Kestenbaum procedure on the vertical rectus muscles with simultaneous compensation of the induced cyclodeviation for nystagmus patients with chin-up or chin-down head posture.

BACKGROUND: Kestenbaum surgery is performed for nystagmus-related abnormal head posture, and symmetrically changes the position of both eyes to shift the null point to the primary position. Most patients with infantile nystagmus have their null point zone in a lateral gaze position. Less frequently, surgery can be performed to reduce chin-up or chin-down head posture. We report indications for, and the results of eight consecutive interventions performed according to the Kestenbaum principle for the reduction of a chin-up or chin-down head posture. METHODS: In a retrospective study, the clinical findings for eight patients who consecutively underwent treatment in the University Eye Hospital of Cologne between 2001 and 2007 were investigated. The patients were aged 6 to 16 years; median age was 6.5 years. For all patients, surgery was to correct a chin-up or chin-down head posture due to infantile nystagmus. Preoperatively, five patients showed a chin-down, three a chin-up head posture. All vertical rectus muscles were recessed or tucked between 6 and 7 mm; the resulting cyclodeviation was reduced by an intervention on the superior oblique muscles (6 to 8 mm tucking, in the case of chin-down, or recession in the case of chin-up head posture). RESULTS: Surgery was successful in seven of the eight patients, with a reduction of the vertical head posture to less than 10 degrees. In the cases of chin-down posture, head posture was reduced to between 0 degrees and a maximum of 20 degrees in one case postoperatively (before the operation 20 degrees to 35 degrees ); in the cases of chin-up posture, to less than 8 degrees (before the operation 25 degrees to 35 degrees). One case showed no postoperative improvement in chin-down posture but a head turn to the left of up to 20 degrees; another case had a remaining chin-up posture of 8 degrees with a right turn of 15 degrees . Binocular vision was better or the same in all cases after surgery. CONCLUSION: For nystagmus patients with chin-up or chin-down head posture, surgery for bilateral parallel shifting of the eyes can considerably improve the head posture. It is possible to compensate the induced cyclodeviation at the same time by bilateral surgery on the superior oblique muscles.

[Surgical options in retraction syndrome]. / Operative Korrektur des Retraktionssyndroms.

BACKGROUND: A causative therapy for Duane's retraction syndrome, which is the most prominent example of connatal ocular misinnervation, does not exist. Eye muscle surgery is indicated in cases with manifest strabismus in primary position and an annoying compensatory head posture to maintain binocular single vision. Different surgical approaches to the different types of Duane's retraction syndrome, mostly on the affected eye but also on the fellow eye, are described in the literature. METHOD: We retrospectively analyzed the pre- and postoperative findings of 55 patients in whom we performed surgery because of Duane's retraction syndrome during the years 1999 to 2004. The type of retraction syndrome, the angle reduction in primary position and the reduction of head posture were evaluated in regard to the surgical procedure chosen. RESULTS: In 37 cases surgery was primary. In 25 cases a single recession of the medial rectus (16 cases) or the lateral rectus (9 cases) muscle of the affected eye was performed. For a dose-response relationship of the one-muscle recessions, the mean angle reduction in the primary position was 2 pdpt (cm/m) per mm recession. The mean reduction of head posture was 1.5 degrees per mm recession. In 10 cases combined surgery on the affected eye was performed. The correlation between the mean angle reduction and the recession was 3 pdpt (cm/m) per 1 mm. CONCLUSION: Depending on the type of retraction syndrome, the angle in primary position, the head posture and the globe retraction, different surgical options exist which aim at rehabilitation of the patient suffering from Duane's retraction syndrome.

[Simulating the outcome of ptosis and squint surgery with digital photomontage]. / Ergebnissimulation bei Ptosis- und Schieloperationen mittels digitaler Fotomontage.

BACKGROUND: When being informed preoperatively about the risks and prospects of ptosis and squint surgery patients may wish to see pictures of the possible outcome. In most cases pre- and postoperative prints of patients with similar problems will be sufficient. But, to come to a decision, some patients need portrait prints of their own face modified to show the changes that could be produced by the surgery proposed. Such photo prints can be rather easily produced with modern computer and software equipment. MATERIALS AND METHODS: Portrait photos have been shot with a digital camera and have been modified in a personal computer with image processing software. RESULTS: Technique and outcome are shown with two case studies. One patient had a slight asymmetry of the upper lids after a bilateral anterior fat resection for dysthyroid exophthalmus. The second patient suffered from a considerable pseudoexotropia caused by retinopathy of prematurity. In both cases the probable result could be simulated photographically to an extent that decision making became rather easy. CONCLUSIONS: Phototechnical simulation of surgical outcome may be useful to produce better information for some patients.

[Basic methods of strabismology]. / Basisuntersuchungen der Strabismologie.

Basic examination techniques for manifest and latent strabismus as well as for paralytic strabismus are discussed. Usually the medical history gives the first clues for the form of strabismus. The examination starts with an evaluation of the head posture. The objective angle is estimated through corneal reflections and the corrective saccade (cover test). Uncover and cover testing allows the differentiation between manifest and latent strabismus. The Lang test, Bagolini's test and the light red glass test provide information regarding quality of binocularity (abnormal and normal retinal correspondence). Estimation of changes in the angle of strabismus in the diagnostic gaze positions by corneal reflections, cover test and the limbus test of Kestenbaum is complemented by testing of the visual acuity and fixation. Without evaluation of fixation neither the cover test nor tests for binocularity can be interpreted adequately.

[Cyclotropia in macula translocation. Possible eye muscle surgery solutions]. / Zyklotropie bei Makulatranslokation. Mögliche augenmuskelchirurgische Lösungen.

BACKGROUND: Macular translocation for treatment of age-related maculopathy often necessitates surgical counter-rotation of the external eye muscles. Excyclorotatory effects can be attained generally by various surgical methods on all extraocular eye muscles. If procedures on different muscles are combined, anterior segment perfusion has to be maintained. PATIENTS AND METHODS: The results of 29 operations were analysed in order to examine the excyclorotatory effects of 4 different combined surgical approaches. RESULTS: In 23 patients a partial transposition of all 4 m. recti together with a high dose combined operation on both oblique muscles yielded a mean effect of 21.6 degrees excyclorotation. In four patients a vertical transposition of the horizontal m. recti in opposite directions together with a high dose combined operation on both oblique muscles led to a mean excyclorotation of 22 degrees. A full tendon transposition of the superior oblique muscle to the nasal part of the orbit in one case combined with a downward transposition of the medial rectus muscle resulted in an excyclorotation of 37 degrees, in another case combined with an anterior margin advancement of the inferior oblique muscle led to an excyclorotation of 35 degrees. CONCLUSIONS: All approaches yielded mean counter-rotatory effects over 20 degrees. The indications are discussed under the aspects of the possibility of a one-step correction of horizontal or vertical angles, dosage, induction of inconcomitancies and operation time.

[Childhood vision disorders. Screening programs in international comparison]. / Kindliche Sehstörungen. Screeningprogramme im internationalen Vergleich.

Worldwide in a number of countries, screening programs aimed at detecting visual disorders in children are established. Repeatedly, proposals are brought forward to optimize already existing programs. Countries without such a program are interested in learning about current models as a guide for planning their own program. This study was performed to take stock of the screening programs for visual dysfunction in children in existence in the years 1999-2000 worldwide. The aspects considered were the child's age at examination, examiner's qualification, type of examinations performed, cost-bearing entity, and cost-efficacy analysis. The health ministries of 190 sovereign countries were asked via a questionnaire for information about possibly existing screening programs. The results of the survey were analyzed quantitatively regarding geographic, political, and socioeconomic aspects, yielding data for the exchange of experience in optimizing existing programs and developing new programs.

Modified transposition procedure of the vertical recti in sixth nerve palsy.

PURPOSE: To report a modified transposition procedure of the vertical recti for severely limited abduction of the globe caused by sixth nerve palsy and to compare this with the Hummelsheim transposition procedure. METHODS: Retrospective study of 13 eyes of 12 patients that had Hummelsheim transposition procedure and 19 eyes of 17 patients that had modified transposition procedure of the vertical recti for severely limited abduction of the globe caused by sixth nerve palsy. The modified transposition procedure joins lateral strips of the vertical recti and sutures this junction to the lateral rectus muscle. Functional results of the Hummelsheim procedure are compared with functional results of the modified transposition procedure. RESULTS: Abductive capacity improved by 4.19 +/- 1.67 mm in the Hummelsheim group and 4.08 +/- 1.7 mm in the modification. The angle of squint changed from +22.33 +/- 6.74 degrees to -0.20 +/- 2.61 degrees in the Hummelsheim group and from +25.54 +/- 5.66 degrees to +0.95 +/- 5.26 degrees in the modification group. The functional results as to abductive capacity and postoperative angle of squint showed no significant difference between the two methods (P >.05, t test). The modification was less time consuming. CONCLUSIONS: A modification of the transposition techniques of eye muscles in sixth nerve palsy is introduced. Its functional results are comparable to the classic technique of Hummelsheim. Operative risk and trauma are reduced, because the technique avoids scleral stitches and was found to be less time consuming than the Hummelsheim procedure.

New onset of crossed eyes in an adult.

A 77-year-old woman presents with a seven-year history of an isolated slowly progressive esotropia with bilateral abduction defects. The only potential cause discovered was dolichoectasia of the intracavernous carotid arteries.

Follow-up of transnasal orbital decompression in severe Graves' ophthalmopathy.

OBJECTIVE: To evaluate the safety and efficacy of transnasal orbital decompression for severe Graves' ophthalmopathy. DESIGN: Retrospective noncomparative case series with extended clinical follow-up. PARTICIPANTS: Seventy-eight consecutive subjects who were operated on for compressive optic neuropathy with loss of visual acuity or visual field defects after failure of medical and radiation therapy. INTERVENTION: Strictly transnasal, endoscopic-controlled bilateral decompression of the medial and inferomedial wall of the orbit. MAIN OUTCOME MEASUREMENTS: Preoperative and postoperative examination, including vision, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and notification of complications, intranasal signs of inflammation, and subjects' assessment of the procedure. RESULTS: One hundred forty-five endonasal decompressions were performed on 78 subjects (63 women, 15 men, 52.2 +/- 10.3 years) during a 10-year period. Sixty five patients were bilaterally operated on; 15 required only unilateral decompression. Four of 78 needed repeat surgery. Visual acuity increased from a preoperative average of 0.50 +/- 0.27 (range, 0.01-1.25) to 0.75 +/- 0.21 (range, 0.01-1.25) postoperatively. An average reduction of proptosis of 3.94 +/- 2.73 mm (range, -1.0-11.0 mm) was achieved with a mean preoperative Hertel measurement of 22.19 +/- 3.13 mm (range, 15-34 mm). Ocular motility was corrected by recession of the medial rectus muscle in 58 of 78 cases. Twenty-six of these 58 cases were simultaneously operated on in the same surgical session immediately after the transnasal decompression, and the others after a period of 2 to 3 months. CONCLUSIONS: The transnasal orbital decompression procedure improved vision, decreased proptosis in a range comparable to more invasive techniques, and had favorable cosmetic results without additional disfiguration by scars. Morbidity was far less than with other approaches. Postdecompression strabismus was successfully managed by recession of both medial orbital muscles in the same surgical session.

Counterrotation of the globe in macular translocation.

BACKGROUND: Macular translocation is a new treatment option in age-related maculopathy. The aim of this study was to report experience with the handling of the sensory problems concerning subjective cyclorotation and binocularity that arise with this technique. METHODS: The data of 33 patients who had undergone macular translocation and counterrotation of the globe by muscle surgery in a first operation, followed by silicone oil removal and sometimes revision of the eye muscles in a second operation, were evaluated. The counterrotation consisted of a partial transposition of the rectus muscles and extensive surgery on the anterior margins of the oblique eye muscles. Subjective monocular cyclorotation, motility and binocularity were tested. RESULTS: In 5 patients after the two operations binocular single vision was proved; in one of these cases there was even stereoscopic function. Seventeen patients excluded one eye: 13 excluded the operated eye, 4 the fellow eye. Eleven patients experienced double vision or tilted images under binocular viewing conditions and thus required further surgery or occlusion of one eye. CONCLUSION: The majority of patients were not hindered by subjective cyclorotation. Nevertheless, in a large proportion of patients binocularity could not be reestablished because of still reduced visual acuity or cyclotropia. The data show that the aim of restoring binocularity can be achieved but in practice is often not attained.

Preliminary report: long-term results of transnasal orbital decompression in malignant Graves' ophthalmopathy.

In order to demonstrate the safety and efficacy of transnasal orbital decompression for malignant Graves' ophthalmopathy, we carried out a retrospective chart review and clinical follow-up examination of 78 consecutive patients who were operated on for compressive optic neuropathy (CON) with loss of visual acuity or visual field defects. The intervention - strictly transnasal, endoscopically controlled, bilateral decompression of the medial and inferomedial wall of the orbit - was performed when medical and radiation therapy had failed. A total of 145 endonasal decompressions were performed on 78 patients (63 female, 15 male, 52. 2 +/- 10.5 yrs.) over 9 years. Of these, 65 were operated bilaterally, 15 required only unilateral decompression; 4 had repeated surgery. Visual acuity increased from an average of 0.50 +/- 0.27 (range, 0.01 - 1.25) to 0.75 +/- 0.21 (range, 0.01 - 1.25). Proptosis decreased by an average of 3.94 +/- 2.73 mm (range, -1.0 - 11.0 mm), from a mean preoperative Hertel measurement of 22.19 +/- 3. 13 mm (range, 15 - 34 mm) to a mean postoperative Hertel measurement of 18.3 +/- 2.65 mm (range, 10 - 26 mm). Ocular motility was corrected by recession of the medial rectus muscle in 58 cases, in 26 cases immediately after decompression in the same surgical session. The transnasal orbital decompression procedure improved vision, decreased proptosis in a range comparable to more invasive techniques and had favorable cosmetic results without additional disfiguring by scars. Post-decompression strabismus was successfully managed by recession of both medial orbital muscles in the same surgical session.

Vertical and cyclotorsional deviations following peribulbar anesthesia.

BACKGROUND: Motility disorders may occur consecutive to peribulbar anesthesia. The underlying pathology is still debated. The aim of the study was to contribute to the discussion by a meticulous orthoptic examination of a series of patients. METHODS: In a series of 16 patients with diplopia after peribulbar anesthesia, measurements of the angle of squint in the nine directions of gaze, Bielschowsky's headtilt test and motility analysis were performed. The findings were discussed with regard to the possible types of muscular lesions. RESULTS: Hypotropia and deorsoadduction accompanied by relatively small cyclotropia were found in all cases. Bielschowsky's head-tilt test mostly revealed neutral findings. CONCLUSION: The findings were discussed under the hypothesis of a fibrotic muscular change in the superior oblique and inferior rectus muscle. This hypothesis turned out to be concordant with the orthoptic measurements, implying that treatment of the disorder should consist in low-dosage recession of the fibrotic muscles, which in our experience was rewarding.

The cost-effectiveness of screening strategies for amblyopia: a preliminary report.

Five screening strategies for amblyopia in different age groups were compared according to a decision-analytical model from the perspective of the health insurance funds. Our findings indicate that the costs per detected case of amblyopia range from about 1200 DM to 3000 DM (613 Euro to 1534 Euro). The two most cost-effective screening strategies were to screen high-risk children up to the age of one by ophthalmologists and to screen all children up to the age of one by ophthalmologists. The screening of high-risk children identifies only about a third of all affected children in this age group, when compared with the number of cases detected by screening all children up to the age of one. However, the average cost per detected case of amblyopia among high-risk children is lower than the cost of screening all children in this age range.

[The Cologne Guidelines Conference: computer-assisted clinical practice guidelines in clinical diagnosis]. / Die Kölner Leitlinien-Konferenz: Computergestützte Leitlinien zur klinischen Diagnostik.

Eighteen clinical practice guidelines on interdisciplinary diagnostic issues were developed at the University Hospital of Cologne, Germany. The guideline committee is organized and directed by the quality control program, which also includes the local Cochrane initiative and a wide range of organizational topics. During guideline development, questions of differential diagnosis were addressed to the same extent as the organizational and financial realization. Broad consideration was given to medicolegal implications, but need for interspecialty cooperation was judged to be more critical and even more relevant in this regard. Guidelines were primarily developed as algorithms and translated to text versions secondarily. Critical steps in the decision tree were supported by rated literature and recommendations weighte by criteria as used in evidence-based medicine. For implementation, guidelines were presented to colleagues in a series of short lectures, as print versions containing all literature used in the developing process, and in hypertext format, which is accessible via intranet. Three levels of presentation were chosen in the html-version: algorithm, decision, and information. The former is due to orientation in the guideline, the second displays the binary question, and the latter makes the scientific background available, together with literature and links for more information. Efforts to check effectiveness are currently been made, questions of efficiency will be addressed in future.

Do standard procedures in squint surgery influence the blood-aqueous barrier?

BACKGROUND AND OBJECTIVE: Surgery on the rectus muscles may interfere with anterior segment perfusion. This study investigates the influence of combined rectus muscle surgery on the blood-aqueous barrier in children. Namely, the influences of tucking and resection procedures were compared. PATIENTS AND METHODS: Laser flare measurements for tyndallometry were performed preoperatively and postoperatively in 25 children. Fifteen of the children had undergone a combination of a rectus recession and tucking; 10 had undergone a combined recession-resection procedure. RESULTS: The mean preoperative flare value was 4.1 photon counts/ms versus 3.7 photon counts/ms postoperatively in the eyes that had undergone surgery. Statistical evaluation showed that the postoperative changes were insignificant. No significant difference was found between the two surgical techniques (tucking vs resection) regarding the preoperative versus postoperative flare value change (level of statistical significance .05). CONCLUSION: Combined squint surgery, either recession-tucking or recession-resection, was not shown to influence the blood-aqueous barrier.

[Quality of vision screening in childhood]. / Qualität des Sehscreenings im Kindesalter.

BACKGROUND: In Germany the paediatricians use three different visual acuity tests (Pictures, Rodenstock-Test, H-Test). We investigated the effectiveness of these procedures. SUBJECTS: In this study 303 children were referred by paediatricians to the study group in the Cologne Augenklinik. They were fully examined by an orthoptist and an ophthalmologist (gold standard). RESULTS: From these data the sensitivity and specificity of the tests used by the paediatricians were calculated. Only the H-Test proved to be satisfactory. CONCLUSION: The actual situation of screening for amblyopia by paediatricians in children aged 3 1/2 to 4 is unsatisfactory in Germany. Paediatricians and ophthalmologists should use a similar test for visual acuity. Continuing education of medical personnel is desirable to ensure an adequate quality of screening.

[Comparison of subjective and objective parameters after oculomotor muscle surgery]. / Vergleich subjektiver und objektiver Parameter nach Augenmuskeloperation.

BACKGROUND: In regard to quality-control studies concerning strabismus surgery we were interested in a comparison of subjective and objective parameters after squint surgery. MATERIALS AND METHODS: In a questionnaire 175 patients were asked for their evaluation of the functional and cosmetic results 1 week and 6 weeks after squint surgery. Parallel, objective parameters like reduction of the squint angle and quality of stereopsis were documented. RESULTS: Overall 94.2% of patients with esotropia (n = 52) were satisfied cosmetically and 5.8% were not 1 week after squint surgery was performed. In the group of a patients with exotropia (n = 36), 91.7% of the patients were satisfied cosmetically and 8.3% were not. Even in cases of esotropia or exotropia no changes in the quality of stereopsis were noted by some patients or they could not be mentioned in the questionnaire. Some patients did not appreciate the improvement of binocular function found in our examination. CONCLUSIONS: Good congruence between objective and subjective results 1 week after squint surgery was found.

The influence of strabismus surgery on the blood-aqueous barrier: tyndallometry case studies in patients with risk factors.

We present tyndallometry as a method for investigation of subclinical changes in anterior-chamber flare in patients with risk factors regarding anterior-segment ischemia after squint surgery. The cases of six adult patients who underwent surgery on the vertical recti and who had additional risk either because of dysthyroid orbitopathy or because of transpositions carried out on the recti are presented. In one case a transient subclinical increase in the flare value was observed. This noninvasive method seems suitable for the provision of further information on the pathophysiology of anterior-segment ischemia and for monitoring of patients at special risk postoperatively such that early treatment can be started if necessary. Additionally, early detection of nonischemic intraocular inflammation in the postoperative course is rendered possible by this examination.

[Disorder of the blood-aqueous barrier after eye muscle operation in children]. / Blut-Kammerwasser-Schranken-Störung nach Augenmuskeloperation bei Kindern.

UNLABELLED: We wanted to study the effect of squint surgery on the blood-aqueous barrier in children. Our interest was to ascertain whether or not there is a breakdown of the blood-aqueous barrier after routine squint surgery, and whether this would need antiinflammatory treatment with steroids. PATIENTS AND METHODS: Forty-seven eyes of 18 girls and 7 boys (age range 4-14 years) were examined. The children were generally healthy and had not undergone any previous eye surgery. The mean age of patients (n = 25) was 7.8 +/- 3.1 years. Using the laser flare meter Kowa FM-500, the flare (photocounts/ms) in the anterior chamber was measured before and on the 2nd day after squint surgery (n = 32). Fifteen eyes served as controls and were not operated on. Following surgery, the operated eyes were treated with aminoglycoside eye drops (three times daily). No steroids or non-steroidal antiinflammatory drugs were applied before or after surgery. RESULTS: The flare values were 4.10 +/- 1.29 photocounts/ms before and 3.89 +/- 1.27 photocounts/ms after squint surgery. There was no significant increase (P = 0.58) of flare on the 2nd postoperative day. CONCLUSION: Our data confirm that there is no clinically significant disruption of the blood-aqueous barrier following squint surgery. We therefore conclude that there is no need for postoperative therapy with steroids.