more

Recommended publications
  • G:\All Users\Sally\COVD Journal\COVD 37 #3\Maples
    Essay Treating the Trinity of Infantile Vision Development: Infantile Esotropia, Amblyopia, Anisometropia W.C. Maples,OD, FCOVD 1 Michele Bither, OD, FCOVD2 Southern College of Optometry,1 Northeastern State University College of Optometry2 ABSTRACT INTRODUCTION The optometric literature has begun to emphasize One of the most troublesome and long recognized pediatric vision and vision development with the advent groups of conditions facing the ophthalmic practitioner and prominence of the InfantSEE™ program and recently is that of esotropia, amblyopia, and high refractive published research articles on amblyopia, strabismus, error/anisometropia.1-7 The recent institution of the emmetropization and the development of refractive errors. InfantSEE™ program is highlighting the need for early There are three conditions with which clinicians should be vision examinations in order to diagnose and treat familiar. These three conditions include: esotropia, high amblyopia. Conditions that make up this trinity of refractive error/anisometropia and amblyopia. They are infantile vision development anomalies include: serious health and vision threats for the infant. It is fitting amblyopia, anisometropia (predominantly high that this trinity of early visual developmental conditions hyperopia in the amblyopic eye), and early onset, be addressed by optometric physicians specializing in constant strabismus, especially esotropia. The vision development. The treatment of these conditions is techniques we are proposing to treat infantile esotropia improving, but still leaves many children handicapped are also clinically linked to amblyopia and throughout life. The healing arts should always consider anisometropia. alternatives and improvements to what is presently The majority of this paper is devoted to the treatment considered the customary treatment for these conditions.
    [Show full text]
  • Sixth Nerve Palsy
    COMPREHENSIVE OPHTHALMOLOGY UPDATE VOLUME 7, NUMBER 5 SEPTEMBER-OCTOBER 2006 CLINICAL PRACTICE Sixth Nerve Palsy THOMAS J. O’DONNELL, MD, AND EDWARD G. BUCKLEY, MD Abstract. The diagnosis and etiologies of sixth cranial nerve palsies are reviewed along with non- surgical and surgical treatment approaches. Surgical options depend on the function of the paretic muscle, the field of greatest symptoms, and the likelihood of inducing diplopia in additional fields by a given procedure. (Comp Ophthalmol Update 7: xx-xx, 2006) Key words. botulinum toxin (Botox®) • etiology • sixth nerve palsy (paresis) Introduction of the cases, the patients had hypertension and/or, less frequently, Sixth cranial nerve (abducens) palsy diabetes; 26% were undetermined, is a common cause of acquired 5% had a neoplasm, and 2% had an horizontal diplopia. Signs pointing aneurysm. It was noted that patients toward the diagnosis are an who had an aneurysm or neoplasm abduction deficit and an esotropia had additional neurologic signs or increasing with gaze toward the side symptoms or were known to have a of the deficit (Figure 1). The diplopia cancer.2 is typically worse at distance. Measurements are made with the Anatomical Considerations uninvolved eye fixing (primary deviation), and will be larger with the The sixth cranial nerve nuclei are involved eye fixing (secondary located in the lower pons beneath the deviation). A small vertical deficit may fourth ventricle. The nerve on each accompany a sixth nerve palsy, but a side exits from the ventral surface of deviation over 4 prism diopters the pons. It passes from the posterior Dr. O’Donnell is affiliated with the should raise the question of cranial fossa to the middle cranial University of Tennessee Health Sci- additional pathology, such as a fourth fossa, ascends the clivus, and passes ence Center, Memphis, TN.
    [Show full text]
  • Diplopia and Torticollis in Adult Strabismus
    Case Report JOJ Ophthal Volume 1 Issue 5 - January 2017 DOI: 10.19080/JOJO.2017.01.555572 Copyright © All rights are reserved by Dora D Fdez-Agrafojo Diplopia and Torticollis in Adult Strabismus Dora D Fdez-Agrafojo1*, Hari Morales2 and Marta Soler2 1Doctor in medicine and surgery, Teknon Medical Center, Spain 2Optometrist, Teknon Medical Center, Spain Submission: November 11, 2016; Published: January 16, 2017 *Corresponding author: Dora D Fdez-Agrafojo, INOF Center, Teknon Medical Center, Barcelona, Spain, Tel: 933933156; Email: Abstract Objective: To expose the diagnosis of an adult patient with vertical and unilateral divergent strabismus and to approach the surgical treatment in order to remove the symptoms of diplopia and signs of torticollis. Method: The measurement of the angle of deviation, the Lancaster test, the Bielchowsky test and the study of ocular motility, both in resolvingexamination the room deviation (versions) of both and directions in the surgery in only room one surgical (test of intervention.ductions), demonstrated the diagnosis: right eye hipertropia (HTR) and right eye exotropia (XTR). Surgical intervention was performed on the right upper rectus muscle and on the right inferior oblique muscle, with the aim of Results: The intervention was satisfactory for both the patient and the medical team, because we were minimized the signs and symptoms. After 4 months the residual deviation angle was minimal and allowed the ability of fusion. Conclusion: The diagnostic and treatment protocol performed in this case show the optimal resolution of the diplopia and torticollis that the patient suffered. Keywords: Strabismus; Torticollis; Diplopia; Lancaster test Introduction c. Refraction (cycloplegic) right eye = +1.50-0.50x170° We believe that, in some cases, in strabismus surgery there may be more than one option in the choice of surgical protocol, d.
    [Show full text]
  • Management of Strabismus in Thyroid Eye Disease
    Eye (2015) 29, 234–237 & 2015 Macmillan Publishers Limited All rights reserved 0950-222X/15 www.nature.com/eye CAMBRIDGE OPHTHALMOLOGICAL SYMPOSIUM Management of R Harrad strabismus in thyroid eye disease Abstract superior rectus.2 Involvement of extra-ocular muscles may be bilateral or unilateral. Thyroid eye disease is an auto-immune Sometimes only one muscle is affected. It is not condition characterised by an acute known why some muscles are more commonly inflammatory phase followed by a fibrotic involved than others. The inferior rectus is the phase, which sometimes leads to restricted bulkiest and most tonically-active extra-ocular eye movements and diplopia. Medical muscle; it may be that the degree of muscle treatment with systemic steroids with or activity and hence blood supply is a factor. without orbital radiotherapy and immunosuppression can control the inflammatory response. Strabismus surgery should be carried out only after the Clinical assessment and non-surgical inflammation is no longer active and after management any decompression surgery. Surgery The presence of lid-lag or lid retraction in an comprises recession of tight muscles using adult presenting with a recent onset of adjustable sutures so as to maximise the area strabismus is highly suggestive of TED. Thyroid of binocular single vision. There is debate as function tests are usually diagnostic, but a small to whether adjustable sutures should be used proportion of patients with TED have normal for the inferior rectus muscle. Patients should thyroid function tests. Patients with TED are be encouraged to have realistic expectations, assessed for disease severity and activity, and as binocular single vision may not be treatment in the form of immunosuppression is achievable in all directions of gaze and lid given depending on the degree of disease retraction may be made worse by surgery.
    [Show full text]
  • Occurrence of Oculomotor Dysfunctions in Acquired Brain Injury: a Retrospective Analysis
    Optometry (2007) 78, 155-161 Occurrence of oculomotor dysfunctions in acquired brain injury: A retrospective analysis Kenneth J. Ciuffreda, O.D., Ph.D., Neera Kapoor, O.D., M.S., Daniella Rutner, O.D., M.S., Irwin B. Suchoff, O.D., D.O.S., M.E. Han, O.D., and Shoshana Craig, O.D. State University of New York State College of Optometry, Raymond J. Greenwald Rehabilitation Center, New York, New York. KEYWORDS Abstract Acquired brain injury; BACKGROUND: The purpose of this retrospective study was to determine the frequency of occurrence Traumatic brain of oculomotor dysfunctions in a sample of ambulatory outpatients who have acquired brain injury injury; (ABI), either traumatic brain injury (TBI) or cerebrovascular accident (CVA), with associated vision Cerebrovascular symptoms. accident; METHODS: Medical records of 220 individuals with either TBI (n ϭ 160) or CVA (n ϭ 60) were Stroke; reviewed retrospectively. This was determined by a computer-based query spanning the years 2000 Oculomotor through 2003, for the frequency of occurrence of oculomotor dysfunctions including accommodation, dysfunction; version, vergence, strabismus, and cranial nerve (CN) palsy. Strabismus; RESULTS: The majority of individuals with either TBI (90%) or CVA (86.7%) manifested an Accommodation; oculomotor dysfunction. Accommodative and vergence deficits were most common in the TBI Eye movements; subgroup, whereas strabismus and CN palsy were most common in the CVA subgroup. The frequency Cranial nerve palsy of occurrence of versional deficits was similar in each diagnostic subgroup. CONCLUSION: These new findings should alert the clinician to the higher frequency of occurrence of oculomotor dysfunctions in these populations and the associated therapeutic, rehabilitative, and quality-of-life implications.
    [Show full text]
  • Care of the Patient with Strabismus: Esotropia and Exotropia
    OPTOMETRIC CLINICAL PRACTICE GUIDELINE OPTOMETRY: THE PRIMARY EYE CARE PROFESSION Doctors of optometry are independent primary health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye, and associated structures as well as diagnose related systemic conditions. Optometrists provide more than two-thirds of the primary eye care services in the United States. They are more widely distributed geographically than other eye care providers and are readily accessible for the delivery of eye and vision care services. There are approximately 36,000 full-time equivalent doctors of optometry currently in practice in the United States. Optometrists practice in more than 6,500 communities Care of the Patient with across the United States, serving as the sole primary eye care providers in more than 3,500 communities. Strabismus: The mission of the profession of optometry is to fulfill the vision and eye care needs of the public through clinical care, research, and education, all Esotropia and of which enhance the quality of life. Exotropia OPTOMETRIC CLINICAL PRACTICE GUIDELINE CARE OF THE PATIENT WITH STRABISMUS: ESOTROPIA AND EXOTROPIA Reference Guide for Clinicians Prepared by the American Optometric Association Consensus Panel on Care of the Patient with Strabismus: Robert P. Rutstein, O.D., Principal Author Martin S. Cogen, M.D. Susan A. Cotter, O.D. Kent M. Daum, O.D., Ph.D. Rochelle L. Mozlin, O.D. Julie M. Ryan, O.D. Edited by: Robert P. Rutstein, O.D., M.S. Reviewed by the AOA Clinical Guidelines Coordinating Committee: David A. Heath, O.D., Ed.M., Chair NOTE: Clinicians should not rely on the Clinical Diane T.
    [Show full text]
  • Binocular Vision and Ocular Motility SIXTH EDITION
    Binocular Vision and Ocular Motility SIXTH EDITION Binocular Vision and Ocular Motility THEORY AND MANAGEMENT OF STRABISMUS Gunter K. von Noorden, MD Emeritus Professor of Ophthalmology Cullen Eye Institute Baylor College of Medicine Houston, Texas Clinical Professor of Ophthalmology University of South Florida College of Medicine Tampa, Florida Emilio C. Campos, MD Professor of Ophthalmology University of Bologna Chief of Ophthalmology S. Orsola-Malpighi Teaching Hospital Bologna, Italy Mosby A Harcourt Health Sciences Company St. Louis London Philadelphia Sydney Toronto Mosby A Harcourt Health Sciences Company Editor-in-Chief: Richard Lampert Acquisitions Editor: Kimberley Cox Developmental Editor: Danielle Burke Project Manager: Agnes Byrne Production Manager: Peter Faber Illustration Specialist: Lisa Lambert Book Designer: Ellen Zanolle Copyright ᭧ 2002, 1996, 1990, 1985, 1980, 1974 by Mosby, Inc. All rights reserved. No part of this publication may be reproduced or transmit- ted in any form or by any means, electronic or mechanical, including photo- copy, recording, or any information storage and retrieval system, without per- mission in writing from the publisher. NOTICE Ophthalmology is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual pa- tient.
    [Show full text]
  • Management of Sixth Nerve Palsy
    100 Prună et al Management of sixth nerve palsy Management of sixth nerve palsy – different approaches Violeta -Ioana Prun ă1, 4, Ligia Gabriela T ătăranu 3, V.M. Prun ă2, Daniela Cioplean 4, R.M. Gorgan 3 1Ph.D Student in Ophthalmology “Carol Davila” University of Medicine and Pharmacy Bucharest, Faculty of Medicine, Department of Ophthalmology 2“Bagdasar-Arseni” Clinic Emergency Hospital, Bucharest, Romania 3“Carol Davila” University of Medicine and Pharmacy Bucharest, Faculty of Medicine, Department of Neurosurgery 4Oftapro Clinic, Bucharest Abstract dysfunction, translated by impossible or Sixth nerve palsy is one of the most very limited abduction of the interested common oculomotor nerve palsy, eye, manifested by diplopia (1), which manifested by abolished or limited significantly reduces patient’s quality of abduction of the affected eye and diplopia. life. Sometimes binocular vision is possible This condition significantly alters patient’s in a compensatory position of the head, quality of life. The authors wish to with face turned toward the affected eye. emphasize forensic implications of this Due to its long intracranial course (2), neuro-muscular dysfunction throughout its with angulation over the petrous apex of management steps, giving some examples the temporal bone, the sixth nerve is of cases, with different etiology and vulnerable to increased intracranial treatment. It’s important to highlight the pressure, skull base trauma, meningeal role of a careful imaging and a good inflammation, and a displacement of the interdisciplinary collaboration in brain stem. Therefore, sixth nerve palsy is management of this paralysis. most common oculomotor nerve palsies, Key words : sixth nerve, palsy, paralysis, representing up to 40% of these.
    [Show full text]
  • An Ophthalmologist's Approach to Visual Processing/Learning
    Chapter 11. An Ophthalmologist’s Approach to Visual Processing/Learning Differences 243 11 An Ophthalmologist’s Approach to Visual Processing/Learning Differences Harold Paul Koller, M.D., F.A.A.P., F.A.A.O. In the past, most ophthalmologists read or The first step in educating ophthalmolo- were told that treatment of the disorders gists is to introduce psychiatry, educational affecting children with dyslexia and other and neuropsychology, physical and occupa- learning disabilities fell outside the field of tional therapy, and educational science in all ophthalmology because the brain, and not the its forms relating to learning differences in eyes, is the main organ active in the process children and adults to the ophthalmology of thinking and learning (Hartstein, 1971; community (Koller & Goldberg, 1999). (An Hartstein & Gable, 1984; Miller, 1988). appendix to this chapter outlines briefly what Because dyslexia, for example, implied an an ophthalmologist in general practice should inability to understand the written word, the know about learning disorders.) The second definitive diagnosis and therapy was in the is to make the diagnosis and treatment of hands of the educators and clinical psycholo- children more efficient by developing a sys- gists, not the ophthalmologist. The role of an tem for classifying disorders that is oriented ophthalmologist, thus, was to rule out disease toward ophthalmologists. This chapter as the first step in determining the reason for describes such a classification system for a learning difference before referring the learning disorders. It then goes on to describe child back to the pediatrician or family doc- causes and treatment of medically based oph- tor for further evaluation and referral.
    [Show full text]
  • Guidelines for Management of Strabismus in Childhood 2012
    The Royal College of Ophthalmologists Guidelines for the Management of Strabismus in Childhood March 2012 Scientific Department 17 Cornwall Terrace London NW1 4QW Telephone: 020 7935 0702 Facsimile: 020 7487 4674 www.rcophth.ac.uk © The Royal College of Ophthalmologists 2012 All rights reserved For permission to reproduce any of the content contained herein please contact [email protected] Contents Page Number 1. Overview 3 2. Introduction 4 3. Aims of Management of Strabismus 5 3.1 History 5 3.2 General Examination 6 3.3 Visual Function 6 3.4 Binocular Vision 7 3.5 Ocular Alignment 7 3.6 Ocular Movements 7 3.7 Ocular Examination 8 3.8 Other tests 8 3.9 Abnormal Neurology 8 3.10 Refraction 9 3.11 Management 10 3.12 Facilities 12 3.13 Communication 12 4. Appendices 14 5. References 30 6. Bibliography 39 7. Authorship and Review Date 40 2 1. Overview This guideline is designed for ophthalmologists managing children with strabismus (syn.squint), which is defined as a pathological misalignment of the visual axes. This is a broad subject and the reader is referred to comprehensive texts, for further information see bibliography (page 42). The guidelines are intended to give general principles of management. It is assumed throughout this document that professionals dealing with common and uncommon cases of strabismus will have had adequate training and experience to manage children with these conditions. This document represents the current view of best practice endorsed by the College. Please also refer to the Royal College Quality standards document1 and Ophthalmic services for children2.
    [Show full text]
  • Management of Diplopia
    Romanian Journal of Ophthalmology, Volume 61, Issue 3, July-September 2017. pp:166-170 REVIEW Management of diplopia Iliescu Daniela Adriana, Timaru Cristina Mihaela, Alexe Nicolae, Gosav Elena, De Simone Algerino, Batras Mehdi, Stefan Cornel Ophthalmology Department, “Dr. Carol Davila” Central Military University Emergency Hospital, Bucharest, Romania Correspondence to: Iliescu Daniela Adriana, MD, Ophthalmology Department, “Dr. Carol Davila” Central Military University Emergency Hospital, Bucharest, 134 Calea Plevnei Street, District 1, Bucharest, Bucharest, Romania, Phone/ fax: +4021 313 71 89, E-mail: [email protected] Accepted: September 9th, 2017 Abstract Diplopia (seeing double) is an ophthalmologic complaint found mainly in elder patients. It can have both ocular and neurological causes. A careful history and clinical examination must detail the type of diplopia (monocular/ binocular), onset, and progression, associated and relieving factors. In case of monocular diplopia, refraction and biomicroscopic examination of the ocular media are mandatory. The cause of ocular misalignment for binocular diplopia must be determined and life-threatening conditions (such as posterior communicating artery aneurysm) must imply an immediate treatment. Management and treatment is always according to the specific cause of diplopia. Keywords: diplopia, binocular vision, strabismus Introduction disappears after the eye is occluded, then it is binocular and an extensive investigation must Diplopia - simultaneous perception of two make the differential diagnosis between multiple images of a single object or seeing double is a etiologies that can cause the misalignment of the common symptom identified in visual axes [1]. ophthalmological and neurological patients. It has many underlying causes. An efficient Monocular diplopia management implies an accurate diagnosis that can be made with a detailed history and a careful Monocular diplopia is often caused by clinical examination.
    [Show full text]
  • The Management of Squint
    Arch Dis Child: first published as 10.1136/adc.64.3.413 on 1 March 1989. Downloaded from Archives of Disease in Childhood, 1989, 64, 413-418 Personal practice The management of squint A R FIELDER Department of Ophthalmology, University of Leicester Medical School, Leicester Squint may be the first sign of a serious ocular or early neonatal life about 32% of infants are diver- systemic disorder, and yet it is also one of the most gent and only 3% convergent.4 As the incidence of common ocular conditions of childhood. It follows divergence is higher in preterm neonates it is likely that while most ocular deviations have no such that during development the eyes are initially sinister connotations, an understanding of the range divergent but that this resolves over the first few of associations is essential to be prepared for this weeks of life. comparatively infrequent but important possibility. Apart from those seen in the neonatal period, Screening for squint has been covered recently' squints are comparatively uncommon in the first few and in this article its presence will be assumed. The months of life, and the term 'infantile' is preferred clinical evaluation of the child with a squint will be to 'congenital' because this type of esotropia is considered first, followed by a discussion of the aims rarely if ever congenital but develops between 3 and and methods of treatment. The main thrust will be 6 months of age. Characteristically the deviation is directed towards the squint itself, but as amblyopia large, constant, and there is no appreciable refrac- is such a frequent and important association this tive error.5 topic will also be covered briefly.
    [Show full text]