Binocular Vision & S trabism us Quarterly© EDITORIAL BOARD Fourth Quarter of 2007, Volume 22 (No.4): Page 296
Leonard Apt Stephen P. Kraft, Canada M. Edward Wilson, Jr. Robert W. Arnold Krystyna Krzystkowa, Kenneth W. Wright E.S. Avetisov, Russia Poland John D. Baker Joseph Lang, Switzerland EMERITUS P. Vital Berard, France Malcolm L. Mazow Frank Billson, Australia Henry S. Metz Shinobu Awaya, Japan Michael C. Brodsky Joel Miller Henderson Almeida, Brazil Jorge A. Caldeira, Brazil James L. Mims III Bruno Bagolini, Italy Alberto O. Ciancia, Scott E. Olitsky Albert W. Biglan Argentina Gian Paolo Paliaga, Italy William N. Clarke, Canada Kenneth J. Ciuffreda Evelyn A. Paysse John S. Crawford† David K. Coats Zane F. Pollard Robert A. Crone, Jeffrey Cooper Julio Prieto-Diaz, Argentina Netherlands Jan-T H.N. de Faber, Edward L. Raab Eugene R. Folk† Netherlands Michael X. Repka David A. Hiles Jay M. Enoch James D. Reynolds David Hubel Caleb Gonzalez David L. Romero-Apis, Bela Julesz Michael H. Graf, Germany Mexico Herbert Kaufmann, Germany David Guyton Alan B. Scott Philip Knapp† Eugene M. Helveston Kurt Simons Burton J. Kushner Richard W. Hertle Annette Spielmann, France Pinhas Nemet, Israel Creig S. Hoyt David R. Stager, Sr. J.V. Plenty, United Kingdom David G. Hunter Martin J. Steinbach, Canada Robert D. Reinecke Robert S. Jampel David S.I. Taylor, England William E. Scott Edouard Khawam, Lebanon Guillermo Velez, Colombia R. Lawrence Tychsen Lionel Kowal, Australia Bruce C. Wick
BINOCULAR VISION & STRABISMUS QUARTERLY (ISSN 1088-6281), the "loftiest scientific journal in the world" is published at an altitude of 9100 feet above sea level, in the shadow of the Continental Divide, in Summit County, Colorado, by BINOCULUS PUBLISHING, PO Box 3727, 740 Piney Acres Circle, Dillon CO 80435-3727 USA; Tel and FAX 970-262-0753. A Medical Scientific E-Periodical. Webmaster: Justin Patnode, Webez.net Internet Services, Dillon, Colorado. Official publication date October 1, 2007. COPYRIGHT 2007. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including xerographic copy, photocopy, recording, or an information storage and retrieval system, without permission in writing from the publisher. EDITORIAL OFFICE / MANUSCRIPTS: Please send to the Editor, Binocular Vision & Strabismus Quarterly, PO Box 3727, 740 Piney Acres Circle, Dillon CO 80435-3727 USA. Please see and use "Instructions for Authors", pages 202-203. Letters to the Editor are considered "for publication" unless otherwise indicated and may be edited and condensed as space dictates. ADVERTISING: Please direct inquiries to BINOCULUS PUBLISHING, PO Box 3727, 740 Piney Acres Circle, Dillon CO 80435-3727 USA. Tel & FAX 970-262-0753. Media kit and rates on request. SUBSCRIPTIONS: Per four issue annual volume only: Individual: $68 a year for a three year subscription ($ 204 =3x68),$78 a year for a two year subscription ($ 156 =2x78), $84 for a one year subscription. Library/Institutions: For 2008, one year subscription $US426, electronic version only. (The reason for this increase over prior years is that, with our conversion to electronic, there is a marked increase in access facility to the journal for library users.)...... Single electronic issues US$47. Back print issues (1985-2006) $36. Please send orders with check or money order payable in US $ funds to Binoculus Publishing, PO Box 3727, 740 Piney Acres Circle, Dillon CO 80435-3727 USA. Visa, Mastercard and American Express charges gladly accepted, especially for International orders. Bound Volumes also available to subscribers. To subscribe or order, Call/Fax 970-262-0753. Email: Judy Robinson
INDEX TO ADVERTISERS, VOLUME 22, NUMBER 4, 2007 Fresnel Prism and Lens Co. Page 194 Burton J. Kushner's Grand Rounds Collection Pages 200,201 Gunter K. von Noorden's History of Strabismology Pages 200,201 Eugene M. Helveston's Surgical Management of Strabismus Pages 200,201 Australian Orthoptic Journal Page 245 British, Irish and American Orthoptic Journals Page 246 “... the belief that one’s view of reality is the only reality is the most dangerous of all delusions ...” -Watzlawick, 1976
EDITOR ISSN 1088-6281 Fourth Quarter of 2007 Paul E. Romano, M.D., M.S.O TABLE OF CONTENTS Volume 22, Number 4 MEDLINE Abbr. Binocul Vis Strabismus Q NLM ID: 9607281
202 Advice and Information for Authors 203 Brian D. Stidham, M.D., Memorial Lectureship 204 Correspondence 206 People and Places; News and Announcements
82 EDITORIALS: In This Issue, Paul E. Romano, M.D., M.S. Ophthalmology Guest: Clear-Eye Optimists, Stephen Moore
*** ORIGINAL SCIENTIFIC ARTICLES *** 210 Safety Stitch: A Modification to Postoperatively Adjustable Suture Strabismus Surgery of the Inferior Rectus Muscle Maria Felisa Shokida, M.D., Jose Gabriel, M.D. and Celia Sanchez, M.D. 216 Radio-Opaque Modification/Substitute for the Wright Superior Oblique Tendon Extender for Superior Oblique Muscle Overaction Strabismus Robert W. Arnold, M.D. and Rachel E. Leman, R.N. 221 Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Is Botulinum Toxin Better Primary Treatment than Surgery? Veronica Hauviller, M.D., Susan Gamio, M.D., and Maria Vanesa Sors, M.D. 235 Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Yoon-Hee Chang, M.D., Jee Ho Chang, M.D., Sueng-Han Han, M.D. & Jong Bok Lee, M.D.
*** CASE REPORTS *** 209 Sixth Nerve Palsy Post Intravitreal Bevacizumab for AMD: A New Possibly Causal Relationship and Complication? Hee-Jung Park, M.D., MPH and John Guy, M.D. 227 Surgical Correction of Synergistic Divergence Strabismus. A Report of Three Cases Eduard Khawam, M.D., Abdallah Terro, M.D., Issam Hamadeh, M.D., and Rula Hamam, M.D.
247 Book Review: Strabismus Surgery and Its Complications by David K. Coats and Scott E. Olitsky. Review by Robert W. Hered, M.D.
242 Abstracts 80 Hyde Park Editorial -198-
Binocular Vision & BOOK REVIEWS, DESCRIPTIONS Fourth Quarter of 2007 Strabismus Quarterly© Volume 22 (No.4): A Medical Scientific E-Periodical for Binoculus Books advertised on following pages pages 198,199
THE HISTORY OF STRABISMOLOGY Edited by Gunter K. Von Noorden, M.D. THE BOOK The HISTORY OF STRABISMOLOGY is the first monograph devoted entirely to the development of strabismology in different regions of the world. Each of the co-authors has been assigned a special chapter in which his or her knowledge of the material is particularly profound. The origins of strabology go back to the beginning of medicine, thousands of years ago. The story how this specialty evolved from quackery and superstition in ancient times to its present state of sophistication is a fascinating one. It should be of more than passing interest, not only to those specialized in this field but also to others with an interest in the history of ophthalmology. The book consists of approximately 400 pages and is abundantly illustrated with fine reproductions of old documents, engravings, drawings and historic instruments, many of which are from ancient and rare manuscripts. Printed on deluxe art paper THE HISTORY OF STRABISMOLOGY is bound by hand and gold embossed on book plate and spine. THE EDITOR Gunter K. Von Noorden is a world-renowned author and strabologist. His expertise in the entire field of stabismus is docu-mented in his textbook (now in its 6th edition) and uniquely qualify him to organize and edit a book on the history of strabology. THE AUTHORS The authors are prominent strabologists from different parts of the world, internationally known for their contributions. Indeed many have actually played an active part in shaping the history of strabismology during the second half of the 20th century. They are joined by a comprehensive ophthalmolgist who is also an ophthalmic historian of international reputation and by one of the leaders of the orthoptic profession. The following contributed to this book: Henderson C. Almeida, MC, Shinobu Awaya, MD, Alberto Brown-Limon, MD, W illiam E. Gillies, MD, Eugene M. Hel;veston, MD, Joseph Lang, MD, Emma Limon de Brown, MD, Gunter K von Noorden, MD., Hans Rmeky, MD, Geraldo Ribeiro de Barros, MD, and Gill Roper-Hall, DBOT, CO, COMT -199-
Binocular Vision & BOOK REVIEWS, DESCRIPTIONS Fourth Quarter of 2007 Strabismus Quarterly© Volume 22 (No.4): A Medical Scientific E-Periodical for Binoculus Books advertised on following pages pages 198,199 -200-
BINOCULAR VISION & STRABISMUS QUARTERLY© The First and Original International Scientific Periodical devoted to Strabismus and Amblyopia Cited Online in MEDLINE and EMBASE; Cited in INDEX MEDICUS and INDEX BINOCULUS
Please enter my PERSONAL electronic subscription (all subscriptions, USA and International) for 3 years 2008-2010 @ $ 68/yr = $204 O 2 years 2008-2009 @ $ 78/yr = $156 O 1 year 2008 @ $ 84/yr = $ 84 O
PERSONAL NOT BV&SQ YES BV&SQ BOOKS: Please send me _____ copy(s) of subscriber subscriber von Noorden: History Strabismology O $ 179 O $ 159 Helveston: Surg Mgmt Strabismus, ed 5 O $ 179 O $ 139 Kushner: Collection BV Grand Rounds O $ 149 O $ 89
Subscriber Savings (total for all 3) ($120)
Please enter my LIBRARY/INSTITUTIONAL electronic subscription (all subscriptions, USA and International) for 1 year 2008 @ $426/yr = $426 O
LIBRARY and INSTITUTIONAL NOT BV&SQ YES BV&SQ BOOKS: Please send _____ copy(s) of subscriber subscriber von Noorden: History Strabismology O $ 289 O $ 229 Helveston: Surg Mgmt Strabismus, ed 5 O $ 289 O $ 229 Kushner: Collection BV Grand Rounds O $ 289 O $ 189
Subscriber Savings (total for all 3) ($260)
SHIPPING and HANDLING: Continental United States $ 7.50 For EACH book Outside the USA (all) $ 25
ALL ORDERS MUST BE PREPAID IN US$ (Checks must be drawn on a USA bank, please)
Billing: O Check enclosed in US$ Name: Charge it to O VISA O Mastercard O Amer Express Address Card No. Expiration date Ship to: (Books) *** E-MAIL ADDRESS TO WHICH THE JOURNAL LINK IS TO BE SENT> Send Orders to: Binoculus Publishing, PO Box 3727, Dillon CO 80435-3727, USA OR...... Call or FAX:this form to 970-262-0753 DO NOT SEND credit card numbers by email: [email protected] -201- BINOCULAR VISION & Strabismus Quarterly: INSTRUCTIONS FOR AUTHORS SUBMISSION OF MANUSCRIPTS (TYPESCRIPTS) the following parts in this order: ABSTRACT; INTRODUCTION (BACKGROUND AND PURPOSE OR PROBLEM); Electronic Submission: Send one copy of your Letter of MATERIALS, SUBJECTS AND METHODS; RESULTS*; transmittal, copyright transfer, and permissions for publications DISCUSSION OF RESULTS; CONCLUSIONS (& of photos (see below for details of these), and one copy of your recommendations) REFERENCES; TABLES; LEGENDS FOR paper/manuscript, using a word processing program for FIGURES; FIGURES. Microsoft/ Office typed in a loose typewriter typeface, and In the "Discussion of Results", do not introduce new reference double-spaced. Include all Tables and Figures (graphs, line material. Instead, we expect you to integrate YOUR NEW drawings, and photos) preferably as part of the manuscript rather RESULTS into the current body of knowledge. Specifically: your than as attachments. to: [email protected] results should be compared to results obtained by prior workers: Confirmations and agreements should be pointed out. But Standard Hardcopy Submission: Send four (4) copies, typed in discordances also require enumeration, discussion, and a loose typewriter typeface, and double-spaced with xerographic explanation. Unique or unexpected results demand copies of all figures (graphs, line drawings, and photos). Also interpretation. The statistical significance* of results must be send two (2) originals of all computer generated/printed figures considered and their application should also be entertained. and glossy photo prints of and figure by EITHER US Post Office or a delivery service TO: EDITOR, BINOCULAR REFERENCES: Order these numerically in sequence as they VISION appear in the text. Indicate a reference number in the text with 740 PINEY ACRES CIRCLE PO BOX 3727 a full sized Arabic numeral enclosed in parentheses, i.e. (1). On DILLON CO 80435-3727 USA the separate Reference page they should be numbered Please also send a CD or 3.5" diskette copy of your manuscript consecutively and typed double-spaced. Author's names and made on an IBM or IBM compatible PC using Word Perfect 10 Journal titles should be abbreviated, without periods, as in Index or Microsoft word processing program.EITHER WAY- Send a Medicus. For journals punctuate in the following order: covering letter of transmittal with name, address, telephone and Author'(s) last name Initials ["et al" acceptable for more than FAX numbers, email address of corresponding author, i.e.,the 3]:[colon] Article title with sub-title, if any.[period] IM Journal author to whom letters of receipt and acceptance, galley proofs abbreviation [Bolded] year; volume number in Arabic numerals: and reprint request forms are to be sent. inclusive pages. Example: Note: To comply with the Copyright Act of 1976, include also the 1. Jones AB, Jones CD, Jones EF, et al: Results of Laser following COPYRIGHT TRANSFER STATEMENT, signed by Surgery for Strabismus. J Outst Surg l999; 2:301-304. each and all authors: "The undersigned author(s) transfers all For book references: author, title, volume (if more than one) copyright ownership of the manuscript entitled (title of article) to edition number (if other than the first), publisher, city and year. Binocular Vision & Strabismus Quarterly/Binoculus Publishing If the reference is a chapter in a book, the order changes as in the event the work is published. The author(s) warrants that follows: the author of the chapter, title of the chapter, "in" book the article is original, is not under consideration by another title, volume, edition, editors, publisher, city, year, inclusive journal, and has not been previously published". pages of the chapter. Authors are responsible for accuracy. References: If "PERSONAL COMMUNICATIONS", major TABLES: Always "portrait" (< 7" W), NOT "landscape" amounts of text or any Figures from any previously published configuration which requires undesirable sideways position.. paper are included in your paper, include also reprint FIGURES: PHOTOS, GRAPHICS, DRAWINGS permissions from prior author and publisher if printed. (see Electronic submission, email or on CD is usually acceptable. "Sources, Credits, and Permits", below). Standard Hard copy methods: Photo materials for halftones All manuscripts, including solicited material, is subject to editorial (photographs, photomicrographs, electron micrographs, review and revision. Only manuscripts in English are considered. roentgenograms) should be submitted cropped and unmounted. All Manuscripts submitted become the property of the Journal On the back of each print, affix a pretyped label with the figure and may not be published elsewhere without written permission number, an arrow and/or "top" indicating the top edge, and the from both this Editor and Publisher. last name of the first author. Line drawings, charts, and diagrams There are no publication or "page" charges to authors except for should be professionally prepared. For computer generated illustrations or printed length in excess of 12 pages. But no graphics, please submit originals, rather than photographic charges are levied without consent of the corresponding author. prints. Typewritten labels and lettering are not acceptable in graphics. Insure that lettering is large enough to be legible if and TEXT STYLE AND CONTENT when reduced for publication. Page Headers Each and every page, including xerographic Legends for Figures: typed double-spaced in consecutive order figure copies, Legends for Figures, Tables and References, on a separate page following References. Start each with first should be arabic numbered consecutively with an abbreviated author's name in parentheses. Indicate scale when appropriate. title but NO authors' names at the page top. The Title page is State clearly the point which the Figure is illustrating. Use arrows page 1, ABSTRACT is page 2. on photos liberally to identify and point out structures. [Assume Title Page: Declarative titles are acceptable and encouraged. the reader is not an expert like you are but rather a student.] (Pretend you are writing a newspaper headline.) SOURCES, CREDITS, PERMITS Précis: Include a one sentence précis (35 words or less) Quotations must be accurate and give full credit to the source. summarizing the main outcome/finding of the study. Brief properly credited quotes do not require permission of the List in this order: All author(s)full names AND ALL DEGREES as original author or publisher ("fair use"). For large amounts of text desired when published, academic and institutional affiliations, or any figures previously published permission to quote and sources of support, and other acknowledgements. Restate for reproduce must be obtained by the submitting author: original publication the corresponding author's name, address, telephone copies of the letters from the original author and publisher and FAX numbers, with e-mail address. granting permission to reproduce the work must accompany your ABSTRACT: :Do not restate the title as the title will always manuscript. Photo permits: if the subject can be recognized, i.e., appear with the abstract. On a separate page (2) provide an any picture which contains more than just eyes and an abstract-summary of about 200 words, clearly and concisely unidentifiable bridge of the nose, written permission to publish stating in paragraphs titled respectively the Background and the picture must be obtained from any subject over age 8 years Purpose (or Problem), Methods of study, the major Results, and old (and the parents if a minor under age 18). principal Conclusions. CONSERVATIVE statements as to * Statistical Analysis of Results Mandatory. But give "exact" IMPORTANCE, recommendations, and applications may be probability values (i.e., p = .06). Do not use relative p values appropriate. The abstract should be factual, specific and (i.e.,p >< .05). The term "statistically significant", defined sufficiently complete to provide the reader a quick and traditionally as a p #.05, is a totally arbitrary and unscientific comprehensive view of the content of the paper. [Avoid term and should not be used (J Lab Clin Med 1988. 111:501). generalizations (i.e. "are discussed") OR "baiting" the reader by But do consider whether a result may be "clinically/medically holding back or out on your results or conclusions.] significant". rev 22:(1)-PER TEXT CONTENT: Manuscript material should be organized into -203- D. BRIAN STIDHAM MEMORIAL LECTURESHIP LECTURE to be published annually in Binocular Vision and Strabismus Quarterly To the Editor: Donations Solicited to Fund Lectureship The Pediatric Ophthalmology community lost a great doctor last October 6, 2005, with the death by murder of D. Brian Stidham. I am attempting to create an endowed lectureship to remember Brian in our community and within pediatric ophthalmology, and wonder if I could ask you to consider helping in this regard. I know that your journal concentrates on strabismus and binocular vision, but could I interest you in publishing the "Stidham Lecture in Pediatric Ophthalmology and Strabismus" that will hopefully be given on a yearly basis? I would work with the presenter to make certain that a manuscript would be produced that would be of acceptable quality. Having a target journal for the presentation would be a great carrot to draw top speakers to Tucson on a yearly basis to give such a talk. We have raised $14,000 towards a target of $50,000 endowment that would ensure that the lecture would be perpetuated. I am committed to continue fundraising until the goal is met. If Binocular Vision and Strabismus Quarterly would serve as the publisher of the named lecture, I feel certain we will be able to both attract top speakers and donors to remember Brian in the years ahead, and to provide a great lectureship in pediatric ophthalmology and strabismus to our professional community which would enjoy greater readership and distribution. Joseph M. Miller, M.D., MPH Head, Ophthalmology and Vision Science University of Arizona, Tucson, Arizona In reply: We are honored to be asked and will most definitely be pleased to publish this lecture each year. We would encourage our readership to donate to this fund: Checks should be made payable to The University of Arizona Foundation with memo of "Stidham Endowment" and sent to Dr. Miller at U AZ, Ophthalmology, 655 N. Alvernon Way, Ste 108, Tucson AZ 85711. - PER
ADVICE for authors submitting papers to Binocular Vision & Strabismus Quarterly©
1. READ & FOLLOW INSTRUCTIONS FOR AUTHORS! In legally. Third: It reflects poorly on you as both a health care addition: professional and as a scientist and Fourth: under the worse of 2. READ & FOLLOW INSTRUCTIONS FOR AUTHORS! In circumstances suggests or indicates that you may discriminate addition: against those of lower socio-economic status (research findings). Reviewing the literature: A proper review of the literature starts WRITING STYLE IS IMPORTANT TOO: with a review of current and appropriate textbooks, especially the (from Investor’s Business Daily Nov. 26, 1997 by Morey Stettner) latest edition (currently the Sixth of von Noorden’s Binocular “Make Dry Data Come Alive in Your Reports ... tips on making Vision and Ocular Motility by Mosby, and Duane’s loose-leaf text your technical writing come alive: Clinical Ophthalmology. Anticipating a future requirement, it will 1. Remember that less is more. ... simplify your language and only be to your credit now to specifically state what was included prune extra words. Eliminate jargon, and keep your sentences in your literature search, i.e., the topics or subjects and the sites and paragraphs short. ‘If you write in little bites, you break down searched. For any article submitted here that should include at a lots of information for the readers so that it’s easier to absorb,’ minimum, Index Medicus (Medline) from 1966 to the present, said Carolyn Mulford, president of The Writing Coach. ... Index Bnoculus Primus, 1985 to the present, and the Internet for 2. White in the active voice. ... For example, write ‘When you the American Orthoptic Journal. review the data, you will note these trends’. Avoid saying ‘These trends were noted upon a review of the data.’ Another example: Acceptable TERMINOLOGY not acceptable Write ‘We will examine’, not, ‘This has been examined’. ... AHP Abnormal Head Postures:3 3. Insert ‘talking subheads’. ... unbroken text can intimidate any face turn head turn reader, ... organize your writing in sections with each carrying an chin up/down head up/down easy to understand subhead ... a talking subhead ... alerts the Head tilt reader of what you’re about to discuss ... for instance, instead of retroequatorial myopexy Fadenoperation heading a section with ‘Cost of Scanners’ try ‘Rising Cost of the retroequatorial myopexy posterior fixation suture Next Generation of Scanners’. subheads should average 7 words. suspension-recession hang back, hang loose 4. Run a test. ... ask someone in your audience group to read it. Bielschowsky Head Tilt Test three step test TABLES: Don’t forget the crowding phenomenon. It works in strabolog-y, ist Strabismolog’y, ist Tables too. We prefer spaces to lines to separate the items in a exact p values “Statistically significant” Table. You can also get more material within whatever size limits you may have, using spaces instead of lines, especially vertical Re: “lost to followup” - Avoid this at all costs; First it raises the lines. Horizontal lines are less of a sin. -PER 22(4) possibility that the patient had a (=) bad result or was otherwise so unhappy with their care that they never came back - or went elsewhere or went nowhere out of fear or dissatisfaction. If they are “lost followup” you cannot refute the possiblity that one those very unhapy thingsppened! Second it is inexcusable - medico- -204-
Binocular Vision & Correspondence: Binocular Vision Fourth Quarter of 2007 Strabismus Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical pages 204-205
Letter to the Editor re: Refractive Surgery in Adults with Binocular Vision “Abnormalities”:
Pediatric ophthalmologists should stand improved with contact lens trial.” However, the against spurious claims that laser vision correction facts as presented, and the article’s title, improves amblyopia or binocular function in encourage the naive reader to assume a distinct adult patients. Refractive surgeons, due to their therapeutic effect of refractive surgery when none training and natural proclivities, lack a facile exists. understanding of the vision system beyond the Refractive surgeons are eager to believe optic nerve (some would say, beyond the posterior that their procedures are psychovisually superior lens capsule). In their eagerness to expand to an excellent refraction and well-made “therapeutic” indications for refractive spectacles; or a rigid contact lens for one eye; or procedures, they have wandered into the tall grass clean and well-fitted soft contact lenses for a high of ocular dominance columns and tripped over the spherical myope. They persuade themselves and hidden rocks of sensory fusion. They babble about sometimes lure their patients into the idea that “visual processing”. Unfortunately, members of surgery offers a unique path to improved cortical our sub-specialty occasionally aid and abet them vision function, and publish conceptually in their misadventures. ignorant2, 3, poorly designed4, 5 and badly Wasserman and McCoy1 recently published conducted studies6, 7 to prove it. a letter in the venerable Archives of We can't stop them but we shouldn't help Ophthalmology titled "Improved Binocularity them. Further, journal editors should make greater after Laser in situ Keratomileusis". They use of binocular vision specialists in the peer described a 32 year old lady with a habitually review process for this and similar publications. uncorrected visual acuity of 20/150 OD and 20/30 OS, and a cycloplegic refraction of -1.75 + 4.50 x Sandra M. Brown M.D. 26 OD (20/25) and -1.00 + 0.25 x 170 OS (20/20). Concord, North Carolina Her uncorrected Titmus stereoacuity was 5/9 dots Email: [email protected] (100 arc seconds). One month after refractive surgery, her anisometropia was collapsed and her References uncorrected Titmus stereoacuity was 9/9 dots (40 arc seconds). 1. Wasserman BN, McCoy CC. Improved binocularity after laser in situ keratomileusis. Refractive surgery is a form of optical Arch Ophthalmol 2007; 125:1293-4. correction. It modifies the light focusing 2. Godts D, Tassignon MJ, Gobin L. Binocular properties of the cornea or lens, not the binocular vision impairment after refractive surgery. J processing capabilities of the visual cortex. It is Cataract Refract Surg 2004; 30:101-9 not a therapy for amblyopia; it does not improve 3. Brown SM. Binocular vision impairment after strabismus or binocular function beyond what refractive surgery. J Cataract Refract Surg 2005; could be obtained with the best non-surgical 31:1268-9; author reply 9. optical treatment. Many times the patient, for 4. Holopainen JM, Moilanen JA, Saaren-Seppala convenience or other reasons, will not bother to H, et al. Unilateral photorefractive keratectomy maximize his optical circumstances before for myopic anisometropia improves contrast surgery. The patient described by Wasserman and sensitivity. Ophthalmology 2004; 111:1095-101. McCoy was one such: given her preoperative 5. Brown SM. PRK for myopic anisometropia. corrected visual acuity of 20/25, her corrected Ophthalmology 2005; 112:525; author reply -6. stereopsis would likely have been at least 60 arc 6. Lanza M, Rosa N, Capasso L, et al. Can we seconds (7/9 dots) at the time of the first utilize photorefractive keratectomy to improve examination, and would probably have improved visual acuity in adult amblyopic eyes? to 40 arc seconds with a few weeks of spectacle Ophthalmology 2005; 112:1684-91. wear. The authors did concede “(her) preoperative 7. Brown SM. PRK and amblyopia. decreased stereoacuity may have been related to Ophthalmology 2007; 114:1792; author reply her not wearing corrective devices and may have -205-
Binocular Vision & Correspondence: Binocular Vision Fourth Quarter of 2007 Strabismus Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical pages 204-205 email from one of our readers re 22(3): To: Henry Metz, M.D. Loved your letter to the editor of U.S. News & World Report (February 26, “Thank you for this, but just to let you 2007) May we publish it? -PER. know my copy has hand written comments on, In reply: Please feel free to publish it in your notably, pgs 144,186 & 189.” - H. Journal.
From the Editor, In reply: The Eyes Had It First Glad it got to you OK. And thanks for your observations. Those are all intentional hand Because medical use of Botox was written marks by me, and printed as intended pioneered by a senior scientist at Smith-Kettlewell graphics. They are intended to make sure the Eye Research Institute, our research staff was readers get the right point! Hope you weren’t pleased to see the article “Beyond Wrinkles” offended. -PER (January 22). The piece was beautifully written in a way that could be easily understood by a general audience. The fact that therapeutic uses of this drug now outsell the cosmestic uses was interesting and encouraging, given that it was first developed here to address serious eye conditions. The first published medical use of Botox, originally called Oculinum, was by Alan Scott, MD in 1980. Scott was interested in developing a non-surgical treatment for eyes that cross (strabismus) or that deviate outward as well as a medical treatment fo spastic closure of the muscles of the lids, not allowing the patient to see (blepharospasm). The Food and Drug Administration gave approval for these treatments in 1989 based on the results of the studies of Scott and his team demonstrating the safety and efficacy of this therapy. We are pleased that a therapy developed at Smith-Kettlewell to treat misalignment of the eyes and uncontrolled spasm of the lid muscles has found so many other uses in various fields of medicine. Henry S. Metz, M.D. Executive Director and CEO San Francisco, California
Special Meeting Announcement: (See also page 203) The Brian Stidham Memorial Lectureship will be delivered by Dr. Deborah Vanderveen of Children’s Hospital Boston (Harvard Medical School). The date is Tuesday March 18, 2008. The meeting is held at the University of Arizona in Tucson. Contact: Joseph Miller, M.D., Tel: 520-321-3667, Fax: 520-321-3665. Email: [email protected] -206-
Binocular Vision & People and Places, News and Announcements Fourth Quarter of 2007 Strabismus Quarterly© Volume 22 (No.4): A Medical Scientific E-Periodical Pages 206 Practice Opportunities of age. Grants of up to $20,000 will be awarded. Applications due by March 1, 2008. Contact: Lansing, Michigan. Lansing Ophthalmology, PC is Midge Horton, Executive Director Blind Childrens seeking a pediatric ophthalmologist to join their Center. 323-664-2153 ext.328. large private practice (12 ophthalmologists). Orthoptist on site. Part time Michigan State House Passes SCHIP University faculty position, if desired. Salary: US$220,000 A University/College town, Lansing is from the AAO Washington Report, August 2, centrally located to Chicago, Toronto and Detroit; a 2007, by Catherine Cohen.. Despite a high price tag nice place to live, work, and enjoy a good family and on-going partisan rancor, the House passed the life. State Children’s Health Insurance Program SCHIP) Http://www.loeye.com/contactus.php bill Wednesday night by a vote of 225 to 204. ... Contact: Charles Dobis
In THIS ISSUE Tendon Extender for Superior Oblique Muscle Overaction Strabismus. Binocul Vis Strabismus Q 2007; 22:216-220. We had already picked out a critical guest editorial for this Another report from the northern frontiers where Arnold is last issue of 2007 when we came across “Clear-Eyed Optimists” once again making do with what is available, and then doing better (see prior page 207). But why publish a critical scrooge-y editorial than what we do where everything IS available! at the holiday season? Why not one full of cheerful and happy thoughts and Optimism. So on the previous page we hope you will We wanted to take the opportunity to pick on Ken W right: enjoy this happy headline news (for a change), an encouraging In this paper, we changed the name of his procedure from SO message of good cheer and that it will enlighten and lighten the tendon “expander” to SO tendon EXTENDER because of the present holiday season for you... dictionary definitions of these two relative terms: Please note: the author poses the question “To what do we owe this improvement?” His answer is “Capitalism” Note that his answer is NOT “Socialism”. Another late breaking piece of good news: the ice sheet in Antarctica is enlarging- yes getting bigger, so that shrinkage up at the north pole may be meaningless for planet earth.
Brown SM. Refractive Surgery in Adults with Biniocular vision Abnormalities.Binocul Vis Strabismus Q 2007; 22:204-205 Refractive Surgery FRAUD ?. Or... what you mean by “improve” ? We thank Dr.Brown for exposing this outrage. It looks like fraud. Or to paraphrase Bill Clinton on ”is”: Just what do you mean by “improve”. This is a scientific journal, a scientific forum and we deal in hard facts. This is not an advertisement soliciting business. Hauviller V, Gamio S, Sors MV. Essential Infantile Scientifically, we would say that there was ZERO EVIDENCE OF Esotropia in Neurologically Impaired Pediatric Patients: Is IMPROVEMENT OF BINOCULAR VISION or stereopsis in this Botulinum Toxin Better Primary Treatment than Surgery? case. The authors have taken the new ability of the patient to Binocul Vis Strabismus Q 2007; 22:221-226 achieve better binocular vision without optical correction as an .The answer to the rhetorical question in the title is a improvement. But we are ophthalmic scientists and medical resounding “yes” and the final sentence of the summary is “we now doctors, not salesmen in this forum. The patient might consider use botulinum injections as our primary treatment in these patients.” THEIR SITUATION “improved”, not having to wear spectacles to Considering the pragmatic advantages they describe, we suspect enjoy better binocular vision, but no self respecting vision expert serial Botox will find uses elsewhere in the near future. would consider this to be any real improvement in binocular vision per se as these referenced authors did (and their editor allowed Khawam E, Terro A, Hamadeh I, Hamam. Surgical them to do!). Correction of Synergistic Divergence Strabismus. A Report of Three Cases. Binocul Vis Strabismus Q 2007; 22:227-234. Park H-J, Guy J. Sixth Nervw Palsy Post Intravitreal Authors’ Precis: This is a report of three cases of Bevacizumab for AMD: A New Possibly Causal Relationship congenital synergistic divergence. The procedure of choice would and Complication. Binocul Vis Strabismus Q 2007; 22:209. be denervation/extirpation of the lateral rectus muscle along with We edited this paper by adding the second line of the title, resection of the medial rectus muscle of the affected eye(s). Fairly believing and editing, as we now do, after the official abandonment good ocular alignment and elimination of the simultaneous of key words by the powers that be, to add words here to the title abduction and of the abnormal head posture are possible, but instead, to broaden and make more specific the message relayed abduction and adduction cannot be improved. C’est Ca!-per in the title of any article. The unanticipated effect here, diplopia for the patient, but Chang Y-H, Chang JH, Han S-H, Lee JB. Outcome not seem too serious, especially since it seems to be reversible. Study of Tw o Standard-&-Graduated Augmented Modified But let me tell you: when I awoke from my general anesthesia for Kestenbaum Surgery Protocols for Abnormal Head Postures open heart surgery now some 7 years ago, and I opened my eyes in Infantile Nystagmus. Binocul Vis Strabismus Q 2007; 22:235- to find I had a huge and nasty diagonal vertical diplopia. I 241. The authors have done a lot of work here, to achieve an OK immediately figured I had suffered the dreaded open heart brain for an alternate recipe for this surgical situation, devised to avoid injury! Fortunately when they found my glasses and I put them on, the possibility of complications attending the original surgical recipe. I was able to regain binocular fusion and cure my diplopia. It does re-occurr from time to time but less and less with the passage of time. [it’s an RSO palsy by Bielschowsky head tilt test]. In fact, in this issue, we must commend the various authors for their persistence and success in managing some of the Shokida MF, Gabriel J, Sanchez C. Safety Stitch: A most difficult ocular motility and strabismus problems. Modification to Postoperatively Adjustable suture Strabismus Surgery of the Inferior Rectus Muscle. Binocul Vis Strabismus Also, see the review of Coats and Olitsky’s book on Q 2007; 22:210-215 complications of strabismus surgery, so aptly reviewed in this issue on page 247. And abstracts and Hyde Park editorial with other inter- A clever modification to these procedures which gives esting news of the eye business. -Happy Holidays -per better results than prior similar ones (excellent review of and comparison with prior reports) and removes the procedure from “not recommended” category.. Arnold RW, Leman RE. Radio-Opaque Modification/Substitute for the Wright Superior Oblique -209- Binocular Vision & Sixth Nerve Palsy Post Intravitreal Bevacizumab for AMD: Fourth Quarter of 2007 Strabismus Quarterly© A New Possibly Causal Relationship and Complication? Volume 22 (No:4): A Medical Scientific E-Periodical H-J Park, MD, MPH and J. Guy, MD Pages 209
Case Report Sixth Nerve Palsy Post Intravitreal Bevacizumab for AMD: A New Possibly Causal Relationship and Complication?
HEE-JUNG PARK, M.D., MPH and JOHN GUY, M.D. from the Department of Ophthalmology, University of Florida, Gainesville, Florida
BACKGROUND & INTRODUCTION no afferent pupillary defect. Eye movements showed decreased abduction of the left eye on left lateral gaze. In primary gaze he measured 30 diopters of Bevacizumab is a non-specific vascular esotropia. Confrontation visual fields, intraocular endothelial growth factor (VEGF) inhibitor that was pressure, and biomicroscopy of the anterior segment first approved for treatment of metastatic colon were normal. Ophthalmoscopy showed wet macular cancer. This medication (off-label) and another in this degeneration in the right eye. Contrasted MRI of head class, ranibizumab, have been extensively utilized for and orbit was normal. One month later changes in the treatment of neovascular age-related macular patient’s examination revealed an improvement in degeneration (AMD) and other causes of choroidal abduction of the left eye and the esotropia decreased neovascularization that include high myopia, to 14 diopters in primary gaze. proliferative diabetic retinopathy, retinal vein occlusion, macular edema and neovascular glaucoma. In a review of the medical literature we were unable to find a microvascular ocular motor nerve Although both medications are generally well palsy temporally associated with intravitreal injection tolerated, some serious systemic adverse events have of bevacizumab. This patient, however, seriously been reported. In a study of 412 patients treated with believed that the treatment was the cause of his intravitreal injections of 1.25 mg of bevacizumab, diplopia and he refused any further treatment for his adverse events included transient increase in arterial macular degeneration. blood pressure, dizziness and tinnitus. Despite the increased risks of stroke and MI, Some serious adverse events in this study we cannot establish causality to treatment with any included one case of TIA and two cases of myocardial infarction (one fatal) that occurred within 3 months certainty, as our patient had vasculopathic risk after intraocular injection of bevacizumab. Wu and factors. Still we were unable to find any previously coworkers described seven cases of an acute elevation reported association of intraocular injection with anti- of systemic blood pressure (0.59%), six VEGF agents to a microvascular sixth cranial nerve cerebrovascular accidents (0.5%), five myocardial palsy infarctions (0.4%), two iliac artery aneurysyms WARNING / CONCLUSION (0.17%), two toe amputations (0.17%) and five deaths Here, we wish to alert our colleagues of this (0.4%). A large multi-center trial on ranibizumab potential adverse event. We believe that this relative reported nine cases of MI (3.8%) and nine cases of risk is minor and it should in no way dampen stroke (3.8%) after either 0.3 mg or 0.5 mg of enthusiasm for the off-label use of bevacizumab for repeated intraocular ranibizumab injections. visual loss associated with AMD. Here we report a patient who developed a microvascular sixth cranial nerve palsy after repeated Received for consideration October 16, 2007; intravitreal injections of bevacizumab. accepted for expedited publication October 30, 2007. Correspondence/reprint requests to Dr. Guy, CASE REPORT Dept Ophthalmology, University of Florida, PO Box A 62 year old gentleman received three 100284, Gainesville FL 32610-0284. intravitreal injections of bevacizbumab into his right [email protected] eye, between December 2006 and May 2007, for wet macular degeneration. Five days after his last injection, he complained of binocular horizontal diplopia. He had no other symptoms. He had had an MI 20 years ago. He was a smoker. Medications included 81 mg of aspirin and ibuprofen, as needed. Neuro-ophthalmic examination revealed visual acuity of 20/60 OD and 20/20 OS. There was -210- Binocular Vision & Safety Stitch. A Modification to Postoperatively Adjustable Suture Strabismus Surgery Fourth Quarter of 2007 Strabismus Quarterly© of the Inferior Rectus Muscle Volume 22 (No.4): A Medical Scientific e-Periodical M.F. Shokida, MD, J. Gabriel, MD and C. Sanchez, MD Pages 210-215
Original Scientific Article Safety Stitch: A Modification to Postoperatively Adjustable Suture Strabismus Surgery of the Inferior Rectus Muscle
MARIA FELISA SHOKIDA, M.D., JOSE GABRIEL, M.D. and CELIA SANCHEZ, M.D.
From the Ophthalmology Department of the Hospital Italiano, Buenos Aires, Argentina
ABSTRACT: Objective: To introduce a variation of adjustable suture recession surgery of the inferior rectus muscle by adding a non-absorbable “safety stitch” to reduce post surgery overcorrection. Method: Eleven patients with vertical strabismus who needed inferior rectus recession were the subjects of this study. The vertical deviation was measured preoperatively, 24 hours after the adjustment, and after a minimum of a year followup. An adjustable suture technique through a limbal incision with a silicon sheet was used. We added a non-absorbable suture in the medial edge of the tendon of the inferior rectus muscle and fixed it at the scleral insertion of the muscle. This area of the inferior rectus tendon was exposed for the adjustment, which was performed 24-48 hours after the surgery. The safety suture was then fastened with a knot and 4-6 prism diopters (pd) of undercorrection in down gaze was intentionally left. Results: The average preoperative vertical deviation was 17 prism diopters (pd) in primary position, and 21.6 pd in down gaze. Six of the eleven patients were adjusted postop’ leaving an average residual vertical deviation of 2 pd in primary position and 4.7 pd in down gaze. After a year of followup, the average vertical deviation was 0.4 pd in primary position and 2 pd in down gaze. Ten of the eleven patients were considered to have “successful” primary surgery using this technique. The eleventh required a second operation for an undercorrection which resulted from inadequate original placement of the safety stitch. Conclusion: The non-absorbable safety stitch technique provided satisfactory results, superior to previously reported techniques for postop’ adjustable recession strabismus surgery of the inferior rectus muscle.
Received for consideration March 13, 2007; accepted for publication June 3, 2007. Acknowledgment: The authors thank Patricia Adduci and Leslie France for assistance in the English translation. Correspondence/reprint requests to: Dra. Shokida, Argerich 4749,, (CP 1419) Buenos Aires, Argentina. Email: [email protected] -211- Binocular Vision & Safety Stitch. A Modification to Postoperatively Adjustable Suture Strabismus Surgery Fourth Quarter of 2007 Strabismus Quarterly© of the Inferior Rectus Muscle Volume 22 (No.4): A Medical Scientific e-Periodical M.F. Shokida, MD, J. Gabriel, MD and C. Sanchez, MD Pages 210-215 INTRODUCTION old, that had surgery of the inferior rectus muscle using this new postop’ adjustable suture technique, A postoperative slipped muscle is a surgical from July 2000 to December 2004. Seven had complication described by Parks & Bloom in 1979 superior oblique palsy; two had a III nerve palsy (one (1). It produces a new incomitant strabismus and of them because of meningioma and the other one due undesired overcorrection. The inferior rectus and to orbit fracture); and two patients had developed a medial rectus are the two most common extraocular hypertropia after glaucoma surgery. muscles to sustain this complication. The postoperatively adjustable suture technique of the Patients with previous strabismus surgery or inferior rectus muscle has been controversial because thyroid myopathy were not included. The vertical of frequent postoperative overcorrection See deviation was measured in all gaze positions Discussion for details. As Jampolsky says (2,3) the preoperatively, 24 hours after surgery, and after a inferior rectus muscle is an “unfriendly muscle” minimum followup of one year. However, only the because surgery on it can lead to lid retraction with primary position and down gaze positions were asymmetrical lid fissures and limitation of down gaze. compared pre- and postoperatively. For that reason, some surgeons will no longer use the In this report, a double-armed vicryl 5/0 postop’ adjustable suture technique for the recession (Ethicon) suture was used. The muscle was cut from of the inferior rectus muscle. the sclera and a slipknot was placed for adjustment. The purpose of this paper is to report a new Then a non-absorbable safety stitch (Mersilene 5/0) technique to prevent slippage after an adjustable was anchored from the medial edge of the tendon to suture using a non-absorbable “safety stitch” in the the sclera, fastening it with a half bowknot. medial edge of the tendon. The safety stitch has to be placed transversely to inferior rectus muscle fibers, to insure the muscle and its sheath are fixed together by the safety suture METHODS preventing the muscle slippage. See Figure , below. The subjects of this study were eleven To facilitate delayed adjustment, a silicon patients, five women and six men, aged 13 to 65 years
Figure (Shokida et al): Left: Intraop’:The safety stitch is fixed in the sclera at the tendon insertion with a half bowknot. Right: Postop’ 24-48 hours: The absorbable suture and the safety stitch are adjusted and cut. -212- Binocular Vision & Safety Stitch. A Modification to Postoperatively Adjustable Suture Strabismus Surgery Fourth Quarter of 2007 Strabismus Quarterly© of the Inferior Rectus Muscle Volume 22 (No.4): A Medical Scientific e-Periodical M.F. Shokida, MD, J. Gabriel, MD and C. Sanchez, MD Pages 210-215 sheet was placed intraoperatively under the muscle to In the first 6 months after surgery the inferior prevent adherence to the sclera, as described in a rectus muscle can slip leading to overcorrection. previous report (4). Sometimes, this complication can appear even later. To make sure that our measures were stable, we chose The safety stitch was not tied and fastened a longer followup, a minimum of 12 months. until the end of the adjustment 24-48 hours after surgery, when the vertical deviation was measured The average followup ws 27 months. The and any necessary adjustment was performed to inferior rectus muscle was recessed from 2.5 to 5.5 achieve the desired vertical binocular alignment. A mm from the limbus with an average recession of 3.2. vertical undercorrection of 4-5 pd in down gaze was mm. intentionally left. Then, the two sutures, both the RESULTS absorbable and non-absorbable, were tied. Finally, the silicon sheet was removed and the conjunctiva closed. The individual case data are shown in Table In inferior rectus recession of 5 mm or more (cases 1 1, below. The average data of the vertical deviation and 4) Jampolsky’s technique was used to prevent eyelid retraction (3).
TABLE 1: Individual Case RESULTS in Series of 11 Cases Receiving Safety Stitch for Postoperatively adjustable inferior Rectus Muscle Recession in prism diopters, PP= Primary Position, HT= hypertropia, ET=esotropia, Ortho=orthoptropia, R/L=rt/left -213- Binocular Vision & Safety Stitch. A Modification to Postoperatively Adjustable Suture Strabismus Surgery Fourth Quarter of 2007 Strabismus Quarterly© of the Inferior Rectus Muscle Volume 22 (No.4): A Medical Scientific e-Periodical M.F. Shokida, MD, J. Gabriel, MD and C. Sanchez, MD Pages 210-215
TABLE 2: Average RESULTS in Series of 11 Cases Receiving New Safety Stitch for Postoperatively adjustable inferior Rectus Muscle Recession in prism diopters, PP= Primary Position, HT= hypertropia
preoperatively, post-adjustment and followup in study with good results but only 6 weeks followup. primary position and down gaze are shown in Table They performed bilateral asymmetrical inferior rectus 2, ABOVE. muscle recessions with postop’ adjustable sutures in The average followup was 27 months. The the hypotropic eye to avoid overcorrection. inferior rectus muscle was recessed from 2.5 to 5.5 Sprunger & Helveston (6) found an mm, with a median amount of 3.2 mm. overcorrection rate of 40% when using adjustable The surgery was considered “successful” sutures on the inferior rectus muscle. All their cases when there was no diplopia after a year, and the were adjusted to an orthotropic position. The authors binocular misalignment in primary position was less explained that when the eye moves from abduction to than 3 pd. In Table 1 ten of the 11 patients were adduction the inferior rectus muscle tends to slip and, “successful” by this criteria, Six out of the 11 in the same way, when the inferior oblique muscle patients were initially adjusted to correct diplopia and contracts, the inferior rectus muscles moves to the to achieve the desired binocular alignment in primary medial side. To reduce the risk of slipping, they position. suggested that the inferior rectus muscle should be dissected more than 10 mm from the insertion. They Complications: also suggested bilateral asymmetrical inferior rectus One patient developed an overcorrection and recessions or the use of tandem sutures for thyroid had to have further surgery. In one patient, the suture myopathy. broke during adjustment and had to be replaced. One Vasquez & Muñoz found an average of 12 pd patient developed chemosis due to an allergic reaction postoperative overcorrection in 5 out of 20 patients to the suture. None of them showed eyelid retraction operated with the adjustable suture technique. They postoperatively. recommended leaving the patients with an undercorrection on adjustment. DISCUSSION Ruttum (8) had 53% of cases with overcorrection using an adjustable suture versus 18% The postoperative adjustable suture technique without. They found 2.5 pd correction per mm of for inferior rectus muscle strabismus surgery is recession of the inferior rectus muscle, 4 mm being controversial. Among other complications, there can the average. An inferior rectus recession of 3.5 to 6.5 be slippage of the muscle with secondary mm was performed with overcorrection of 7 to 35 pd. overcorrection. Cruz & Davitt (5) have reported a -214- Binocular Vision & Safety Stitch. A Modification to Postoperatively Adjustable Suture Strabismus Surgery Fourth Quarter of 2007 Strabismus Quarterly© of the Inferior Rectus Muscle Volume 22 (No.4): A Medical Scientific e-Periodical M.F. Shokida, MD, J. Gabriel, MD and C. Sanchez, MD Pages 210-215 In their study 10 out of 30 patients had less than 5 borders of the inferior rectus muscle to the sclera months followup. with absorbable sutures, leaving one extra absorbable suture, for the adjustment, in the middle of the Lueder et al (9), and Krauss & Bullock (10) muscle. This technique has limitations as far as prefer the use of adjustable suture for inferior rectus advancing or recessing the muscle. surgery. On the other hand, Mazow (11) performs it depending on the findings during the surgery. If the In our study, we introduce a new technique inferior rectus muscle is elastic, the adjustable which provides a better fixation to the sclera, to technique is applied; if the muscle is inelastic, it is avoid this complication. We add a non-absorbable avoided. “safety stitch” in the middle edge of the tendon of the inferior rectus muscle, where the muscle traction Chatzistefanou, Kushner & Gentry (12) makes a concavity when a “hang-loose” suture is studied the contact arc of the extraocular muscle by used with the adjustable suture technique. In the using MRI. They found that the inferior and medial recession of the inferior rectus muscle with the rectus muscles have a shorter contact of arc compared adjustable suture technique, we use an absorbable to the lateral and superior rectus muscles. The inferior suture together with a non-absorbable one as a safety rectus muscle has a tendency to slip when it is stitch to avoid later overcorrection. Also we leave an recessed, perhaps because of the tight tissues undercorrection of 4-5 pd in down gaze and warn the surrounding it. In down gaze, they act together patient that any postop’ residual vertical diplopia will moving the pulley backwards and diminishing the improve with time. contact with the sclera. This may explain the tendency to slip after surgery when these muscles are recessed. Case 11, with superior oblique palsy in the right eye, showed hypercorrection with inverted tilt The inferior rectus muscle has different and lower eyelid retraction after 2 months. The anatomic features from the superior rectus muscle, patient was operated upon again and it was found that because of its connections to the inferior oblique the intrasheath portion of the inferior rectus muscle muscle, the vascular bundle and Lockwood’s had slipped 3 mm while the muscle sheath remained ligament. fixed to the reattachment site with the non-absorbable In Graves Disease and other restrictive suture. The slipped inferior rectus muscle was pathology there may also be an abnormal innervation advanced and the patient achieved orthotropia in due to Hering’s Law, which would lead to post primary position and 5 pd hypertropia in down gaze. surgery overcorrection. When the inferior rectus In this case, overcorrection was probably due to a muscle is recessed and the hypotropic eye is able to misplacement of the safety stitch, which had been move upwards, the excess innervation of the superior placed too parallel to the fibers of the muscle instead rectus muscle of the non affected fixing eye, would be of transversely, and pulling out postoperatively. passed onto the superior rectus muscle of the operated That is why we emphasize that the stitch has eye, causing the eye to become hypertropic. to be placed transversely to the muscle fibers to make Wright (13) describes late overcorrection of sure that the muscle and the sheath are fixed together the inferior rectus muscle in some patients with by the suture. This case showed that, even using a Graves Disease who needed further surgery after 4-6 non-absorbable safety stitch, the muscle could slip if weeks. He believes that the overcorrection was due to it is not placed correctly, transversely to the muscle excessive scarring after the extended inferior rectus fibers. dissection performed to avoid eyelid retraction. He suggests limiting the dissection to avoid excessive scars. However, if it is not done, postoperative lower eyelid retraction could increase. CONCLUSION Kushner (14) published a semi-adjustable The variation that we propose to the technique to avoid overcorrections. He fixed the two adjustable suture technique is to add a non- -215- Binocular Vision & Safety Stitch. A Modification to Postoperatively Adjustable Suture Strabismus Surgery Fourth Quarter of 2007 Strabismus Quarterly© of the Inferior Rectus Muscle Volume 22 (No.4): A Medical Scientific e-Periodical M.F. Shokida, MD, J. Gabriel, MD and C. Sanchez, MD Pages 210-215 absorbable “safety stitch” to avoid the slipping of the adjustable suture strabismus surgery. Trans Am inferior rectus muscle. We believe that it is a good Ophthalmol Soc 1993; 91:81. modification to the inferior rectus adjustment. It is 12. Chatzistefanou KI, Kushner BJ, Gentry LR. also important to adjust to leave a little Magnetic resonance imaging of the arc of contact of undercorrection of 5 pd in down gaze because the extraocular muscles: Implications regarding the average correction of pd per mm in the inferior rectus incidence of slipped muscle. J AAPOS 2000; 4:84- recession is greater in down gaze than in primary 93. position. 13. Wright KW. Late overcorrection after inferior rectus recession. Ophthalmology 1996; 103:1503- 1507. REFERENCES 14. Kushner BJ. An evaluation of the semi-adjustable suture strabismus surgical procedure. J AAPOS 1. Parks MM, Bloom JR. The slipped muscle. 2004; 8:481-487. Ophthalmology 1979; 86:1389-1396. 2. Jampolsky A. Surgical leashes and reverse leashes in strabismus surgical management. In: Symposium on Strabismus. Trans New Orleans Acad Ophthalmol, Mosby, St. Louis 1978; 244. 3. Jampolsky A. Current technique of adjustable strabismus surgery. Am J Ophthalmol 1979; 88:406- 418. 4. Shokida MF. Use of a silicon sheet for delayed adjustable strabismus surgery. Ophthalmic Surg 1993; 24:486. 5. Cruz OA, Davitt BV. Bilateral inferior rectus muscle recession for correction of hypotropia in dysthyroid ophthalmopathy. J AAPOS 1999; 3:157- 159. 6. Sprunger DT, Helveston EM. Progressive overcorrection after inferior rectus recession. J Pediatr Ophthalmol Strabismus 1993; 30:145-148. 7. Vazquez CW, Munoz M. Overcorrection after adjustable suture suspension-recession of the inferior rectus muscle in non-thyroid eye disease. Binocul Vis Strabismus Q 1999; 14:103-106. 8. Ruttum MS. Adjustable versus non-adjustable sutures in the recession of the inferior rectus muscle for thyroid ophthalmopathy. Binocul Vis Eye Muscle Surg Q 1995; 10:105-112. 9. Lueder GT., Scott WE, Kutschke PJ, Keech RV. Long-term results of adjustable sutures surgery for strabismus secondary to thyroid ophthalmopathy. Ophthalmology 1992; 99:993-997. 10. Krauss DJ, Bullock JD. Treatment of thyroid ocular myopathy with adjustable and non-adjustable suture strabismus surgery. Trans Am Ophthalmol Soc 1993; 91:67-84. 11. Mazow ML. Discussion of treatment of thyroid ocular myopathy with adjustable suture and non- -216- Binocular Vision & Radio-Opaque Modification/Substitute fo the Wright Superior Oblique Tendon Extender Fourth Quarter of 2007 Strabismus Quarterly© for Superior Oblique Muslce Overaction Strabismus Volume 22 (No.4): A Medical Scientific E-Periodical R.W. Arnold, MD and R.E. Leman, RN Pages 216-220
Original Scientific Article Radio-Opaque Modification/Substitute for the Wright Superior Oblique Tendon Extender for Superior Oblique Muscle Overaction Strabismus
ROBERT W. ARNOLD, M.D. and RACHEL E. LEMAN, R.N. from Ophthalmic Associates (Dr. Arnold) and the University of Alaska, Anchorage School of Nursing (Ms. Leman)
ABSTRACT: Kenneth Wright developed a technique for graded weakening of the superior oblique by increasing the effective length of this extraocular muscle’s long tendon with a piece of silicone rubber retinal encircling band commonly used by eye surgeons for retinal detachment repairs1. In the absence of specific any retinal bands in our Children’s Hospital, the following technique was developed affording a non-invasive ability to monitor, which was less intricate than the techniques so well described by Demer2. We substituted the “Mini Vessel Loop” (by Maxxim Medical or Henley International). It is an elastic smooth silicone rubber cord that is radio-opaque, and can easily be seen on X-rays and CT scans. It is not an ophthalmologic medical device but it rather is designed to loop around and identify and gently retract blood vessels and nerves in any form of surgery where needed. We demonstrated success similar to that achieved by Wright in 43 patients using these radio-opaque, silicone Mini Vessel loops.
Financial Disclosure: The authors have no financial interest in Mini Vessel loops. This is an off label use of radio opaque tendon expanders. Received and accepted for publication August 30, 2007. Correspondence/reprint request to Dr. Arnold, Ophthalmic Associates, 542 West Second Ave, Anchorage AK 99501. Fax: 907 278 1705. Email: [email protected] -217- Binocular Vision & Radio-Opaque Modification/Substitute fo the Wright Superior Oblique Tendon Extender Fourth Quarter of 2007 Strabismus Quarterly© for Superior Oblique Muslce Overaction Strabismus Volume 22 (No.4): A Medical Scientific E-Periodical R.W. Arnold, MD and R.E. Leman, RN Pages 216-220
INTRODUCTION: The “Mini Vessel Loop” (by Maxxim Medical or Henley International) is an elastic Kenneth Wright developed a technique for smooth silicone cord that is opaque, and can graded weakening of the superior oblique by easily be seen on X-rays. It is not an expansion with a piece of silicone retinal ophthalmologic medical device but it rather encircling band1. In the absence of specific retinal designed to gently retract and identify blood band in the Children’s Hospital, the following vessels and nerves in any form of surgery where technique was developed affording a non- needed. invasive ability to monitor less intricate than the techniques so well described by Demer2. From 1993-1999, pre-measured portions or lengths of this Mini Vessel loop (white or METHODS: yellow) were sewn end-to-end to the divided ends In an IRB approved strabismus study, of the superior oblique tendon, with 8-0 nylon from 1993 through 1999, all cases of strabismus suture ( See Figure 1, below) in cases of in a community-based pediatric eye practice were monitored. -218- Binocular Vision & Radio-Opaque Modification/Substitute fo the Wright Superior Oblique Tendon Extender Fourth Quarter of 2007 Strabismus Quarterly© for Superior Oblique Muslce Overaction Strabismus Volume 22 (No.4): A Medical Scientific E-Periodical R.W. Arnold, MD and R.E. Leman, RN Pages 216-220 strabismus due to significant overactive superior traction test. oblique extraocular muscles, Brown’s syndrome The mean superior oblique lengthening in and orbital strabismus with positive SO traction these 72 surgeries was 5.2 mm OD [in right eyes] tests. These cases were compared to cases of A- and 4.7 mm ) OS [in left eyes]. pattern with overacting superiior obliques undergoing strabismus surgery during the same During this time, another 27 A-pattern time period treated with perpendicular shift of the strabismus surgery cases (age 9±9 years) did not superior oblique tendon insertion. Three cases have significant superior oblique overaction and came to neuroimaging for various reasons. therefore had perpendicular superior oblique insertion shift. RESULTS: Three cases had head X-rays and/or During the study interval, 1,111 adult and computed tomography that easily demonstrated pediatric strabismus cases were performed. In the presence and orientation of the superior these, 72 superior oblique tendons (in 43 patients) oblique Mini Vessel Loop extenders (See were extended with Mini Vessel loops (4% of Figures 2, below, and 3, next page.) strabismus cases). The breakdown of indications was: 26 cases of A-esotropia with overacting We did not specifically look for displace- superior obliques (age 7±8 years), 4 cases of A- exotropia with overacting superior obliques, 9 cases of Brown’s syndrome and 4 cases of orbital strabismus with a positive tight superior oblique -219- Binocular Vision & Radio-Opaque Modification/Substitute fo the Wright Superior Oblique Tendon Extender Fourth Quarter of 2007 Strabismus Quarterly© for Superior Oblique Muslce Overaction Strabismus Volume 22 (No.4): A Medical Scientific E-Periodical R.W. Arnold, MD and R.E. Leman, RN Pages 216-220
ment of the trochlea in these cases. With follow- ups of 6-12 years postoperatively, in no case did the Mini Vessel Loop cause either brief or prolonged orbital inflammation, though in one case, an appparent, self-limited case of superior oblique myokimia was home-video documented in a pediatric patient living in a remote Alaska village. The parent videoed ocular movements while the child watched TV and promptly flew the media in to us for rapid interpretation and recommendations. CONCLUSION: The Mini Vessel Loop is an inexpensive and readily available alternative to retinal encircling band for superior oblique tendon extension3,4. Consisting of medical silicone rubber like retinal encircling bands, they do not appear to cause any inflammation and if and when needed, can be non-invasively observed using ordinary X-rays. -220- Binocular Vision & Radio-Opaque Modification/Substitute fo the Wright Superior Oblique Tendon Extender Fourth Quarter of 2007 Strabismus Quarterly© for Superior Oblique Muslce Overaction Strabismus Volume 22 (No.4): A Medical Scientific E-Periodical R.W. Arnold, MD and R.E. Leman, RN Pages 216-220
REFERENCES
1. Wright KW. Superior oblique silicone expander for Brown syndrome and superior oblique overaction. J Pediatr Ophthalmol Strabismus. Mar-Apr 1991;28(2):101-107. 2. Demer JL, Clark RA, Kono R, Wright W, Velez F, Rosenbaum AL. A 12-year, prospective study of extraocular muscle imaging in complex strabismus. J AAPOS. Dec 2002;6(6):337-347. 3. Wright KW. Results of the superior oblique tendon elongation procedure for severe Brown's syndrome. Trans Am Ophthalmol Soc 2000;98:41-48; discussion 48-50. 4. Stolovitch C, Leibovitch I, Loewenstein A. Long-term results of superior oblique tendon elongation for Brown's Syndrome. J Pediatr Ophthalmol Strabismus. 2002;39(2):90-93. -221- Binocular Vision & Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Fourth Quarter of 2007 Strabismus Quarterly© Is Botulinum Toxin Better Primary Treatment than Surgery? Volume 22 (No.4): A Medical Scientific e-Periodical V. Hauviller, M.D, S. Gamio, MD and MV Sors, MD Pages 221-226
Original Scientific Article
Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Is Botulinum Toxin Better Primary Treatment than Surgery?
VERONICA HAUVILLER, M.D., SUSANA GAMIO, M.D., and MARIA VANESA SORS, M.D. from the Hospital de Niños R Gutierrez, Buenos Aires, Argentina
ABSTRACT: A prospective study was performed over a 10-year period on 25 children with infantile esotropia and neurological problems to answer this question. From November 1996 to March 2006 they were treated with injections of botulinum toxin (Botox®) of both medial rectus extraocular muscles. Mean age was 26.4 months. (range 9 -76 months) and mean initial angle was 35 prism diopters (PD) (range 20 - 60 PD). RESULTS: 18 patients (72%) remained orthotropic ±10PD at 29 months (range 6 - 59 months) after last injection at an average last followup examination interval of 29 months (range 6-59 months) . Average number of injection treatments was 1.5 per patient. We compared our success rate data with those obtained with primary conventional strabismus surgical procedures in 2 previously published series. Treatment with botulinum toxin seemed to produce better results than one surgical series and at least equally similar results to the other one. Because there are, as well, so many other advantages to the injection procedure including superior safety and economy, we now use botulinum injections as our primary treatment in these patients.
Received for consideration March 19, 2007; accepted for publication June 23, 2007.
Correspondence/reprint requests to: Dr. Hauviller, Lafinur 2974 PBA, Buenos Aires 1245, Argentina. Fax: 541-14-805-4620. Email: [email protected]
-222- Binocular Vision & Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Fourth Quarter of 2007 Strabismus Quarterly© Is Botulinum Toxin Better Primary Treatment than Surgery? Volume 22 (No.4): A Medical Scientific e-Periodical V. Hauviller, M.D, S. Gamio, MD and MV Sors, MD Pages 221-226 INTRODUCTION Alternate patch occlusion of the eyes for at least 15 days before treatment was indicated and In essential infantile esotropia there is no carried out. associated neurological abnormality, but this esotropia is more frequent in premature and One dose of 2,5 - 3,75 U of botulinum toxin neurologically impaired children. Surgery in type A, (Botox® by Allergan) was injected in this group is often delayed for various reasons both medial rectus muscles under general and the results of surgery are therefore less anesthesia in every case and without satisfactory. Under or overcorrection results electromyographical guidance. are more frequent than in non-neurological The patients were re-examined postoperative- patients. ly after 7 days and every 30 days thereafter. Botulinum toxin has been used to treat cases of Every patient with a postop’ residual strabismus at risk for surgical overcorrection. It esotropia angle greater than 10 prism diopters is not known whether this method is (PD) was reinjected until the postop’ esotropia specifically applicable to essential infantile angle remained less than 10 PD. If that result esotropia in neurologically impaired infants. could not be obtained with injection, such Therefore we undertook to study this. To our patients received conventional strabismus eye knowledge this is the first study comparing the muscle surgery. success rate of botulinum in these cases with the succes rate in previously published standard RESULTS: strabismus surgery in neurologically impaired Of our 25 patients, 18 (72%) of patients patients. remained in between 10 PD of esotropia and orthotropia with an average follow up of 29 months (range 6 - 59 months) after last injec- PATIENTS AND METHODS: tion. (See Table 1, next page.) Every consecutive patient with infantile Nine of the 18 patients (50%) received one esotropia and neurological impairment treatment, eight (44,4%) received two and one registered at the Ophthalmologic Department of (5,5%) was treated 3 times. The average was 1. the Children Hospital Ricardo Gutiérrez from 5 Botox treatments per patient. November 1996 to March 2006 were included. Because of residual esotropia not adequately Patients with Duane’s Syndrome, sixth nerve responding to Botox injection, the remaining 7 palsy and accommodative esotropia were patients were operated on and their esotropia excluded. Clinical evidence of oblique muscle corrected by conventional eye muscle surgery. dysfunctions, alphabetic pattern, optic nerve No one remained overcorrected. hypoplasia or atrophy were also reasons for exclusion. (Continued) The resulting cohort of 25 patients in this study had hydrocephalia (8 cases), microcephalia (2), West's Syndrome (1), Prader Willy's Syndrome (1), hemiparesia (1), myelomeningocele (5), maturation delay (3), leucoamalacia (1), cerebral palsy(2) and intracerebral hemorrhage(1). (See Table 1, next page.) State of the fundus and refraction were recorded as was the prescription of glasses when needed previous to the strabismus thera-peutic procedure. The strabismic angle was measured by two of the double blind authors, with prisms, by cover test or by Krimsky corneal light reflection test. -223- Binocular Vision & Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Fourth Quarter of 2007 Strabismus Quarterly© Is Botulinum Toxin Better Primary Treatment than Surgery? Volume 22 (No.4): A Medical Scientific e-Periodical V. Hauviller, M.D, S. Gamio, MD and MV Sors, MD Pages 221-226
TABLE 1. Methods and Subjects and Results in Study of Botulinum Toxin Injection Primary Treatment of Essential Infantile Esotropia in 25 Neurologically Impaired Children
DD = Developmental Delay; DP = Prism Diopters Esodeviation; MMC =Myelomeningocoele
Figure 16 -224- Binocular Vision & Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Fourth Quarter of 2007 Strabismus Quarterly© Is Botulinum Toxin Better Primary Treatment than Surgery? Volume 22 (No.4): A Medical Scientific e-Periodical V. Hauviller, M.D, S. Gamio, MD and MV Sors, MD Pages 221-226
TABLE 2. Comparison of Results in Three Studies of Botulinum Toxin Injection Treatment Versus Surgical Treatment of Essential Infantile Esotropia in Neurologically Impaired Children
PD = Prism Diopters Esodeviation; “Central” Neurologic Impairment = prematurity, hydrocephalus, developmental delay, cerebral palsy, myelomenigocoele, intracerebral hemorrhage, seizures, fetal alcohol syndrome, encephalocoele, Down Syndrome. “Ocular” Neurologic or Sensory Motor = optic nerve hypoplasia,optic atrophy, Duane syndrome, VI cranial nerve palsy, retinopathy of prematurity.
Figure 1 (Hauviller): Patient with West Syndrome and esotropia, before (left) and after (right) botulinum treatment.
Figure 16 -225- Binocular Vision & Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Fourth Quarter of 2007 Strabismus Quarterly© Is Botulinum Toxin Better Primary Treatment than Surgery? Volume 22 (No.4): A Medical Scientific e-Periodical V. Hauviller, M.D, S. Gamio, MD and MV Sors, MD Pages 221-226 (RESULTS, continued from page 222) Complications: In 14 cases transient palpebral ptosis and in 8 cases vertical strabismic deviations were detected. The latter, when long-lasting were treated by being alternately occluded by patching. Temporary overcorrection (consecutive exotropia) was observed and recorded in all the successful injection patients (mean angle of exotropia (XT) was 31.5 PD, range 10-65 PD. Three of the unsuccessfully injected have had a residual exoshift, mean angle 20 PD (range 10-30 PD). DISCUSSION. In strabismic patients with neurological impairment, the surgical outcome is less favorable than in healthy patients. Different results would be influenced by sensorial (smaller fusional reserve) and motor reasons (muscular dystonia). In part the poor results of surgery in this group of patients might be related to the more conservative delayed treatment given to these infants.
Comparison With Previously Published series of similar cases (see Table 2, prior page),... Holman and Merritt (1) reported 29 operated pediatric neurological patients: only 55.2% remained orthotropic. 24.1% of them showed residual esotropia and 20,7% were overcorrected. Their mean follow-up was 25 months and the mean age 31 months. Their series also included some patients with sensorial and motor ocular conditions like optic nerve hypoplasia and atrophy, Duane's Syndrome and, sixth nerve palsy. Our series Figure 2: (Hauviller et al): Patient with myelo- excluded this kind of patients, not allowing an meningocoele before (top) and after (bottom) entirely valid comparison. treatment with injections of botulinum toxin. Their success rate is statistically significantly lower than ours. (chi square test , p<0.02). Moguel (3) recommended Botox not as a Charles and Moore (2) reported a 74% success primary treatment strategy but rather as an rate in 28 premature or neurological children 27 alternative therapy when the patient can not months after surgery. Average age was 15 months. undergo further surgery procedures for strabismus. 14 patients were reoperated: 6 under corrected and 2 overcorrected, 5 for inferior oblique over action The predicting factors for success help to define and 1 for DVD. the ideal candidate for each determined treatment strategy. In the case of botulinum toxin, younger Statistically significant differences could not be age (4), smaller esotropia angles, (5,6) a capacity detected comparing out results with these authors’ for future binocular fusion (7), and the type of success rate. esotropia (5) have been reported as favorable for Twenty-three pediatric patients with systemic or Botox injection. Not one of these predictor factors neurological conditions treated with botulinum for success is present in this type of patients with toxin were reported by Moguel (3). Age, follow up congenital esotropia and neurological impairment, and success rate data were not available but their so the reason for our group of patients' good outcome has been favorable. A statistical response is unknown. On the other hand the non- comparison with our series is not possible. neurologic esotropic patients do not respond action so well or easily to the Botox treatment. -226- Binocular Vision & Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Fourth Quarter of 2007 Strabismus Quarterly© Is Botulinum Toxin Better Primary Treatment than Surgery? Volume 22 (No.4): A Medical Scientific e-Periodical V. Hauviller, M.D, S. Gamio, MD and MV Sors, MD Pages 221-226 Advantages of botulinum toxin: treatment of 5) Hauviller V, Gamio S, Tartara A: Botulinum toxin therapy in paediatric esotropia: risk factors for strabismus include: The incidence of complications th is rather low and rarely significant enough to make failure. In Transactions 27 Meeting European the patient discontinue repeated treatment (8). Strabismological Association, Ed De Faber 2001, 199-201. Also, the shorter anesthetic time is welcome and 6) Tejedor J, Rodriguez JM: Long-term outcome desireable in all infants, but especially neurological and predictor variables in the treatment of acquired impaired children. esotropia with botulinum toxin. Invest Ophthalmol Vis Sci.2001; 42:2542-6. Not one permanent overcorrection was observed in our series. 7) Dawson E, Marshman WE, Lee JP: Role of botulinum toxin A in surgically overcorrected The toxin injection produces neither scars nor exotropia J AAPOS 1999 Oct 3(5) 269-71. restrictions, can be repeated with minimal and less 8) Dutton JJ, Fowler AM: Botulinum toxin in risk than repeated surgeries, and does not require Ophthalmology. Survey of Ophthalmology, 2007; tracheal intubation, all signficant advantages. The 52, 13-31. whole procedure lasts but a few minutes. Disadvantages include: a frequent need of repeated procedures, postop’ blepharoptosis, vertical deviations, and the fact some patients do not respond well, the treatment isn’t effective even if it is safe, and they must be operated upon by conventional strabismus surgery with its more serious risks and complications.
CONCLUSION In our series of neurological impaired pediatric patients, botulinum toxin allowed similar or higher success rate compared with 2 previously published similar surgery series in these patients. Being a simple and safe procedure, it is now considered in our hospital to be indicated as the primary treatment strategy for these neurologically impaired esotropic infants and children. References: 1) Holman RE, Merritt JC: Infantile Esotropia: results in the neurologic impaired and normal child at NCMH (six years), J Ped Ophthalm Strab 1986, 23(1) 41-5. 2) Charles SJ, Moore AT: Results of early surgery for infantile esotropia in normal and neurologically impaired infants. Eye 1992 (6Pt): 603-6. 3) Moguel Ancheita S, Martinez Oropeza S: Uso de la toxina botulínica en estrabismos asociados a padecimientos sistémicos en los niños. Actas de Clade, Acapulco, ed M. ArroyoYllanes, 1998, 91-5. 4) Campos E., Schiavi C, Bellusci C: Critical age of botulinum toxin treatment in essential infantile esotropia. J of Ped Opthalm and Strab 2000; 37:328-332. -227- Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007 Strabismus Quarterly© A Report of Three Cases Volume 22 (No.4): A Medical Scientific E-Periodical E. Khawam, MD, A. Terro, MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234
Case Reports Surgical Correction of Synergistic Divergence Strabismus A Report of Three Cases Eduard Khawam, M.D, Abdallah Terro, M.D., Issam Hamadeh, M.D., and Rula Hamam, M.D.
from the Department of Ophthalmology, American University of Beirut,
Lebanon
ABSTRACT: Background and purpose: To review and explain some of the characteristics of synergistic divergence and compare the surgical effects on each of those characteristics. Methods of study: Three patients demonstrating findings characteristic of synergistic divergence, two bilateral and one unilateral, are reported. Surgery consisted on denervation extirpation of the lateral rectus muscle along with resection of the medial rectus muscle of the affected eye or supramaximal recession of the lateral rectus muscle and resection of the antagonist medial rectus muscle of the affected eye. Results: The simultaneous abduction and the abnormal head posture responded well to surgery. The exotropia was reduced. The deficient adduction, the total absence of active abduction and the infraduction of the synkinetically abducting eye remained unchanged. Conclusion: Synergistic divergence is a severe exotropic form of Duane’s Syndrome where the feature of simultaneous abduction is the most striking. To date, no surgical procedure leads to satisfactory results on all the characteristics of synergistic divergence. Although some important features can be satisfactorily improved, some others do not respond to current surgical techniques. Corresponding Author and reprint requests: Dr. Khawam, American University of Beirut Medical Center, P.O. Box 11-0236/B32, Beirut, Lebanon. Tel: +961-3-346161
Email: [email protected] -228- Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007 Strabismus Quarterly© A Report of Three Cases Volume 22 (No.4): A Medical Scientific E-Periodical E. Khawam, MD, A. Terro, MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234
INTRODUCTION with minimal ocular movement. However, in case the LR has both normal innervation by the Synergistic divergence (SD) is a VIth and anomalous innervation by the IIIrd, congenital syndrome of limitation of adduction simple observation (5) reveals the following: As with simultaneous abduction (SA) of both eyes the fixing RE, whether affected or not, moves on attempted gaze into the field of action of the from primary to right gaze, the affected LE weak medial rectus (MR) muscle, large angle simultaneously moves out due to co-contraction exotropia, face turn, and often depression of the of the LR muscle. As the RE moves back synkinetically abducting eye (1,2). toward the primary position, the non-fixing LE Electromyography (EMG) has demonstrated reduces its outward position since the MR of the simultaneous innervations of the horizontal affected LE is now inhibited by Sherington’s rectus muscles on the involved side. This Law. Finally, if the RE now continues to fix innervational pattern is paradoxical, showing toward adduction, the non-fixing LE abducts via increased firing of the lateral rectus (LR) Hering’s Law if, and only if, the left LR muscle muscle on opposite gaze, suggesting that this has any normal innervation. condition is due to neurological miswiring and should be considered an exotropic variant of SD can be unilateral or, rarely, bilateral. Duane’s Syndrome (DS) (3,4). The LR muscle The laterality (6) has a similar distribution to can be only anomalously innervated by the that seen in DS. The left eye (LE) is affected in oculomotor nerve or both anomalously and 64%, the right eye (RE) in 26% and both eyes in normally by the abducens nerve (5). Wagner et 10%. 63% were males and 37% were females. al (6) demonstrated by EMG normal innervation of the MR muscle and maintenance of a normal SD can also be observed iatrogenically pattern of reciprocal innervation with respect to following large MR recession (9) and/or LR gaze. However, Thomas et al (2) reported one resection (10) or under topical anesthesia after case of congenital bilateral SD where, on forced disinserting the MR muscle (5) of the eye generation technique, both lateral rectus affected with DS. Whether it is congenital or muscles contracted on attempted levoversion iatrogenic, it is the quantitatively greater and dextroversion as well as attempted innervation of the LR muscle compared to its convergence. However, the medial rectus antagonist MR muscle by the oculomotor nerve muscles did not contract on any of these that produces abduction of the affected eye(s) at attempted movements. Moreover, EMG of the the same time as attempted abduction of the medial rectus muscles showed a flat tracing. fellow fixing eye (3,5).
The infraduction of the synkinetically It is the weakened or paralytic MR abducting eye as well as the A-pattern with muscle that is overpowered by the intensely further divergence of the eyes in downgaze are anomalously innervated LR muscle that believed to be due respectively to co-contraction produces the observed simultaneous abduction of the SO muscles (7) or to increased motor unit on attempted adduction, instead of a simply activity of the MR muscles on attempted upgaze deficient adduction with retraction of the globe observed electromyographically (8). seen in most cases of DS in opposite gaze. So, the SA, also known as the “splits”, becomes the Clinically it is very difficult to rule in or retraction equivalent. rule out a normal or sub-normal recruitment of the LR muscle because in most cases, the Patients with SD adopt a face turn. In affected globe is frozen in a large exo position unilateral cases, it is always to the side opposite -229- Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007 Strabismus Quarterly© A Report of Three Cases Volume 22 (No.4): A Medical Scientific E-Periodical E. Khawam, MD, A. Terro, MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234 the affected eye. In bilateral cases, it is always with SD, bilateral in one case and unilateral in to the side of the fixing eye. The objective of the second (11). MRI disclosed bilateral the face turn is threefold: 1) To balance the hypoplasia of the oculomotor nerve in both innervational forces placing the fixing eye’s patients, and absence of the abducens nerve on position and the innervation to reduce outward the affected side exhibiting SD. rotation of the non-fixing affected eye by inhibiting recruitment of the MR muscle SD has been reported to be associated therefore eliminating the SA and decreasing the with Marcus Gunn jaw-winking (12), congenital exotropia. 2) To balance the mechanical factors fibrosis, DS (7), aberrant trigemino-oculomotor by placing the non-fixing eye in the field of innervation (17) or arthrogryposis multiplex action of the densily contracted LR muscle. 3) (13), Horner Syndrome (14). Our cases showed To obtain compensatory fusion in unilateral none of these anomalies, but one patient (case cases. In unilateral cases affecting, say the LE, 1) was affected with Joubert Syndrome and all with face turn to right the left exotropia three cases have marked neuro-developmental decreases because as the fixing RE moves delay. toward the primary position, the non-fixing PURPOSE affected LE reduces its outward deviation since co-contraction of the LR muscle is now The primary objective of this report is: a) diminished because of MR reciprocal inhibition To present the findings of three patients with by Sherington’s Law. This face turn not only SD, two bilateral and one unilateral involving reduces outward rotation of the affected eye but the left eye; b) To compare the results of also may allow a compensatory fusion in recession-resection of the horizontal rectus unilateral cases. In bilateral cases, patients muscles to “denervation/extirpation” of the LR alternate face turn to the side of the fixing eye in muscle(s) of the affected eye(s) later followed order to reduce the outward rotation of the with ipsilateral MR resection; and c) To fellow eye, but compensatory fusion is unlikely describe a simple technique of the in severe cases. denervation/extirpation procedure of the LR muscle. Patients with SD exhibit a large angle exotropia, increasing on attempted adduction of Additionally, the purpose of this study is the involved eye(s). The LR muscle of the to show that despite ocular alignment and affected eye becomes extremely restricted, improvement or elimination of the SA, fibrotic and loses all its elasticity. There is a adduction deficit can not be restored despite triple dose for the propensity to LR contracture surgical crippling of the affected LR muscle. (5): The position of extreme exo position, the intensive anomalous innervation of the LR GOAL OF SURGERY AND SURGICAL muscle and abduction of the affected eye(s) to MANAGEMENT either sidegaze. Bilateral cases progress to the The goal of surgery in our three patients most extreme degrees of relatively immobile was to align the eyes, abate the SA, eliminate exotropia. the face turn and restore adduction. We did not, There is no neuropathologic report of SD obviously, expect recovery of abduction since to our knowledge. However magnetic resonance all three patients showed, clinically, absence of imaging (MRI) across the brainstem level was any active abduction except in the moderately performed in two patients with congenital affected right eye of case 2. fibrosis of the extraocular muscles associated -230- Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007 Strabismus Quarterly© A Report of Three Cases Volume 22 (No.4): A Medical Scientific E-Periodical E. Khawam, MD, A. Terro, MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234
We chose to compare the surgical results CASE REPORTS of supramaximal recession of the LR muscle and resection of its antagonist MR muscle to Case 1 “denervation/extirpation” of the LR muscle of A 9 month-old girl was referred to our the affected eye along with MR muscle out-patient department because of a very large resection done at a later stage. variable angle exotropia since birth, abnormal Previously reported surgical procedures eye movements and abnormal head posture. (12) consisted mainly of supramaximally Neurological exam at the age of 6 months recessing the LR muscle of the affected eye revealed severe psychomotor delay due to along with resection of its antagonist MR Joubert Syndrome. muscle. Total tenotomy of the LR muscle. Joubert Syndrome (15) is a rare genetic Myectomy of the inferior oblique (IO) muscle disorder that affects the area of the brain that and superior oblique (SO) tenotomy with controls balance and coordination. The disorder recession of the LR muscle and a reverse rectus is characterized by absence or maldevelopment muscle union procedure (reverse Jensen) to the of a part of the brain called the cerebellar MR of the affected eye. LR recession of the vermis and malformed brainstem. good eye with a large LR muscle recession of the affected eye. Bilateral SO transplantation to We examined the child in May 2004. She the superior aspect of the MR muscle without showed a 50 prism diopter (pd) exotropia of trochlear fracture. Extirpation of the right LR either eye and an alternate face turn to the side muscle and disinsertion of the left LR muscle in of the fixing eye. Binocular fixation pattern a case of bilateral SD. revealed equal fixation with a steady fixation reflex and a normal following reflex of either Analysis of the results of these eye. Cycloplegic refraction with 0.25% procedures seemed to indicate that a crippling scopolamine showed +4.0 sphere in each eye. procedure to the LR muscle of the affected eye Ocular rotations showed absence of adduction is required to abolish the face turn and the SA. in either eye. On attempted dextroversion, the Our technique of denervation/extirpation RE abducted further and the LE simultaneously of the LR muscle was the following: A abducted with slight depression. On attempted Gundersen muscle resection forceps engaged levoversion, the LE abducted further and the RE the LR muscle far posteriorly. The muscle was simultaneously abducted with significant then disinserted and all the muscle fibers depression. Bilateral SD was diagnosed. Patient anterior to the forceps were excised. A second was put on alternate occlusion of his optically Gundersen muscle forceps engaged the LR corrected eyes. On October 12, 2004, at the age muscle more posteriorly before releasing the of 14 months, the right LR muscle was first one, excising again the muscle fibers supramaximally recessed 20 mm and the right anterior to the second forceps. This was carried MR muscle was resected 7 mm. Forced duction on until we found no more muscle fibers. So the testing under general anesthesia showed most LR muscle was piece-meal, bit by bit excised severe bilateral restriction of adduction and flush with the Gundersen forceps until we neither eye could be brought to the midline as reached the penetration site to posterior tenon, well as severe bilateral restriction of abduction. practically excising the whole sub-tenon portion Following surgery, the exotropia was reduced of the LR muscle. but the SA remained in both eyes on attempted dextroversion or levoversion. On January 25, -231- Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007 Strabismus Quarterly© A Report of Three Cases Volume 22 (No.4): A Medical Scientific E-Periodical E. Khawam, MD, A. Terro, MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234
2005, at the age of 17 months, the left LR was severely limited with inability of the eye to denervated/extirpated. Postoperatively the XT reach the midline but remained halfway was further reduced, the SA disappeared in the between the outer canthus and the midline. LE on attempted dextroversion, but remained, Clinically, there was no active abduction in the although improved, in the RE on attempted left eye. The diagnosis was bilateral SD, levoversion. On May 3, 2005, at the age of 21 moderate in the RE and severe in the LE. On months, right LR denervation/extirpation and 9 June 12, 2005, left LR denervation/extirpation mm left MR resection were performed, was done under general anesthesia. Forced following which S.A. disappeared in either eye duction testing revealed severe restriction to on attempted side gazes, but left the patient with abduction and extremely severe restriction to a mild residual XT. Abduction as well as adduction in both eyes. Post operatively, the adduction remained marquedly limited in both exotropia was reduced, the SA disappeared in eyes. On January 2007, over 2 years the LE but remained in the RE. On May 9, postoperatively I and II and 20 months 2006, recession of the right LR muscle 25 mm postoperatively III, she was horizontally straight from the limbus and resection of the antagonist in the primary position. Ductions showed MR muscle 7 mm were done. In December absence of abduction and adduction of both 2006, one and a half years following left LR eyes with an A pattern to the deviation showing denervation/extirpation, and seven months 20 pd of esotropia in upgaze and 20 pd of following recession/resection procedure on the exotropia in downgaze. Infraduction of the horizontal rectus muscles of the right eye, simultaneously abducting eye remained the limitation of adduction remained the same in same in both eyes. both eyes. There was residual left exotropia of 25 prism diopters. The SA was absent in the Case 2 RE, but remained minimally in the severely A 4 and a half year old little girl was affected LE. On January 6, 2007, the left MR referred from the pediatric department because muscle was resected 9 mm. On April 5, 2007, of bilateral exotropia, abnormal ocular three months later, there was a minimal residual movements and bilateral blepharoptosis since exotropia of 12 pd and absence of any abnormal birth. She was diagnosed by the pediatric head posture. Abduction and adduction were neurologist as having psychomotor limited to 50% of normal in the right eye and developmental delay due to frontal brain totally absent in the left eye. There was no SA atrophy. in either eye.
Eye exam showed bilateral exotropia of Case 3 45 pd, bilateral SA on attempted dextroversion A one and a half year old. girl presented and levoversion, bilateral mild blepharoptosis. with a history of left exotropia since birth. She Fixation and following reflexes were normal in was diagnosed by the pediatric department with both eyes and the patient assumed alternately a psychomotor developmental delay, severe face turn toward the side of the fixing microcephaly and brain atrophy. Eye exam eye. On ductions, the right eye showed revealed left exotropia of 45 pd and left moderate limitation of adduction and abduction, hypotropia of 20 pd. There was marked the eye adducting and abducting midway limitation to adduction in the LE, the eye hardly between the midline and the corresponding adducting beyond the outer canthus. On canthus (50% of normal adduction and attempted dextroversion, the RE abducted abduction). In the left eye, adduction was normally and the LE abducted simultaneously -232- Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007 Strabismus Quarterly© A Report of Three Cases Volume 22 (No.4): A Medical Scientific E-Periodical E. Khawam, MD, A. Terro, MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234 with further depression. The RE showed normal To our surprise, adduction as well as ocular movements. Cycloplegic retinoscopy abduction remained absent in all the severely showed +1.50 cylinder x90 in the RE and -6.00 affected eyes and did not change in the sphere + 6.00 cylinder x90 in the LE. She moderately affected eye. fixated with her RE and assumed a face turn to the right. Binocular fixation pattern testing DISCUSSION showed severe amblyopia in the LE We present three patients with congenital (“Afixation”). The refractive errors were SD, a rare condition considered as an extreme corrected and amblyopia therapy was started variant of DS. Two of them are bilateral (cases immediately with occlusion of her RE. On June 1 and 2) and one unilateral affecting the LE 12, 2005, at the age of 5 years and 5 months, a (case 3). None of them showed globe retraction left LR denervation/extirpation was performed. on attempted adduction of the affected eye, the Forced duction testing under general anesthesia SA being the retraction equivalent. All 3 showed very severe restriction to adduction and patients had face turn, to the side of the fixing abduction of the LE. In December 2006, one eye in bilateral cases and opposite the affected and a half years postoperatively, adduction of eye in the unilateral case. the LE did not improve and the left exotropia remained the same, but SA improved a great By clinical observation, none of our three deal. On January 6, 2007, the left MR muscle patients demonstrated active abduction of the was resected 10 mm. Three months severely affected eyes, suggesting absence of postoperatively, there was still a residual left the abducens nerve as MRI across the brainstem exotropia of 20 pd but absence of the abnormal level disclosed in two reported patients (11). head posture. The SA was abated but abduction and adduction remained totally absent in the left All three patients had severe adduction eye. Infraduction of the synkinetically abducting deficit, totally absent except in case 2 in the left eye remained the same. mildly affected eye where adduction as well as abduction, although limited, were present. The SURGICAL OUTCOME lack of restoration of any adduction in the severely affected eyes in our three reported The striking feature of SA in all the cases suggest MR paralysis as observed severely affected eyes responded best to LR electromyographically in one patient (2). denervation/extirpation only when the antagonist MR muscle was resected. In the We believe the infraduction of the moderately affected eye, it responded favorably synkinetically abducting eye seen in cases 1 and to supramaximal recession of the LR muscle 3 is due to co-contraction of the IR muscles and with resection of its antagonist MR muscle. the MR muscles rather than co-contraction of the SO muscles because the depression of the The abnormal head posture disappeared simultaneously abducting eye takes place in the and the exotropia was satisfactorily reduced field where the vertical action of the vertical when the MR muscle was resected in the eye recti predominates and because the SO muscles where the LR muscle was previously do not significantly depress the eye below the denervated/extirpated. midline (16), especially in abduction.
Depression of the synkinetically The large A-pattern seen in case 1 abducting eye present in cases 1 and 3 did not confirms the assumption of Brodsky (7) that the improve. divergence of the eyes in downgaze is due to -233- Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007 Strabismus Quarterly© A Report of Three Cases Volume 22 (No.4): A Medical Scientific E-Periodical E. Khawam, MD, A. Terro, MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234 recruitment of the SO muscles in downgaze and the severe anomalous innervation and the severe that the esotropia in upgaze is due to co- restriction of the LR muscle. contraction of the MR muscles. A substantial amount of exotropia The severe restrictions of the MR remained in two patients. We believe resection muscles as well as restrictions of the LR of the MR muscle should be done, in severe muscles in all our severely affected eyes are cases, along with denervation/extirpation of the due, we believe, to denervation of these muscles LR muscle. and to the severe anomalous innervation of the LR muscle. CONCLUSIONS
Our surgical results compare with those SD is a rare entity of miswiring, of Hamed (12) in that no overcorrection considered an extreme variant of DS. occurred despite surgical crippling of the Unlike DS, there is quantitatively greater anomalously innervated LR muscles and in that anomalous innervation of the LR muscle of the SA could only be ablated or markedly improved affected eye compared to its antagonist MR in severely affected eyes when denervation/ muscle. extirpation of the LR muscle is done along with resection of the antagonist MR muscle. The On side gaze toward the opposite side, supramaximal recession of the LR muscle along there is simultaneous abduction of the affected with resection of its antagonist did not eliminate eye instead of simple limitation of adduction or improve the S.A. in severely affected eyes and retraction of the globe. This simultaneous probably because of its attachments to the rectus abduction, also called “the splits”, becomes the muscles, thru the intermuscular membrane and retraction equivalent. tenon’s capsule. However, this latter procedure did eliminate the SA in the moderately affected The lack of restoration of any adduction eye. The elimination of the SA in all our three of the severely affected eyes despite surgical reported cases following crippling surgery of crippling of the LR muscle could be due either the LR muscles confirms that the mechanism of to paralysis or loss of contractility of the MR the S.A. is the severe anomalous innervation of muscle. the LR muscles. To date, no known surgical procedure The question of whether there is any would lead to satisfactory results. However, normal LR recruitment in addition to the severe surgical crippling of the affected LR muscle – anomalous recruitment is academic in this type either by denervation/extirpation of the LR of DS since one must perform a crippling muscle along with resection of its antagonist weakening procedure of the LR muscle, which MR muscle in severe cases – or by simultaneously diminishes both anomalous and supramaximal recession of the LR muscle along any existing normal LR innervations (5). with resection of the MR muscle in moderately or mildly affected cases - seems to be the Face turn disappeared in all our patients procedure of choice to eliminate or improve the following either procedure. The restoration of a SA, the exotropia and the abnormal head normal head posture is due to the balance of the posture. Adduction, in severe cases does not innervational (normal and anomalous) as well as respond to surgery. mechanical forces by significant weakening of -234- Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007 Strabismus Quarterly© A Report of Three Cases Volume 22 (No.4): A Medical Scientific E-Periodical E. Khawam, MD, A. Terro, MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234
REFERENCES electrooculographic study. Br J Ophthalmol 1989;73:68-75. 1. Znajda JP, Krill AE. Congenital medial rectus 14. Jimura T, Tagami Y, Isayama Yet al. A case of muscle palsy with simultaneous abduction of the two synergistic divergence associated with Horner’s eyes. Am J Ophthalmol. 1969; 68: 1050-1052. syndrome. Folia Ophthalmologica Japonica. 1983; 2.Thomas R, Mathai A, Greser Sc, and Ratnammal J. 34: 477-480. J Pediatric Ophthalmol Strabismus. 1993; 30: 15. Ferland R. J. et al. Abnormal cerebellar 122,123 development and axonal decussation due to mutations 3.Wilcox LM, Gittinger JW, Breinin GM. Congenital in AHI1 in Joubert syndrome. Nature Genetics, adduction palsy and synergistic divergence. Am J September 2004, 36:1008-1013. Ophthalmol. 1981; 91:1-7. 16. Kushner BJ. Ocular torsion: Rotations around the 4. Huber A. Electrophysiology of the retraction “WHY” axis. J AAPOS 2004; 8:1-12. syndrome. Br J Ophthalmol. 1974; 58:293-300 17. Kaban TJ, Smith K, Orton RB. Synergistic 5. Jampolsky A. Duane syndrome In: Rosenbaum AL, divergence associated with aberrant trigeminal Santiago AP: Clinical Strabismus Management innervation. Can J Ophthalmol. 1994; 29: 146-149. Philadelphia. W.B. Saunders 1999; 325. 6. Wagner RS, Caput AR, Froman LP. Congenital unilateral adduction deficit with simultaneous abduction: a variant of Duane’s retraction syndrome. Ophthalmology 1987; 94: 1049-1053. 7. Brodsky MC. A congenital fibrosis syndrome caused by deficient innervation to extraocular muscles. Ophthalmology 1998; 105: 717-725. 8. Houtma WA, Van Weerden JW, Robenson PH,et al. Hereditary congenital external ophthalmoplegia. Ophthalmologica 1986;193:207-218. 9. Nelson LB. Severe adduction deficiency following a large medial rectus recession in Duane’s retraction syndrome. Arch Ophthalmol. 1986;102:859-862. 10. Metz HS. Duane’s retraction syndrome and severe adduction deficiency (letter). Arch Ophthalmol. 1986;104:1586-1587. 11. Kim JH, Hwang JM. Hypoplastic oculomotor nerve and absent abducens nerve in congenital fibrosis syndrome and synergistic divergence with magnetic resonance imaging. Ophthalmology 2005; 112: 1-9. 12. Hamed LM, Lingua RW, Fanous MM, Saunders TG, Lusby FW. Synergistic divergence: saccadic velocity analysis and surgical results. J Pediatr Ophthalmol Strabismus. 1992; 29: 30-37. 13. Cruysberg JRM, Mtonda AT, Dvinkorke-Eerola KV, Huygen PLM. Congenital adduction palsy and synergistic divergence: a clinical and -235- Binocular Vision & Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Fourth Quarter of 2007 Strabismus Quarterly© Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Volume 22 (No.4): A Medical Scientific E-Periodical Y-H Chang, MD, JH Chang, MD, S-H Han, MD and JB Lee, MD Pages 235-241
Original Scientific Article Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus
YOON-HEE CHANG, M.D.1, JEE HO CHANG, M.D.2, SUENG-HAN HAN, M.D.3 and JONG BOK LEE, M.D.3
From the Departments of Ophthalmology Ajou University School of Medicine, Suwon (1), Soonchunnhyang University College of Medicine, Bucheon (2) and Institute of Vision Research, Yonsei University (3), Seoul, Korea
ABSTRACT: Background and Purpose: Since Kestenbaum and Anderson, several ophthalmologists have reported the results of different surgical procedures for abnormal head posture in infantile nystagmus. In this study, we tried to evaluate the surgical results of Parks’ original 5-6-7-8 mm modified Kestenbaum procedure and our own 6-7-6-7 mm modified Kestenbaum procedure, designed to reduce some of the problems encountered with other variations of these techniques. Methods: Medical records of 92 patients, who had modified Kestenbaum surgery (5-6-7-8 mm or 6- 7-6-7 mm) at The Yonsei Medical Center, from March 1991 to September 2001 with a follow-up period of more than 6 months, were reviewed retrospectively. We compared Parks’ modified Kestenbaum surgery (5- 6-7-8 mm) performed on 51 patients with our own modified Kestenbaum surgery (6-7-6-7 mm) on 41 patients. Each procedure was done with graded augmentation according to the amount of the face turn and the null point in electro-oculography. Results: In the follow-up of an average 33 months, 45 out of 51 patients (88.2%) who underwent Parks’ modified procedures showed face turn less than 10°. In the follow-up of an average 29 months, 36 out of 41 patients (87.8%) with 6-7-6-7 mm procedure had face turn less than 10°. Conclusions: We suggest that 6-7-6-7 mm modified Kestenbaum procedures with a graded augmentation may be a safe and efficient procedure to correct abnormal head posture in infantile nystagmus with a minimum decrease in ocular motility. Presented in part at the 2003 annual meeting of the American Association for Pediatric Ophthalmology and Strabismus, Waikoloa, Hawaii, 2003 Authors do not have any financial conflict or interest in the subject matter in this manuscript. Received for consideration July 7, 2007; accepted for publication July 24, 2007. Reprint requests to Jong Bok Lee, MD, Department of Ophthalmology, Yonsei Medical Center, Yonsei University College of Medicine, C.P.O. Box 8044, Seoul, Korea, 120-752; Tel: 82-2-2228-3570; Fax: 82-2-312-0541; e-mail: [email protected] -236- Binocular Vision & Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Fourth Quarter of 2007 Strabismus Quarterly© Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Volume 22 (No.4): A Medical Scientific E-Periodical Y-H Chang, MD, JH Chang, MD, S-H Han, MD and JB Lee, MD Pages 235-241
INTRODUCTION procedure for the two yoke muscles involved as a treatment (12). Although their rationales for the Infantile nystagmus may be present at birth but surgical approach differed, their resulting usually develops in the first few months of life (1). procedures achieved the same ends, namely, the Typical infantile nystagmus is conjugate and elimination of the AHP by rotation of both eyes in horizontal, and it is best described as a jerk the direction of the face turn in order to match and nystagmus with increasing velocity of the slow make coincident the “null or neutral point” of the phase of the waveform (2). In infantile nystagmus, nystagmus as near as possible with the primary the frequency and the amplitude of the nystagmus position of gaze. may be diminished in a particular position of gaze. This is referred to as a null point or a neutral zone. In 1973, Parks proposed a modification of the The neutral point is that position of gaze where Kestenbaum procedure (5 mm, 6 mm, 7 mm, and there is a change in direction, i.e. jerk left to jerk 8 mm) with a total of 13 mm of surgery performed right, and the null zone is that position of gaze on each eye, 5 & 8, and 6 & 7 mms (13). At that where the oscillation is least intense. Unless the time Parks believed that these amounts of surgery null or neutral point coincides with the primary were the maximum amounts which could be position, the patients tend to have an abnormal performed and still preserve full ductions. This head posture (AHP), turning or tilting their face or became known as the classic modified head so that the eyes are at the null or neutral Kestenbaum procedure. Later, following Parks, point to maximize their visual acuity by Calhoun, Nelson and other ophthalmologists dampening the nystagmus (3). reported the results of different surgical procedures to correct AHP (14-19). The etiologic mechanism of this oscillation remains elusive. Defects involving the saccadic, In this study, our purpose was to evaluate and optokinetic, smooth pursuit, and fixation systems, compare surgical results for Parks’ original 5-6-7- as well as the neural integrator for conjugate 8 mm modified Kestenbaum procedure and our horizontal gaze, have been proposed (4, 5). More own 6-7-6-7 mm modified Kestenbaum procedure. evidence is accumulating that the slow phase is the MATERIALS, SUBJECTS & METHODS problem (2, 6). The fast phase is a normal saccade and fulfills the criteria for a usual saccade. The This study was approved by the ethics initial description of attempted treatment of committee of Yonsei University Medical Center, infantile nystagmus was reported by Metzger who Seoul, Korea, in accordance with the ethical prescribed prism spectacles with the base to the standards laid down in the 1964 Declaration of direction of AHP (7). Other treatment modalities Helsinki. such as minus lenses, pharmacologic agents and Medical records of ninety-two patients, who botulinum toxin injection have all been described had modified Kestenbaum surgery (either Parks 5- in different studies but the beneficial effects were 6-7-8 mm or our own 6-7-6-7 mm) for AHP limited (8-10). secondary to infantile nystagmus at Yonsei Surgical treatment for infantile nystagmus was Medical Center, over a ten and half year period, first advocated independently and almost from March 1991 to September 2001, with a simultaneously by Anderson and Kestenbaum in follow-up period of more than 6 months and early 1950s (11, 12). In 1953, Kestenbaum without vertical AHP, were reviewed recommended surgical shifting of both eyes by retrospectively. The following information was performing identical amounts of recession/ resec- recorded: age at first examination, associated tion procedure for all four horizontal rectus strabismus or other ocular disease, visual acuity, muscles, in the direction of the rapid phase of size in degrees of AHP, null/neutral point on nystagmus away from the null point (11). In an electro-oculography (EOG), age at time of attempt to explain AHP, Anderson believed that surgery, amount of surgery, and the date and the the muscles acting in the slow phase of the ocular motility findings at last examination. nystagmus overacted. He advised a weakening -237- Binocular Vision & Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Fourth Quarter of 2007 Strabismus Quarterly© Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Volume 22 (No.4): A Medical Scientific E-Periodical Y-H Chang, MD, JH Chang, MD, S-H Han, MD and JB Lee, MD Pages 235-241
The indication for surgery was an unacceptable (5-6-7-8 mm). For a face turn to the right, the AHP (a face turn of 10/ or more) with one null or surgery performed is: right medial rectus neutral point. Orthopedic protractors recession, 5 mm; right lateral rectus resection, 8 (goniometers) were used to estimate the mm; left lateral rectus recession, 7 mm; left preoperative face turn for distant fixation. EOG medial rectus resection, 6 mm. using the Nicolet Compact Four/CA 2000, Group 2: Our own modified Kestenbaum Nicolet, U.S.A. was performed in 74 cooperative surgery (6-7-6-7 mm). For a face turn to the right, patients. Electrodes were attached on the medial the surgery performed is: right medial rectus and lateral canthi of both eyes and a ground recession, 6 mm; right lateral rectus resection, 7 electrode was attached on the forehead. Impedance mm; left lateral rectus recession, 7 mm; left of electrodes was adjusted to less than 5 Kohms in medial rectus resection, 6 mm. total, and within 3 Kohms of each other. The null or neutral points were investigated. The values of We performed Parks’ original 5-6-7-8 the angle of AHP measured by goniometer were modified and augmented modified Kestenbaum relatively larger than those measured by EOG. The surgery on 51 patients and our own 6-7-6-7 difference was about 5/. We preferred to study the modified Kestenbaum and augmented modified null or neutral point measured by EOG to the surgery on 41 patients. Each procedure was done clinically measured angle of face turn. with a graded augmentation according to the amount of the face turn and the null points in EOG The patients were divided into two groups: (see Table 1, below). Group 1: Parks’ modified Kestenbaum surgery
Table 1. METHODS : SURGERY : Amount of graded augmentation in modified Kestenbaum Procedures Graded according to the amount of abnormal head posture (AHP)
degrees Graded augmentation of AHP by EOG Group1 (Parks’ original 5-6-7-8 Group2 (Our own 6-7-6-7 modified Kestenbaum surgery) modified Kestenbaum surgery)
20 - 25 5-6-7-8 mm* 6-7-6-7 mm†
30 - 35 20% augmentation 20% augmentation (6.0 - 7.2 - 8.4 - 9.6 mm) (7.2 - 8.4 - 7.2 - 8.4 mm)
40/ or more 30% augmentation 30% augmentation (6.5 - 7.8 - 9.1 - 10.4 mm) (7.8 - 9.1 - 7.8 - 9.1 mm)
10-15 Minus-one procedure Minus-one procedure (4-5-6-7 mm) (5-6-5-6 mm)
*: For a face turn to the right, the surgery performed is: right medial rectus recession, 5 mm; right lateral rectus resection, 8 mm; left lateral rectus recession, 7 mm; left medial rectus resection, 6 mm.
†: For a face turn to the right, the surgery performed is: right medial rectus recession, 6 mm; right lateral rectus resection, 7 mm; left lateral rectus recession, 7 mm; left medial rectus resection, 6 mm -238- Binocular Vision & Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Fourth Quarter of 2007 Strabismus Quarterly© Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Volume 22 (No.4): A Medical Scientific E-Periodical Y-H Chang, MD, JH Chang, MD, S-H Han, MD and JB Lee, MD Pages 235-241
Twelve patients with strabismus also demographic characteristics of the patients were underwent their appropriately modified summarized in Table 2, below . Kestenbaum procedures with the final surgical In Group 1, six patients had concurrent amount adjusted to correct both the strabismus and strabismus, and two had oculocutaneous albinism. the AHP. All the surgical procedures were In Group 2, six patients had concurrent performed by senior author (JBL). strabismus, one had microphthalmos, and one had Surgical “success” was defined as a clinically bilateral congenital cataract. manifest face turn (horizontal AHP) less than 10/. The preoperative degree of face turn ranged Statistical analysis was performed using chi- from 15 to 45 degrees, and 68 of the 92 patients square tests, and p values less than 0.05 were (74.0%) had an AHP of 20-30 degrees. considered “statistically significant”. In the postop’ follow-up of an average 33 RESULTS Of the total 92 patients, 61 patients were male and 31 were female. Fifty-one patients comprised Group 1 and 41 patients comprised Group 2. The
Table 2. METHODS : 92 SUBJECT-PATIENTS: (see Table 1 for surgery) Demographic characteristics of patients including:. Preoperative AHP= abnormal head posture in degrees by EOG; *= mean standard deviation (range). Characteristics Group 1 # Group 2 #
Total no. patients 51 41
Male 33 28 Female 18 13
Age at surgery (years) 8.4±5.0 (2–34)* 6.5±3.9 (2-21)*
Follow-up period (months) 33.0±25.7 (6-77)* 29.0±22.6 (6-69)*
Preoperative AHP (/) 26.4±6.4 (20-45)* 25.6±6.0 (15-35)*
15/ or less 0 2 20-25/ 24 23 30-35/ 25 16 40/ or more 2 0
#Group 1 = Parks modified 5-6-7-8- and graded augmented modified Kestenbaum surgery
#Group 2 = Our modified 6-7-6-7- and graded augmented modified Kestenbaum surgery -239- Binocular Vision & Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Fourth Quarter of 2007 Strabismus Quarterly© Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Volume 22 (No.4): A Medical Scientific E-Periodical Y-H Chang, MD, JH Chang, MD, S-H Han, MD and JB Lee, MD Pages 235-241
months, 4 out of 51 patients (88.2%) in Group (“successful”) in the follow-up of an average 29 1 showed a face turn less than 10 degrees months (see Tables 3, 4, below). There was no (“successful”), and 36 out of 41 patients (87.8%) “statistically significant” difference in the in Group 2 had AHP less than 10 degrees “success” rate between the two groups (p=0.899).
Table 3. RESULTS; GROUP 1: Parks’ original 5-6-7-8 standard modified and augmented modified Kestenbaum Surgery for Abnormal Head Postures Due to Infantile Nystagmus *”successful” correction= residual face turn (AHP) less than 10 degrees by EOG
No. of patients with a result of: Total patients Overcorrection Correction Undercorrection (% “success”) “success”
5-6-7-8 procedure 1 23 0 24 (95.8)
20 %-augmented 0 21 4 25 (84.0) 5-6-7-8 procedure
30%-augmented 0 1 1 2 (50) 5-6-7-8 procedure
Total 1 45 5 51 (88.2)
Table 4. RESULTS; GROUP 2: Our Protocol 6-7-6-7 standard modified and augmented modified Kestenbaum Surgery for Abnormal Head Postures Due Infantile Nystagmus ”successful” correction= residual face turn (AHP) less than 10 degrees by EOG
No. of patients with a Result of:
Total patients Overcorrection Correction Undercorrection + (% “success) ”success”
Minus-one 0 2 0 2 (100) 6-7-6-7 procedure
Standard 0 21 2 23 (91.3) 6-7-6-7 procedure
20 %-augmented 0 13 3 16 (81.3) 6-7-6-7 procedure
Total 0 36 5 41 (87.8) -240- Binocular Vision & Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Fourth Quarter of 2007 Strabismus Quarterly© Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Volume 22 (No.4): A Medical Scientific E-Periodical Y-H Chang, MD, JH Chang, MD, S-H Han, MD and JB Lee, MD Pages 235-241
In Group 1, overcorrection occurred in one torticollis and one case of head tilt after an case: one changed from a 20/ right face turn to a average 33 months follow-up period. Taylor 20/ left face turn postoperatively. Undercorrection reported that a larger 8-9 mm recession of the LR occurred in five cases: four had their face turn on the side of the slow phase of nystagmus and a reduced from 30/ to 15/-20/; one had their face larger 6 mm recession of the MR of the opposite turn reduced from 40/ to 15/-20/. In Group 2, no eye in conjunction with smaller 6 mm resections overcorrection was noted, and undercorrection of both respective antagonist (Taylor-Parks occurred in five cases: three had their face turn modified Anderson-Kestenbaum operation) (16). reduced from 30/ to 15/; two had their face turn This operation, with a 70% success rate (7 of 10 reduced from 25/ to 15/. Concurrent strabismus patients), did not result in any limitation of eye was corrected in twelve patients, and esotropia of movement up to 35/ to 45/ face turns over an 12 prism diopter remained in one patient of Group average 17.8 months follow-up period. Spielmann 1 who had esotropia of 35 prism diopter has also used the retroequatorial myopexy preoperatively. In Group 1, one patient showed (posterior fixation suture) in conjunction with the slight limitation of motility, but subsequent traditional Kestenbaum procedure (17). Mitchell strabismus was not observed in any patient. In recommended a plus one operation (6-7-8-9 mm) Group 2, one patient developed exotropia of 12 (18). Scott and Kraft reported the graded prism diopter postoperatively, but the ductions augmentation of the Parks’ 5-6-7-8 modified were not limited in any case. Kestenbaum procedure (19). Their procedure had a correction of AHP less than 15/ in 78% of DISCUSSION OF RESULTS patients. All of these studies were on a relatively In this study, we evaluated two different small number of patients, usually less than ten. surgical protocols used to treat infantile nystagmus The study by Scott and Kraft was certainly one of as to the patients’ improvement in AHP. The the largest and it included 25 patients in all. The amount of surgery we used was more conservative major criticism of large augmented surgery was than the amounts previously reported (14-16, 18). the concern of possible motility limitations after In our modification, medial rectus was recessed or the operation. Our previous study with 63 patients resected by 6 mm, and lateral rectus was recessed suggested that Parks’ modified Kestenbaum or resected by 7 mm. Total of 13 mm of surgery procedure, with appropriated graded augmentation was performed on each eye so that the rotation of up to 30%, is effective for AHP in infantile the eyeball may be similar to that in Parks’ nystagmus without the need for larger modification. This small surgical modification augmentation (20). produced encouraging results in our patients. It is difficult to compare our results with many Since Anderson and Kestenbaum, other of previous reports. Each study used a different strabologists modified the procedure increasing definition of success, and the amount of AHP of the amount of surgery because the classic the patients was different. In our modified measurements failed to fully correct the AHP. procedure, the 8 mm of large resection in Parks’ Subsequent reports by many authors appeared on modified Kestenbaum procedure and large the classic plus additional amount of surgery, such recession in 40% or 60% augmented Kestenbaum as classic plus 40% or classic plus 60%. Calhoun procedure can be avoided. The face turn values & Harley proposed 40% augmented Parks’ measured by EOG were relatively smaller than modified Kestenbaum procedure (7.0-8.4-9.8-11.2 those by goniometer. We suggest that this is the mm) (14). They reported a 75% success rate (3 of key reason for our successful results with less 4 cases) with a 75% side effect of mild gaze palsy augmented surgery. With repeated measurement after an average 5.8 months follow-up period. of the AHP and assessment by EOG during our Nelson & coworkers reported 40% augmentation long-term follow-up, this smaller amount of for patients with 30° face turn and 60% graded augmentation proved to correct face turn augmentation for those with 45° face turn (15). satisfactorily. This emphasizes a meticulous work- They claimed a cure in 8 of 15 patients (53.3%) up in each case with repeated testing to make sure reporting side effects of one case of vertical that the AHP is stabilized and constant. These -241- Binocular Vision & Outcome Study of Two Standard-&-Graduated Augmented Modified Kestenbaum Fourth Quarter of 2007 Strabismus Quarterly© Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Volume 22 (No.4): A Medical Scientific E-Periodical Y-H Chang, MD, JH Chang, MD, S-H Han, MD and JB Lee, MD Pages 235-241 findings are much encouraging to the pediatric 8. Allen ED, Davies PD: Role of contact lenses in the ophthalmologist and strabismus surgeon in that a management of congenital nystagmus Br J Ophthalmol lesser amount of surgery can result in successful 1983;67:834-836. results. With our cumulated experience and high 9. Helveston EM, Pogrebniak AE: Treatment of rate of success, we suggest that our own 6-7-6-7 acquired nystagmus with botulinum A toxin. Am J mm modification is as good as, if not probably Ophthalmol 1988;106:584-586. better than, prior reports and recommendations. 10. Carlow TJ: Medical treatment of nystagmus and ocular motor disorders. Int Ophthalmol Clin However, our study has some limitations. This 1986;26:251-264. is neither a randomized, comparative trial nor 11. Kestenbaum A: New operation for nystagmus. Bull prospective study. We cannot conclude the Soc Ophtalmol Fr 1953;6:599-602. effectiveness but suggest the efficacy. The 12. Anderson JR: Causes and treatment of congenital retrospective methodology does not allow accurate eccentric nystagmus. Br J Ophthamol 1953;37:267- comparison due to patient selection bias, dropouts, 280. and baseline confounders. Prospective study with 13. Parks MM: Congenital nystagmus surgery. Am the pre- and postoperative sensory testing and best Orthop J 1973;23:35-39. corrected visual acuity would be needed. 14. Calhoun JH, Harley RD: Surgery for abnormal head CONCLUSIONS position in congenital nystagmus. Trans Am Ophthalmol Soc 1973;71:70-87. We reviewed medical records of ninety-two 15. Nelson LB, Ervin-Mulvey LD, Calhoun JH, et al: patients who had modified Kestenbaum surgery Surgical management for abnormal head position in (5-6-7-8 mm or 6-7-6-7 mm) for AHP secondary nystagmus: the augmented modified Kestenbaum to infantile nystagmus. procedure. Br J Ophthalmol 1984;68:796-800. We propose that 6-7-6-7 mm modified 16. Taylor JN: Surgery for horizontal nystagmus; Kestenbaum surgery with our own graded Anderson-Kestenbaum operation. Aust J Ophthalmol augmentation may a safe and efficient procedure 1973;1:114-116. for AHP in infantile nystagmus with a minimum 17. Spielmann A: Treatment chirurgical du nystagmus. decrease in ocular motility. Arch Ophthalmol 1977;37:75. 18. Mitchell PR, Wheeler MB, Parks MM: Kestenbaum REFERENCES surgical procedure for torticollis secondary to congenital 1. Spielmann A: Clinical rationale for manifest nystagmus. J Pediatr Ophthalmol Strabismus congenital nystagmus surgery. J AAPOS 2000; 1987;24:87-92. 4:67-74. 19. Scott WE, Kraft SP: Surgical treatment of 2. Dell’Osso LF, Daroff RB: Congenital nystagmus compensatory head position in congenital nystagmus. J waveforms and foveation strategy. Doc Ophthalmol Pediatr Ophthalmol Strabismus 1984;21:85-95. 1975; 39:155-182. 20. Lee IS, Lee JB, Kim HS et al. Modified Kestenbaum 3. Cooper EL, Sandall S: Surgical treatment of surgery for correction of abnormal head posture in congenital nystagmus. Arch Ophthalmol 1969; 81:473- infantile nystagmus: Outcome in 63 patients with graded 480. augmentation. Binocul Vis Strabismus Q 2000; 15:53- 4. Hertle RW, Dell’Osso LF: Clinical and ocular motor 58. analysis of congenital nystagmus in infancy. J AAPOS 1999; 3:70-79. 5. Scott AB: Nystagmus. Int Ophthalmol Clin 1964;4:755-773. 6. Reinecke RD: Idiopathic infantile nystagmus: Diagnosis and treatment. J AAPOS 1997; 1:67-82. 7. Metzger EL: Correction of congenital nystagmus. Am J Ophthalmol 1950;33:1796-1797. -242- Binocular Vision & ABSTRACTS Fourth Quarter of 2007 Strabismus Quarterly© Volume 22 (No.4): A Medical Scientific E-Periodical Page 242-244 Vision / Visual Acuity / Amblyopia Chandler DL,Beck RW et al and the PEDIG. Am J Ophthalmol 2007; 144:487-496 [Authors Abstract] Learning to Identify Crowded Letters: Does It Purpose: To determine the amount and time course Improve Reading Speed? Chung STL. Vision Research of binocular visual acuity improvement during treatment of 2007; 47:3150 3159. [Author Abstract] bilateral refractive amblyopia in children three to less than 10 years of age. Design: Prospective, multicenter, Crowding, the difficulty in identifying a letter noncomparative intervention. embedded in other letters, has been suggested as an explanation for slow reading in peripheral vision. In this study, Methods: One hundred and thirteen children (mean we asked whether crowding in peripheral vision can be age, 5.1 years) with previously untreated bilateral refractive reduced through training on identifying crowded letters, and if amblyopia were enrolled at 27 community and university based so, whether these changes will lead to improved peripheral sites and were provided with optimal spectacle correction. reading speed. We measured the spatial extent of crowding, Bilateral refractive amblyopia was defined as 20/40 to 20/400 and reading speeds for a range of print sizes at 10° inferior best corrected binocular visual acuity in the presence of 4.00 visual field before and after training. Following training, diopters (D) or more of hypermetropia by spherical equivalent, averaged letter identification performance improved by 88% at 2.00 D or more of astigmatism, or both in each eye...measured the trained (the closest) letter separation. The improvement at baseline and at 5, 13, 26 and 52 weeks. The primary study transferred to other untrained separations such that the spatial outcome was binocular acuity at one year. extent of crowding decreased by 38%. However, averaged Results: Mean binocular visual acuity improved from maximum reading speed improved by a mere 7.2%. These 0.50 logarithm of the minimum angle of resolution (logMAR) findings demonstrated that crowding in peripheral vision could units (20/63) at baseline to 0.11 logMAR units (20/25) at one be reduced through training. Unfortunately, the reduction in the year (mean improvement, 3.9 lines; 95% confidence interval crowding effect did not lead to improved peripheral reading [CI], 3.5 to 4.2). Mean improvement at one year for the 84 speed. (Fax: 713-743-2053) children with baseline binocular acuity of 20/40 to 20/80 was 3.4 lines (95% CI, 3.2 to 3.7) and for the 16 children with baseline binocular acuity of 20/100 to 20/320 was 6.3 lines Acuity, Crowding, Reading and Fixation Stability. (95% CI, 5.1 to 7.5). The cumulative probability of binocular Falkenberg HK, Rubin GS, Bex PJ. Vision Research 2007; visual acuity of 20/25 or better was 21% at five weeks, 46% at 47:126-135. [Authors Abstract] 13 weeks, 59% at 26 weeks and 74% at 52 weeks. People with age-related macular disease frequently Conclusions: Treatment of bilateral refractive experience reading difficulty that could be attributed to poor amblyopia with spectacle correction improves binocular visual acuity, elevated crowding or unstable fixation associated with acuity in children three to less than 10 years of age, with most peripheral visual field dependence. We examine how the size, improving to 20/25 or better within one year. (Dr. Wallace, location, spacing and instability of retinal images affect the Jaeb Center for Health Research, 15310 Amberly Dr, Suite visibility of letters and words at different eccentricities. Fixation 350, Tampa FL 33647) instability was simulated in normally sighted observers by randomly jittering single or crowded letters or words along a circular arc of fixed eccentricity. Visual performance was Risk of Bilateral Visual Impairment in Persons with assessed at different levels of instability with forced choice Amblyopia: the Rotterdam Study. Van Leeuwen R, measurements of acuity, crowding and reading speed in a Eijkemans MJ, Vingerling JR et al. Br J Ophthalmol, May rapid serial visual presentation paradigm. In the periphery: (1) 2007. As abstracted by the AAOs Specialty News and acuity declined; (2) crowding increased for acuity- and Views Section on Pediatric/Strabismus members D Coats, eccentricity-corrected targets; and (3) the rate of reading fell D Alcorn, J Bloom, D Hug, A Hutchinson, S Olitsky and D with acuity-, crowding - and eccentricity–corrected targets. Vanderveen. “Risk of Bilateral Visual Impairment is Acuity and crowding were unaffected by even high levels of Doubled in People With Amblyopia. image instability. However, reading speed decreased with Amblyopia is a leading cause of poor vision in young image instability, even though the visibility of the component people. One common justification for diagnosis and treatment letters was unaffected. The results show that reading of amblyopia is to decrease the risk of bilateral vision loss later performance cannot be standardized across the visual field by in life. However, most discussion regarding the risk of bilateral correcting the size, spacing and eccentricity of letters or visual loss in people with amblyopia have been theoretical or words. The results suggest that unstable fixation my contribute anecdotal in nature. A recent study by Van Leeuwen et al to reading difficulties in people with low vision and therefore provides quantitative data to substantiate this concern. The that rehabilitation may benefit from fixation training. (Dr. researchers used data from the Rotterdam Study to estimate Falkenberg, Dept Optometry & Visual Science, Buskerud the risk of bilateral visual impairment (BVI). The study University College, Frogsvei 41, 3601 Kongsberg, Norway) consisted of a population based cohort of subjects 55 years or over (n=5220), including 192 people with amblyopia. Using a Early Spectacle Correction Can Successfully Treat multistate life table, the lifetime risk of BVI was determined. For Most children with Bilateral Refractive Amblyopia. As RE- the subjects with amblyopia, the lifetime risk for BVI in patients abstracted by the AAO Academy Express, October 3, with a history of amblyopia was 18% and for those patients 2007. Am J Ophthalmol October 2007. without amblyopia it was 10%. Patients with a history of amblyopia who suffered from BVI lived an average of 7.2 years A propsective, multicenter, noncomparative study of after loss of vision. Those without amblyopia lived 6.7 years 113 children between 3 and 9 years old finds that 73 percent with BVI. This study indicates that amblyopia nearly doubles improved binocular visual acuity to 20/25 or better after one the lifetime risk of BVI. The information from this study can be year of spectacle correction alone. Only 12 percent of cases used to provide data for future studies regarding the cost required patching or atropine. Children who started with visual effectiveness of amblyopia detection and treatment. acuity of 20/100 or worse showed the greatest improvement, averaging 6.3 lines after one year. Correspondence re: Lanza M, Rosa N, Capasso L et al. Can we utilize photorefractive keratectomy to improve Treatment of Bilateral Refractive Amblyopia in visual acuity in adult amblyopic eyes? Ophthalmology Children Three to Less than 10 Years of Age. Wallace DK, -243- Binocular Vision & ABSTRACTS Fourth Quarter of 2007 Strabismus Quarterly© Volume 22 (No.4): A Medical Scientific E-Periodical Page 242-244 2005; 112:1684-1691. Correspondence, with author reply in Stereopsis-Dependent Deficits in Maximum Motion Ophthalmology 2007; 114:1792 Displacement in Strabismic and Anisometropic Amblypia. I read with concern Lanza et al’s article on utilizing Ho CS, Giaschi DE. Vision Research 2007; 47:2778-2785. photorefractive keratectomy (PRK) to improve visual acuity in [Authors Abstract] adult amblyopic eyes. ... there is no description of how VA was Direction discrimination thresholds for maximum measured. ... the article is incomprehensible as published. ... motion displacement (Dmax) have been previously reported to the patient cohort displays some baffling clinical be abnormal in amblyopic children We looked at Dmax characteristics. A comprehensive formal definition of amblyopia thresholds for random dot kinematograms (RDKs) biased was not given, and we were not assured that these patients toward low or high level motion mechanisms Dmax is thought carried a diagnosis of amblyopia from childhood. ... patients to be limited, for high level motion mechanisms, by the underwent a cycloplegic refraction at the first visit and a efficiency of object feature tracking and probability of false “subjective” refraction at a subsequent visit. ... Comparing best matches. To reduce the influence of low level mechanisms, we spectacle corrected VAs before and after surgery ignored the determined thresholds also for a high pass filtered version of effect of minification from glasses as opposed to correction at the RDKs. Performance did not significantly differ between the corneal plane. ... as regards the statistical analysis, Figures strabismic and anisometropic groups with amblyopia, although 6, 7 and 10 show gross outliers and - even were the data both groups performed significantly worse that the age credible - the correlation coefficients should have been matched control group. Dmax thresholds were higher for calculated with and without these eyes/patients. Finally, children with poor stereoacuity. This was significant in both because all forms of corneal refractive surgery degrade the anisometropic and strabismic groups, and more robust for high higher order optical performance of the cornea, as an expert in pass filtered RDKs than for unfiltered RDKs. The results imply amblyopia diagnosis and treatment, I do no understand how that impairment of the extra striate dorsal stream is a likely part PRK could improve the vision function of adult amblyopic eyes, of the neural deficit underlying both strabismic and except through changes in magnification or other artifactual anisometropic amblyopia. This deficit appears to be more issues such as the elimination of dirty and poorly fitting contact dependent on extent of binocularity than etiology. Our findings lenses. A physiologically plausible and comprehensive suggest a possible relationship between fine stereopsis, explanation for these alleged positive effects should be coarse stereopsis, and motion correspondence mechanisms. proposed. (Dr. Ho, Dept Ophthalmology, Univ British Columbia, Room Sandra M. Brown, M.D. A146, BC Childrens Hospital 4480 Oak St, Vancouver BC Canada V6H 3V4. Fax: 604-875-2683) Concord, North Carolina, U.S.A. In reply: The Role of Binocular Stereopsis in Monoptic “ ... Dr. Brown’s comments offer guidance Depth Perception. Wilcox LM, Harris JM, McKee SP. Vision concerning the design of prospective work that we hope might Research 2007; 47:2367-2377. [Authors Abstract] validate our findings. ... We hope that in the future amblyopia experts such as Dr Brown might collaborate on prospective In his study of depth from monocular elements, Kaye studies with refractive surgeons to confirm or refute our (1978) reported that monocular stimuli, briefly presented to one findings. eye in a stereoscopic display, generated reliable depth percepts. Here we replicate and extend Kaye’s findings in an Nicola Rosa, MD and Michele Lanza, MD effort to identify the mechanism underlying the phenomenon. Napoli Italy Out experiments show that the perception of depth is not a simple result of monocular local sign, for the percept of depth disappears when one eye is patched. In subsequent Strabismus, Management experiments we assess the possibility that the percept results from a very coarse stereoscopic match to either the centroid of Current Concepts in the Management of the luminance distribution in the unstimulated eye or a simple Concomitant Exodeviations. Eibschitz-Tsimhoni M, Archer match to the line of sight in the unstimulated eye. Our results SM, Furr BA, Del Monte MA. Comp Ophthalmol Update consistently support the match-to-fovea account, and lead us 2007; 8:213-223. [Authors Abstract] to conclude that monoptic depth is a stereoscopic Intermittent exotropia is the most common form of phenomenon. (Dr. Wilcox, Dept Psychology, Centre for Vision divergent strabismus. Treatment is indicated with increasing Research, York University, Toronto Canada, M3J 1P3. Fax: tropia phase to preserve or restore binocular function and 416-736-2377) restore/reconstruct normal ocular alignment. While medical treatment is sometimes helpful for temporary relief, surgical Mechanisms of Perceptual Learning of Depth therapy is the preferred definitive treatment modailty by most Discrimination in Random Dot Stereograms. Gantz L, pediatric ophthalmologists and strabismologists. Congenital Patel SS, Chung STL, Harwerth RS. Vision Research 2007; exotropia is rare and is associated with a high incidence of 47:2170-2178. [Authors Abstract] amblyopia. The treatment of choice in this condition is also Perceptual learning is a training induced surgical. Sensory exotropia is most ofter acquired after improvement in performance. Mechanisms underlying the monocular visual loss. The preferred treatment is surgical perceptual learning of depth discrimination in dynamic random recession/resection on the impaired eye. Convergence dot stereograms were examined by assessing insufficiency is usually not diagnosed until the teenage years or stereothresholds as a function of decorrelation. The inflection later, and it is best approached nonsurgically with convergence point of the decorrelation function was defined as the level of exercises. In this article, we review the current literature and decorrelation corresponding to 1.4 times the threshold when practice on the diagnosis and management of exotropia with decorrelation is 0%. In general, stereothresholds increased emphasis on intermittent exotropia. (Dr. Eibschitz-Tsimhoni, with increasing decorrelation. Following training, 1000 Wall St, Ann Arbor MI 48105. Email: [email protected]) stereothresholds and standard errors of measurement decrease systematically for all tested decorrelation values. Binocular Vision Post training decorrelation functions were reduced by a multiplicative constant (approximately 5), exhibiting changes in stereothresholds without changes in the inflection points. -244- Binocular Vision & ABSTRACTS Fourth Quarter of 2007 Strabismus Quarterly© Volume 22 (No.4): A Medical Scientific E-Periodical Page 242-244 Disparity energy model simulations indicate that a post-training patients with residual esotropia. The resultant underaction of reduction in neuronal noise can sufficiently account for the the medial rectus muscle after re-recession is relatively mild perceptual learning effects. In two subjects, learning effects and causes no major problems. (Dr. Rajavi, No.31, Rafat were retained over a period of six months, which may have Avenue, Shariati Street Tehran, Iran application for training stereo deficient subjects. Dr. Harwerth, Email: [email protected] College of Optometry, Univ Houston, 505 J David Armistead Building, Houston TX 77204-2020. Fax: 713-743-2053) Myopia Strabismus Surgery, Outcome / Complications Genetic Dissection of Myopia Evidence or Linkage of Ocular Axial Length to Chromosome 5q. Zhu G, Hewit Effect on Intraocular Pressure of Extraocular AW, Ruddle JB et al. Ophthalmology 2007. [Authors Muscle Surgery for Thyroid-Associated Ophthalmopathy. Abstact] Gomi CF, Yates B, Kikkawa DO, Levi L, Weinreb RN, Granet DB. Am J Ophthalmol 2007; 144:654-657 [Authors Purpose: To estimate heritability and locate Abstract] quantitative trait loci influencing axial length. Purpose: To study the effect of extraocular muscle Design: Classic twin study of monozygotic and surgery on intraocular pressure (IOP) in patients with thyroid- dizygotic twins reared together. associated ophthalmopathy. Participants: Eight hundred ninety-three individuals Design: Retrospective, observational case series. from 460 families were recruited through the Twin Eye Study in Tasmania and Brisbane Adolescent Twin Study (BATS) and Methods: The medical records of patients with had ocular axial length measured. restrictive myopathy secondary to thyroid-associated ophthalmopathy who underwent strabismus surgery from July Methods: Structural equation modeling on the entire 1, 1997 through July 31, 2003 were reviewed and analyzed sample was used to estimate genetic and environmental retrospectively. Seventeen patients met the criteria and were components of variation in axial length. Analysis of existing included in this study. All patients were seen at the Thyroid microsatellite marker genomewide linkage scan data was Eye Center at the University of California, San Diego, a performed on 318 individuals from 142 BATS families. university-based tertiary referral center. The main outcome Main Outcome Measures: Ocular axial length. measure was IOP readings obtained before and after surgery Results: The heritability estimate for axial length, in both primary gaze and upgaze. adjusted for age and sex, in the full sample was 0.81. The Results: A statistically significant decrease in IOP in highest multipoint logarithm of the odds (LOD) score observed upgaze was noted after extraocular muscle recession. The was 3.40 (genomewide P=0.0004), on chromosome 5q (at 98 mean IOP before surgery was 16.6 ±3.76 mm Hg in primary centimorgans [cM]). Additional regions with suggestive gaze and 23.2 ±7.27 mm Hg in upgaze. After strabismus multipoint LOD scores were also identified on chromosome 6 surgery, the mean IOP (after one month was 15.7 ±2.36 mm (LOD scores, 2.13 at 76 cM and 2.05 at 83 cM), chromosome Hg (P=.215) in primary gaze and 18.9 ±2.96 mm Hg in upgaze 10 (LOD score, 2.03 at 131 cM) and chromosome 14 (LOD (P=.001). Conclusions: Strabismus surgery resulted in a score, 2.84 at 97 cM). Conclusion: Axial length, a significant reduction in IOP in the early postoperative period in major endophenotype for refractive error, is highly heritable patients with restrictive myopathy secondary to thyroid- and is likely to be influenced by one or more genes on the long associated ophthalmopathy. (Dr. Granet, Dept Ophthalmology, arm of chromosome 5. (Prof. Mackey, Centre for Eye UC San Diego, 9415 Campus Point Dr., La Jolla CA 92093) Research Australia, Royal Victorian Eye and Ear Hospital, 32 Gisborne St, East Melbourne, Victoria, Australia 3002). Lateral Rectus Resection Versus Medial Rectus Re- Recession for Residual Esotropia: Early Results of a Unilateral Atropine for Amblyopia May Not Alter the Randomized Clinical Trial. Rajavi Z, Ghadim M, Ramezani Refractive Status of the Sound Eye. As abstracted by the A, Azemati M, Daneshvar. Cl Exp Ophthalmol 2997; AAO Academy Express August 15, 2007. 35:520-526. [Authors Abstract] This prospective, randomized study finds that the Methods: This randomized controlled clinical trial mean change in refractive error in the [UNTREATED]sound included 25 patients (mean age, 18.8 ±8.7 years) with residual eye of those treated with [UNILATERAL] atropine was -0.21 D. esotropia who were candidates for reoperation. They were In the patching[?] group, the mean change was -0.06 D - an randomly assigned into two groups: re-recession group (n=12), interesting finding that contradicts the theory that atropine can in which the medial rectus muscle was recessed again, and the be used to treat progression of myopia. [?HOW SO???? -Ed] resection group (n=13), in which lateral rectus muscle resection was performed. Postoperative deviation #10 prism diopters was considered to be treatment success. Results: The success rate of the re-recession group and the resection group was 67% and 54% respectively; this difference was not statistically significant. Each 1 mm of medial rectus re-recession and lateral rectus resection corrected 7.5 ±1.2 and 2.5 ±0.5 prism diopters of residual esotropia, Edited by P.E. Romano, MD, MSO, Editor BV&SQ. Abstracts respectively. In 50% of the re-recession group, mild medial are selected on the basis of interest to our readers. To avoid duplication you will find none are from The American Orthoptic rectus muscle underaction occurred; however, only 16.5% Journal, The Australian or British-Irish Orthoptic Journal, The developed an increase in the near point of convergence. Major Journal of the American Association for Pediatric intraoperative and postoperative complications, including Ophthalmology and Strabismus, The Journal of Pediatric overcorrection and slippage or a lost muscle, did not occur in Ophthalmology and Strabismus, or Strabismus, as most of our any of the patients. readers already subscribe to and/or read them. Publication herein does not constitute endorsement, recommendation or Conclusions: Medial rectus muscle re-recession a validation of author’s conclusions. can be a substitute for lateral rectus muscle resection in -245- -246- -247- Binocular Vision & New Book Review Fourth Quarter of 2007 Strabismus Quarterly© Strabismus Surgery and Its Complications Volume 22 (No.4): A Medical Scientific E-Periodical by David K. Coats and Scott E. Olitsky Page 247
New Book Review Strabismus Surgery and Its Complications David K. Coats, M.D. & Scott E. Olitsky, M.D.
Springer-Verlag, Haberstrasse 7, D-69126 Heidelberg, Germany. Tel:49-6221/345-4301, Fax: 49-6221/345-4229, Email: [email protected]. ISBN: 978-3-540-32703- 5. 318 pages. 8.5x11x.75" (21.5x28x2cm) US$199, Euro 171.15.
Given the evolution of strabismus surgery techniques over recent years, a new comprehensive reference is welcome. “Strabismus Surgery and Its Complications” succeeds in compiling much of the knowledge influencing modern strabismus surgery. The authors’ objective was to create a single resource for surgical planning. This text addresses strabismus surgery from preoperative planning to postoperative management. “Strabismus Surgery and Its Complications” functions as a surgical atlas, but with more detailed text than the typical atlas. The book first addresses surgically relevant anatomy and physiology, followed by discussions of perioperative management. Surgical complications, common and rare, are addressed in detail. Thirty-two chapters are organized into two major sections. The first section covers preoperative surgery planning, surgical technique and postoperative care. The details of posterior fixation and combined rectus surgery technique portion of the book is muscle recession/transposition are absent. structured around surgical maneuvers rather Typical rectus muscle reoperation techniques than clinical disorders. For example, one will are not discussed, other than treatment for a not find discussion of surgical options for the slipped muscle or stretched scar. treatment of Duane’s Syndrome, superior oblique palsy or consecutive exotropia, but will The book includes excellent original find a comprehensive description of several illustrations, both drawings and photographs. inferior oblique muscle surgical techniques. The atlas-like layout of the book is attractive This organizational approach may frustrate and functional. In addition, an accompanying readers searching for the correct procedure for a DVD includes image files of the book’s original given condition. If the reader wants detail on a figures as well as three video segments of given surgical procedure, however, the text will common surgical techniques. Unfortunately, the serve as a valuable guide. The second section of copy editing of this first edition is imprecise, the book addresses surgical complications, from distracting from an otherwise excellent mild to severe. The complications section is reference. very comprehensive and well referenced. “Strabismus Surgery and Its In “Strabismus Surgery and Its Complications” is an excellent updated surgical Complications” details of most surgical atlas as well as a detailed text of modern procedures are well described and illustrated. strabismus surgery. The authors offer multiple surgical approaches Robert W. Hered, M.D. when viable. Some procedures are described in Jacksonville, Florida more detail than others, however. For instance, -248- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256
HYDE PARK EDITORIAL: The Editor's Soapbox, Sandbox & B'LOG (Prehistoric) Since 1985 Flat Flounder Binocular Vision; More Stereoscopic Movies; OCT; Synophrys; Supernormal Visual Acuity; War Eye Trauma; Memory; Motorcycle morbidity and mortality; Ethanol and Accidents; Computer Problems. The Importance to Nature of Binocular Vision and Binocularity When we saw this picture we thought, what stronger evidence could nature give of the importance of two eyed binocular vision than to rearrange anatomy so radically, when necessary, to preserve it !? from National Geographic November 2007. This larval flounder swims with other fish for now, hidden from predators by transparency (the color is an effect of lighting). It will soon be a bottom dweller that shimmies into the sand, gazing upward. Eyes start out one on each side; as the skull develops, one migrates to join the other. -249- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256 -250- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256 Vision: SEEING and NOT SEEING Athletic Vision and Golfing ??? First a very personal anecdote about seeing. from The Wall Street Journal October 27- Your Editor has had beetle brows all his life, 28, 2007 “Golf Journal” by John Paul including “synophrys” the fusion- joining together Newport. The Eyes Have It. New research aims of both brows nasally into one continuous bilateral to help players focus on the key role of vision. brow as it were. As all you ladies know, this is NO- “For most of us subprofessionals, the chief NO cosmetically and it is the first thing to go when advantage of great vision in golf would seem the girls learn how to pluck their brows. You never to be finding lost balls in the woods. see women with ANY hair between their eye brows Distance markers and laser range finders take anymore and the only difference is the size of the the visual guess-work out of judging gap between the nasal ends of their brows, which I approach shots, and up on the green, who but think seems to increase for fashion’s sake every Mr. Magoo can’t see the hole? But almost year. My condition even has a lay name, “unibrow” everything I thought I knew about this and Unibrow is grounds for elimination. Last time I subject turns out to be wrong. Superior was in for a haircut, Deanna, the lady who cuts my vision is a huge advantage in golf, especially hair, suggested we eliminate my unibrow with a when it comes to putting. Many of the little hot waxing job. So we did. world’s best players, including Tiger Woods and seven other PGA Tour winners this year I never checked it until I faced myself in the (Vijay Singh, Fred Funk and Masters mirror the next AM. I didn’t recognize myself! I Champion (continued in clipping below and then certaintly looked radically different! continued from clipping:-) I found it difficult to accept that just giving ... Stan Utely, formerly one of the up a half inch of fur could change my appearance Tour’s best putters and now arguably the so... No wonder women spend so much time (and game’s hottest putting instructor. He didn’t money) taking care of their faces... hesitate to attribute part of his success as a putter to the fact that he always read 20-10 on the eye charts, .. (Joe DiMaggio similarly cred- ited much of his prowess in base- ball to 20-10 vision. ...” [as do also many of the to p race car drivers like recently retired former World Formula 1 Cham- p i on Michael Schumaker and many of the flying aces of various conflicts since WWI -Ed] -251- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256 Conversley, this is also why now I find my math, along with three years of relevant penchant for pushing 200 mph on those Nevada professional experience. ... Commercial “open road” (actually closed public roads) rally- airline pilots are generally allowed to wear races has decreased significantly: I’ve lost a half glasses, contacts or have vision correction line of my best corrected vision in both eyes due to surgery. ... Navy’s refractive surgery early cataract changes- and even more in contrast research is unusually authoritative because of sensitivity I suspect, and that means a lot at those its independence from commercial speeds... I just can’t see as well and as far as I used companies and industry bias. In May, the Air to and I don’t like that at all. But I’m going to wait Force changed its policy to allow people for surgery until those accommodative and applying for aviation jobs to have had Lasik surgery. That follows a similar move by the accommodating IOLs are good enough to give me Navy last year. ... doctors have feared that supernormal powers of near vision and corneal extreme environments, such as those found surgery can give me supernormal distance vision underwater on in space, could cause flap like these golfers! dislocations, possibly leading to a catastrophic vision loss. Navy research has found that the three year risk for such Astronaut Vision dislocations is extremely small , about 1 in from The Wall Street Journal September 9000. ... People who had an early type of 21, 2007 by Leila Abboud. vision corrections surgery - RK, or radial keratotomy - can suffer alarming corneal Want to Work In Space? Squinters changes at high altitude. Military doctors Can Now Apply. “Poor eyesight has long documented the problems in studies done on been the bugaboo of many aspiring RK patients on Pike’s Peak in Colorado in astronauts, disqualifying more would-be the early 1990s. The findings helped to space travelers than any other physical explain the experience of a renowned requirement since the beginning of the U.S. mountain climber and RK patient, Beck astronaut program in 1959. Now, nearly a Weathers, whose eyesight failure on Mount half century after the program began NASA Everest was described in the 1998 book ‘Into is loosening its vision standards, allowing Thin Air’. The same Pike’s Peak studies, more men and women to reach for dreams of however, found no such problems with PRK. flying into space. ... NASA said for the first ... two new technologies: wavefront-guided time it will consider applicants who have software and the femtosecond laser. ... The undergone two common types of vision femtosecond laser, better known as correction surgery: laser assisted in situ IntraLase, offers more precision than keratomileusis, known as Lasik; and handheld devices and is used in what is photorefractive keratectomy, or PRK. It will popularly called ‘all-laser Lasik’. With these also slightly relax requirements for technologies, Lasik is as good as PRK. ...” uncorrected vision to allow more contenders who wear glasses or contact lenses. ... NASA [currently] allows some people who wear More Sad War Stories re Eyes glasses or contacts to be astronauts - but only if their vision needs just minor correction, so In the last issue we printed fellow pediatric that they can still function without them if ophthalmologist and Flight Surgeon Enzenauer’s necessary. ... the changes, which follows account of his service doing unofficial eye surgery similar moves by the Navy and Air Force in Afghanistan. The following report suggest they regarding eyesight standards for pilots, really do need more properly trained and assigned people whose uncorrected vision would eye surgeons over there, and also perhaps even otherwise disqualify them can get surgery. more and better protective eye shields. If I were ...NASA astronaut applicants need a assinged over there I think I would just wear my full bachelor’s degree in engineering, science or face racing helmet and eye shield! -252- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256 from USA TODAY November 14, 2007 the country for blind rehabilitation that teach by Gregg Zoroya. Blinded by the war: Eye visually impaired veterans how to function injuries hit troops hard. Mortars, roadside in society. The centers have 241 beds, and it bombs send lives into darkness. “... more than takes an average of nearly three months to 1100 veterans of Iraq and Afghanistan - 13% get in. Iraq and Afghanistan casualties go to of all seriously wounded casualties - undergo the front of the line, says Stan Poel, VA surgery for damaged eyes. That is the highest direction of rehabilitation services for the percentage for eye wounds in any major conflict blind. So far, 53 have enrolled in the blind dating to World War I, see Figure ... eye rehabilitation programs, the VA says. ... The injuries have become one VA does not provide of the most devastating guide dogs, but it helps consequences of a war in link veterans with guide which roadside bombs, dog schools that mortars and grenades are commonly provide a the most commonly used dog and training weapons against U.S. virtually free to troops. Brain injuries and veterans, Poel says. ... amputations have long Brain injuries also been the focus of the danger to vision. “... in a damage such weapons are study of 101 Iraq and inflicting, but in recent Afghanistan war weeks the Army has veterans with mild acknowledged that serious traumatic brain injuries. eye wounds have Many are still in the accumulated at almost service. Goodrich found twice the rate as wounds that 40% to 45% of the requiring amputations. patients suffered vision Body armor that protects loss even though their vital organs and the skull is eyes were physically saving lives. But troops healthy. The biggest eyes and limbs remain problem was an inability particularly vulnerable to for both eyes to operate the blizzard of shrapnel precisely together. [?Isn’t from such explosions. ... that what we call Partial or total vision has been restored in STRABISMUS?-eD] This can lead to eye strain most cases involving eye injuries, military and blurred vision. ... routine eye statistics show. But hundreds of troops have examinations may not uncover the problems. been left with impaired vision, and dozens ‘In many cases, we’re seeing active-duty have been blinded. Troops in Iraq routinely troops, and they want to get back and join wear protective eyewear, but it doesn’t their units’ ...’So they don’t want to hear that always work. When a roadside bomb in there’s something they need to go get treated Baghdad blew a hole through the heavily for’.” armored vehicle carry Army Sgt. Luis Martinez last April, the force from the blast Trauma Care Here in U.S. stripped off his helmet, headset and goggles. from The Wall Street Journal October 3, ... The blast also drove the frame of his 2007 by Laura Landro. A Dangerous Gap in protective eyewear into his face. ... Because Trauma Care. Systems to transfer patients to the Pentagon has no rehabilitation services best equipped hospital fall short in most states. for the blind, the path to recovery often leads “... Trauma from injuries including directly to the Department of Veterans accidents, falls and violence is the leading Affairs. The VA operates 10 centers across -253- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256 cause of death for Americans under the age PUBLIC SAFETY of 44, claiming more than 140,000 lives and permanently disabling 80,000 people annually. But only one in four lives in an from The Wall Street Journal September 18, area served by a coordinated system to 2007 by Jonathan Welsh. The New transfer patients to designated trauma centers Motorcycles: Bigger, Faster, Deadlier. Trend from less equipped hospitals, according to toward outsize power and lighter weight the American College of Surgeons, which coincides with increase in fatalities. “ ... 2007, sets standards for trauma care. ... In the the deadliest year yet for motorcycle riders. meantime, it’s often up to patients and ... a horsepower battle in the cycle industry families to be prepared and know what level has produced bikes that have the power of a of trauma care their local hospital can car but often weigh less than ever. ... but the provide before an accident happens - or what bikes’ potential speed and violent arrangements the the hospital has to transfer acceleration can quickly overwhelm all but patients if necessary. Patients can check out the most skilled riders. These high the American College of surgeons Web site, performance machines, often called which has a list of verified trauma centers ‘superbikes’ or supersports’, accounted for and the level of care they provide: less than 10% of motorcycle registrations in 2005 but accounted for more than 25% of (www.facs.org/trauma/verified.html). rider fatalities. ... The total number of rider At highest risk are those in rural areas, where deaths has more than doubled since 1997. At nearly 60% of trauma deaths occur even the current rate, some safety experts say, though such areas account for only 20% of fatalities in 2007 could surpass the previous the population. ...” peak of 4955 set in 1980. ... In addition to more powerful machines, an influx of inexperienced riders is also helping to drive ABOUT MEMORY accident rates higher. And as more middle National Geographic portrays relative age consumers return to motorcycling - often memory this way: Consider a brain synapse after not having ridden for 20 years or more, to be equivalent to a memory byte. Your more older riders are being killed in crashes. brain is still vastly superior to any hardware. Another contributing factor: a trend toward more liberal helmet laws. ... During June, July and August, about one in four patients hurt in traffic accidents have been motorcycle riders. ... the nearly 200 horsepower generated by the company’s new ZX-14 or rival bike maker Suzuki Motor Corps GSX-R1000. The Suzuki weighs barely 400 pounds with a full fuel tank, and can accelerate to 60 mph in about 2.5 [=F1!] seconds. ... Although a tripling of motorcycle sales over the past decade accounts for some of the rising death rate, fatal motorcycle accidents have also risen proportionally. Over the time period of the IIHS study, from 2000 to 2005, the death rate for motorcyclists rose to 7.5 deaths per 10,000 registered motorcycles from 7.1. In the same period, the percentage of motorcycle deaths -254- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256 among all highway fatalities rose to 10% from 7%. compared with 24% 10 years earlier. In the same Superbike riders had a death rate of 22.5 for every period, the fatality percentage for riders younger 10,000 registered motorcycles. In 2005, riders 40 or than 30 years of age fell to 32% from 41%. ...” older accounted for 47% of motorcycle fatalities, -255- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256 WARNING !!!! THIS is really frightening: Overall this means about three out of every eight fatal accidents have one or more people who are legally intoxicated. To that add perhaps an equal number of those who are illegally intoxicated on illegal drugs. And figuring most people are usually unintoxicated only during their working hours or at least until lunchtime.... =We try to stay off the roads between 3 PM and 3 AM ! During those hours, simple arithmetic suggests that many of your fellow motorists may be incompetent. -256- Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007 Strabism us Quarterly© Volume 22 (No.4): A Medical Scientific e-Periodical Pages 248-256 Another supporting opinion supporting prior comment on computers: And also, see, if you had just ordered a trial of, or bot Pivot.Pro software from Portrait.com as we recommended in the last issue’s Lead Editorial, you could just rotate this comic 90 degrees to more easily read it. But do note well the punch line in the last frame: “ I was having a bad day anyway.” And Note Bene that he is working on a (laptop) computer -the only character in the strip that is! No wonder he was having a bad day before Sherman came along!!!! - confirming my complaints in previous issues about computers. Do have a good holiday season. Just stay away from your computer and it will be! -per [ alias “hatesgates”, “gateshater”]