Eyeglasses for Children - a Survey of Daily Practice.

BACKGROUND: Glasses for children are recommended and prescribed by different groups of professionals. We set out to compare the prescription practices of ophthalmologists, orthoptists and optometrists/opticians in Switzerland. METHODS: Online questionnaire on the prescription and recommendation of glasses in fictitious cases of children of different ages, refractive values and symptoms. The questionnaire was sent out to members of the Swiss Ophthalmological Society, Swiss Orthoptics and Schweizerischer Berufsverband für Augenoptik und Optometrie. RESULTS: 307 questionnaires were analysed. Optometrists/opticians recommended glasses with a significantly smaller cycloplegic refraction value (p < 0.005) than did orthoptists and ophthalmologists. In the example of a 14-year-old asymptomatic child, ophthalmologists recommended glasses at + 2.64 [Dpt], orthoptists at + 2.44 [Dpt] and optometrists/opticians at + 1.32 [Dpt]. Optometrists/opticians tended to recommend slightly higher correction values in glasses than did ophthalmologists and orthoptists. CONCLUSION: In Switzerland, optometrists/opticians recommend glasses with significantly smaller cycloplegic refraction values than do orthoptists and ophthalmologists, regardless of age or symptoms described in these fictitious cases.

Malposition of Teeth and Jaws in Patients with Congenital Superior Oblique Palsy.

BACKGROUND: Patients with congenital superior oblique palsy tend to adopt a head tilt to the contralateral side to maintain binocular single vision. It has long been recognised that facial asymmetries may be caused by a head tilt. The aim of this study was to describe the effect of habitual head tilt due to congenital superior oblique palsy on dental occlusion. PATIENTS AND METHODS: The study was designed as a descriptive cohort study. Ten patients with congenital superior oblique palsy (3 female, 7 male; mean age 51.7 (y) ± 15.8 SD, ranging from 19 to 69 (y)) underwent orthodontic examination. Orthodontic findings and values for vertical, torsional and horizontal deviation measured with the Harms tangent screen and stereopsis using a random dot test were compared. RESULTS: Three orthodontic parameters were found to correlate significantly or at least as trend with orthoptic parameters. Midline deviation of the upper jaw to the face (rho = 0.623; p = 0.054) and anterior positioning of upper first molar in the sagittal plane (rho = 0.594; p = 0.07) correlate with the vertical deviation; overbite correlates with horizontal deviation measured in the primary position (rho = 0.768; p = 0.016). CONCLUSIONS: In this small study, three orthodontic parameters correlated with orthoptic findings in patients with congenital superior oblique palsy. Further studies are needed to establish whether congenital superior oblique palsy is more frequent in patients exhibiting abnormal values of these orthodontic parameters.

Measurement of Optic Nerve Sheath Diameter: Differences between Methods? A Pilot Study.

BACKGROUND: Quantification of the optic nerve sheath diameter is a promising approach for the detection of elevated intracranial pressure. The comparability of current methods is unclear. The objective of this study was to assess the relationship between optic nerve sheath diameter as measured with computed tomography, magnetic resonance tomography and ultrasound in patients without known optic nerve disease or increased intracranial pressure. PATIENTS AND METHODS: 15 patients (60.8 [years]±16.73 SD; 7 female) with paranasal sinus pathology in whom computed tomography and magnetic resonance imaging were performed underwent optic nerve sheath diameter measurements by ultrasound, as well as an ophthalmological examination. Ultrasound-, computed tomography- and magnetic resonance imaging-derived maximal optic nerve sheath diameter values 3 mm behind the globe were compared. RESULTS: Optic nerve sheath diameter measured (n=30) by ultrasound (mean 6.2 [mm]±0.84 SD) was significantly (p<0.01) higher than optic nerve sheath diameter in computed tomography (5.2±1.11) or magnetic resonance imaging (5.3±1.14). There was no significant (p=0.24) difference between optic nerve sheath diameter measured in computed tomography and magnetic resonance tomography. CONCLUSIONS: The comparability of optic nerve sheath diameter measurements in patients without known optic nerve disease and assumed normal intracranial pressure appears to be given between computed tomography and magnetic resonance tomography, while comparability between ultrasound and computed tomography or magnetic resonance tomography seems to be less reliable.

Inferior oblique muscle anteriorization in congenital superior oblique palsy.

BACKGROUND: Inferior oblique muscle overaction of variable amounts is usually present with congenital superior oblique palsy. Inferior oblique muscle anteriorization has been described as a suitable surgical procedure in this entity. The aim of this study was to investigate the effect of inferior oblique muscle anteriorization in patients with congenital superior oblique palsy on vertical, torsional and horizontal alignment. PATIENTS AND METHODS: The study was designed as an institutional retrospective cohort study. 45 patients with congenital superior oblique palsy (15 female, 30 male; mean age 36 years ± 19.2 SD, ranging from 6 to 75 years) underwent inferior oblique muscle anteriorization between 2000 and 2010. Preoperative amounts of vertical, torsional and horizontal deviation (using Harms tangent screen), measurements of Bielschowsky head tilt phenomenon as well as stereopsis (Lang test) were compared with findings three months and one year postoperatively. RESULTS: Preoperative vertical deviation in primary position measured 10.1° (mean; range 0-19). Three months postoperatively vertical deviation was significantly reduced (p<0.001) to 4° (mean; range 0-20). After one year vertical deviation measured 3.5° (mean; range 0-15). The values three months postoperatively did not significantly differ from those one year postoperatively (p=0.46). CONCLUSIONS: Inferior oblique muscle anteriorization leads to a significant and sustained improvement of ocular alignment in patients with congenital superior oblique palsy of various degrees of severity. Thus the procedure is recommendable as a first line treatment in this clinical situation.

Treatment of traumatic corneal abrasions: a three-arm, prospective, randomized study.

PURPOSE: To compare three different treatment modalities for traumatic corneal abrasions. METHODS: We conducted a prospective, randomized, masked, three-arm clinical study of patients presenting with superficial corneal foreign bodies. Treatment modalities were: (1) pressure patching with ofloxacin ointment (patch group, PG, n = 18), (2) therapeutic contact lens with ofloxacin eye drops (contact lens group, CLG, n = 20) and (3) ofloxacin ointment alone (ointment group, OG, n = 28). Primary outcome measure was the difference of the mean corneal abrasion area between the three groups at 3 different time points (baseline, day 1 and day 7). RESULTS: A total of 66 patients were included in the study over a period of 2 years. Mean initial corneal abrasion area was 3.6 ± 3.4 mm² in the PG, 4.2 ± 4.0 mm² in the CLG and 3.7 ± 3.1 mm² in the OG (p = 0.875). Differences in corneal abrasion area at any time point were not statistically significant (abrasion area decrease from presentation to day 1 was 3.4 ± 3.3 mm² in the PG, 4.1 ± 4.0 mm² in the CLG and 3.5 ± 3.1 mm² in the OG, p = 0.789). The epithelium was healed in all patients at day 7. CONCLUSIONS: Treating traumatic corneal abrasions by pressure patching, a bandage contact lens or ointment alone was equal in reducing the abrasion area or reducing pain. According to our results the treatment of choice for traumatic abrasions may be adapted to the needs and preferences of the patient.

[Terson's syndrome--a neglected problem?]. / Terson-Syndrom--ein vernachlässigtes Problem?

BACKGROUND: The aim of our study was to analyze the incidence and prognostic value of intraocular hemorrhages caused by subarachnoid hemorrhages. PATIENTS AND METHODS: Retrospective data analysis of all patients with subarachnoid hemorrhage admitted to the University Hospital Zurich between 2005 and 2010. All patients have been classified according to Glasgow Coma, Hunt and Hess, WFNS and Fisher Scales. RESULTS: Out of 391 patients only 26 have been examined by an ophthalmologist. 11/26 (42%) showed Terson's syndrome, compared to 11/391 (2.8%) in the overall cohort. In patients with intraocular hemorrhages there was a trend for a lower GCS and higher Hunt and Hess, WFNS and Fisher scales. CONCLUSION: Intraocular hemorrhages are a relatively frequent, seemingly neglected complication of subarachnoid hemorrhages, and correlate with a higher mortality and morbidity in prospective studies. Routine fundoscopy of heavily impaired patients should be considered.

Horizontal and vertical angle kappa.

BACKGROUND: The aim of this study is to report the geometric range of angle kappa formation in patients with and without strabismus. PATIENTS AND METHODS: This is a retrospective study of three patients with angle kappa in different planes. Routine eye examinations, including visual acuity, slit-lamp examination, and ophthalmoscopy, were performed. A thorough orthoptic examination revealed a notable difference between the prism and alternate-cover test and the Hirschberg measurements. RESULTS: The first patient exhibited a bilateral vertical angle kappa into opposite directions due to retinochoroidal scars. Two other patients presented with horizontal angle kappa deviations. In one patient a true accommodative esotropia was exaggerated by a right negative angle kappa. The other patient had a pseudoexotropia due to bilateral positive angle kappa. Macular ectopia was noted in all cases. CONCLUSIONS: The patients herein reported demonstrate a marked variability of angle kappa occurrence in the horizontal and vertical plane. The angle kappa can exaggerate or conceal the size of the true heterotropia.

Retinal astrocytomas: long-term follow-up.

BACKGROUND: Retinal astrocytomas are exceedingly rare benign tumours of the retina. Their occurrence can be solitary or multiple, uni- or bilateral, isolated or in association with a phakomatosis such as tuberous sclerosis or neurofibromatosis type 1. PATIENTS AND METHODS: We report the long-term follow-up in three patients with retinal astrocytomas. RESULTS: Over many years of follow-up all astrocytomas showed very little progression and no deterioration of visual function. Subtle changes occurred inside the lesions. CONCLUSIONS: Even after long-term follow-up the natural course of retinal astrocytic hamartomas seems to be favourable, with visual loss and significant growth being unlikely to occur. A thorough ophthalmological and general evaluation, in order to rule out an underlying systemic disease and to document the ocular status, are needed initially. Thereafter eye examinations can be scheduled in long intervals.

Identification of physically fatiguing tasks performed during aircraft open-basket ground de-icing activities.

BACKGROUND: Airplane de-icing technicians work from either an open-basket or closed-basket. OBJECTIVE: The objective of this study is to identify the tasks that have an influence on the physical fatigue of open-basket aircraft de-icing technicians. METHODS: In a Canadian airport during the winter of 2016-2017, a field study was conducted in which the heart rate of 12 volunteer participants was collected. The data was analyzed along with the 22 tasks that make up the activity of open-basket aircraft de-icing. For each participant, the mean absolute cardiac cost per task was compared. The evolution of the cardiac signal based on the resting heart rate and steady state limit was also characterized. RESULTS: According to the cumulative results fatigue occurs for periodic tasks as well as double tasks. More precisely, the most physically fatiguing tasks are spraying de-icing and anti-icing fluids, moving the basket and truck, as well as tactile control and de-icing quality control at ground level. CONCLUSIONS: Similar studies would need to be conducted in other aircraft de-icing facilities to improve the generalization of the results.

[Long-term follow-up after surgery for exodeviation]. / Langzeitergebnisse nach chirurgischer Korrektur von Exodeviationen.

BACKGROUND: In strabismus surgery the challenge is the preoperative determination of the surgical dosage. We assessed the long-term follow-up after strabismus surgery for exodeviations and evaluated the employed dosage. PATIENTS AND METHODS: We present a study of 53 consecutive patients who underwent surgery for exodeviations. One year postoperative results were analysed based on strict criteria. Out of the original group of 53 patients we could evaluate the long-term follow-up in 18 patients, after an average period of 13 years. The criteria for patients with intermittent exotropia and decompensating exophoria after one year and in the long-term follow-up were determined as follows: very good: orthophoria or orthotropia with exo- or esophoria less than 5 PD; good: orthotropia with exo- or esotropia less than 10 PD; satisfactory: orthotropia with exo- or esophoria > 10 PD but less than the preoperative angle; bad: constant eso- or exotropia or > preoperative angle. For patients with a constant divergent strabismus the following criteria were determined: very good: orthophoria or orthotropia with exo- or esophoria less than 5 PD; good: exo- or esophoria less than 10 PD or tropia of 5 degrees (microstrabismus); satisfactory: exo- or esophoria > 10 PD or exo- or esotropia > 10 PD but < preoperative angle; bad: same as preoperative or more. A subgroup analysis of 41 patients who underwent monolateral combined rectus muscle surgery was performed regarding their long-term follow-up (average: 13 years) as well. Concurrently the patients completed a questionnaire. RESULTS: One year postoperatively 6 outcomes were very good, 14 good, 31 satisfactory and 2 were poor. On average 13 years postoperatively the same patients were evaluated based on the same strict criteria. No outcome was very good, 4 good, 12 satisfactory and 2 were poor. The judgement of the patients in the questionnaire was at both times clearly better. The exo-shift in the first postoperative year was 3.5 degrees , in the next on average 12 years the mean divergent strabismus angle increased by another 2.9 degrees. CONCLUSIONS: The outcome evaluation after a long-term follow-up showed amazingly stable results compared to the follow-up after one year. With a more aggressive dosage we could have achieved more orthophoric results, but also more undesirable overcorrections.

[Rectus muscle transposition for the treatment of complex ocular motility disorders]. / Transposition gerader Augenmuskeln zur Behandlung komplexer Motilitätsstörungen.

BACKGROUND: Transposition techniques alter the muscle paths thereby creating new directions of muscle force. Extraocular muscle transposition procedures have been used to treat abducens palsy, Duane's retraction syndrome, double-elevator palsy and other complex ocular motility abnormalities. The purpose of this study was to evaluate the surgical and functional results of rectus muscle transposition in patients with different aetiologies of severe ocular motility deficits. PATIENTS AND METHODS: Between 1992 and 2008 rectus muscle transposition surgery has been performed on 31 patients. In this retrospective case series one patient with an abducens nerve palsy is presented as an example. In addition, six patients with motility disorders of different aetiologies who had transposition manoeuvers were evaluated. Preoperative, surgical and postoperative data are reported. RESULTS: Rectus muscle transposition has been performed because of severe functional loss of the lateral rectus muscle, the superior rectus muscle or the medial rectus muscle as well as in myopic strabismus fixus. One of the patients had traumatic sixth nerve palsy. The underlying pathology in patients who had superior transposition of the horizontal rectus muscles were double-elevator palsy, congenital oculomotor nerve palsy and hypotropia caused by sphenoid wing hypoplasia. A nasal transposition of the vertical rectus muscles was performed in traumatic and tumour-associated muscle loss of the medial rectus muscle. The large preoperative deviations were markedly reduced postoperatively and even ocular motility partially improved. CONCLUSIONS: Transposition surgery seems to be a suitable procedure for the treatment of complex ocular motility disorders. In cases of a complete lack of function of an extraocular muscle or in complex, uncommon conditions, which are difficult to treat with any other surgery, muscle transposition seems to be an effective procedure.

Ocular pulse amplitude as a diagnostic adjunct in giant cell arteritis.

BACKGROUND: To develop an algorithm based on the ocular pulse amplitude (OPA) to predict the probability of a positive temporal artery biopsy (TAB) result in the acute phase of suspected giant cell arteritis (GCA). METHODS: Unilateral TAB was performed and ipsilateral OPA measurements were taken by Dynamic Contour Tonometry. Among the clinical signs and laboratory findings tested in univariate analyses, OPA, Erythrocyte Sedimentation Rate (ESR) and thrombocyte count showed a strong association with a positive TAB result. Algorithm parameters were categorized into three groups (OPA >3.5, 2.5-3.5, and <2.5 mm Hg; ESR <25, 25-60, and >60 mm/h; thrombocyte count <250'000, 250'000-500'000, and >500'000/µl). Score values (0, 1, and 2) were attributed to each group, resulting in a total score range from 0 to 6. A univariate logistic regression analysis using the GCA diagnosis as the dependent and the total score as the independent variate was fitted and probability estimates were calculated. RESULTS: Thirty-one patients with suspected GCA undergoing TAB during an eighteen-month observation period were enrolled. Twenty patients showed histologically proven GCA. Four patients had score values ≤2, fourteen between 3 and 4, and thirteen of ≥5. The corresponding estimated probabilities of GCA were<7, 52.6, and >95%. CONCLUSION: The present study confirms previous findings of reduced OPA levels, elevated ESR, and elevated thrombocyte counts in GCA. It indicates that a sum score based on OPA, ESR, and thrombocyte count can be helpful in predicting TAB results, especially at the upper and the lower end of the sum score range.

Magnetic resonance imaging of the human lateral geniculate body.

We used magnetic resonance imaging to map the human lateral geniculate body. The optimal imaging plane was determined by obtaining axial and coronal scans in two normal brains obtained at autopsy. The brain specimens were then sectioned and individual slices were compared with matching magnetic resonance images. After the lateral geniculate body was identified using this correlative anatomic approach, the nucleus was imaged in four normal subjects.

Unilateral swollen disc due to increased intracranial pressure.

Truly unilateral papilledema is rare and poses a diagnostic problem. The authors have prospectively looked for patients with truly unilateral papilledema and found 15 patients, 10 of whom had idiopathic intracranial hypertension. Neuroimaging did not indicate a reason for the lack of swelling in the other nerve. The visual deficits and outcomes were similar to those of patients with bilateral papilledema. Although monocular papilledema is uncommon, a lumbar puncture with opening pressure measurement should be considered.

Three-dimensional Hess screen test with binocular dual search coils in a three-field magnetic system.

PURPOSE: To establish an objective Hess screen test that allows a simultaneous and binocular analysis of all three axes of eye rotation. METHODS: In orthotropic and strabismic human subjects, both eyes were recorded with dual scleral search coils in a three-field magnetic system. Before mounting the search coil annuli on the eyes, the voltage offsets of each channel and the relative magnitudes of the three magnetic fields were determined. For calibration, subjects were only required to fix monocularly on a single reference target. During fixation of targets on the Hess screen by the uncovered eye, the three-dimensional eye position of both the occluded and the viewing eye was simultaneously measured. RESULTS: For clinical interpretation, an easy to understand graphical description of the three-dimensional Hess screen test was developed. Positions of orthotropic and strabismic eyes tended to follow Listing's law, which in both eyes allowed the determination of the primary position, that is, the position of gaze from which pure horizontal and pure vertical movements do not lead to an ocular rotation about the line-of-sight. To a first approximation, the location of primary position is a result of the summation of the individual rotation axes of the six extraocular muscles and thus can be used to infer which muscle is paretic. CONCLUSIONS: The three-dimensional Hess screen test with binocular dual search coils in a three-field magnetic system is an objective method to assess the ocular alignment in three dimensions with high precision. From these recordings, the clinician can relate deviations of primary position to specific eye muscle palsies.

A comparison of imaging techniques for diagnosing drusen of the optic nerve head.

OBJECTIVE: To determine the best imaging procedure for diagnosing drusen of the optic nerve head. METHODS: We reviewed retrospectively the clinical records of 142 patients (261 eyes) with suspected drusen of the optic disc. The patients were referred to our hospital over a 7-year period and evaluated by B-scan echography, orbital computed tomographic (CT) scan, and/or preinjection control photography for detection of autofluorescence. The relative diagnostic yield of these imaging techniques was compared. RESULTS: Thirty-six of the 261 eyes were evaluated using all 3 imaging techniques, with drusen of the optic nerve head diagnosed in 21 eyes. Findings from B-scan echography were positive in all 21 eyes compared with 9 positive findings from the CT scans and 10 positive findings from the preinjection control photographs (P<.01 for B-scan echography vs both CT scan and preinjection control photography). In 82 eyes with suspected buried drusen of the optic nerve head, B-scan echography showed drusen in 39 eyes compared with 15 eyes in which drusen were shown using preinjection control photography (P<.001). In the whole series, no diagnosis of drusen was made by either preinjection control photography or CT scan and was missed on B-scan echography. CONCLUSIONS: Drusen of the optic nerve head are diagnosed most reliably using B-scan echography compared with both preinjection control photography and CT scans. Preinjection control photography should be performed mainly when confirmation of visible drusen of the optic disc is desired. Neuroimaging using CT is suitable to exclude diagnosis of an intracranial mass lesion and possibly to detect buried drusen of the optic nerve head at the same time.

24-hour blood pressure monitoring in patients with anterior ischemic optic neuropathy.

OBJECTIVE: To define parameters of ambulatory diurnal blood pressure in patients who had experienced anterior ischemic optic neuropathy (AION) in a case-controlled study. PARTICIPANTS AND METHODS: Twenty-four patients with AION and 24 control subjects who were matched for age, gender, medical diagnoses, and medications underwent ambulatory automated blood pressure monitoring for 24 hours. RESULTS: The overall diurnal pattern of blood pressure appeared to be normal in all subjects, showing lower blood pressures at night than during the day, an overnight nadir, and an ascending blood pressure curve in the morning to reach daytime levels. Also, patients with AION did not differ from control subjects with respect to the nighttime diastolic nadir or daytime peak systolic blood pressure. However, during the daytime, patients with AION had lower mean systolic and diastolic blood pressures than did matched control subjects. The widest difference between their blood pressure curves occurred after awakening in the morning, when patients with AION had a less steep and more irregular rise of blood pressure. Patients who had signs of vertebrobasilar insufficiency in addition to AION had lower mean diastolic blood pressure during both daytime and nighttime and a lower minimum daytime diastolic blood pressure. CONCLUSIONS: On ambulatory measurements of diurnal blood pressure, patients with AION consistently had a lower mean blood pressure than did control subjects and a lag in the usual rise in blood pressure in the morning to meet increasing daytime demands for perfusion. Chronic hypoperfusion of small end-arterial vessels that supply the optic nerve head may predispose to AION, and may be caused by relative hypotension owing to overtreated hypertension or to abnormal vascular autoregulation. Internists should be asked to monitor blood pressure carefully when treating hypertensive patients who are at risk for AION, to avoid hypotension, especially on awakening in the morning.

Discovering a dys-covering lid.

A patient with a large pituitary adenoma presenting with signs of primary aberrant regeneration of the left oculomotor nerve is reported. The proposed pathophysiological mechanisms involved in this syndrome are discussed and the known lesions causing it are listed. The various presentations of a pituitary adenoma, common and less common, are reviewed. Although neuroimaging is readily available, predicting the site of the lesion based on a meticulous clinical examination remains a challenge for ophthalmologists.