ulakbİmbinocular vision & strabismus quarterly (issn 1088-6281), the "loftiest scientific...

BINOCULAR VISION & STRABISMUS QUARTERLY (ISSN 1088-6281), the "loftiest scientific journal in the world" ispublished 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 andFAX 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 byany means, electronic or mechanical, including xerographic copy, photocopy, recording, or an information storage andretrieval system, without permission in writing from the publisher.

EDITORIAL OFFICE / MANUSCRIPTS: Please send to the Editor, Binocular Vision & Strabismus Quarterly, PO Box3727, 740 Piney Acres Circle, Dillon CO 80435-3727 USA. Please see and use "Instructions for Authors", pages202-203. Letters to the Editor are considered "for publication" unless otherwise indicated and may be edited andcondensed as space dictates.

ADVERTISING: Please direct inquiries to BINOCULUS PUBLISHING, PO Box 3727, 740 Piney Acres Circle, DillonCO 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 isthat, with our conversion to electronic, there is a marked increase in access facility to the journal for libraryusers.).........Single electronic issues US$47. Back print issues (1985-2006) $36. Please send orders with check ormoney order payable in US $ funds to Binoculus Publishing, PO Box 3727, 740 Piney Acres Circle, Dillon CO80435-3727 USA. Visa, Mastercard and American Express charges gladly accepted, especially for Internationalorders. Bound Volumes also available to subscribers. To subscribe or order, Call/Fax 970-262-0753. Email: JudyRobinson <[email protected]> Or order on the website at www.binocularvision.net

Disclaimer: The ideas/opinions expressed in Binocular Vision & Strabismus Quarterly do not necessarily reflect thoseof the publisher or editorial staff. BV&Sq makes every effort to maintain accuracy; however, cannot guaranteeaccuracy of contents or claims of advertisers. The reader should consult the maker or manufacturer's instructionsbefore using any product appearing in BV&Sq.

The designation of individual issues is by the quarter, not the season, because seasons are never the same, butopposite, in the Northern and Southern hemispheres. The seasons are however designated on the cover with theNorthern season on the top and, inverted below, the current season in the Southern hemisphere.

Bin ocula r Vis ion & S trab ism us Qu arte rly© EDITORIAL BOARD Fourth Quarter of 2007, Volume 22 (No.4): Page 296

Leonard AptRobert W. ArnoldE.S. Avetisov, RussiaJohn D. BakerP. Vital Berard, FranceFrank Billson, AustraliaMichael C. BrodskyJorge A. Caldeira, BrazilAlberto O. Ciancia, ArgentinaKenneth J. CiuffredaDavid K. CoatsJeffrey CooperJan-T H.N. de Faber, NetherlandsJay M. EnochCaleb GonzalezMichael H. Graf, GermanyDavid GuytonEugene M. HelvestonRichard W. HertleCreig S. HoytDavid G. HunterRobert S. JampelEdouard Khawam, LebanonLionel Kowal, Australia

Stephen P. Kraft, CanadaKrystyna Krzystkowa, PolandJoseph Lang, SwitzerlandMalcolm L. MazowHenry S. MetzJoel MillerJames L. Mims IIIScott E. OlitskyGian Paolo Paliaga, ItalyEvelyn A. PaysseZane F. PollardJulio Prieto-Diaz, ArgentinaEdward L. RaabMichael X. RepkaJames D. ReynoldsDavid L. Romero-Apis, MexicoAlan B. ScottKurt SimonsAnnette Spielmann, FranceDavid R. Stager, Sr.Martin J. Steinbach, CanadaDavid S.I. Taylor, EnglandGuillermo Velez, ColombiaBruce C. Wick

M. Edward Wilson, Jr.Kenneth W. Wright

EMERITUS

Shinobu Awaya, JapanHenderson Almeida, BrazilBruno Bagolini, ItalyAlbert W. BiglanWilliam N. Clarke, CanadaJohn S. Crawford†Robert A. Crone, NetherlandsEugene R. Folk†David A. HilesDavid HubelBela JuleszHerbert Kaufmann, GermanyPhilip Knapp†Burton J. KushnerPinhas Nemet, IsraelJ.V. Plenty, United KingdomRobert D. ReineckeWilliam E. ScottR. Lawrence Tychsen

INDEX TO ADVERTISERS, VOLUME 22, NUMBER 4, 2007Fresnel 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

mailto:[email protected]

“... 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 2007Paul 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 Authors203 Brian D. Stidham, M.D., M emorial Lectureship204 Correspondence206 People and Places; News and Announcem ents

82 EDITORIALS: In This Issue, Paul E. Romano, M.D., M.S. OphthalmologyGuest: Clear-Eye Optimists, Stephen Moore

*** ORIGINAL SCIENTIFIC ARTICLES ***210 Safety Stitch: A Modification to Postoperatively Adjustable Suture Strabismus Surgery

of the Inferior Rectus MuscleMaria Felisa Shokida, M.D., Jose Gabriel, M.D. and Celia Sanchez, M.D.

216 Radio-Opaque Modification/Substitute for the Wright Superior Oblique Tendon Extenderfor Superior Oblique Muscle Overaction StrabismusRobert W. Arnold, M.D. and Rachel E. Leman, R.N.

221 Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Is BotulinumToxin 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 SurgeryProtocols for Abnormal Head Postures in Infantile NystagmusYoon-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 andComplication?Hee-Jung Park, M.D., MPH and John Guy, M.D.

227 Surgical Correction of Synergistic Divergence Strabismus. A Report of Three CasesEduard 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

Stra bismus Qu arte rly© Volume 22 (N o.4):A Medical Scientif ic E-Periodical for Binoculus Books advertised on following pages pages 198,199

THE HISTORY OF STRABISMOLOGYEdited by Gunter K. Von Noorden, M.D.

THE BOOKThe 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 knowledgeof the material is particularly profound. The origins of strabology go back to the beginning of medicine, thousands of yearsago. The story how this specialty evolved from quackery and superstition in ancient times to its present state ofsophistication is a fascinating one. It should be of more than passing interest, not only to those specialized in this field butalso to others with an interest in the history of ophthalm ology.

The book consists of approximately 400 pages and is abundantly illustrated with fine reproductions of o lddocuments, engravings, drawings and historic instruments, many of which are from ancient and rare manuscripts. Printedon 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. H is expertise in the entire field of stabismusis docu-mented in his textbook (now in its 6 th edition) and uniquely qualify him to organize and edit a book on the history ofstrabology. 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 reputationand 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 GillRoper-Hall, DBOT, CO, COMT

-199-

Binocular Vision & BOOK REVIEWS, DESCRIPTIONS Fourth Quarter of 2007

Stra bismus Qu arte rly© Volume 22 (N o.4):A Medical Scientif ic 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 AmblyopiaCited Online in MEDLINE and EMBASE; Cited in INDEX MEDICUS and INDEX BINOCULUS

Please enter my PERSONAL electronic subscription

(all subscriptions, USA and International) for3 years 2008-2010 @ $ 68/yr = $204 O2 years 2008-2009 @ $ 78/yr = $156 O1 year 2008 @ $ 84/yr = $ 84 O

PERSONAL NOT BV&SQ YES BV&SQBOOKS: Please send me _____ copy(s) of subscriber subscriber

von Noorden: History Strabismology O $ 179 O $ 159Helveston: Surg Mgmt Strabismus, ed 5 O $ 179 O $ 139Kushner: 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) for1 year 2008 @ $426/yr = $426 O

LIBRARY and INSTITUTIONAL NOT BV&SQ YES BV&SQBOOKS: Please send _____ copy(s) of subscriber subscriber

von Noorden: History Strabismology O $ 289 O $ 229Helveston: Surg Mgmt Strabismus, ed 5 O $ 289 O $ 229Kushner: Collection BV Grand Rounds O $ 289 O $ 189

Subscriber Savings (total for all 3) ($260)

SHIPPING and HANDLING: Continental United States $ 7.50For 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 em ail: [email protected]


BINOCULAR VISION & Strabismus Quarterly: INSTRUCTIONS FOR AUTHORS

SUBMISSION OF MANUSCRIPTS (TYPESCRIPTS)

Electronic Submission: Send one copy of your Letter oftransmittal, copyright transfer, and permissions for publicationsof photos (see below for details of these), and one copy of yourpaper/manuscript, using a word processing program forMicrosoft/ Office typed in a loose typewriter typeface, anddouble-spaced. Include all Tables and Figures (graphs, linedrawings, and photos) preferably as part of the manuscript ratherthan as attachments. to: [email protected]

Standard Hardcopy Submission: Send four (4) copies, typed ina loose typewriter typeface, and double-spaced with xerographiccopies of all figures (graphs, line drawings, and photos). Alsosend two (2) originals of all computer generated/printed figuresand glossy photo prints of and figure by EITHER US Post Officeor a delivery service TO: EDITOR, BINOCULARVISION

740 PINEY ACRES CIRCLE PO BOX 3727DILLON CO 80435-3727 USA

Please also send a CD or 3.5" diskette copy of your manuscriptmade on an IBM or IBM compatible PC using Word Perfect 10or Microsoft word processing program.EITHER WAY- Send acovering letter of transmittal with name, address, telephone andFAX numbers, email address of corresponding author, i.e.,theauthor to whom letters of receipt and acceptance, galley proofsand reprint request forms are to be sent.Note: To comply with the Copyright Act of 1976, include also thefollowing COPYRIGHT TRANSFER STATEMENT, signed byeach and all authors: "The undersigned author(s) transfers allcopyright ownership of the manuscript entitled (title of article) toBinocular Vision & Strabismus Quarterly/Binoculus Publishingin the event the work is published. The author(s) warrants thatthe article is original, is not under consideration by anotherjournal, and has not been previously published".

References: If "PERSONAL COMMUNICATIONS", majoramounts of text or any Figures from any previously publishedpaper are included in your paper, include also reprintpermissions from prior author and publisher if printed. (see"Sources, Credits, and Permits", below).All manuscripts, including solicited material, is subject to editorialreview and revision. Only manuscripts in English are considered.All Manuscripts submitted become the property of the Journaland may not be published elsewhere without written permissionfrom both this Editor and Publisher. There are no publication or "page" charges to authors except forillustrations or printed length in excess of 12 pages. But nocharges are levied without consent of the corresponding author.

TEXT STYLE AND CONTENTPage Headers Each and every page, including xerographicfigure copies, Legends for Figures, Tables and References,should be arabic numbered consecutively with an abbreviatedtitle but NO authors' names at the page top. The Title page ispage 1, ABSTRACT is page 2.Title Page: Declarative titles are acceptable and encouraged.(Pretend you are writing a newspaper headline.)Précis: Include a one sentence précis (35 words or less)summarizing the main outcome/finding of the study.List in this order: All author(s)full names AND ALL DEGREES asdesired when published, academic and institutional affiliations,sources of support, and other acknowledgements. Restate forpublication the corresponding author's name, address, telephoneand FAX numbers, with e-mail address.ABSTRACT: :Do not restate the title as the title will alwaysappear with the abstract. On a separate page (2) provide anabstract-summary of about 200 words, clearly and conciselystating in paragraphs titled respectively the Background andPurpose (or Problem), Methods of study, the major Results, andprincipal Conclusions. CONSERVATIVE statements as toIMPORTANCE, recommendations, and applications may beappropriate. The abstract should be factual, specific andsufficiently complete to provide the reader a quick andcomprehensive view of the content of the paper. [Avoidgeneralizations (i.e. "are discussed") OR "baiting" the reader byholding back or out on your results or conclusions.] TEXT CONTENT: Manuscript material should be organized into

the following parts in this order: ABSTRACT; INTRODUCTION(BACKGROUND AND PURPOSE OR PROBLEM);MATERIALS, SUBJECTS AND METHODS; RESULTS*;DISCUSSION OF RESULTS; CONCLUSIONS (&recommendations) REFERENCES; TABLES; LEGENDS FORFIGURES; FIGURES. In the "Discussion of Results", do not introduce new referencematerial. Instead, we expect you to integrate YOUR NEWRESULTS into the current body of knowledge. Specifically: yourresults should be compared to results obtained by prior workers:Confirmations and agreements should be pointed out. Butdiscordances also require enumeration, discussion, andexplanation. Unique or unexpected results demandinterpretation. The statistical significance* of results must beconsidered and their application should also be entertained.

REFERENCES: Order these numerically in sequence as theyappear in the text. Indicate a reference number in the text witha full sized Arabic numeral enclosed in parentheses, i.e. (1). Onthe separate Reference page they should be numberedconsecutively and typed double-spaced. Author's names andJournal titles should be abbreviated, without periods, as in IndexMedicus. For journals punctuate in the following order:Author'(s) last name Initials ["et al" acceptable for more than3]:[colon] Article title with sub-title, if any.[period] IM Journalabbreviation [Bolded] year; volume number in Arabic numerals:inclusive pages. Example: 1. Jones AB, Jones CD, Jones EF, et al: Results of LaserSurgery for Strabismus. J Outst Surg l999; 2:301-304. For book references: author, title, volume (if more than one)edition number (if other than the first), publisher, city and year.If the reference is a chapter in a book, the order changes asfollows: the author of the chapter, title of the chapter, "in" booktitle, volume, edition, editors, publisher, city, year, inclusivepages of the chapter. Authors are responsible for accuracy.

TABLES: Always "portrait" (< 7" W), NOT "landscape"configuration which requires undesirable sideways position..FIGURES: PHOTOS, GRAPHICS, DRAWINGS Electronic submission, email or on CD is usually acceptable.Standard Hard copy methods: Photo materials for halftones(photographs, photomicrographs, electron micrographs,roentgenograms) should be submitted cropped and unmounted.On the back of each print, affix a pretyped label with the figurenumber, an arrow and/or "top" indicating the top edge, and thelast name of the first author. Line drawings, charts, and diagramsshould be professionally prepared. For computer generatedgraphics, please submit originals, rather than photographicprints. Typewritten labels and lettering are not acceptable ingraphics. Insure that lettering is large enough to be legible if andwhen reduced for publication. Legends for Figures: typed double-spaced in consecutive orderon a separate page following References. Start each with firstauthor's name in parentheses. Indicate scale when appropriate.State clearly the point which the Figure is illustrating. Use arrowson photos liberally to identify and point out structures. [Assumethe reader is not an expert like you are but rather a student.]

SOURCES, CREDITS, PERMITSQuotations must be accurate and give full credit to the source.Brief properly credited quotes do not require permission of theoriginal author or publisher ("fair use"). For large amounts of textor any figures previously published permission to quote andreproduce must be obtained by the submitting author: originalcopies of the letters from the original author and publishergranting permission to reproduce the work must accompany yourmanuscript. Photo permits: if the subject can be recognized, i.e.,any picture which contains more than just eyes and anunidentifiable bridge of the nose, written permission to publishthe picture must be obtained from any subject over age 8 yearsold (and the parents if a minor under age 18).* Statistical Analysis of Results Mandatory. But give "exact"probability values (i.e., p = .06). Do not use relative p values(i.e.,p >< .05). The term "statistically significant", definedtraditionally as a p #.05, is a totally arbitrary and unscientificterm and should not be used (J Lab Clin Med 1988. 111:501). But do consider whether a result may be "clinically/medicallysignificant". rev 22:(1)-PER

-203-

D. BRIAN STIDHAM MEMORIAL LECTURESHIP

LECTURE to be published annually in Binocular Vision and Strabismus Quarterly

Donations Solicited to Fund LectureshipTo the Editor: The Pediatric Ophthalmology community lost a great doctor last October 6, 2005, with thedeath by murder of D. Brian Stidham. I am attempting to create an endowed lectureship to remember Brian in our community andwithin pediatric ophthalmology, and wonder if I could ask you to consider helping in thisregard. I know that your journal concentrates on strabismus and binocular vision, but could Iinterest 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 certainthat a manuscript would be produced that would be of acceptable quality. Having a targetjournal for the presentation would be a great carrot to draw top speakers to Tucson on a yearlybasis to give such a talk. We have raised $14,000 towards a target of $50,000 endowment that would ensure that thelecture would be perpetuated. I am committed to continue fundraising until the goal is met. IfBinocular Vision and Strabismus Quarterly would serve as the publisher of the named lecture, I feelcertain we will be able to both attract top speakers and donors to remember Brian in the yearsahead, and to provide a great lectureship in pediatric ophthalmology and strabismus to ourprofessional community which would enjoy greater readership and distribution.

Joseph M. Miller, M.D., MPHHead, Ophthalmology and Vision Science

University of Arizona, Tucson, ArizonaIn reply: We are honored to be asked and will most definitely be pleased to publish this lecture eachyear. We would encourage our readership to donate to this fund: Checks should be made payableto 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! Inaddition:2. READ & FOLLOW INSTRUCTIONS FOR AUTHORS! Inaddition:

Reviewing the literature: A proper review of the literature startswith a review of current and appropriate textbooks, especially thelatest edition (currently the Sixth of von Noorden’s BinocularVision and Ocular Motility by Mosby, and Duane’s loose-leaf textClinical Ophthalmology. Anticipating a future requirement, it willonly be to your credit now to specifically state what was includedin your literature search, i.e., the topics or subjects and the sitessearched. For any article submitted here that should include at aminimum, Index Medicus (Medline) from 1966 to the present,Index Bnoculus Primus, 1985 to the present, and the Internet forthe American Orthoptic Journal.

Acceptable TERMINOLOGY not acceptableAHP Abnormal Head Postures:3 face turn head turn chin up/down head up/down Head tiltretroequatorial myopexy Fadenoperationretroequatorial myopexy posterior fixation suturesuspension-recession hang back, hang looseBielschowsky Head Tilt Test three step teststrabolog-y, ist Strabismolog’y, istexact p values “Statistically significant”

Re: “lost to followup” - Avoid this at all costs; First it raises thepossibility that the patient had a (=) bad result or was otherwiseso unhappy with their care that they never came back - or wentelsewhere or went nowhere out of fear or dissatisfaction. If theyare “lost followup” you cannot refute the possiblity that one thosevery unhapy thingsppened! Second it is inexcusable - medico-

legally. Third: It reflects poorly on you as both a health careprofessional and as a scientist and Fourth: under the worse ofcircumstances suggests or indicates that you may discriminateagainst those of lower socio-economic status (research findings).

WRITING STYLE IS IMPORTANT TOO:(from Investor’s Business Daily Nov. 26, 1997 by Morey Stettner)“Make Dry Data Come Alive in Your Reports ... tips on makingyour technical writing come alive:1. Remember that less is more. ... simplify your language andprune extra words. Eliminate jargon, and keep your sentencesand paragraphs short. ‘If you write in little bites, you break downlots of information for the readers so that it’s easier to absorb,’said Carolyn Mulford, president of The Writing Coach. ...2. White in the active voice. ... For example, write ‘When youreview the data, you will note these trends’. Avoid saying ‘Thesetrends were noted upon a review of the data.’ Another example:Write ‘We will examine’, not, ‘This has been examined’. ...3. Insert ‘talking subheads’. ... unbroken text can intimidate anyreader, ... organize your writing in sections with each carrying aneasy to understand subhead ... a talking subhead ... alerts thereader of what you’re about to discuss ... for instance, instead ofheading a section with ‘Cost of Scanners’ try ‘Rising Cost of theNext Generation of Scanners’. subheads should average 7 words.4. Run a test. ... ask someone in your audience group to read it.TABLES: Don’t forget the crowding phenomenon. It works inTables too. We prefer spaces to lines to separate the items in aTable. You can also get more material within whatever size limitsyou may have, using spaces instead of lines, especially verticallines. Horizontal lines are less of a sin. -PER 22(4)

Binocular Vision & Correspondence: Binocular Vision Fourth Quarter of 2007

Stra bismus Qu arte rly© Volume 22 (N o.4):A Medical Scientif ic e-Periodical pages 204-205

-204-

Letter to the Editor re:Refractive Surgery in Adults with Binocular Vision “Abnormalities”:

Pediatric ophthalmologists should standagainst spurious claims that laser vision correctionimproves amblyopia or binocular function inadult patients. Refractive surgeons, due to theirtraining and natural proclivities, lack a facileunderstanding of the vision system beyond theoptic nerve (some would say, beyond the posteriorlens capsule). In their eagerness to expand“therapeutic” indica tions for ref ractiveprocedures, they have wandered into the tall grassof ocular dominance columns and tripped over thehidden rocks of sensory fusion. They babble about“visual processing”. Unfortunately, members ofour sub-specialty occasionally aid and abet themin their misadventures.

Wasserman and McCoy1 recently publisheda letter in the venerable Archives ofOphthalmology titled "Improved Binocularityafter Laser in situ Keratomileusis". Theydescribed a 32 year old lady with a habituallyuncorrected visual acuity of 20/150 OD and 20/30OS, and a cycloplegic refraction of -1.75 + 4.50 x26 OD (20/25) and -1.00 + 0.25 x 170 OS (20/20).Her uncorrected Titmus stereoacuity was 5/9 dots(100 arc seconds). One month after refractivesurgery, her anisometropia was collapsed and heruncorrected Titmus stereoacuity was 9/9 dots (40arc seconds).

Refractive surgery is a form of opticalcorrection. It modifies the light focusingproperties of the cornea or lens, not the binocularprocessing capabilities of the visual cortex. It isnot a therapy for amblyopia; it does not improvestrabismus or binocular function beyond whatcould be obtained with the best non-surgicaloptical treatment. Many times the patient, forconvenience or other reasons, will not bother tomaximize his optical circumstances beforesurgery. The patient described by Wasserman andMcCoy was one such: given her preoperativecorrected visual acuity of 20/25, her correctedstereopsis would likely have been at least 60 arcseconds (7/9 dots) at the time of the firstexamination, and would probably have improvedto 40 arc seconds with a few weeks of spectaclewear. The authors did concede “(her) preoperativedecreased stereoacuity may have been related toher not wearing corrective devices and may have

improved with contact lens trial.” However, thefacts as presented, and the article’s title,encourage the naive reader to assume a distincttherapeutic effect of refractive surgery when noneexists.

Refractive surgeons are eager to believethat their procedures are psychovisually superiorto an excellent refraction and well-madespectacles; or a rigid contact lens for one eye; orclean and well-fitted soft contact lenses for a highspherical myope. They persuade themselves andsometimes lure their patients into the idea thatsurgery offers a unique path to improved corticalvision function, and publish conceptuallyignorant2, 3, poorly designed4, 5 and badlyconducted studies6, 7 to prove it.

We can't stop them but we shouldn't helpthem. Further, journal editors should make greateruse of binocular vision specialists in the peerreview process for this and similar publications.

Sandra M. Brown M.D.Concord, North Carolina

Email: [email protected]

References

1. Wasserman BN, McCoy CC. Improvedbinocularity after laser in situ keratomileusis.Arch Ophthalmol 2007; 125:1293-4.2. Godts D, Tassignon MJ, Gobin L. Binocularvision impairment after refractive surgery. JCataract Refract Surg 2004; 30:101-93. Brown SM. Binocular vision impairment afterrefractive surgery. J Cataract Refract Surg 2005;31:1268-9; author reply 9.4. Holopainen JM, Moilanen JA, Saaren-SeppalaH, et al. Unilateral photorefractive keratectomyfor myopic anisometropia improves contrastsensitivity. Ophthalmology 2004; 111:1095-101.5. Brown SM. PRK for myopic anisometropia.Ophthalmology 2005; 112:525; author reply -6.6. Lanza M, Rosa N, Capasso L, et al. Can weutilize photorefractive keratectomy to improvevisual acuity in adult amblyopic eyes?Ophthalmology 2005; 112:1684-91.7. Bro wn SM . PRK and amblyopia .Ophthalmology 2007; 114:1792; author reply


Binocular Vision & Correspondence: Binocular Vision Fourth Quarter of 2007

Stra bismus Qu arte rly© Volume 22 (N o.4):A Medical Scientif ic e-Periodical pages 204-205

-205-

email from one of our readers re 22(3):

“Thank you for this, but just to let youknow my copy has hand written comments on,notably, pgs 144,186 & 189.” - H.

From the Editor, In reply:Glad it got to you OK. And thanks for your

observations. Those are all intentional handwritten marks by me, and printed as intendedgraphics. They are intended to make sure thereaders get the right point! Hope you weren’toffended. -PER

To: Henry Metz, M.D. Loved your letter to theeditor of U.S. News & World Report (February 26,2007) May we publish it? -PER.In reply: Please feel free to publish it in yourJournal.

The Eyes Had It First

Because medical use of Botox waspioneered by a senior scientist at Smith-KettlewellEye Research Institute, our research staff waspleased to see the article “Beyond Wrinkles”(January 22). The piece was beautifully written ina way that could be easily understood by a generalaudience. The fact that therapeutic uses of thisdrug now outsell the cosmestic uses wasinteresting and encouraging, given that it was firstdeveloped 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 anon-surgical treatment for eyes that cross(strabismus) or that deviate outward as well as amedical treatment fo spastic closure of themuscles of the lids, not allowing the patient to see(blepharosp asm). The Food an d Dru gAdministration gave approval for these treatmentsin 1989 based on the results of the studies of Scottand his team demonstrating the safety andefficacy of this therapy. We are pleased that atherapy developed at Smith-Kettlewell to treatmisalignment of the eyes and uncontrolled spasmof the lid muscles has found so many other uses invarious 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 TuesdayMarch 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]


Binocular Vision & People and Places, News and Announcements Fourth Quarter of 2007

Stra bismus Qu arte rly© Volume 22 (N o.4):A Medical Scientif ic E-Periodical Pages 206

-206-

Practice Opportunities

Lansing, Michigan. Lansing Ophthalmology, PC isseeking a pediatric ophthalmologist to join theirlarge private practice (12 ophthalmologists).Orthoptist on site. Part time Michigan StateUniversity faculty position, if desired. Salary:US$220,000 A University/College town, Lansing iscentrally located to Chicago, Toronto and Detroit; anice place to live, work, and enjoy a good familylife. Http://www.loeye.com/contactus.phpContact: Charles Dobis <[email protected]>

Albuquerque, New Mexico: Family Eye Care andChildren’s Eye Center. A booming pediatricophthalmology practice booked out for 3 months.Emphasis will be placed on sharing responsibilitiesand revenue among physicians in an equitablemanner. Bonus based on productivity in addition tobase salary. Contact: Todd A. Goldblum, [email protected]. familyeyenm.comwww. kidseyenm.com

Pittsburgh, Pennsylvania. Senior partner’sretirement offers a unique change to join a buysprivate practice with established patient base.Pediatric Ophthalmology and Strabismus, Inc. Hasthree offices and academic appointments atChildren’s Hospital of Pittsburgh with opportunityfor teaching and research. Contact:Mrs. Judy Laughlin at [email protected]

Research Grants

The New York Chapter of the Pediatric Glaucomaand Cataract Family Association through the AlbertMedow Eye Foundation will be offering multipleresearch grants varying in amounts of $1000 to$10,000 for fiscal year 2007-2008. The grants arerestricted to projects dealing with pediatric anteriorsegment problems such as glaucoma or cataracts orother disorders that are associated with or may leadto the development of glaucoma or cataracts such asjuvenile rheumatoid arthritis or Peters Anomaly.Contact: Norman B. Medow, MD, Albert MedowEye Foundation, 225 East 64th St, New York NY10021.

The Blind Childrens Center announces theavailability of funding to support one year seedgrants for research to gain better understanding ofvisual impairment in children from birth to six years

of age. Grants of up to $20,000 will be awarded.Applications due by March 1, 2008. Contact:Midge Horton, Executive Director Blind ChildrensCenter. 323-664-2153 ext.328.

House Passes SCHIP

from the AAO Washington Report, August 2,2007, by Catherine Cohen.. Despite a high price tagand on-going partisan rancor, the House passed theState Children’s Health Insurance Program SCHIP)bill Wednesday night by a vote of 225 to 204. ...monumental expansion of coverage for the nation’slow-income children by adding $50 million to theprogram and a two year fix for Medicare physicianpayments. ... The Children’s Health and MedicareProtection Act (H.R. 3162) is financed by a 45percent increase in tobacco taxes and a phase out ofthe 12 percent to 19 percent differential thatMedicare Advantage plans enjoy over fee-for-service Medicare. ... It derails scheduled paymentcuts to physicians in 2008 and 2009 and provides a(point).5 percent positive update in those years. In2010 and 2012, physicians would face reductionsof 11 percent to 12 percent, because of a change tothe update factor. Physician fees would be updatedbeginning in 2010 through a system of six separatetarget formulas, including primary and preventivecare; all other evaluation and management services;imaging; major procedures; anesthesia; and minorprocedures and other services. ... problematicMedicare provisions were added..., including theauthority... to cut payments to physicians foroveruse of key codes. ... The biggest challenge...however, is the presidential threat of a veto. TheWhite House and key Republican leaders want tofund the current SCHIP program, but do notsupport [this] major push toward nationalgovernment health [email protected]

Meeting Announcement

Midway, Utah. THE 5TH Annual Solitude PediatricOphthalmology Roundtable Conference. TheZermatt Resort. February 16-17, 2008. (A “ski”meeting. Free time from 9:00 AM to 4:00 PM)Registered participants should bring a few of theirmost interesting or challenging cases for presen-tation and discussion in groups of no larger than15-20 participants. Contact: Intermountain Health-are CME Office. Tel: 800-842-5498; Fax: 801-442-3929; email: [email protected]

Http://www.loeye.com/contactus.php



Binocular Vision & Ed itorial: Fourth Quarter of 2007Stra bismus Qu arte rly© Volume 22 (N o.4):A Medical Scientif ic E-Periodical P. E. Romano, MD, MSOphthalmology Page 208

-208-

EDITORIAL: Optimists; “Improve”? Safety Stitches;Expanders vs Extenders; Serial Botox®; Surgery forSynergistic Divergence; Kestenbaums at length.

In THIS ISSUE

W e had already picked out a critical guest editorial for th islast issue of 2007 when we came across “Clear-Eyed Optimists”(see prior page 207). But why publish a critical scrooge-y editorialat the holiday season? Why not one full of cheerful and happythoughts and Optimism. So on the previous page we hope you willenjoy this happy headline news (for a change), an encouragingmessage of good cheer and that it will enlighten and lighten thepresent holiday season for you...

Please note: the author poses the question “To what dowe owe this improvement?” His answer is “Capitalism” Note thathis answer is NOT “Soc ialism”.

Another late breaking piece of good news: the ice sheetin Antarctica is enlarging- yes getting bigger, so that shrinkage upat the north pole may be meaningless for planet earth.

Brown SM. Refractive Surgery in Adults withBiniocular vision Abnormalities.Binocul Vis Strabismus Q2007; 22:204-205

Refractive Surgery FRAUD ?.

Or... what you mean by “improve” ?

W e thank Dr.Brown for exposing this outrage. It looks likefraud. Or to paraphrase Bill Clinton on ”is”: Just what do you meanby “improve”. This is a scientific journal, a scientific forum and wedeal in hard facts. This is not an advertisement soliciting business.Scientifically, we would say that there was ZERO EVIDENCE OFIMPROVEMENT OF BINOCULAR VISION or stereopsis in th iscase. The authors have taken the new ability of the patient toachieve better binocular vision without optical correction as animprovement. But we are ophthalmic sc ientists and medicaldoctors, not salesmen in this forum. The patient might considerTHEIR SITUATION “improved”, not having to wear spectacles toenjoy better binocular vision, but no self respecting vision expertwould consider this to be any real improvement in binocular visionper se as these referenced authors did (and their editor allowedthem to do!).

Park H-J, Guy J. Sixth Nervw Palsy Post IntravitrealBevacizumab for AMD: A New Possib ly Causal Relationshipand Complication. Binocul Vis Strabismus Q 2007; 22:209.

W e edited this paper by adding the second line of the title,believing and editing, as we now do, after the official abandonmentof key words by the powers that be, to add words here to the titleinstead, to broaden and make more specific the message relayedin the title of any article.

The unanticipated effect here, diplopia for the patient, butnot seem too serious, especially since it seems to be reversible.But let me tell you: when I awoke from my general anesthesia foropen heart surgery now some 7 years ago, and I opened my eyesto f ind I had a huge and nasty diagonal vertical diplop ia. Iimmediately figured I had suffered the dreaded open heart braininjury! Fortunately when they found my glasses and I put them on,I was able to regain binocular fusion and cure my diplopia. It doesre-occurr from time to time but less and less with the passage oftime. [it’s an RSO palsy by Bielschowsky head tilt test].

Shokida MF, Gabriel J, Sanchez C. Safety Stitch: AModification to Postoperatively Adjustable suture StrabismusSurgery of the Inferior Rectus Muscle. Binocul Vis StrabismusQ 2007; 22:210-215

A clever modification to these procedures which givesbetter results than prior similar ones (excellent review of andcomparison with prior reports) and removes the procedure from“not recommended” category..

Arn o l d R W , L em a n R E . R a d i o -O p a q u eModification/Substitute for the Wright Superior Oblique

Tendon Extender for Superior Oblique Muscle OveractionStrabism us. Binocul Vis Strabismus Q 2007; 22:216-220.

Another report from the northern fron tiers where Arnold isonce again making do with what is available, and then doing betterthan what we do where everything IS available!

W e wanted to take the opportunity to pick on Ken W right:In this paper, we changed the name of his procedure from SOtendon “expander” to SO tendon EXTENDER because of thedictionary definitions of these two relative terms:

Hauviller V, Gamio S, Sors MV. Essential InfantileEsotropia in Neurologically Impaired Pediatric Patients: IsBotulinum Toxin Better Primary Treatment than Surgery?Binocul Vis Strabismus Q 2007; 22:221-226

.The answer to the rhetorical question in the title is aresounding “yes” and the final sentence of the summary is “we nowuse botulinum injections as our primary treatment in these patients.”Considering the pragmatic advantages they describe, we suspectseria l Botox will find uses elsewhere in the near fu ture.

Khawam E, Terro A, Hamadeh I, Hamam. SurgicalCorrection of Synergistic Divergence Strabismus. A Report ofThree Cases. Binocul Vis Strabismus Q 2007; 22:227-234.

Authors’ Precis: This is a report of three cases ofcongenital synergistic divergence. The procedure of choice wouldbe denervation/extirpation of the lateral rec tus musc le along withresection of the medial rectus muscle of the affected eye(s). Fairlygood ocular alignment and elimination of the simultaneousabduction and of the abnormal head posture are possible, butabduction and adduction cannot be improved. C’est Ca!-per

Chang Y-H, Chang JH, Han S-H, Lee JB. OutcomeStudy of Tw o Standard-&-Graduated Augmented ModifiedKestenbaum Surgery Protocols for Abnormal Head Posturesin Infantile Nystagmus. Binocul Vis Strabismus Q 2007; 22:235-241. The authors have done a lot of work here, to achieve an OKfor an alternate recipe for this surgical situation, devised to avoidthe possibility of complications attending the original surgical recipe.

In fact, in this issue, we must commend the variousauthors for their persistence and success in managing some of themost difficult ocular motility and strabismus problems.

Also, see the review of Coats and Olitsky’s book oncomplications of strabismus surgery, so aptly reviewed in this issueon page 247. And abstracts and Hyde Park editorial w ith other inter-esting news of the eye business. -Happy Holidays -per

Binocular Vision & Six th Nerve Palsy Post In trav itrea l Bevacizumab for AMD: Fourth Quarter of 2007Stra bismus Qu arte rly© A New Possibly Causal Relationship and Complication? Volume 22 (N o:4):A Medical Scientif ic E-Periodical H-J Park , MD, MPH and J . Guy, MD Pages 209

-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

Bevacizumab is a non-specific vascularendothelial growth factor (VEGF) inhibitor that wasfirst approved for treatment of metastatic coloncancer. This medication (off-label) and another in thisclass, ranibizumab, have been extensively utilized fortreatment of neovascular age-related maculardegeneration (AMD) and other causes of choroidalneovascularization that include high myopia,proliferative diabetic retinopathy, retinal veinocclusion, macular edema and neovascular glaucoma.

Although both medications are generally welltolerated, some serious systemic adverse events havebeen reported. In a study of 412 patients treated withintravitreal injections of 1.25 mg of bevacizumab,adverse events included transient increase in arterialblood pressure, dizziness and tinnitus.

Some serious adverse events in this studyincluded one case of TIA and two cases of myocardialinfarction (one fatal) that occurred within 3 monthsafter intraocular injection of bevacizumab. Wu andcoworkers described seven cases of an acute elevationof systemic blood pressure (0.59%), sixcerebrovascular accidents (0.5%), five myocardialinfarctions (0.4%), two iliac artery aneurysyms(0.17%), two toe amputations (0.17%) and five deaths(0.4%). A large multi-center trial on ranibizumabreported nine cases of MI (3.8%) and nine cases ofstroke (3.8%) after either 0.3 mg or 0.5 mg ofrepeated intraocular ranibizumab injections.

Here we report a patient who developed amicrovascular sixth cranial nerve palsy after repeatedintravitreal injections of bevacizumab.

CASE REPORTA 62 year old gentleman received three

intravitreal injections of bevacizbumab into his righteye, between December 2006 and May 2007, for wetmacular degeneration. Five days after his lastinjection, he complained of binocular horizontaldiplopia. He had no other symptoms. He had had anMI 20 years ago. He was a smoker. Medicationsincluded 81 mg of aspirin and ibuprofen, as needed.

Neuro-ophthalmic examination revealedvisual acuity of 20/60 OD and 20/20 OS. There was

no afferent pupillary defect. Eye movements showeddecreased abduction of the left eye on left lateralgaze. In primary gaze he measured 30 diopters ofesotropia. Confrontation visual fields, intraocularpressure, and biomicroscopy of the anterior segmentwere normal. Ophthalmoscopy showed wet maculardegeneration in the right eye. Contrasted MRI of headand orbit was normal. One month later changes in thepatient’s examination revealed an improvement inabduction of the left eye and the esotropia decreasedto 14 diopters in primary gaze.

In a review of the medical literature we wereunable to find a microvascular ocular motor nervepalsy temporally associated with intravitreal injectionof bevacizumab. This patient, however, seriouslybelieved that the treatment was the cause of hisdiplopia and he refused any further treatment for hismacular degeneration.

Despite the increased risks of stroke and MI,we cannot establish causality to treatment with anycertainty, as our patient had vasculopathic riskfactors. Still we were unable to find any previouslyreported association of intraocular injection with anti-VEGF agents to a microvascular sixth cranial nervepalsy

WARNING / CONCLUSION

Here, we wish to alert our colleagues of thispotential adverse event. We believe that this relativerisk is minor and it should in no way dampenenthusiasm for the off-label use of bevacizumab forvisual loss associated with AMD.

Received for consideration October 16, 2007;accepted for expedited publication October 30, 2007.

Correspondence/reprint requests to Dr. Guy,Dept Ophthalmology, University of Florida, PO Box100284 , Ga inesv i l l e FL 32610-0284 [email protected]


Binocular Vision & Safe ty Stitch. A Modifica tion to Postop eratively Adjustable Suture S trabism us Surge ry Fourth Quarter of 2007Stra bismus Qu arte rly© of the Infer ior Rectus M usc le Volume 22 (N o.4):A Medical Scientif ic e-Periodical M.F . Shok ida, MD, J . Gabrie l, MD and C. Sanchez, MD Pages 210-215

-210-

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 inferiorrectus 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 thesubjects 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 witha silicon sheet was used. We added a non-absorbable suture in the medial edge of the tendon of theinferior rectus muscle and fixed it at the scleral insertion of the muscle. This area of the inferior rectustendon was exposed for the adjustment, which was performed 24-48 hours after the surgery. The safetysuture was then fastened with a knot and 4-6 prism diopters (pd) of undercorrection in down gaze wasintentionally left.

Results: The average preoperative vertical deviation was 17 prism diopters (pd) in primaryposition, and 21.6 pd in down gaze. Six of the eleven patients were adjusted postop’ leaving an averageresidual 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 elevenpatients were considered to have “successful” primary surgery using this technique. The eleventhrequired a second operation for an undercorrection which resulted from inadequate original placementof the safety stitch.

Conclusion: The non-absorbable safety stitch technique provided satisfactory results, superiorto previously reported techniques for postop’ adjustable recession strabismus surgery of the inferiorrectus 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-

Figure (Shokida et al): Left: Intraop’:The safety stitch is fixed in the sclera at the tendon insertion with a halfbowknot. Right: Postop’ 24-48 hours: The absorbable suture and the safety stitch are adjusted and cut.

INTRODUCTION

A postoperative slipped muscle is a surgicalcomplication described by Parks & Bloom in 1979(1). It produces a new incomitant strabismus andundesired overcorrection. The inferior rectus andmedial rectus are the two most common extraocularmuscles to sustain this complication. Thepostoperatively adjustable suture technique of theinferior rectus muscle has been controversial becauseof frequent postoperative overcorrection SeeDiscussion for details. As Jampolsky says (2,3) theinferior rectus muscle is an “unfriendly muscle”because surgery on it can lead to lid retraction withasymmetrical lid fissures and limitation of down gaze.For that reason, some surgeons will no longer use thepostop’ adjustable suture technique for the recessionof the inferior rectus muscle.

The purpose of this paper is to report a newtechnique to prevent slippage after an adjustablesuture using a non-absorbable “safety stitch” in themedial edge of the tendon.

METHODS

The subjects of this study were elevenpatients, five women and six men, aged 13 to 65 years

old, that had surgery of the inferior rectus muscleusing this new postop’ adjustable suture technique,from July 2000 to December 2004. Seven hadsuperior oblique palsy; two had a III nerve palsy (oneof them because of meningioma and the other one dueto orbit fracture); and two patients had developed ahypertropia after glaucoma surgery.

Patients with previous strabismus surgery orthyroid myopathy were not included. The verticaldeviation was measured in all gaze positionspreoperatively, 24 hours after surgery, and after aminimum followup of one year. However, only theprimary position and down gaze positions werecompared pre- and postoperatively.

In this report, a double-armed vicryl 5/0(Ethicon) suture was used. The muscle was cut fromthe sclera and a slipknot was placed for adjustment.Then a non-absorbable safety stitch (Mersilene 5/0)was anchored from the medial edge of the tendon tothe sclera, fastening it with a half bowknot.

The safety stitch has to be placed transverselyto inferior rectus muscle fibers, to insure the muscleand its sheath are fixed together by the safety suturepreventing the muscle slippage. See Figure , below.

To facilitate delayed adjustment, a silicon


-212-

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

sheet was placed intraoperatively under the muscle toprevent adherence to the sclera, as described in aprevious report (4).

The safety stitch was not tied and fasteneduntil the end of the adjustment 24-48 hours aftersurgery, when the vertical deviation was measuredand any necessary adjustment was performed toachieve the desired vertical binocular alignment. Avertical undercorrection of 4-5 pd in down gaze wasintentionally left. Then, the two sutures, both theabsorbable and non-absorbable, were tied. Finally, thesilicon sheet was removed and the conjunctiva closed.In inferior rectus recession of 5 mm or more (cases 1and 4) Jampolsky’s technique was used to preventeyelid retraction (3).

In the first 6 months after surgery the inferiorrectus muscle can slip leading to overcorrection.Sometimes, this complication can appear even later.To make sure that our measures were stable, we chosea longer followup, a minimum of 12 months.

The average followup ws 27 months. Theinferior rectus muscle was recessed from 2.5 to 5.5mm from the limbus with an average recession of 3.2.mm.

RESULTS

The individual case data are shown in Table1, below. The average data of the vertical deviation


-213-

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 inprimary position and down gaze are shown in Table2, ABOVE.

The average followup was 27 months. Theinferior rectus muscle was recessed from 2.5 to 5.5mm, with a median amount of 3.2 mm.

The surgery was considered “successful”when there was no diplopia after a year, and thebinocular misalignment in primary position was lessthan 3 pd. In Table 1 ten of the 11 patients were“successful” by this criteria, Six out of the 11patients were initially adjusted to correct diplopia andto achieve the desired binocular alignment in primaryposition.

Complications:

One patient developed an overcorrection andhad to have further surgery. In one patient, the suturebroke during adjustment and had to be replaced. Onepatient developed chemosis due to an allergic reactionto the suture. None of them showed eyelid retractionpostoperatively.

DISCUSSION

The postoperative adjustable suture techniquefor inferior rectus muscle strabismus surgery iscontroversial. Among other complications, there canbe slippage of the muscle with secondaryovercorrection. Cruz & Davitt (5) have reported a

study with good results but only 6 weeks followup.They performed bilateral asymmetrical inferior rectusmuscle recessions with postop’ adjustable sutures inthe hypotropic eye to avoid overcorrection.

Sprunger & Helveston (6) found anovercorrection rate of 40% when using adjustablesutures on the inferior rectus muscle. All their caseswere adjusted to an orthotropic position. The authorsexplained that when the eye moves from abduction toadduction the inferior rectus muscle tends to slip and,in the same way, when the inferior oblique musclecontracts, the inferior rectus muscles moves to themedial side. To reduce the risk of slipping, theysuggested that the inferior rectus muscle should bedissected more than 10 mm from the insertion. Theyalso suggested bilateral asymmetrical inferior rectusrecessions or the use of tandem sutures for thyroidmyopathy.

Vasquez & Muñoz found an average of 12 pdpostoperative overcorrection in 5 out of 20 patientsoperated with the adjustable suture technique. Theyrecommended leaving the patients with anundercorrection on adjustment.

Ruttum (8) had 53% of cases withovercorrection using an adjustable suture versus 18%without. They found 2.5 pd correction per mm ofrecession of the inferior rectus muscle, 4 mm beingthe average. An inferior rectus recession of 3.5 to 6.5mm was performed with overcorrection of 7 to 35 pd.


-214-

In their study 10 out of 30 patients had less than 5months followup.

Lueder et al (9), and Krauss & Bullock (10)prefer the use of adjustable suture for inferior rectussurgery. On the other hand, Mazow (11) performs itdepending on the findings during the surgery. If theinferior rectus muscle is elastic, the adjustabletechnique is applied; if the muscle is inelastic, it isavoided.

Chatzistefanou, Kushner & Gentry (12)studied the contact arc of the extraocular muscle byusing MRI. They found that the inferior and medialrectus muscles have a shorter contact of arc comparedto the lateral and superior rectus muscles. The inferiorrectus muscle has a tendency to slip when it isrecessed, perhaps because of the tight tissuessurrounding it. In down gaze, they act togethermoving the pulley backwards and diminishing thecontact with the sclera. This may explain the tendencyto slip after surgery when these muscles are recessed.

The inferior rectus muscle has differentanatomic features from the superior rectus muscle,because of its connections to the inferior obliquemuscle, the vascular bundle and Lockwood’sligament.

In Graves Disease and other restrictivepathology there may also be an abnormal innervationdue to Hering’s Law, which would lead to postsurgery overcorrection. When the inferior rectusmuscle is recessed and the hypotropic eye is able tomove upwards, the excess innervation of the superiorrectus muscle of the non affected fixing eye, would bepassed onto the superior rectus muscle of the operatedeye, causing the eye to become hypertropic.

Wright (13) describes late overcorrection ofthe inferior rectus muscle in some patients withGraves Disease who needed further surgery after 4-6weeks. He believes that the overcorrection was due toexcessive scarring after the extended inferior rectusdissection performed to avoid eyelid retraction. Hesuggests limiting the dissection to avoid excessivescars. However, if it is not done, postoperative lowereyelid retraction could increase.

Kushner (14) published a semi-adjustabletechnique to avoid overcorrections. He fixed the two

borders of the inferior rectus muscle to the sclerawith absorbable sutures, leaving one extra absorbablesuture, for the adjustment, in the middle of themuscle. This technique has limitations as far asadvancing or recessing the muscle.

In our study, we introduce a new techniquewhich provides a better fixation to the sclera, toavoid this complication. We add a non-absorbable“safety stitch” in the middle edge of the tendon of theinferior rectus muscle, where the muscle tractionmakes a concavity when a “hang-loose” suture isused with the adjustable suture technique. In therecession of the inferior rectus muscle with theadjustable suture technique, we use an absorbablesuture together with a non-absorbable one as a safetystitch to avoid later overcorrection. Also we leave anundercorrection of 4-5 pd in down gaze and warn thepatient that any postop’ residual vertical diplopia willimprove with time.

Case 11, with superior oblique palsy in theright eye, showed hypercorrection with inverted tiltand lower eyelid retraction after 2 months. Thepatient was operated upon again and it was found thatthe intrasheath portion of the inferior rectus musclehad slipped 3 mm while the muscle sheath remainedfixed to the reattachment site with the non-absorbablesuture. The slipped inferior rectus muscle wasadvanced and the patient achieved orthotropia inprimary position and 5 pd hypertropia in down gaze.In this case, overcorrection was probably due to amisplacement of the safety stitch, which had beenplaced too parallel to the fibers of the muscle insteadof transversely, and pulling out postoperatively.

That is why we emphasize that the stitch hasto be placed transversely to the muscle fibers to makesure that the muscle and the sheath are fixed togetherby the suture. This case showed that, even using anon-absorbable safety stitch, the muscle could slip ifit is not placed correctly, transversely to the musclefibers.

CONCLUSION

The variation that we propose to theadjustable suture technique is to add a non-


-215-

absorbable “safety stitch” to avoid the slipping of theinferior rectus muscle. We believe that it is a goodmodification to the inferior rectus adjustment. It isalso important to adjust to leave a littleundercorrection of 5 pd in down gaze because theaverage correction of pd per mm in the inferior rectusrecession is greater in down gaze than in primaryposition.

REFERENCES

1. Parks MM, Bloom JR. The slipped muscle.Ophthalmology 1979; 86:1389-1396.2. Jampolsky A. Surgical leashes and reverse leashesin strabismus surgical management. In: Symposiumon Strabismus. Trans New Orleans AcadOphthalmol, Mosby, St. Louis 1978; 244.3. Jampolsky A. Current technique of adjustablestrabismus surgery. Am J Ophthalmol 1979; 88:406-418.4. Shokida MF. Use of a silicon sheet for delayedadjustable strabismus surgery. Ophthalmic Surg1993; 24:486.5. Cruz OA, Davitt BV. Bilateral inferior rectusmuscle recession for correction of hypotropia indysthyroid ophthalmopathy. J AAPOS 1999; 3:157-159.6. Sprunger DT, Helveston EM. Progressiveovercorrection after inferior rectus recession. JPediatr Ophthalmol Strabismus 1993; 30:145-148.7. Vazquez CW, Munoz M. Overcorrection afteradjustable suture suspension-recession of the inferiorrectus muscle in non-thyroid eye disease. Binocul VisStrabismus Q 1999; 14:103-106.8. Ruttum MS. Adjustable versus non-adjustablesutures in the recession of the inferior rectus musclefor thyroid ophthalmopathy. Binocul Vis Eye MuscleSurg Q 1995; 10:105-112.9. Lueder GT., Scott WE, Kutschke PJ, Keech RV.Long-term results of adjustable sutures surgery forstrabismus secondary to thyroid ophthalmopathy.Ophthalmology 1992; 99:993-997.10. Krauss DJ, Bullock JD. Treatment of thyroidocular myopathy with adjustable and non-adjustablesuture strabismus surgery. Trans Am OphthalmolSoc 1993; 91:67-84.11. Mazow ML. Discussion of treatment of thyroidocular myopathy with adjustable suture and non-

adjustable suture strabismus surgery. Trans AmOphthalmol Soc 1993; 91:81.12. Chatzistefanou KI, Kushner BJ, Gentry LR.Magnetic resonance imaging of the arc of contact ofextraocular muscles: Implications regarding theincidence of slipped muscle. J AAPOS 2000; 4:84-93.13. Wright KW. Late overcorrection after inferiorrectus recession. Ophthalmology 1996; 103:1503-1507.14. Kushner BJ. An evaluation of the semi-adjustablesuture strabismus surgical procedure. J AAPOS2004; 8:481-487.

Binocular Vision & Radio-Opaque Modification/Substitute fo the Wright Superior Oblique Tendon Extender Fourth Quarter of 2007Stra bismus Qu arte rly© for Superior Oblique Muslce Overaction Strabismus Volume 22 (N o.4):A Medical Scientif ic E-Periodical R.W . Arno ld , MD and R.E. Leman, RN Pages 216-220

-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.

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 AK99501. Fax: 907 278 1705. Email: [email protected]



-217-

INTRODUCTION:

Kenneth Wright developed a technique forgraded weakening of the superior oblique byexpansion with a piece of silicone retinalencircling band1. In the absence of specific retinalband in the Children’s Hospital, the followingtechnique was developed affording a non-invasive ability to monitor less intricate than thetechniques so well described by Demer2.

METHODS:

In an IRB approved strabismus study,from 1993 through 1999, all cases of strabismusin a community-based pediatric eye practice weremonitored.

The “Mini Vessel Loop” (by MaxximMedical or Henley International) is an elasticsmooth silicone cord that is opaque, and caneasily be seen on X-rays. It is not anophthalmologic medical device but it ratherdesigned to gently retract and identify bloodvessels and nerves in any form of surgery whereneeded.

From 1993-1999, pre-measured portionsor lengths of this Mini Vessel loop (white oryellow) were sewn end-to-end to the divided endsof the superior oblique tendon, with 8-0 nylonsuture ( See Figure 1, below) in cases of


-218-

strabismus due to significant overactive superioroblique extraocular muscles, Brown’s syndromeand orbital strabismus with positive SO tractiontests. These cases were compared to cases of A-pattern with overacting superiior obliquesundergoing strabismus surgery during the sametime period treated with perpendicular shift of thesuperior oblique tendon insertion. Three casescame to neuroimaging for various reasons.

RESULTS:

During the study interval, 1,111 adult andpediatric strabismus cases were performed. Inthese, 72 superior oblique tendons (in 43 patients)were extended with Mini Vessel loops (4% ofstrabismus cases). The breakdown of indicationswas: 26 cases of A-esotropia with overactingsuperior obliques (age 7±8 years), 4 cases of A-exotropia with overacting superior obliques, 9cases of Brown’s syndrome and 4 cases of orbitalstrabismus with a positive tight superior oblique

traction test.

The mean superior oblique lengthening inthese 72 surgeries was 5.2 mm OD [in right eyes]and 4.7 mm ) OS [in left eyes].

During this time, another 27 A-patternstrabismus surgery cases (age 9±9 years) did nothave significant superior oblique overaction andtherefore had perpendicular superior obliqueinsertion shift.

Three cases had head X-rays and/orcomputed tomography that easily demonstratedthe presence and orientation of the superioroblique Mini Vessel Loop extenders (SeeFigures 2, below, and 3, next page.)

We did not specifically look for displace-


-219-

ment of the trochlea in these cases. With follow-ups of 6-12 years postoperatively, in no case didthe Mini Vessel Loop cause either brief orprolonged orbital inflammation, though in onecase, an appparent, self-limited case of superioroblique myokimia was home-video documentedin a pediatric patient living in a remote Alaskavillage. The parent videoed ocular movementswhile the child watched TV and promptly flewthe media in to us for rapid interpretation andrecommendations.

CONCLUSION:

The Mini Vessel Loop is an inexpensiveand readily available alternative to retinalencircling band for superior oblique tendonextension3,4. Consisting of medical siliconerubber like retinal encircling bands, they do notappear to cause any inflammation and if andwhen needed, can be non-invasively observedusing ordinary X-rays.


-220-

REFERENCES

1. Wright KW. Superior oblique siliconeexpander for Brown syndrome and superior obliqueoveraction. 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, prospectivestudy of extraocular muscle imaging in complexstrabismus. J AAPOS. Dec 2002;6(6):337-347.

3. Wright KW. Results of the superioroblique tendon elongation procedure for severeBrown's syndrome. Trans Am Ophthalmol Soc2000;98:41-48; discussion 48-50.

4. Stolovitch C, Leibovitch I, Loewenstein A.Long-term results of superior oblique tendonelongation for Brown's Syndrome. J PediatrOphthalmol Strabismus. 2002;39(2):90-93.

Binocular Vision & Essential Infantile Esotropia in Neurologically Impaired Pediatric Patients: Fourth Quarter of 2007Stra bismus Qu arte rly© Is Botulinum Toxin Better Primary Treatment than Surgery? Volume 22 (N o.4):A Medical Scientif ic e-Periodical V . Hauv ille r, M.D, S . Gamio , MD and MV Sors , MD Pages 221-226

-221-


Essential Infantile Esotropia in Neurologically

Impaired Pediatric Patients: Is Botulinum ToxinBetter 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 withinfantile esotropia and neurological problems to answer this question.

From November 1996 to March 2006 they were treated with injections of botulinumtoxin (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 - 59months) 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. Wecompared our success rate data with those obtained with primary conventional strabismussurgical procedures in 2 previously published series. Treatment with botulinum toxin seemedto produce better results than one surgical series and at least equally similar results to theother one. Because there are, as well, so many other advantages to the injection procedureincluding superior safety and economy, we now use botulinum injections as our primarytreatment 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-

INTRODUCTION

In essential infantile esotropia there is noassociated neurological abnormality, but thisesotropia is more frequent in premature andneurologically impaired children. Surgery inthis group is often delayed for various reasonsand the results of surgery are therefore lesssatisfactory. Under or overcorrection resultsare more frequent than in non-neurologicalpatients.

Botulinum toxin has been used to treat cases ofstrabismus at risk for surgical overcorrection. Itis not known whether this method isspecifically applicable to essential infantileesotropia in neurologically impaired infants.Therefore we undertook to study this. To ourknowledge this is the first study comparing thesuccess rate of botulinum in these cases withthe succes rate in previously published standardstrabismus surgery in neurologically impairedpatients.

PATIENTS AND METHODS:

Every consecutive patient with infantileesotropia and neurological impairmentregistered at the Ophthalmologic Department ofthe Children Hospital Ricardo Gutiérrez fromNovember 1996 to March 2006 were included.

Patients with Duane’s Syndrome, sixth nervepalsy and accommodative esotropia wereexcluded. Clinical evidence of oblique muscledysfunctions, alphabetic pattern, optic nervehypoplasia or atrophy were also reasons forexclusion.

The resulting cohort of 25 patients in this studyhad hydrocephalia (8 cases), microcephalia (2),West's Syndrome (1), Prader Willy's Syndrome(1), hemiparesia (1), myelomeningocele (5),maturation delay (3), leucoamalacia (1),c e r e b r a l p a l s y ( 2 ) a n d i n t ra c e r e br a lhemorrhage(1). (See Table 1, next page.)

State of the fundus and refraction were recordedas was the prescription of glasses when neededprevious to the strabismus thera-peuticprocedure.

The strabismic angle was measured by twoof the double blind authors, with prisms, bycover test or by Krimsky corneal light reflectiontest.

Alternate patch occlusion of the eyes for atleast 15 days before treatment was indicated andcarried out.

One dose of 2,5 - 3,75 U of botulinum toxintype A, (Botox® by Allergan) was injected inboth medial rectus muscles under generalanes thesia in every case and withoutelectromyographical guidance.

The patients were re-examined postoperative-ly after 7 days and every 30 days thereafter.

Every patient with a postop’ residualesotropia angle greater than 10 prism diopters(PD) was reinjected until the postop’ esotropiaangle remained less than 10 PD. If that resultcould not be obtained with injection, suchpatients received conventional strabismus eyemuscle surgery.

RESULTS:

Of our 25 patients, 18 (72%) of patientsremained in between 10 PD of esotropia andorthotropia with an average follow up of 29months (range 6 - 59 months) after last injec-tion. (See Table 1, next page.)

Nine of the 18 patients (50%) received onetreatment, eight (44,4%) received two and one(5,5%) was treated 3 times. The average was 1.5 Botox treatments per patient.

Because of residual esotropia not adequatelyresponding to Botox injection, the remaining 7patients were operated on and their esotropiacorrected by conventional eye muscle surgery.No one remained overcorrected.

(Continued)


-223-

Figure 16

TABLE 1. Methods and Subjects and Results in Study ofBotulinum Toxin Injection Primary Treatment of

Essential Infantile Esotropia in 25 Neurologically Impaired Children

DD = Developmental Delay; DP = Prism Diopters Esodeviation; MMC =Myelomeningocoele


-224-

Figure 16

TABLE 2. Comparison of Results in Three Studies ofBotulinum Toxin Injection Treatment Versus Surgical Treatment of

Essential Infantile Esotropia in Neurologically Impaired Children

PD = Prism Diopters Esodeviation;

“Central” Neurologic Im pairm ent = 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 nervepalsy, retinopathy of prematurity.

Figure 1 (Hauviller): Patient with West Syndrome and esotropia, before (left) and after (right) botulinum treatment.


-225-

Figure 2: (Hauviller et al): Patient with myelo-meningocoele before (top) and after (bottom)treatment with injections of botulinum toxin.

(RESULTS, continued from page 222)

Complications: In 14 cases transient palpebralptosis and in 8 cases vertical strabismic deviationswere detected. The latter, when long-lasting weretreated by being alternately occluded by patching.

Temporary overcorrection (consecutiveexotropia) was observed and recorded in all thesuccessful injection patients (mean angle ofexotropia (XT) was 31.5 PD, range 10-65 PD.Three of the unsuccessfully injected have had aresidual exoshift, mean angle 20 PD (range 10-30PD).

DISCUSSION.

In strabismic patients with neurologicalimpairment, the surgical outcome is less favorablethan in healthy patients. Different results would beinfluenced by sensorial (smaller fusional reserve)and motor reasons (muscular dystonia). In part thepoor results of surgery in this group of patientsmight be related to the more conservative delayedtreatment given to these infants.

Comparison With Previously Published seriesof similar cases (see Table 2, prior page),...

Holman and Merritt (1) reported 29 operatedpediatric neurological patients: only 55.2%remained orthotropic. 24.1% of them showedresidual esotropia and 20,7% were overcorrected.Their mean follow-up was 25 months and the meanage 31 months. Their series also included somepatients with sensorial and motor ocular conditionslike optic nerve hypoplasia and atrophy, Duane'sSyndrome and, sixth nerve palsy. Our seriesexcluded this kind of patients, not allowing anentirely valid comparison.

Their success rate is statistically significantlylower than ours. (chi square test , p<0.02).

Charles and Moore (2) reported a 74% successrate in 28 premature or neurological children 27months after surgery. Average age was 15 months.14 patients were reoperated: 6 under corrected and2 overcorrected, 5 for inferior oblique over actionand 1 for DVD.

Statistically significant differences could not bedetected comparing out results with these authors’success rate.

Twenty-three pediatric patients with systemic orneurological conditions treated with botulinumtoxin were reported by Moguel (3). Age, follow upand success rate data were not available but theiroutcome has been favorable. A statisticalcomparison with our series is not possible.

Moguel (3) recommended Botox not as aprimary treatment strategy but rather as analternative therapy when the patient can notundergo further surgery procedures for strabismus.

The predicting factors for success help to definethe ideal candidate for each determined treatmentstrategy. In the case of botulinum toxin, youngerage (4), smaller esotropia angles, (5,6) a capacityfor future binocular fusion (7), and the type ofesotropia (5) have been reported as favorable forBotox injection. Not one of these predictor factorsfor success is present in this type of patients withcongenital esotropia and neurological impairment,so the reason for our group of patients' goodresponse is unknown. On the other hand the non-neurologic esotropic patients do not respond actionso well or easily to the Botox treatment.


-226-

Advantages of botulinum toxin: treatment ofstrabismus include: The incidence of complicationsis rather low and rarely significant enough to makethe patient discontinue repeated treatment (8).

Also, the shorter anesthetic time is welcome anddesireable in all infants, but especially neurologicalimpaired children.

Not one permanent overcorrection was observedin our series.

The toxin injection produces neither scars norrestrictions, can be repeated with minimal and lessrisk than repeated surgeries, and does not requiretracheal intubation, all signficant advantages. Thewhole procedure lasts but a few minutes.

Disadvantages include: a frequent need ofrepeated procedures, postop’ blepharoptosis,vertical deviations, and the fact some patients donot respond well, the treatment isn’t effective evenif it is safe, and they must be operated upon byconventional strabismus surgery with its moreserious risks and complications.

CONCLUSION

In our series of neurological impaired pediatricpatients, botulinum toxin allowed similar or highersuccess rate compared with 2 previously publishedsimilar surgery series in these patients. Being asimple and safe procedure, it is now considered inour hospital to be indicated as the primarytreatment strategy for these neurologically impairedesotropic infants and children.

References:

1) Holman RE, Merritt JC: Infantile Esotropia:results in the neurologic impaired and normal childat NCMH (six years), J Ped Ophthalm Strab 1986,23(1) 41-5.

2) Charles SJ, Moore AT: Results of earlysurgery for infantile esotropia in normal andneurologically impaired infants. Eye 1992 (6Pt):603-6.

3) Moguel Ancheita S, Martinez Oropeza S: Usode la toxina botulínica en estrabismos asociados apadecimientos sistémicos en los niños. Actas deClade, Acapulco, ed M. ArroyoYllanes, 1998, 91-5.

4) Campos E., Schiavi C, Bellusci C: Criticalage of botulinum toxin treatment in essentialinfantile esotropia. J of Ped Opthalm and Strab2000; 37:328-332.

5) Hauviller V, Gamio S, Tartara A: Botulinumtoxin therapy in paediatric esotropia: risk factors forfailure. In Transactions 27th Meeting EuropeanStrabismological Association, Ed De Faber 2001,199-201.

6) Tejedor J, Rodriguez JM: Long-term outcomeand predictor variables in the treatment of acquiredesotropia with botulinum toxin. Invest OphthalmolVis Sci.2001; 42:2542-6.

7) Dawson E, Marshman WE, Lee JP: Role ofbotulinum toxin A in surgically overcorrectedexotropia J AAPOS 1999 Oct 3(5) 269-71.

8) Dutton JJ, Fowler AM: Botulinum toxin inOphthalmology. Survey of Ophthalmology, 2007;52, 13-31.

Binocular Vision & Surgical Correction of Synergistic Divergence Strabismus Fourth Quarter of 2007Stra bismus Qu arte rly© A Report of Three Cases Volume 22 (N o.4):A Medical Scientif ic E-Periodical E . Khawam, MD, A . Terro , MD, I. Hamadeh, MD and R. Hamam, MD Pages 227-234

-227-

Case Reports

Surgical Correction of Synergistic DivergenceStrabismus

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 characteristicsof synergistic divergence and compare the surgical effects on each of those characteristics.

Methods of study: Three patients demonstrating findings characteristic of synergisticdivergence, two bilateral and one unilateral, are reported. Surgery consisted on denervationextirpation of the lateral rectus muscle along with resection of the medial rectus muscle of theaffected eye or supramaximal recession of the lateral rectus muscle and resection of theantagonist medial rectus muscle of the affected eye.

Results: The simultaneous abduction and the abnormal head posture responded well tosurgery. The exotropia was reduced. The deficient adduction, the total absence of activeabduction and the infraduction of the synkinetically abducting eye remained unchanged.

Conclusion: Synergistic divergence is a severe exotropic form of Duane’s Syndrome wherethe feature of simultaneous abduction is the most striking.

To date, no surgical procedure leads to satisfactory results on all the characteristics ofsynergistic 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




-228-

INTRODUCTION

Synergistic divergence (SD) is acongenital syndrome of limitation of adductionwith simultaneous abduction (SA) of both eyeson attempted gaze into the field of action of theweak medial rectus (MR) muscle, large angleexotropia, face turn, and often depression of thes y n k i n e t i c a l l y a b d u c t i n g e ye ( 1 , 2 ) .Electromyography (EMG) has demonstratedsimultaneous innervations of the horizontalrectus muscles on the involved side. Thisinnervational pattern is paradoxical, showingincreased firing of the lateral rectus (LR)muscle on opposite gaze, suggesting that thiscondition is due to neurological miswiring andshould be considered an exotropic variant ofDuane’s Syndrome (DS) (3,4). The LR musclecan be only anomalously innervated by theoculomotor nerve or both anomalously andnormally by the abducens nerve (5). Wagner etal (6) demonstrated by EMG normal innervationof the MR muscle and maintenance of a normalpattern of reciprocal innervation with respect togaze. However, Thomas et al (2) reported onecase of congenital bilateral SD where, on forcedgeneration technique, both lateral rectusmuscles contracted on attempted levoversionand dextroversion as well as attemptedconvergence. However, the medial rectusmuscles did not contract on any of theseattempted movements. Moreover, EMG of themedial rectus muscles showed a flat tracing.

The infraduction of the synkineticallyabducting eye as well as the A-pattern withfurther divergence of the eyes in downgaze arebelieved to be due respectively to co-contractionof the SO muscles (7) or to increased motor unitactivity of the MR muscles on attempted upgazeobserved electromyographically (8).

Clinically it is very difficult to rule in orrule out a normal or sub-normal recruitment ofthe LR muscle because in most cases, theaffected globe is frozen in a large exo position

with minimal ocular movement. However, incase the LR has both normal innervation by theVIth and anomalous innervation by the IIIrd,simple observation (5) reveals the following: Asthe fixing RE, whether affected or not, movesfrom primary to right gaze, the affected LEsimultaneously moves out due to co-contractionof the LR muscle. As the RE moves backtoward the primary position, the non-fixing LEreduces its outward position since the MR of theaffected LE is now inhibited by Sherington’sLaw. Finally, if the RE now continues to fixtoward adduction, the non-fixing LE abducts viaHering’s Law if, and only if, the left LR musclehas any normal innervation.

SD can be unilateral or, rarely, bilateral.The laterality (6) has a similar distribution tothat seen in DS. The left eye (LE) is affected in64%, the right eye (RE) in 26% and both eyes in10%. 63% were males and 37% were females.

SD can also be observed iatrogenicallyfollowing large MR recession (9) and/or LRresection (10) or under topical anesthesia afterdisinserting the MR muscle (5) of the eyeaffected with DS. Whether it is congenital oriatrogenic, it is the quantitatively greaterinnervation of the LR muscle compared to itsantagonist MR muscle by the oculomotor nervethat produces abduction of the affected eye(s) atthe same time as attempted abduction of thefellow fixing eye (3,5).

It is the weakened or paralytic MRmuscle that is overpowered by the intenselyanomalously innervated LR muscle thatproduces the observed simultaneous abductionon attempted adduction, instead of a simplydeficient adduction with retraction of the globeseen in most cases of DS in opposite gaze. So,the SA, also known as the “splits”, becomes theretraction equivalent.

Patients with SD adopt a face turn. Inunilateral cases, it is always to the side opposite


-229-

the affected eye. In bilateral cases, it is alwaysto the side of the fixing eye. The objective ofthe face turn is threefold: 1) To balance theinnervational forces placing the fixing eye’sposition and the innervation to reduce outwardrotation of the non-fixing affected eye byinhibiting recruitment of the MR muscletherefore eliminating the SA and decreasing theexotropia. 2) To balance the mechanical factorsby placing the non-fixing eye in the field ofaction of the densily contracted LR muscle. 3)To obtain compensatory fusion in unilateralcases. In unilateral cases affecting, say the LE,with face turn to right the left exotropiadecreases because as the fixing RE movestoward the primary position, the non-fixingaffected LE reduces its outward deviation sinceco-contraction of the LR muscle is nowdiminished because of MR reciprocal inhibitionby Sherington’s Law. This face turn not onlyreduces outward rotation of the affected eye butalso may allow a compensatory fusion inunilateral cases. In bilateral cases, patientsalternate face turn to the side of the fixing eye inorder to reduce the outward rotation of thefellow eye, but compensatory fusion is unlikelyin severe cases.

Patients with SD exhibit a large angleexotropia, increasing on attempted adduction ofthe involved eye(s). The LR muscle of theaffected eye becomes extremely restricted,fibrotic and loses all its elasticity. There is atriple dose for the propensity to LR contracture(5): The position of extreme exo position, theintensive anomalous innervation of the LRmuscle and abduction of the affected eye(s) toeither sidegaze. Bilateral cases progress to themost extreme degrees of relatively immobileexotropia.

There is no neuropathologic report of SDto our knowledge. However magnetic resonanceimaging (MRI) across the brainstem level wasperformed in two patients with congenitalfibrosis of the extraocular muscles associated

with SD, bilateral in one case and unilateral inthe second (11). MRI disclosed bilateralhypoplasia of the oculomotor nerve in bothpatients, and absence of the abducens nerve onthe affected side exhibiting SD.

SD has been reported to be associatedwith Marcus Gunn jaw-winking (12), congenitalfibrosis, DS (7), aberrant trigemino-oculomotorinnervation (17) or arthrogryposis multiplex(13), Horner Syndrome (14). Our cases showednone of these anomalies, but one patient (case1) was affected with Joubert Syndrome and allthree cases have marked neuro-developmentaldelay.

PURPOSE

The primary objective of this report is: a)To present the findings of three patients withSD, two bilateral and one unilateral involvingthe left eye; b) To compare the results ofrecession-resection of the horizontal rectusmuscles to “denervation/extirpation” of the LRmuscle(s) of the affected eye(s) later followedwith ipsilateral MR resection; and c) Todescr ibe a s imp le technique of thedenervation/extirpation procedure of the LRmuscle.

Additionally, the purpose of this study isto show that despite ocular alignment andimprovement or elimination of the SA,adduction deficit can not be restored despitesurgical crippling of the affected LR muscle.

GOAL OF SURGERY AND SURGICALMANAGEMENT

The goal of surgery in our three patientswas to align the eyes, abate the SA, eliminatethe face turn and restore adduction. We did not,obviously, expect recovery of abduction sinceall three patients showed, clinically, absence ofany active abduction except in the moderatelyaffected right eye of case 2.


-230-

We chose to compare the surgical resultsof supramaximal recession of the LR muscleand resection of its antagonist MR muscle to“denervation/extirpation” of the LR muscle ofthe affected eye along with MR muscleresection done at a later stage.

Previously reported surgical procedures(12) consisted mainly of supramaximallyrecessing the LR muscle of the affected eyealong with resection of its antagonist MRmuscle. Total tenotomy of the LR muscle.Myectomy of the inferior oblique (IO) muscleand superior oblique (SO) tenotomy withrecession of the LR muscle and a reverse rectusmuscle union procedure (reverse Jensen) to theMR of the affected eye. LR recession of thegood eye with a large LR muscle recession ofthe affected eye. Bilateral SO transplantation tothe superior aspect of the MR muscle withouttrochlear fracture. Extirpation of the right LRmuscle and disinsertion of the left LR muscle ina case of bilateral SD.

Analysis of the results of theseprocedures seemed to indicate that a cripplingprocedure to the LR muscle of the affected eyeis required to abolish the face turn and the SA.

Our technique of denervation/extirpationof the LR muscle was the following: AGundersen muscle resection forceps engagedthe LR muscle far posteriorly. The muscle wasthen disinserted and all the muscle fibersanterior to the forceps were excised. A secondGundersen muscle forceps engaged the LRmuscle more posteriorly before releasing thefirst one, excising again the muscle fibersanterior to the second forceps. This was carriedon until we found no more muscle fibers. So theLR muscle was piece-meal, bit by bit excisedflush with the Gundersen forceps until wereached the penetration site to posterior tenon,practically excising the whole sub-tenon portionof the LR muscle.

CASE REPORTS

Case 1

A 9 month-old girl was referred to ourout-patient department because of a very largevariable angle exotropia since birth, abnormaleye movements and abnormal head posture.Neurological exam at the age of 6 monthsrevealed severe psychomotor delay due toJoubert Syndrome.

Joubert Syndrome (15) is a rare geneticdisorder that affects the area of the brain thatcontrols balance and coordination. The disorderis characterized by absence or maldevelopmentof a part of the brain called the cerebellarvermis and malformed brainstem.

We examined the child in May 2004. Sheshowed a 50 prism diopter (pd) exotropia ofeither eye and an alternate face turn to the sideof the fixing eye. Binocular fixation patternrevealed equal fixation with a steady fixationreflex and a normal following reflex of eithereye. Cycloplegic refraction with 0.25%scopolamine showed +4.0 sphere in each eye.Ocular rotations showed absence of adductionin either eye. On attempted dextroversion, theRE abducted further and the LE simultaneouslyabducted with slight depression. On attemptedlevoversion, the LE abducted further and the REsimultaneously abducted with significantdepression. Bilateral SD was diagnosed. Patientwas put on alternate occlusion of his opticallycorrected eyes. On October 12, 2004, at the ageof 14 months, the right LR muscle wassupramaximally recessed 20 mm and the rightMR muscle was resected 7 mm. Forced ductiontesting under general anesthesia showed mostsevere bilateral restriction of adduction andneither eye could be brought to the midline aswell as severe bilateral restriction of abduction.Following surgery, the exotropia was reducedbut the SA remained in both eyes on attempteddextroversion or levoversion. On January 25,


-231-

2005, at the age of 17 months, the left LR wasdenervated/extirpated. Postoperatively the XTwas further reduced, the SA disappeared in theLE on attempted dextroversion, but remained,although improved, in the RE on attemptedlevoversion. On May 3, 2005, at the age of 21months, right LR denervation/extirpation and 9mm left MR resection were performed,following which S.A. disappeared in either eyeon attempted side gazes, but left the patient witha mild residual XT. Abduction as well asadduction remained marquedly limited in botheyes. On January 2007, over 2 yearspostoperatively I and II and 20 monthspostoperatively III, she was horizontally straightin the primary position. Ductions showedabsence of abduction and adduction of botheyes with an A pattern to the deviation showing20 pd of esotropia in upgaze and 20 pd ofexotropia in downgaze. Infraduction of thesimultaneously abducting eye remained thesame in both eyes.

Case 2

A 4 and a half year old little girl wasreferred from the pediatric department becauseof bilateral exotropia, abnormal ocularmovements and bilateral blepharoptosis sincebirth. She was diagnosed by the pediatricn e u r o l o g i s t a s h a v i n g p sy c h o m oto rdevelopmental delay due to frontal brainatrophy.

Eye exam showed bilateral exotropia of45 pd, bilateral SA on attempted dextroversionand levoversion, bilateral mild blepharoptosis.Fixation and following reflexes were normal inboth eyes and the patient assumed alternately asevere face turn toward the side of the fixingeye. On ductions, the right eye showedmoderate limitation of adduction and abduction,the eye adducting and abducting midwaybetween the midline and the correspondingcanthus (50% of normal adduction andabduction). In the left eye, adduction was

severely limited with inability of the eye toreach the midline but remained halfwaybetween the outer canthus and the midline.Clinically, there was no active abduction in theleft eye. The diagnosis was bilateral SD,moderate in the RE and severe in the LE. OnJune 12, 2005, left LR denervation/extirpationwas done under general anesthesia. Forcedduction testing revealed severe restriction toabduction and extremely severe restriction toadduction in both eyes. Post operatively, theexotropia was reduced, the SA disappeared inthe LE but remained in the RE. On May 9,2006, recession of the right LR muscle 25 mmfrom the limbus and resection of the antagonistMR muscle 7 mm were done. In December2006, one and a half years following left LRdenervation/extirpation, and seven monthsfollowing recession/resection procedure on thehorizontal rectus muscles of the right eye,limitation of adduction remained the same inboth eyes. There was residual left exotropia of25 prism diopters. The SA was absent in theRE, but remained minimally in the severelyaffected LE. On January 6, 2007, the left MRmuscle was resected 9 mm. On April 5, 2007,three months later, there was a minimal residualexotropia of 12 pd and absence of any abnormalhead posture. Abduction and adduction werelimited to 50% of normal in the right eye andtotally absent in the left eye. There was no SAin either eye.

Case 3

A one and a half year old. girl presentedwith a history of left exotropia since birth. Shewas diagnosed by the pediatric department withp s y c h o m o t o r d e v e l o p m e n t a l d e l a y ,microcephaly and brain atrophy. Eye examrevealed left exotropia of 45 pd and lefthypotropia of 20 pd. There was markedlimitation to adduction in the LE, the eye hardlyadducting beyond the outer canthus. Onattempted dextroversion, the RE abductednormally and the LE abducted simultaneously


-232-

with further depression. The RE showed normalocular movements. Cycloplegic retinoscopyshowed +1.50 cylinder x90 in the RE and -6.00sphere + 6.00 cylinder x90 in the LE. Shefixated with her RE and assumed a face turn tothe right. Binocular fixation pattern testingshowed severe amblyopia in the LE(“Afixation”). The refractive errors werecorrected and amblyopia therapy was startedimmediately with occlusion of her RE. On June12, 2005, at the age of 5 years and 5 months, aleft LR denervation/extirpation was performed.Forced duction testing under general anesthesiashowed very severe restriction to adduction andabduction of the LE. In December 2006, oneand a half years postoperatively, adduction ofthe LE did not improve and the left exotropiaremained the same, but SA improved a greatdeal. On January 6, 2007, the left MR musclewas resected 10 mm. Three monthspostoperatively, there was still a residual leftexotropia of 20 pd but absence of the abnormalhead posture. The SA was abated but abductionand adduction remained totally absent in the lefteye. Infraduction of the synkinetically abductingleft eye remained the same.

SURGICAL OUTCOME

The striking feature of SA in all theseverely affected eyes responded best to LRdenervation/ext irpat ion only w hen th eantagonist MR muscle was resected. In themoderately affected eye, it responded favorablyto supramaximal recession of the LR musclewith resection of its antagonist MR muscle.

The abnormal head posture disappearedand the exotropia was satisfactorily reducedwhen the MR muscle was resected in the eyewhere the LR muscle was previouslydenervated/extirpated.

Depression of the synkineticallyabducting eye present in cases 1 and 3 did notimprove.

To our surprise, adduction as well asabduction remained absent in all the severelyaffected eyes and did not change in themoderately affected eye.

DISCUSSION

We present three patients with congenitalSD, a rare condition considered as an extremevariant of DS. Two of them are bilateral (cases1 and 2) and one unilateral affecting the LE(case 3). None of them showed globe retractionon attempted adduction of the affected eye, theSA being the retraction equivalent. All 3patients had face turn, to the side of the fixingeye in bilateral cases and opposite the affectedeye in the unilateral case.

By clinical observation, none of our threepatients demonstrated active abduction of theseverely affected eyes, suggesting absence ofthe abducens nerve as MRI across the brainstemlevel disclosed in two reported patients (11).

All three patients had severe adductiondeficit, totally absent except in case 2 in themildly affected eye where adduction as well asabduction, although limited, were present. Thelack of restoration of any adduction in theseverely affected eyes in our three reportedcases suggest MR paralysis as observedelectromyographically in one patient (2).

We believe the infraduction of thesynkinetically abducting eye seen in cases 1 and3 is due to co-contraction of the IR muscles andthe MR muscles rather than co-contraction ofthe SO muscles because the depression of thesimultaneously abducting eye takes place in thefield where the vertical action of the verticalrecti predominates and because the SO musclesdo not significantly depress the eye below themidline (16), especially in abduction.

The large A-pattern seen in case 1confirms the assumption of Brodsky (7) that thedivergence of the eyes in downgaze is due to


-233-

recruitment of the SO muscles in downgaze andthat the esotropia in upgaze is due to co-contraction of the MR muscles.

The severe restrictions of the MRmuscles as well as restrictions of the LRmuscles in all our severely affected eyes aredue, we believe, to denervation of these musclesand to the severe anomalous innervation of theLR muscle.

Our surgical results compare with thoseof Hamed (12) in that no overcorrectionoccurred despite surgical crippling of theanomalously innervated LR muscles and in thatSA could only be ablated or markedly improvedin severely affected eyes when denervation/extirpation of the LR muscle is done along withresection of the antagonist MR muscle. Thesupramaximal recession of the LR muscle alongwith resection of its antagonist did not eliminateor improve the S.A. in severely affected eyesprobably because of its attachments to the rectusmuscles, thru the intermuscular membrane andtenon’s capsule. However, this latter proceduredid eliminate the SA in the moderately affectedeye. The elimination of the SA in all our threereported cases following crippling surgery ofthe LR muscles confirms that the mechanism ofthe S.A. is the severe anomalous innervation ofthe LR muscles.

The question of whether there is anynormal LR recruitment in addition to the severeanomalous recruitment is academic in this typeof DS since one must perform a cripplingweakening procedure of the LR muscle, whichsimultaneously diminishes both anomalous andany existing normal LR innervations (5).

Face turn disappeared in all our patientsfollowing either procedure. The restoration of anormal head posture is due to the balance of theinnervational (normal and anomalous) as well asmechanical forces by significant weakening of

the severe anomalous innervation and the severerestriction of the LR muscle.

A substantial amount of exotropiaremained in two patients. We believe resectionof the MR muscle should be done, in severecases, along with denervation/extirpation of theLR muscle.

CONCLUSIONS

SD is a rare entity of miswiring,considered an extreme variant of DS.

Unlike DS, there is quantitatively greateranomalous innervation of the LR muscle of theaffected eye compared to its antagonist MRmuscle.

On side gaze toward the opposite side,there is simultaneous abduction of the affectedeye instead of simple limitation of adductionand retraction of the globe. This simultaneousabduction, also called “the splits”, becomes theretraction equivalent.

The lack of restoration of any adductionof the severely affected eyes despite surgicalcrippling of the LR muscle could be due eitherto paralysis or loss of contractility of the MRmuscle.

To date, no known surgical procedurewould lead to satisfactory results. However,surgical crippling of the affected LR muscle –either by denervation/extirpation of the LRmuscle along with resection of its antagonistMR muscle in severe cases – or bysupramaximal recession of the LR muscle alongwith resection of the MR muscle in moderatelyor mildly affected cases - seems to be theprocedure of choice to eliminate or improve theSA, the exotropia and the abnormal headposture. Adduction, in severe cases does notrespond to surgery.


-234-

REFERENCES

1. Znajda JP, Krill AE. Congenital medial rectus

muscle palsy with simultaneous abduction of the two

eyes. Am J Ophthalmol. 1969; 68: 1050-1052.

2.Thomas R, Mathai A, Greser Sc, and Ratnammal J.

J Pediatric Ophthalmol Strabismus. 1993; 30:

122,123

3.Wilcox LM, Gittinger JW, Breinin GM. Congenital

adduction palsy and synergistic divergence. Am J

Ophthalmol. 1981; 91:1-7.

4. Huber A. Electrophysiology of the retraction

syndrome. Br J Ophthalmol. 1974; 58:293-300

5. Jampolsky A. Duane syndrome In: Rosenbaum AL,

Santiago AP: Clinical Strabismus Management

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

s y n e r g i s t i c d i v e r g e n c e : a c l in i c a l a nd

electrooculographic study. Br J Ophthalmol

1989;73:68-75.

14. Jimura T, Tagami Y, Isayama Yet al. A case of

synergistic divergence associated with Horner’s

syndrome. Folia Ophthalmologica Japonica. 1983;

34: 477-480.

15. Ferland R. J. et al. Abnormal cerebellar

development and axonal decussation due to mutations

in AHI1 in Joubert syndrome. Nature Genetics,

September 2004, 36:1008-1013.

16. Kushner BJ. Ocular torsion: Rotations around the

“WHY” axis. J AAPOS 2004; 8:1-12.

17. Kaban TJ, Smith K, Orton RB. Synergistic

divergence associated with aberrant trigeminal

innervation. Can J Ophthalmol. 1994; 29: 146-149.

Binocular Vision & Outcome Study of Two Standard-&-Graduated Augmented Modif ied Kestenbaum Fourth Quarter of 2007Stra bismus Qu arte rly© Surgery Protocols for Abnormal Head Postures in Infantile Nystagmus Volume 22 (N o.4):A Medical Scientif ic E-Periodical Y-H Chang, MD, JH Chang, MD, S-H Han, MD and JB Lee, MD Pages 235-241

-235-


Outcome Study of Two Standard-&-GraduatedAugmented 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), SoonchunnhyangUniversity 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 thisstudy, we tried to evaluate the surgical results of Parks’ original 5-6-7-8 mm modified Kestenbaumprocedure and our own 6-7-6-7 mm modified Kestenbaum procedure, designed to reduce some of theproblems 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 ofmore 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 41patients. Each procedure was done with graded augmentation according to the amount of the face turn andthe null point in electro-oculography.

Results: In the follow-up of an average 33 months, 45 out of 51 patients (88.2%) who underwentParks’ modified procedures showed face turn less than 10°. In the follow-up of an average 29 months, 36 outof 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 gradedaugmentation may be a safe and efficient procedure to correct abnormal head posture in infantile nystagmuswith a minimum decrease in ocular motility.

Presented in part at the 2003 annual meeting of the American Association for PediatricOphthalmology 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-

INTRODUCTION

Infantile nystagmus may be present at birth butusually develops in the first few months of life (1).Typical infantile nystagmus is conjugate andhorizontal, and it is best described as a jerknystagmus with increasing velocity of the slowphase of the waveform (2). In infantile nystagmus,the frequency and the amplitude of the nystagmusmay be diminished in a particular position of gaze.This is referred to as a null point or a neutral zone.The neutral point is that position of gaze wherethere is a change in direction, i.e. jerk left to jerkright, and the null zone is that position of gazewhere the oscillation is least intense. Unless thenull or neutral point coincides with the primaryposition, the patients tend to have an abnormalhead posture (AHP), turning or tilting their face orhead so that the eyes are at the null or neutralpoint to maximize their visual acuity bydampening the nystagmus (3).

The etiologic mechanism of this oscillationremains elusive. Defects involving the saccadic,optokinetic, smooth pursuit, and fixation systems,as well as the neural integrator for conjugatehorizontal gaze, have been proposed (4, 5). Moreevidence is accumulating that the slow phase is theproblem (2, 6). The fast phase is a normal saccadeand fulfills the criteria for a usual saccade. Theinitial description of attempted treatment ofinfantile nystagmus was reported by Metzger whoprescribed prism spectacles with the base to thedirection of AHP (7). Other treatment modalitiessuch as minus lenses, pharmacologic agents andbotulinum toxin injection have all been describedin different studies but the beneficial effects werelimited (8-10).

Surgical treatment for infantile nystagmus wasfirst advocated independently and almostsimultaneously by Anderson and Kestenbaum inearly 1950s (11, 12). In 1953, Kestenbaumrecommended surgical shifting of both eyes byperforming identical amounts of recession/ resec-tion procedure for all four horizontal rectusmuscles, in the direction of the rapid phase ofnystagmus away from the null point (11). In anattempt to explain AHP, Anderson believed thatthe muscles acting in the slow phase of thenystagmus overacted. He advised a weakening

procedure for the two yoke muscles involved as atreatment (12). Although their rationales for thesurgical approach differed, their resultingprocedures achieved the same ends, namely, theelimination of the AHP by rotation of both eyes inthe direction of the face turn in order to match andmake coincident the “null or neutral point” of thenystagmus as near as possible with the primaryposition of gaze.

In 1973, Parks proposed a modification of theKestenbaum procedure (5 mm, 6 mm, 7 mm, and8 mm) with a total of 13 mm of surgery performedon each eye, 5 & 8, and 6 & 7 mms (13). At thattime Parks believed that these amounts of surgerywere the maximum amounts which could beperformed and still preserve full ductions. Thisbecame known as the classic modifiedKestenbaum procedure. Later, following Parks,Calhoun, Nelson and other ophthalmologistsreported the results of different surgicalprocedures to correct AHP (14-19).

In this study, our purpose was to evaluate andcompare surgical results for Parks’ original 5-6-7-8 mm modified Kestenbaum procedure and ourown 6-7-6-7 mm modified Kestenbaum procedure.

MATERIALS, SUBJECTS & METHODS

This study was approved by the ethicscommittee of Yonsei University Medical Center,Seoul, Korea, in accordance with the ethicalstandards laid down in the 1964 Declaration ofHelsinki.

Medical records of ninety-two patients, whohad modified Kestenbaum surgery (either Parks 5-6-7-8 mm or our own 6-7-6-7 mm) for AHPsecondary to infantile nystagmus at YonseiMedical Center, over a ten and half year period,from March 1991 to September 2001, with afollow-up period of more than 6 months andwithout ver t ical AHP, were reviewedretrospectively. The following information wasrecorded: age at first examination, associatedstrabismus or other ocular disease, visual acuity,size in degrees of AHP, null/neutral point onelectro-oculography (EOG), age at time ofsurgery, amount of surgery, and the date and theocular motility findings at last examination.


-237-

Table 1. METHODS : SURGERY : Amount of graded augmentation in modified Kestenbaum Procedures Graded according to the amount of abnormal head posture (AHP)

degreesof AHPby EOG

Graded augmentation

Group1 (Parks’ original 5-6-7-8modified Kestenbaum surgery)

Group2 (Our own 6-7-6-7modified Kestenbaum surgery)

20 - 25 5-6-7-8 mm* 6-7-6-7 mm†

30 - 35 20% augmentation(6.0 - 7.2 - 8.4 - 9.6 mm)

20% augmentation(7.2 - 8.4 - 7.2 - 8.4 mm)

40/ or more 30% augmentation(6.5 - 7.8 - 9.1 - 10.4 mm)

30% augmentation(7.8 - 9.1 - 7.8 - 9.1 mm)

10-15 Minus-one procedure(4-5-6-7 mm)

Minus-one procedure(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

The indication for surgery was an unacceptableAHP (a face turn of 10/ or more) with one null orneu t r a l po in t . Orthope dic pro t r ac to rs(goniometers) were used to estimate thepreoperative face turn for distant fixation. EOGusing the Nicolet Compact Four/CA 2000,Nicolet, U.S.A. was performed in 74 cooperativepatients. Electrodes were attached on the medialand lateral canthi of both eyes and a groundelectrode was attached on the forehead. Impedanceof electrodes was adjusted to less than 5 Kohms intotal, and within 3 Kohms of each other. The nullor neutral points were investigated. The values ofthe angle of AHP measured by goniometer wererelatively larger than those measured by EOG. Thedifference was about 5/. We preferred to study thenull or neutral point measured by EOG to theclinically measured angle of face turn.

The patients were divided into two groups:

Group 1: Parks’ modified Kestenbaum surgery

(5-6-7-8 mm). For a face turn to the right, thesurgery performed is: right medial rectusrecession, 5 mm; right lateral rectus resection, 8mm; left lateral rectus recession, 7 mm; leftmedial rectus resection, 6 mm.

Group 2: Our own modified Kestenbaumsurgery (6-7-6-7 mm). For a face turn to the right,the surgery performed is: right medial rectusrecession, 6 mm; right lateral rectus resection, 7mm; left lateral rectus recession, 7 mm; leftmedial rectus resection, 6 mm.

We performed Parks’ original 5-6-7-8modified and augmented modified Kestenbaumsurgery on 51 patients and our own 6-7-6-7modified Kestenbaum and augmented modifiedsurgery on 41 patients. Each procedure was donewith a graded augmentation according to theamount of the face turn and the null points in EOG(see Table 1, below).


-238-

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 0 220-25/ 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

Twelve patients with strabismus alsounderwent their appropriately modifiedKestenbaum procedures with the final surgicalamount adjusted to correct both the strabismus andthe AHP. All the surgical procedures wereperformed by senior author (JBL).

Surgical “success” was defined as a clinicallymanifest face turn (horizontal AHP) less than 10/.Statistical analysis was performed using chi-square tests, and p values less than 0.05 wereconsidered “statistically significant”.

RESULTS

Of the total 92 patients, 61 patients were maleand 31 were female. Fifty-one patients comprisedGroup 1 and 41 patients comprised Group 2. The

demographic characteristics of the patients weresummarized in Table 2, below .

In Group 1, six patients had concurrentstrabismus, and two had oculocutaneous albinism.In Group 2, six patients had concurrentstrabismus, one had microphthalmos, and one hadbilateral congenital cataract.

The preoperative degree of face turn rangedfrom 15 to 45 degrees, and 68 of the 92 patients(74.0%) had an AHP of 20-30 degrees.

In the postop’ follow-up of an average 33


-239-

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

(% “success”)Overcorrection Correction

“success”

Undercorrection

5-6-7-8 procedure 1 23 0 24 (95.8)

20 %-augmented

5-6-7-8 procedure0 21 4 25 (84.0)

30%-augmented

5-6-7-8 procedure

0 1 1 2 (50)

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

+ (% “success)Overcorrection Correction

”success”

Undercorrection

Minus-one

6-7-6-7 procedure

0 2 0 2 (100)

Standard

6-7-6-7 procedure0 21 2 23 (91.3)

20 %-augmented

6-7-6-7 procedure

0 13 3 16 (81.3)

Total0 36 5 41 (87.8)

months, 4 out of 51 patients (88.2%) in Group1 showed a face turn less than 10 degrees(“successful”), and 36 out of 41 patients (87.8%)in Group 2 had AHP less than 10 degrees

(“successful”) in the follow-up of an average 29months (see Tables 3, 4, below). There was no“statistically significant” difference in the“success” rate between the two groups (p=0.899).


-240-

In Group 1, overcorrection occurred in onecase: one changed from a 20/ right face turn to a20/ left face turn postoperatively. Undercorrectionoccurred in five cases: four had their face turnreduced from 30/ to 15/-20/; one had their faceturn reduced from 40/ to 15/-20/. In Group 2, noovercorrection was noted, and undercorrectionoccurred in five cases: three had their face turnreduced from 30/ to 15/; two had their face turnreduced from 25/ to 15/. Concurrent strabismuswas corrected in twelve patients, and esotropia of12 prism diopter remained in one patient of Group1 who had esotropia of 35 prism diopterpreoperatively. In Group 1, one patient showedslight limitation of motility, but subsequentstrabismus was not observed in any patient. InGroup 2, one patient developed exotropia of 12prism diopter postoperatively, but the ductionswere not limited in any case.

DISCUSSION OF RESULTS

In this study, we evaluated two differentsurgical protocols used to treat infantile nystagmusas to the patients’ improvement in AHP. Theamount of surgery we used was more conservativethan the amounts previously reported (14-16, 18).In our modification, medial rectus was recessed orresected by 6 mm, and lateral rectus was recessedor resected by 7 mm. Total of 13 mm of surgerywas performed on each eye so that the rotation ofthe eyeball may be similar to that in Parks’modification. This small surgical modificationproduced encouraging results in our patients.

Since Anderson and Kestenbaum, otherstrabologists modified the procedure increasingthe amount of surgery because the classicmeasurements failed to fully correct the AHP.Subsequent reports by many authors appeared onthe classic plus additional amount of surgery, suchas classic plus 40% or classic plus 60%. Calhoun& Harley proposed 40% augmented Parks’modified Kestenbaum procedure (7.0-8.4-9.8-11.2mm) (14). They reported a 75% success rate (3 of4 cases) with a 75% side effect of mild gaze palsyafter an average 5.8 months follow-up period.Nelson & coworkers reported 40% augmentationfor patients with 30° face turn and 60%augmentation for those with 45° face turn (15).They claimed a cure in 8 of 15 patients (53.3%)reporting side effects of one case of vertical

torticollis and one case of head tilt after anaverage 33 months follow-up period. Taylorreported that a larger 8-9 mm recession of the LRon the side of the slow phase of nystagmus and alarger 6 mm recession of the MR of the oppositeeye in conjunction with smaller 6 mm resectionsof both respective antagonist (Taylor-Parksmodified Anderson-Kestenbaum operation) (16).This operation, with a 70% success rate (7 of 10patients), did not result in any limitation of eyemovement up to 35/ to 45/ face turns over anaverage 17.8 months follow-up period. Spielmannhas also used the retroequatorial myopexy(posterior fixation suture) in conjunction with thetraditional Kestenbaum procedure (17). Mitchellrecommended a plus one operation (6-7-8-9 mm)(18). Scott and Kraft reported the gradedaugmentation of the Parks’ 5-6-7-8 modifiedKestenbaum procedure (19). Their procedure hada correction of AHP less than 15/ in 78% ofpatients. All of these studies were on a relativelysmall number of patients, usually less than ten.The study by Scott and Kraft was certainly one ofthe largest and it included 25 patients in all. Themajor criticism of large augmented surgery wasthe concern of possible motility limitations afterthe operation. Our previous study with 63 patientssuggested that Parks’ modified Kestenbaumprocedure, with appropriated graded augmentationup to 30%, is effective for AHP in infantilenystagmus without the need for largeraugmentation (20).

It is difficult to compare our results with manyof previous reports. Each study used a differentdefinition of success, and the amount of AHP ofthe patients was different. In our modifiedprocedure, the 8 mm of large resection in Parks’modified Kestenbaum procedure and largerecession in 40% or 60% augmented Kestenbaumprocedure can be avoided. The face turn valuesmeasured by EOG were relatively smaller thanthose by goniometer. We suggest that this is thekey reason for our successful results with lessaugmented surgery. With repeated measurementof the AHP and assessment by EOG during ourlong-term follow-up, this smaller amount ofgraded augmentation proved to correct face turnsatisfactorily. This emphasizes a meticulous work-up in each case with repeated testing to make surethat the AHP is stabilized and constant. These


-241-

findings are much encouraging to the pediatricophthalmologist and strabismus surgeon in that alesser amount of surgery can result in successfulresults. With our cumulated experience and highrate of success, we suggest that our own 6-7-6-7mm modification is as good as, if not probablybetter than, prior reports and recommendations.

However, our study has some limitations. Thisis neither a randomized, comparative trial norprospective study. We cannot conclude theeffectiveness but suggest the efficacy. Theretrospective methodology does not allow accuratecomparison due to patient selection bias, dropouts,and baseline confounders. Prospective study withthe pre- and postoperative sensory testing and bestcorrected visual acuity would be needed.

CONCLUSIONS

We reviewed medical records of ninety-twopatients who had modified Kestenbaum surgery(5-6-7-8 mm or 6-7-6-7 mm) for AHP secondaryto infantile nystagmus.

We propose that 6-7-6-7 mm modifiedKestenbaum surgery with our own gradedaugmentation may a safe and efficient procedurefor AHP in infantile nystagmus with a minimumdecrease in ocular motility.

REFERENCES

1. Spielmann A: Clinical rationale for manifestcongenital nystagmus surgery. J AAPOS 2000;4:67-74.2. Dell’Osso LF, Daroff RB: Congenital nystagmus

waveforms and foveation strategy. Doc Ophthalmol

1975; 39:155-182.

3. Cooper EL, Sandall S: Surgical treatment of

congenital nystagmus. Arch Ophthalmol 1969; 81:473-

480.

4. Hertle RW, Dell’Osso LF: Clinical and ocular motor

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.

8. Allen ED, Davies PD: Role of contact lenses in the

management of congenital nystagmus Br J Ophthalmol

1983;67:834-836.

9. Helveston EM, Pogrebniak AE: Treatment of

acquired nystagmus with botulinum A toxin. Am J

Ophthalmol 1988;106:584-586.

10. Carlow TJ: Medical treatment of nystagmus and

ocular motor disorders. Int O phtha lmol C lin

1986;26:251-264.

11. Kestenbaum A: New operation for nystagmus. Bull

Soc Ophtalmol Fr 1953;6:599-602.

12. Anderson JR: Causes and treatment of congenital

eccentric nystagmus. Br J Ophthamol 1953;37:267-

280.

13. Parks MM: Congenital nystagmus surgery. Am

Orthop J 1973;23:35-39.

14. Calhoun JH, Harley RD: Surgery for abnormal head

position in congenital nystagmus. Trans Am

Ophthalmol Soc 1973;71:70-87.

15. Nelson LB, Ervin-Mulvey LD, Calhoun JH , et al:

Surgical management for abnormal head position in

nystagmus: the augmented modified Kestenbaum

procedure. Br J Ophthalmol 1984;68:796-800.

16. Taylor JN: Surgery for horizontal nystagmus;

Anderson-Kestenbaum operation. Aust J Ophthalmol

1973;1:114-116.

17. Spielmann A: Treatment chirurgical du nystagmus.

Arch Ophthalmol 1977;37:75.

18. Mitchell PR, Wheeler MB, Parks MM: Kestenbaum

surgical procedure for torticollis secondary to congenital

nystagmus. J Pedia tr Ophtha lmol Strab ismus

1987;24:87-92.

19. Scott WE, Kraft SP: Surgical treatment of

compensatory head position in congenital nystagmus. J

Pediatr Ophthalmol Strabismus 1984;21:85-95.

20. Lee IS, Lee JB, Kim HS et al. Modified Kestenbaum

surgery for correction of abnormal head posture in

infantile nystagmus: Outcome in 63 patients with graded

augmentation. Binocul Vis Strabismus Q 2000; 15:53-

58.

Binocular Vision & ABSTRACTS Fourth Quarter of 2007

Stra bismus Qu arte rly© Volume 22 (N o.4):A Medical Scientif ic E-Periodical Page 242-244

-242-

Vision / Visual Acuity / Amblyopia

Learning to Identify Crowded Letters: Does ItImprove Reading Speed? Chung STL. Vision Research2007; 47:3150 3159. [Author Abstract]

Crowding, the difficulty in identifying a letterembedded in other letters, has been suggested as anexplanation for slow reading in peripheral vision. In this study,we asked whether crowding in peripheral vision can bereduced through training on identifying crowded letters, and ifso, whether these changes will lead to improved peripheralreading speed. We measured the spatial extent of crowding,and reading speeds for a range of print sizes at 10° inferiorvisual field before and after training. Following training,averaged letter identification performance improved by 88% atthe trained (the closest) letter separation. The improvementtransferred to other untrained separations such that the spatialextent of crowding decreased by 38%. However, averagedmaximum reading speed improved by a mere 7.2%. Thesefindings demonstrated that crowding in peripheral vision couldbe reduced through training. Unfortunately, the reduction in thecrowding effect did not lead to improved peripheral readingspeed. (Fax: 713-743-2053)

Acuity, Crowding, Reading and Fixation Stability.Falkenberg HK, Rubin GS, Bex PJ. Vision Research 2007;47:126-135. [Authors Abstract]

People with age-related macular disease frequentlyexperience reading difficulty that could be attributed to pooracuity, elevated crowding or unstable fixation associated withperipheral visual field dependence. We examine how the size,location, spacing and instability of retinal images affect thevisibility of letters and words at different eccentricities. Fixationinstability was simulated in normally sighted observers byrandomly jittering single or crowded letters or words along acircular arc of fixed eccentricity. Visual performance wasassessed at different levels of instability with forced choicemeasurements of acuity, crowding and reading speed in arapid serial visual presentation paradigm. In the periphery: (1)acuity declined; (2) crowding increased for acuity- andeccentricity-corrected targets; and (3) the rate of reading fellwith acuity-, crowding - and eccentricity–corrected targets.Acuity and crowding were unaffected by even high levels ofimage instability. However, reading speed decreased withimage instability, even though the visibility of the componentletters was unaffected. The results show that readingperformance cannot be standardized across the visual field bycorrecting the size, spacing and eccentricity of letters orwords. The results suggest that unstable fixation my contributeto reading difficulties in people with low vision and thereforethat rehabilitation may benefit from fixation training. (Dr.Falkenberg, Dept Optometry & Visual Science, BuskerudUniversity College, Frogsvei 41, 3601 Kongsberg, Norway)

Early Spectacle Correction Can Successfully TreatMost children with Bilateral Refractive Amblyopia. As RE-abstracted by the AAO Academy Express, October 3,2007. Am J Ophthalmol October 2007.

A propsective, multicenter, noncomparative study of113 children between 3 and 9 years old finds that 73 percentimproved binocular visual acuity to 20/25 or better after oneyear of spectacle correction alone. Only 12 percent of casesrequired patching or atropine. Children who started with visualacuity of 20/100 or worse showed the greatest improvement,averaging 6.3 lines after one year.

Treatment of Bilateral Refractive Amblyopia inChildren Three to Less than 10 Years of Age. Wallace DK,

Chandler DL,Beck RW et al and the PEDIG. Am JOphthalmol 2007; 144:487-496 [Authors Abstract]

Purpose: To determine the amount and time courseof binocular visual acuity improvement during treatment ofbilateral refractive amblyopia in children three to less than 10years of age. D e s i g n : P r ospec t i ve , mu l t i ce n t e r ,noncomparative intervention.

Methods: One hundred and thirteen children (meanage, 5.1 years) with previously untreated bilateral refractiveamblyopia were enrolled at 27 community and university basedsites and were provided with optimal spectacle correction.Bilateral refractive amblyopia was defined as 20/40 to 20/400best corrected binocular visual acuity in the presence of 4.00diopters (D) or more of hypermetropia by spherical equivalent,2.00 D or more of astigmatism, or both in each eye...measuredat baseline and at 5, 13, 26 and 52 weeks. The primary studyoutcome was binocular acuity at one year.

Results: Mean binocular visual acuity improved from0.50 logarithm of the minimum angle of resolution (logMAR)units (20/63) at baseline to 0.11 logMAR units (20/25) at oneyear (mean improvement, 3.9 lines; 95% confidence interval[CI], 3.5 to 4.2). Mean improvement at one year for the 84children with baseline binocular acuity of 20/40 to 20/80 was3.4 lines (95% CI, 3.2 to 3.7) and for the 16 children withbaseline binocular acuity of 20/100 to 20/320 was 6.3 lines(95% CI, 5.1 to 7.5). The cumulative probability of binocularvisual acuity of 20/25 or better was 21% at five weeks, 46% at13 weeks, 59% at 26 weeks and 74% at 52 weeks.

Conclusions: Treatment of bilateral refractiveamblyopia with spectacle correction improves binocular visualacuity in children three to less than 10 years of age, with mostimproving to 20/25 or better within one year. (Dr. Wallace,Jaeb Center for Health Research, 15310 Amberly Dr, Suite350, Tampa FL 33647)

Risk of Bilateral Visual Impairment in Persons withAmblyopia: the Rotterdam Study. Van Leeuwen R,Eijkemans MJ, Vingerling JR et al. Br J Ophthalmol, May2007. As abstracted by the AAOs Specialty News andViews Section on Pediatric/Strabismus members D Coats,D Alcorn, J Bloom, D Hug, A Hutchinson, S Olitsky and DVanderveen. “Risk of Bilateral Visual Impairment isDoubled in People With Amblyopia.

Amblyopia is a leading cause of poor vision in youngpeople. One common justification for diagnosis and treatmentof amblyopia is to decrease the risk of bilateral vision loss laterin life. However, most discussion regarding the risk of bilateralvisual loss in people with amblyopia have been theoretical oranecdotal in nature. A recent study by Van Leeuwen et alprovides quantitative data to substantiate this concern. Theresearchers used data from the Rotterdam Study to estimatethe risk of bilateral visual impairment (BVI). The studyconsisted of a population based cohort of subjects 55 years orover (n=5220), including 192 people with amblyopia. Using amultistate life table, the lifetime risk of BVI was determined. Forthe subjects with amblyopia, the lifetime risk for BVI in patientswith a history of amblyopia was 18% and for those patientswithout amblyopia it was 10%. Patients with a history ofamblyopia who suffered from BVI lived an average of 7.2 yearsafter loss of vision. Those without amblyopia lived 6.7 yearswith BVI. This study indicates that amblyopia nearly doublesthe lifetime risk of BVI. The information from this study can beused to provide data for future studies regarding the costeffectiveness of amblyopia detection and treatment.

Correspondence re: Lanza M, Rosa N, Capasso L etal. Can we utilize photorefractive keratectomy to improvevisual acuity in adult amblyopic eyes? Ophthalmology



-243-

2005; 112:1684-1691. Correspondence, with author reply inOphthalmology 2007; 114:1792

I read with concern Lanza et al’s article on utilizingphotorefractive keratectomy (PRK) to improve visual acuity inadult amblyopic eyes. ... there is no description of how VA wasmeasured. ... the article is incomprehensible as published. ...the patient cohort displays some baffling clinicalcharacteristics. A comprehensive formal definition of amblyopiawas not given, and we were not assured that these patientscarried a diagnosis of amblyopia from childhood. ... patientsunderwent a cycloplegic refraction at the first visit and a“subjective” refraction at a subsequent visit. ... Comparing bestspectacle corrected VAs before and after surgery ignored theeffect of minification from glasses as opposed to correction atthe corneal plane. ... as regards the statistical analysis, Figures6, 7 and 10 show gross outliers and - even were the datacredible - the correlation coefficients should have beencalculated with and without these eyes/patients. Finally,because all forms of corneal refractive surgery degrade thehigher order optical performance of the cornea, as an expert inamblyopia diagnosis and treatment, I do no understand howPRK could improve the vision function of adult amblyopic eyes,except through changes in magnification or other artifactualissues such as the elimination of dirty and poorly fitting contactlenses. A physiologically plausible and comprehensiveexplanation for these alleged positive effects should beproposed.

Sandra M. Brown, M.D.

Concord, North Carolina, U.S.A.

In reply:

“ ... Dr. Brown’s comments offer guidanceconcerning the design of prospective work that we hope mightvalidate our findings. ... We hope that in the future amblyopiaexperts such as Dr Brown might collaborate on prospectivestudies with refractive surgeons to confirm or refute ourfindings.

Nicola Rosa, MD and Michele Lanza, MD

Napoli Italy

Strabismus, Management

Current Concepts in the Management ofConcomitant Exodeviations. Eibschitz-Tsimhoni M, ArcherSM, Furr BA, Del Monte MA. Comp Ophthalmol Update2007; 8:213-223. [Authors Abstract]

Intermittent exotropia is the most common form ofdivergent strabismus. Treatment is indicated with increasingtropia phase to preserve or restore binocular function andrestore/reconstruct normal ocular alignment. While medicaltreatment is sometimes helpful for temporary relief, surgicaltherapy is the preferred definitive treatment modailty by mostpediatric ophthalmologists and strabismologists. Congenitalexotropia is rare and is associated with a high incidence ofamblyopia. The treatment of choice in this condition is alsosurgical. Sensory exotropia is most ofter acquired aftermonocular visual loss. The preferred treatment is surgicalrecession/resection on the impaired eye. Convergenceinsufficiency is usually not diagnosed until the teenage years orlater, and it is best approached nonsurgically with convergenceexercises. In this article, we review the current literature andpractice on the diagnosis and management of exotropia withemphasis on intermittent exotropia. (Dr. Eibschitz-Tsimhoni,1000 Wall St, Ann Arbor MI 48105. Email: [email protected])

Binocular Vision

Stereopsis-Dependent Deficits in Maximum MotionDisplacement in Strabismic and Anisometropic Amblypia.Ho CS, Giaschi DE. Vision Research 2007; 47:2778-2785.[Authors Abstract]

Direction discrimination thresholds for maximummotion displacement (Dmax) have been previously reported tobe abnormal in amblyopic children We looked at Dmaxthresholds for random dot kinematograms (RDKs) biasedtoward low or high level motion mechanisms Dmax is thoughtto be limited, for high level motion mechanisms, by theefficiency of object feature tracking and probability of falsematches. To reduce the influence of low level mechanisms, wedetermined thresholds also for a high pass filtered version ofthe RDKs. Performance did not significantly differ betweenstrabismic and anisometropic groups with amblyopia, althoughboth groups performed significantly worse that the agematched control group. Dmax thresholds were higher forchildren with poor stereoacuity. This was significant in bothanisometropic and strabismic groups, and more robust for highpass filtered RDKs than for unfiltered RDKs. The results implythat impairment of the extra striate dorsal stream is a likely partof the neural deficit underlying both strabismic andanisometropic amblyopia. This deficit appears to be moredependent on extent of binocularity than etiology. Our findingssuggest a possible relationship between fine stereopsis,coarse stereopsis, and motion correspondence mechanisms.(Dr. Ho, Dept Ophthalmology, Univ British Columbia, RoomA146, BC Childrens Hospital 4480 Oak St, Vancouver BCCanada V6H 3V4. Fax: 604-875-2683)

The Role of Binocular Stereopsis in MonopticDepth Perception. Wilcox LM, Harris JM, McKee SP. VisionResearch 2007; 47:2367-2377. [Authors Abstract]

In his study of depth from monocular elements, Kaye(1978) reported that monocular stimuli, briefly presented to oneeye in a stereoscopic display, generated reliable depthpercepts. Here we replicate and extend Kaye’s findings in aneffort to identify the mechanism underlying the phenomenon.Out experiments show that the perception of depth is not asimple result of monocular local sign, for the percept of depthdisappears when one eye is patched. In subsequentexperiments we assess the possibility that the percept resultsfrom a very coarse stereoscopic match to either the centroid ofthe luminance distribution in the unstimulated eye or a simplematch to the line of sight in the unstimulated eye. Our resultsconsistently support the match-to-fovea account, and lead usto conclude that monoptic depth is a stereoscopicphenomenon. (Dr. Wilcox, Dept Psychology, Centre for VisionResearch, York University, Toronto Canada, M3J 1P3. Fax:416-736-2377)

Mechanisms of Perceptual Learning of DepthDiscrimination in Random Dot Stereograms. Gantz L,Patel SS, Chung STL, Harwerth RS. Vision Research 2007;47:2170-2178. [Authors Abstract]

Perceptual learning is a training inducedimprovement in performance. Mechanisms underlying theperceptual learning of depth discrimination in dynamic randomdot stereograms were examined by assessingstereothresholds as a function of decorrelation. The inflectionpoint of the decorrelation function was defined as the level ofdecorrelation corresponding to 1.4 times the threshold whendecorrelation is 0%. In general, stereothresholds increasedwith increasing decorrelation. Following training,stereothresholds and standard errors of measurementdecrease systematically for all tested decorrelation values.Post training decorrelation functions were reduced by amultiplicative constant (approximately 5), exhibiting changes instereothresholds without changes in the inflection points.



-244-

Edited by P.E. R om ano , MD , MSO, Ed itor BV&SQ . Abstractsare se lec ted on the basis o f inte res t to our re aders . To avoidduplication you wil l f ind none are from The American OrthopticJourna l, The Au stralian or British-Ir ish Or thoptic Journ al, TheJournal of the American Assoc iation for PediatricOphtha lm ology and S trabismus, The Journa l of P ediatr icOphthalmology and Strabismus, or Stra bis m us, as most of ourreaders already subscribe to a nd/or rea d the m. Publicationherein does not constitute endorsement, recommendation ora validation of author’s conclusions.

Disparity energy model simulations indicate that a post-trainingreduction in neuronal noise can sufficiently account for theperceptual learning effects. In two subjects, learning effectswere retained over a period of six months, which may haveapplication for training stereo deficient subjects. Dr. Harwerth,College of Optometry, Univ Houston, 505 J David ArmisteadBuilding, Houston TX 77204-2020. Fax: 713-743-2053)

Strabismus Surgery, Outcome / Complications

Effect on Intraocular Pressure of ExtraocularMuscle Surgery for Thyroid-Associated Ophthalmopathy.Gomi CF, Yates B, Kikkawa DO, Levi L, Weinreb RN,Granet DB. Am J Ophthalmol 2007; 144:654-657 [AuthorsAbstract]

Purpose: To study the effect of extraocular musclesurgery on intraocular pressure (IOP) in patients with thyroid-associated ophthalmopathy.

Design: Retrospective, observational case series.

Methods: The medical records of patients withrestrictive myopathy secondary to thyroid-associatedophthalmopathy who underwent strabismus surgery from July1, 1997 through July 31, 2003 were reviewed and analyzedretrospectively. Seventeen patients met the criteria and wereincluded in this study. All patients were seen at the ThyroidEye Center at the University of California, San Diego, auniversity-based tertiary referral center. The main outcomemeasure was IOP readings obtained before and after surgeryin both primary gaze and upgaze.

Results: A statistically significant decrease in IOP inupgaze was noted after extraocular muscle recession. Themean IOP before surgery was 16.6 ±3.76 mm Hg in primarygaze and 23.2 ±7.27 mm Hg in upgaze. After strabismussurgery, the mean IOP (after one month was 15.7 ±2.36 mmHg (P=.215) in primary gaze and 18.9 ±2.96 mm Hg in upgaze(P=.001). Conclusions: Strabismus surgery resulted in asignificant reduction in IOP in the early postoperative period inpatients with restrictive myopathy secondary to thyroid-associated ophthalmopathy. (Dr. Granet, Dept Ophthalmology,UC San Diego, 9415 Campus Point Dr., La Jolla CA 92093)

Lateral Rectus Resection Versus Medial Rectus Re-Recession for Residual Esotropia: Early Results of aRandomized Clinical Trial. Rajavi Z, Ghadim M, RamezaniA, Azemati M, Daneshvar. Cl Exp Ophthalmol 2997;35:520-526. [Authors Abstract]

Methods: This randomized controlled clinical trialincluded 25 patients (mean age, 18.8 ±8.7 years) with residualesotropia who were candidates for reoperation. They wererandomly assigned into two groups: re-recession group (n=12),in which the medial rectus muscle was recessed again, and theresection group (n=13), in which lateral rectus muscleresection was performed. Postoperative deviation #10 prismdiopters was considered to be treatment success.

Results: The success rate of the re-recession groupand the resection group was 67% and 54% respectively; thisdifference was not statistically significant. Each 1 mm of medialrectus re-recession and lateral rectus resection corrected 7.5±1.2 and 2.5 ±0.5 prism diopters of residual esotropia,respectively. In 50% of the re-recession group, mild medialrectus muscle underaction occurred; however, only 16.5%developed an increase in the near point of convergence. Majorintraoperative and postoperative complications, includingovercorrection and slippage or a lost muscle, did not occur inany of the patients.

Conclusions: Medial rectus muscle re-recessioncan be a substitute for lateral rectus muscle resection in

patients with residual esotropia. The resultant underaction ofthe medial rectus muscle after re-recession is relatively mildand causes no major problems. (Dr. Rajavi, No.31, RafatAvenue, Shariati Street Tehran, Iran


Myopia

Genetic Dissection of Myopia Evidence or Linkageof Ocular Axial Length to Chromosome 5q. Zhu G, HewitAW, Ruddle JB et al. Ophthalmology 2007. [AuthorsAbstact]

Purpose: To estimate heritability and locatequantitative trait loci influencing axial length.

Design: Classic twin study of monozygotic anddizygotic twins reared together.

Participants: Eight hundred ninety-three individualsfrom 460 families were recruited through the Twin Eye Study inTasmania and Brisbane Adolescent Twin Study (BATS) andhad ocular axial length measured.

Methods: Structural equation modeling on the entiresample was used to estimate genetic and environmentalcomponents of variation in axial length. Analysis of existingmicrosatellite marker genomewide linkage scan data wasperformed on 318 individuals from 142 BATS families.

Main Outcome Measures: Ocular axial length.

Results: The heritability estimate for axial length,adjusted for age and sex, in the full sample was 0.81. Thehighest multipoint logarithm of the odds (LOD) score observedwas 3.40 (genomewide P=0.0004), on chromosome 5q (at 98centimorgans [cM]). Additional regions with suggestivemultipoint LOD scores were also identified on chromosome 6(LOD scores, 2.13 at 76 cM and 2.05 at 83 cM), chromosome10 (LOD score, 2.03 at 131 cM) and chromosome 14 (LODscore, 2.84 at 97 cM). Conclusion: Axial length, amajor endophenotype for refractive error, is highly heritableand is likely to be influenced by one or more genes on the longarm of chromosome 5. (Prof. Mackey, Centre for EyeResearch Australia, Royal Victorian Eye and Ear Hospital, 32Gisborne St, East Melbourne, Victoria, Australia 3002).

Unilateral Atropine for Amblyopia May Not Alter theRefractive Status of the Sound Eye. As abstracted by theAAO Academy Express August 15, 2007.

This prospective, randomized study finds that themean change in refractive error in the [UNTREATED]soundeye of those treated with [UNILATERAL] atropine was -0.21 D.In the patching[?] group, the mean change was -0.06 D - aninteresting finding that contradicts the theory that atropine canbe used to treat progression of myopia. [?HOW SO???? -Ed]


Binocular Vision & New Book Review Fourth Quarter of 2007Stra bismus Qu arte rly© Strabismus Surgery and Its Complications Volume 22 (N o.4):A Medical Scientif ic E-Periodical by David K. Coats and Sco tt E. Olitsky Page 247

-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, Euro171.15.

Given the evolution of strabismussurgery techniques over recent years, a newcomprehens ive r ef er en ce is w elcome.“Strabismus Surgery and Its Complications”succeeds in compiling much of the knowledgeinfluencing modern strabismus surgery. Theauthors’ objective was to create a singleresource for surgical planning. This textaddresses strabismus surgery from preoperativeplanning to postoperative management.“Strabismus Surgery and Its Complications”functions as a surgical atlas, but with moredetailed text than the typical atlas.

The book first addresses surgicallyrelevant anatomy and physiology, followed bydiscussions of perioperative management.Surgical complications, common and rare, areaddressed in detail. Thirty-two chapters areorganized into two major sections. The firstsection covers preoperative surgery planning,surgical technique and postoperative care. Thesurgery technique portion of the book isstructured around surgical maneuvers ratherthan clinical disorders. For example, one willnot find discussion of surgical options for thetreatment of Duane’s Syndrome, superioroblique palsy or consecutive exotropia, but willfind a comprehensive description of severalinferior oblique muscle surgical techniques.This organizational approach may frustratereaders searching for the correct procedure for agiven condition. If the reader wants detail on agiven surgical procedure, however, the text willserve as a valuable guide. The second section ofthe book addresses surgical complications, frommild to severe. The complications section isvery comprehensive and well referenced.

In “Strabismus Surgery and ItsComplications” details of most surgicalprocedures are well described and illustrated.The authors offer multiple surgical approacheswhen viable. Some procedures are described inmore detail than others, however. For instance,

details of posterior fixation and combined rectusmuscle recession/transposition are absent.Typical rectus muscle reoperation techniquesare not discussed, other than treatment for aslipped muscle or stretched scar.

The book includes excellent originalillustrations, both drawings and photographs.The atlas-like layout of the book is attractiveand functional. In addition, an accompanyingDVD includes image files of the book’s originalfigures as well as three video segments ofcommon surgical techniques. Unfortunately, thecopy editing of this first edition is imprecise,distracting from an otherwise excellentreference.

“ S t r a b ism u s Surge ry and I t sComplications” is an excellent updated surgicalatlas as well as a detailed text of modernstrabismus surgery.

Robert W. Hered, M.D.Jacksonville, Florida

mailto:[email protected].

Binocular Vision & Hyde Park Editorial Fourth Quarter of 2007

Stra bism us Qu arte rly© Vo lum e 22 (No .4):A Medical Scienti fic e-Periodical Pages 248-256

-248-

HYDE PARK EDITORIAL: The Editor's Soapbox, Sandbox & B'LOG

(Prehistoric) Since 1985

Flat Flounder Binocular Vision; More StereoscopicMovies; OCT; Synophrys; Supernormal Visual Acuity;War Eye Trauma; Memory; Motorcycle morbidity andmortality; Ethanol and Accidents; Computer Problems.

The Importance to Nature of

Binocular Vision and Binocularity

When we saw this picture we thought, whatstronger evidence could nature give of theimportance of two eyed binocular vision than torearrange anatomy so radically, when necessary, topreserve it !?

from National Geographic November 2007.This larval flounder swims with other fish for now,hidden from predators by transparency (the coloris an effect of lighting). It will soon be a bottomdweller that shimmies into the sand, gazingupward. Eyes start out one on each side; as theskull develops, one migrates to join the other.



-249-



-250-

Vision: SEEING and NOT SEEING

First a very personal anecdote about seeing.Your Editor has had beetle brows all his life,including “synophrys” the fusion- joining togetherof both brows nasally into one continuous bilateralbrow as it were. As all you ladies know, this is NO-NO cosmetically and it is the first thing to go whenthe girls learn how to pluck their brows. You neversee women with ANY hair between their eye browsanymore and the only difference is the size of thegap between the nasal ends of their brows, which Ithink seems to increase for fashion’s sake everyyear. My condition even has a lay name, “unibrow”and Unibrow is grounds for elimination. Last time Iwas in for a haircut, Deanna, the lady who cuts myhair, suggested we eliminate my unibrow with alittle hot waxing job. So we did.

I never checked it until I faced myself in themirror the next AM. I didn’t recognize myself! Icertaintly looked radically different!

I found it difficult to accept that just givingup a half inch of fur could change my appearanceso... No wonder women spend so much time (andmoney) taking care of their faces...

Athletic Vision and Golfing ???

from The Wall Street Journal October 27-28, 2007 “Golf Journal” by John PaulNewport. The Eyes Have It. New research aimsto help players focus on the key role of vision.“For most of us subprofessionals, the chiefadvantage of great vision in golf would seemto be finding lost balls in the woods.Distance markers and laser range finders takethe visual guess-work out of judgingapproach shots, and up on the green, who butMr. Magoo can’t see the hole? But almosteverything I thought I knew about thissubject turns out to be wrong. Superiorvision is a huge advantage in golf, especiallywhen it comes to putting. Many of theworld’s best players, including Tiger Woodsand seven other PGA Tour winners this year(Vijay Singh, Fred Funk and MastersChampion (continued in clipping below and thencontinued from clipping:-)

... Stan Utely, formerly one of theTour’s best putters and now arguably thegame’s hottest putting instructor. He didn’thesitate to attribute part of his success as a

putter to the factthat he alwaysread 20-10 onthe eye charts, ..(Joe DiMaggiosimilarly cred-ited much of hisprowess in base-ball to 20-10vision. ...” [as doalso many of theto p race card r i v e r s l i k erecently retiredf o r m e r Wo r l dFormula 1 Cham-p i o n M i c h a e lSchumaker andmany of the flyingaces of variousconfl icts s inceWWI -Ed]



-251-

Conversley, this is also why now I find mypenchant for pushing 200 mph on those Nevada“open road” (actually closed public roads) rally-races has decreased significantly: I’ve lost a halfline of my best corrected vision in both eyes due toearly cataract changes- and even more in contrastsensitivity I suspect, and that means a lot at thosespeeds... I just can’t see as well and as far as I usedto and I don’t like that at all. But I’m going to waitfor surgery until those accommodative andaccommodating IOLs are good enough to give mesupernormal powers of near vision and cornealsurgery can give me supernormal distance visionlike these golfers!

Astronaut Vision

from The Wall Street Journal September21, 2007 by Leila Abboud.

Want to Work In Space? SquintersCan Now Apply. “Poor eyesight has longbeen the bugaboo of many aspir ingastronauts, disqualifying more would-bespace travelers than any other physicalrequirement since the beginning of the U.S.astronaut program in 1959. Now, nearly ahalf century after the program began NASAis loosening its vision standards, allowingmore men and women to reach for dreams offlying into space. ... NASA said for the firsttime it will consider applicants who haveundergone two common types of visioncorrection surgery: laser assisted in situkeratomileus is, known as Lasik; andphotorefractive keratectomy, or PRK. It willa l so s l igh t ly re lax r equ i r emen ts foruncorrected vision to allow more contenderswho wear glasses or contact lenses. ... NASA[currently] allows some people who wearglasses or contacts to be astronauts - but onlyif their vision needs just minor correction, sothat they can still function without them ifnecessary. ... the changes, which followssimilar moves by the Navy and Air Forceregarding eyesight standards for pilots,people whose uncorrected vision wouldotherwise disqualify them can get surgery.. . .NASA astronaut appl icants need abachelor’s degree in engineering, science or

math, along with three years of relevantprofessional experience. ... Commercialairline pilots are generally allowed to wearglasses, contacts or have vision correctionsurgery. . . . Navy’s refractive surgeryresearch is unusually authoritative because ofi t s i n d e p e n d e n c e f r o m c o m m e r c i a lcompanies and industry bias. In May, the AirForce changed its policy to allow peopleapplying for aviation jobs to have had Lasiksurgery. That follows a similar move by theNavy last year. ... doctors have feared thatextreme environments, such as those foundunderwater on in space, could cause flapd i s l o c a t io n s , p o s s i b l y l e a d i n g t o acatastrophic vision loss. Navy research hasfound that the three year risk for suchdislocations is extremely small , about 1 in9000. ... People who had an early type ofvision corrections surgery - RK, or radialkeratotomy - can suffer alarming cornealchanges at high altitude. Military doctorsdocumented the problems in studies done onRK patients on Pike’s Peak in Colorado inthe early 1990s. The findings helped toexplain the experience of a renownedmountain climber and RK patient, BeckWeathers, whose eyesight failure on MountEverest was described in the 1998 book ‘IntoThin Air’. The same Pike’s Peak studies,however, found no such problems with PRK.... two new technologies: wavefront-guidedsoftware and the femtosecond laser. ... Thefemtosecond l a se r , be t te r known asIntraLase, offers more precision thanhandheld devices and is used in what ispopularly called ‘all-laser Lasik’. With thesetechnologies, Lasik is as good as PRK. ...”

More Sad War Stories re Eyes

In the last issue we printed fellow pediatricophthalmologist and Flight Surgeon Enzenauer’saccount of his service doing unofficial eye surgeryin Afghanistan. The following report suggest theyreally do need more properly trained and assignedeye surgeons over there, and also perhaps evenmore and better protective eye shields. If I wereassinged over there I think I would just wear my fullface racing helmet and eye shield!



-252-

from USA TODAY November 14, 2007by Gregg Zoroya. Blinded by the war: Eyeinjuries hit troops hard. Mortars, roadsidebombs send lives into darkness. “... more than1100 veterans of Iraq and Afghanistan - 13%of all seriously wounded casualties - undergosurgery for damaged eyes. That is the highestpercentage for eye wounds in any major conflictdating to World War I, see Figure ... eyeinjuries have become oneof the most devastatingconsequences of a war inwhich roadside bombs,mortars and grenades arethe most commonly usedw e a po n s a g a i n s t U . S .troops. Brain injuries andamputat ions have longbeen the focus of thedamage such weapons areinflicting, but in recentw e e k s t h e A rm y h asacknowledged that seriouse y e w o u n d s h a v eaccumula ted a t a lmosttwice the rate as woundsr e q u i r i n g a m p u t a t i o n s .Body armor that protectsvital organs and the skull issaving lives. But troopseyes and limbs remainparticularly vulnerable tothe blizzard of shrapnelfrom such explosions. ...Partial or total vision has been restored inmost cases involving eye injuries, militarystatistics show. But hundreds of troops havebeen left with impaired vision, and dozenshave been blinded. Troops in Iraq routinelywear protective eyewear, but it doesn’talways work. When a roadside bomb inBaghdad blew a hole through the heavilyarmored vehicle carry Army Sgt. LuisMartinez last April, the force from the blaststripped off his helmet, headset and goggles.... The blast also drove the frame of hisprotective eyewear into his face. ... Becausethe Pentagon has no rehabilitation servicesfor the blind, the path to recovery often leadsdirectly to the Department of VeteransAffairs. The VA operates 10 centers across

the country for blind rehabilitation that teachvisually impaired veterans how to functionin society. The centers have 241 beds, and ittakes an average of nearly three months toget in. Iraq and Afghanistan casualties go tothe front of the line, says Stan Poel, VAdirection of rehabilitation services for theblind. So far, 53 have enrolled in the blindrehabilitation programs, the VA says. ... The

VA does not provideguide dogs, but it helpslink veterans with guided o g s c h o o l s t h a tcommonly provide ad o g a n d t r a i n i n gv i r t u a l l y f r e e t oveterans, Poel says. ...

Brain injuries alsodanger to vision. “... in astudy of 101 Iraq andA f g h a n i s t a n w a rv e t e r a n s w i t h m i ldtraumatic brain injuries.Many are still in theservice. Goodrich foundthat 40% to 45% of thepatients suffered visionloss even though theireyes were physicallyhealthy. The biggestproblem was an inabilityfor both eyes to operateprecisely together. [?Isn’tt h a t w h a t w e c a l l

STRABISMUS?-eD] This can lead to eye strainand b lur red v is ion . . . . r ou t ine eyeexaminations may not uncover the problems.‘In many cases, we’re seeing active-dutytroops, and they want to get back and jointheir units’ ...’So they don’t want to hear thatthere’s something they need to go get treatedfor’.”

Trauma Care Here in U.S.

from The Wall Street Journal October 3,2007 by Laura Landro. A Dangerous Gap inTrauma Care. Systems to transfer patients tobest equipped hospital fall short in most states.“ . . . Trauma f rom in ju r ies inc ludingaccidents, falls and violence is the leading



-253-

cause of death for Americans under the ageof 44, claiming more than 140,000 lives andpermanen t l y d i sab l ing 80 ,000 peopleannually. But only one in four lives in anarea served by a coordinated system totransfer patients to designated trauma centersfrom less equipped hospitals, according tothe American College of Surgeons, whichsets standards for trauma care. ... In themeantime, it’s often up to patients andfamilies to be prepared and know what levelof trauma care their local hospital canprovide before an accident happens - or whatarrangements the the hospital has to transferpatients if necessary. Patients can check outthe American College of surgeons Web site,which has a list of verified trauma centersand the level of care they provide:

(www.facs.org/trauma/verified.html).At highest risk are those in rural areas, wherenearly 60% of trauma deaths occur eventhough such areas account for only 20% ofthe population. ...”

ABOUT MEMORY

National Geographic portrays relativememory this way: Consider a brain synapseto be equivalent to a memory byte. Yourbrain is still vastly superior to any hardware.

PUBLIC SAFETY

from The Wall Street Journal September 18,2007 by Jonathan Welsh. The NewMotorcycles: Bigger, Faster, Deadlier. Trendtoward outsize power and lighter weightcoincides with increase in fatalities. “ ... 2007,the deadliest year yet for motorcycle riders.... a horsepower battle in the cycle industryhas produced bikes that have the power of acar but often weigh less than ever. ... but theb i k e s ’ p o t e n t i a l s p e e d a n d v i o l e n tacceleration can quickly overwhelm all butthe most ski l led r iders. These h ighp e r f o r m a n c e m a c h i n e s , of t e n c al l ed‘superbikes’ or supersports’, accounted forless than 10% of motorcycle registrations in2005 but accounted for more than 25% ofrider fatalities. ... The total number of riderdeaths has more than doubled since 1997. Atthe current rate, some safety experts say,fatalities in 2007 could surpass the previouspeak of 4955 set in 1980. ... In addition tomore powerful machines, an influx ofinexperienced riders is also helping to driveaccident rates higher. And as more middleage consumers return to motorcycling - oftenafter not having ridden for 20 years or more,more older riders are being killed in crashes.Another contributing factor: a trend towardmore liberal helmet laws. ... During June,July and August, about one in four patientshurt in t raf f ic acc idents have beenmotorcycle riders. . . . the nearly 200horsepower generated by the company’s newZX-14 or rival bike maker Suzuki MotorCorps GSX-R1000. The Suzuki weighsbarely 400 pounds with a full fuel tank, andcan accelerate to 60 mph in about 2.5 [=F1!]seconds . . . . Al t hough a t r ipl ing o fmotorcycle sales over the past decadeaccounts for some of the rising death rate,fatal motorcycle accidents have also risenproportionally. Over the time period of theIIHS study, from 2000 to 2005, the deathrate for motorcyclists rose to 7.5 deaths per10,000 registered motorcycles from 7.1. Inthe same per iod, the percentage ofmotorcycle deaths

http://www.facs.org/trauma/verified.html).



-254-

among all highway fatalities rose to 10% from 7%.Superbike riders had a death rate of 22.5 for every10,000 registered motorcycles. In 2005, riders 40 orolder accounted for 47% of motorcycle fatalities,

compared with 24% 10 years earlier. In the sameperiod, the fatality percentage for riders youngerthan 30 years of age fell to 32% from 41%. ...”



-255-

WARNING !!!! THIS is really frightening: Overall this means about three out of every eight fatalaccidents have one or more people who are legally intoxicated. To that add perhaps an equal number ofthose who are illegally intoxicated on illegal drugs. And figuring most people are usually unintoxicatedonly during their working hours or at least until lunchtime.... =We try to stay off the roads between 3 PMand 3 AM ! During those hours, simple arithmetic suggests that many of your fellow motorists may beincompetent.



-256-

Another supporting opinion supporting prior comment on computers: And also, see, if you hadjust ordered a trial of, or bot Pivot.Pro software from Portrait.com as we recommended in the last issue’sLead 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 Benethat he is working on a (laptop) computer -the only character in the strip that is! No wonder he washaving a bad day before Sherman came along!!!! - confirming my complaints in previous issues aboutcomputers.

Do have a good holiday season. Just stay away from your computer and it will be!

-per [ alias “hatesgates”, “gateshater”]

ulakbİmbinocular vision & strabismus quarterly (issn 1088-6281), the "loftiest scientific...

Documents