Efficacy and safety of adjustable suture in horizontal strabismus: Comparative study of children versus adults.

OBJECTIVE: Adjustable suture procedures allow addressing the unpredictability of some postoperative results in strabismus surgery. The purpose of the study was to compare the effectiveness of adjustable and non-adjustable suture in the treatment of horizontal strabismus in children and adults. METHODS: Prospective study including patients undergoing strabismus surgery to correct horizontal strabismus with fixed hanging suture (non-adjustable suture group) and adjustable suture. Visual acuity, amblyopia, deviation, oblique muscle involvement, previous surgeries, nystagmus, need for adjustment, and complications were recorded. The variables were recorded in the immediate postoperative period, at one week and at 3 and 6 months. RESULTS: 186 patients were included: 157 (84.4%) with adjustable suture and 29 (15.6%) with non-adjustable suture, of which 119 were children and 67 were adults. Postoperatively, 19 children (16.0%) and 19 adults (28.4%) required adjustment (p = 0.044). Of 157 patients with adjustable suture, it was adjusted in 20% (32/157). Success after adjustment was higher for adjustable suture (91.72% vs 79.31%; p = 0.043) and remained for 6 months (p < 0.05). Previous surgery (p = 0.004) and exotropia (p = 0.018) correlated with the need for adjustment. CONCLUSIONS: 20% of patients with horizontal strabismus can benefit from a postoperative adjustment to improve the surgical result. The adjustable suture was shown to be superior to the fixed hanging suture and is an excellent surgical option, both in children and adults.

Satisfaction with strabismus surgery based on the opinion of expert surgeons. / Satisfacción de la cirugía de estrabismo basada en la opinión de cirujanos expertos.

PURPOSE: To assess the perception of strabismus surgeons in Spain regarding patient satisfaction after surgery, by analysing the types of strabismus with the most satisfied patients, as well as the causes of dissatisfaction. METHODS: A survey was carried out among the members of the Spanish Strabology Society who were over 50 years of age, active in Spain, with more than 20 years of surgical experience, and whose main surgical activity was strabismus. The questionnaire consisted of 18 questions about the perception of patient satisfaction according to the type of strabismus, patient age, as well as the most frequent cause of dissatisfaction after surgery. RESULTS: The questionnaires were completed by a total of 29 surgeons, with a mean of 31 years of surgical experience. The most frequent cause of perceived dissatisfaction was residual strabismus. No differences were found in the satisfaction index between children and adults. The surgery that was considered to produce greater satisfaction was endotropia, followed by decompensated 4th nerve palsy, and exotropia, while 3rd nerve palsy was the cause of the most dissatisfaction. CONCLUSIONS: According to strabismus surgeons, endotropia is the most satisfactory surgery for the patient, followed by exotropia, vertical strabismus, and traumatic paralysis of the 4th cranial nerve.

Myopia progression and axial elongation in Spanish children: Efficacy of atropine 0.01% eye-drops.

PURPOSE: To assess myopia progression in Spanish children and whether treatment with low-dose atropine eye drops delays myopia progression and axial elongation. METHODS: 339 eyes of 339 Caucasian patients with myopia, aged 5 to 11 years, were examined. Participants were randomized to a treatment arm, receiving one atropine (0.01%) eye drop/day for two, and an untreated control arm. At the baseline and 2-year follow-up visits, we recorded: spherical equivalent (SE), axial length (AL), mean keratometry (Mean-K) and anterior chamber depth (ACD). We also examined the rate of children with higher myopia progression (change in SE >1 D/2 years) and identified risk factors for progression. RESULTS: In 339 eyes of the 339 children (age=7.61; SD 1.70; range 5-11 years), the mean baseline SE was-2.15 (SD 0.62) D, and AL was 24.24 (SD 0.79) mm. After 2 years, higher increases occurred in all variables except ACD in the untreated group vs. the atropine group, respectively: SE (-0.51 (SD 0.39) D vs. -0.76 (SD 0.37) D, P<0.001), AL (0.20 (SD 0.20) mm vs. 0.37 (SD 0.27) mm, P<0.001) and Mean-K (0.01 (0.28) D vs. 0.09 (0.32) D, P=0.018). Myopia progression was reduced by 32% in the treatment group. There were more progressors >1D/2y in the control group: 62/168 (36.9%) vs. 35/171 (20.5%) (P<0.001). Atropine was identified as a protective factor against myopia progression (B=1.12; 95% CI= 0.98-1.27; P=<0.001). CONCLUSION: Spanish children showed a low rate of myopia progression. Atropine 0.01% showed a significant effect in slowing the progression of both refractive error and axial elongation.

Oculomotor nerve palsy in herpes zoster ophthalmicus: Presentation of 4 cases. / Parálisis oculomotoras en el contexto de una reactivación del virus varicela-zóster: a propósito de 4 casos.

Varicella zoster virus (VZV) infection has a high prevalence worldwide. Within the multiple ophthalmologic manifestations that VZV can cause, sudden diplopia is among them. A review is presented of four clinical cases of 3rd and 4th oculomotor nerve palsies in herpes zoster ophthalmicus. A review is also presented of the physiopathology and most important clinical manifestations. Imaging tests are essential in order to rule out complications. Systemic antiviral administration is the correct treatment.

Neuro-ophthalmological manifestations as complication of an infection with Mycoplasma pneumoniae and subsequent development of disseminated acute encephalitis. / Manifestaciones neuroftalmológicas como complicación de una infección por Mycoplasma pneumoniae y desarrollo posterior de una encefalitis aguda diseminada.

The purpose of this article is to describe two paediatric neuro-ophthalmological clinical cases caused by a systemic infection due to Mycoplasma pneumoniae (M. pneumoniae). The cases are two girls aged 14 and 12 seen in the Emergency Department: The first one had internuclear ophthalmoplegia and second with loss of vision and headache. They had no other neurological foci. Magnetic resonance imaging showed hyperintense plaques in both, suggestive of a demyelinating disease. One month later, the neuro-ophthalmological symptoms resolved, with normal follow-up magnetic resonance imagings. The diagnosis was acute disseminated encephalitis secondary to M. pneumoniae. The diagnosis was made using PCR (gold standard) and/or IgM in serology. It is important to think about this possible aetiology in cases of suggestive demyelinating disease. There is controversy about the role of antibiotics and on whether corticosteroids are contemplated. In conclusion, M. pneumoniae must be a differential diagnosis in acute neuro-ophthalmological disorders in children.

Quality of life and visual function in children with glaucoma in Spain. / Estudio de la calidad de vida y la función visual en niños con glaucoma en España.

OBJECTIVE: To evaluate the effect of glaucoma on visual function, as well as quality of life in children and quality of life perceived by caregivers in children up to 16 years of age. MATERIAL AND METHODS: An observational and prospective study was designed using the questionnaire GQL-15 (Glaucoma Quality of Life) and conducted on children and caregivers. The questionnaire VFQ-25 (Visual Functioning Questionnaire) was conducted on children. Different variables of the clinical history that could influence the quality of life and visual function were recorded. RESULTS: The study included 24 patients with a mean age of 9.13±3.08 years, and included 3 with unilateral involvement, and 20 diagnosed with primary congenital glaucoma. Parents reported a worse quality of life than children. The result of the GQL-15 survey was 32.3±11.56 points in children and 37.52±14.59 points in caregivers (P=.001). The parameter most related to quality of life and visual function was the mean deviation (MD) of the visual field in the best eye. A statistically significant correlation was found between the result of GQL-15 and the mean deviation of the visual field (children: R=0.63, P<.01, caregivers: R=0.81, P<.001). CONCLUSIONS: Functional loss has an impact on the quality of life and visual function in children with glaucoma, although the quality of life perceived by the caregivers is worse than that perceived by the child.

Assessment of extraocular muscle thickness and correlation study using optical coherence tomography. / Evaluación del grosor de los músculos extraoculares y estudio de correlación mediante tomografía de coherencia óptica.

OBJECTIVE: To report reference values for the horizontal rectus muscles thickness using Spectral Domain optical coherence tomography (SD-OCT), and to evaluate whether there are any correlations between the muscle thickness and gender, age, or axial length (AL). MATERIAL AND METHODS: A cross-sectional study was conducted on 131 right eyes of healthy subjects. The gender and age were recorded, and axial length was measured using an optical biometer. The medial rectus (MR) muscle thickness was measured at 7.2 and 9.2mm from the limbus, and the lateral rectus (LR) at 8.5 and 10.5mm from the limbus using OCT. A multivariate model was adjusted to determine whether gender, age, and axial length could have an impact on the muscle thickness. RESULTS: Mean age was 43.3±20.9 years (range 6-86), and 59% were women. Mean AL was 24.9±2.7mm (range: 20.4-33.8). Mean thickness was 188.5±51.2µm (range 69-342) for the LR at 8.5 and 186.5±45.9µm (range 75-269) at 10.5mm, and for the MR, 158.1±39.1µm (range 69-273) at 7.2mm and 193.7±55.9µm (range 105-386) at 9.2mm. A correlation was observed between the AL and MR thickness (R=-.255; P=.023) while no correlation was observed for the LR (P≥0.203). No correlations were found between thickness and gender or thickness and age (P≥0.125). CONCLUSIONS: The reference ranges of the horizontal rectus muscles thickness was described using SD-OCT, observing an association between the AL and the MR thickness.

Response to tocilizumab treatment in Graves' ophthalmopathy by measuring rectus muscle thickness and chemosis using optical coherence tomography. / Evaluación del grosor de los músculos extraoculares y la quemosis tras tocilizumab en oftalmopatía de Graves mediante tomografía de coherencia óptica.

PURPOSE: To assess the extraocular muscle thickness and chemosis after treatment with tocilizumab in patients with active Graves' ophthalmopathy by optical coherence tomography. METHODS: Case series of five patients with active Graves' ophthalmopathy (clinical activity score ≥4/10) treated with 4 doses of tocilizumab. These patients had been previously treated with corticosteroids with no response. Spectral-domain optical coherence tomography was employed to determine lateral and medial rectus muscle thickness and chemosis before and after 4 doses of tocilizumab given monthly. Scanning was performed at 3 and 9 o'clock (nasal and temporal). RESULTS: The study included four women and one man with a median age of 52 years (range: 38-73). Median Graves' ophthalmopathy activity duration was 17 months (12-18). Median medial rectus and determine lateral thicknesses pre-treatment were 249µm (174-366) and 337µm (142-443), respectively. Median chemosis was 409µm (290-610). After tocilizumab treatment, median muscle thicknesses reduced to 157µm (88-187) and 197µm (99-290), respectively (P=.043; Wilcoxon) and chemosis to 59µm (0-78). Median clinical activity score decreased from 5 (4-8) to 1 (0-3). CONCLUSIONS: A reduction in extraocular muscle thickness and chemosis was observed after treatment with tocilizumab in Graves' ophthalmopathy patients using an optical coherence tomography, so this technique could be a useful complementary technique to assess the therapeutic responses.

Topical brinzolamide in congenital nystagmus: A retrospective study. / Brinzolamida tópica en el nistagmo congénito: Estudio retrospectivo.

OBJECTIVE: To evaluate the effect of treatment with topical brinzolamide on visual acuity and nystagmus intensity in patients with congenital nystagmus. MATERIAL AND METHODS: A retrospective study was designed in which the clinical records of 14 patients with congenital nystagmus were reviewed. All patients underwent a complete ophthalmological examination and a Perea video-oculography (VOG) before, and three days after, initiation of treatment with topical brinzolamide (Azopt). Five expert researchers evaluated the intensity of nystagmus by video before and after treatment. Finally, the subjective improvement of the patients was recorded. RESULTS: Statistically significant differences were found in pre- and post-treatment binocular near visual acuity. A slight increase in the frequency of nystagmus was found, which was statistically significant with the horizontal gaze to the left and with the gaze downwards (P=.04, P=.03, respectively). The kappa index concordance between the researchers evaluating the intensity of nystagmus was 0.014. Only two of the patients noticed improvement in visual acuity, and one patient noticed improvement in the aesthetic aspect. CONCLUSIONS: In spite of an improvement in nystagmus, it was slight, not cosmetically appreciable by patients in most cases, and was not related to a significant improvement in visual acuity or in patient quality of life. Further studies are needed to evaluate the effects of topical brinzolamide, and to establish potential therapeutic indications in nystagmus.

Agreement between intraoperative measurements and optical coherence tomography of the limbus-insertion distance of the extraocular muscles. / Concordancia de la distancia desde la inserción hasta el limbo de los músculos rectos entre la medida intraoperatoria y con tomografía de coherencia óptica.

OBJECTIVE: To assess the agreement between intraoperative measurements of the limbus-insertion distance of the extraocular muscles with those measured by spectral domain optical coherence tomography. METHODS: An analysis was made of a total of 67 muscles of 21 patients with strabismus. The limbus-insertion distance of the horizontal rectus muscles were measured using pre-operative SD-OCT and intra-operatively in 2 ways: 1) direct, after a conjunctival dissection in patients who underwent surgery, or 2) transconjunctival in patients who were treated with botulinum toxin, or in those who were not going to be operated. The intraclass correlation coefficient and Bland-Altman plots were calculated to determine the concordance between the 2 methods. RESULTS: The mean age was 45.9 ±20.9 years (range 16 to 85), with 52% being women. The percentage of identification by direct intraoperative measurement was 95.6% (22/23), by transconjunctival intraoperative measurement 90.9% (40/44), and by OCT 85% (57/67), with 22 muscles finally being analysed for the agreement study between direct intraoperative measurement and OCT measurements, and 35 muscles for the agreement between transconjuctival intraoperative measurement and OCT. The intraclass correlation coefficient showed good agreement with OCT and direct intraoperative measurements (0.931; 95% confidence interval (95% CI): 0.839-0.972; P<.001), and with transconjunctival intraoperative measurements (0.889; 95% CI: 0.790-0.942; P<.001). CONCLUSIONS: The SD-OCT is an effective technique to measure the distance from the insertion of the horizontal rectus muscles to the limbus, with a high agreement with intraoperative measurements being demonstrated.

[Surgical treatment of nystagmus with horizontal torticollis]. / Tratamiento quirúrgico del nistagmo con tortícolis horizontal.

PURPOSE: To study the effect of modified Anderson's procedure in nystagmus surgery with pure horizontal torticollis. METHOD: Retrospective study of 8 patients with nystagmus and pure horizontal torticollis that were surgically treated in our hospital in a 4 years period. Mean age of the sample was 9 years, SD 8.6 (range 4-30). Large bilateral recessions were made in the yoke rectus muscles that are responsible for the versions to obtain the null position. The amount of surgery was variable according to the torticollis intensity and the association of strabismus. Follow-up length ranged from 15 to 45 months (average 31.14, SD 11.55). RESULTS: Torticollis improved in all patients at the end of the study. A good result was achieved in 62.5% of the cases, with a residual torticollis inferior to 10 degrees. In two cases, severe torticollis improved to a moderate one (10-20 degrees ). Torticollis reversal occurred in one patient, who needed a second operation. Neither clinically significant ductions limitations, nor secondary strabismus were found. CONCLUSIONS: The modified Anderson's procedure was effective for treating moderate horizontal torticollis with nystagmus. Severe torticollis were not totally corrected. Large muscle recessions were not associated with clinically significant ductions limitations. There was not secondary strabismus (Arch Soc Esp Oftalmol 2003; 78: 481-486).

Binocular vision in glaucoma.

OBJECTIVE: To describe the possible impairment of binocular vision in primary open angle glaucoma (POAG) patients. METHOD: A cross-sectional study was conducted on 58 glaucoma patients, 76 ocular hypertensives and 82 normal subjects. They were examined with a battery of binocular tests consisting of the measurement of phoria angles, amplitudes of fusion (AF), near point of convergence (NPC) assessment, an evaluation of suppression (Worth test), stereoacuity according to Titmus, and TNO tests. RESULTS: The patients with glaucoma showed significantly increased phoria angles, especially in near vision, compared with the ocular hypertensives and controls (P=.000). AF were reduced mainly in near distances compared to hypertensives and controls (P=.000). The NPC of glaucoma was higher than the other two groups (P=.000). No differences were found in the near-distance suppression test between the three groups (P=.682), but there were differences in the distance vision of patients with glaucoma compared to hypertensives (OR=3.867, 95% CI; 1.260-11.862; P=.008) and controls (OR= 5.831, 95% CI; 2.229-15.252; P=.000). The stereoacuity of patients with glaucoma was reduced in both tests (P=.001). CONCLUSIONS: POAG is mostly associated with, an increased exophoria in near vision, a decreased AF in near vision, a far-distance NPC, central suppression in far-vision, and a loss of stereoacuity. These changes do not seem to appear early as they were not observed in hypertensive patients versus controls.