[Changes in accommodation in children with hyperopic anisometropia and unilateral amblyopia after laser refractive surgery and pleoptic treatment]. / Izmenenie akkomodatsii u detei s gipermetropicheskoi anizometropiei i odnostoronnei ambliopiei posle refraktsionno-lazernoi operatsii i pleopticheskogo lecheniya.

PURPOSE: This study comparatively analyzes the state of accommodation in children with hyperopic anisometropia and amblyopia after femtosecond laser-assisted in situ keratomileusis (Femto-LASIK) combined with pleoptic treatment, and after conventional pleoptic treatment. MATERIAL AND METHODS: The first group consisted of 30 children with medium and high hyperopia, high and medium amblyopia, and anisometropia greater than 3.0 diopters, who underwent Femto-LASIK in the amblyopic eye. The second group consisted of 28 children with similar local status, who were prescribed traditional correction and received conservative treatment. The follow-up period was 1.5 years. RESULTS: After 1.5 years, higher visual acuity (p<0.05) was achieved in the first group. A significant increase in the coefficient of accommodative response (CAR) was observed in the operated amblyopic eyes in group 1 - by 0.1±0.02 c.u. compared to the control group (p<0.05). In both groups there was an upwards trend for the coefficient of microfluctuations (CMF) in the amblyopic eye, but in the first group CMF increased more significantly (p<0.05). The objective accommodative response (OAR) and positive relative accommodation (PRA) of the amblyopic eye showed a double increase - by 1.0±0.23 and 0.9±0.38 diopters, respectively, at the end of treatment in the first group. The increase in similar indicators in the second group was insignificant (p<0.05). In children of the first group the difference in ciliary muscle thickness (CMT) of the amblyopic eye with disabled and enabled accommodation increased by 0.04±0.01 mm (p<0.05) in the anterior part of the ciliary muscle at the levels of CMTmax and CMT1. CONCLUSION: The data obtained in this study indicate the strong effect of refractive laser surgery in combination with pleoptic treatment on improving the visual acuity and the state of accommodation of the amblyopic and paired dominant eyes in children with hyperopic anisometropia, in contrast to conventional methods of treatment.

Tratamento da aniseiconia induzida na correção óptica de anisometropia em escolares do ensino fundamental / Treatment of aniseikonia induced by optical correction of anisometropia in elementary school children

Resumo Objetivos: Comparar a aniseiconia e a estereopsia em escolares anisometropes do primeiro ano do ensino fundamental corrigidos com lentes oftálmicas de estoque com curvas-base selecionadas para minimizar a diferença de tamanho interocular das imagens retínicas e com lentes iseicônicas sugeridas pelo software Aniseikonia Inspector 3 e verificar a preferência dos escolares por uma destas formas de correção. Métodos: Dezenove escolares com anisometropia ≥ 1,5 D em meridianos correspondentes no uso de óculos com lentes oftálmicas de estoque e com lentes iseicônicas foram avaliados para aniseiconia (software Aniseikonia Inspector 3) e estereopsia (teste Stereo Fly test com símbolos LEA. A preferência por uma das formas de correção foi verificada após 40-50 dias de uso dos óculos. Resultados: As médias e os desvios-padrão das aniseiconias vertical e horizontal no uso de óculos com lentes oftálmicas de estoque e com lentes iseicônicas foram, respectivamente, -1,05% ± 2,20% e -1,37% ± 2,36% (p=0,82739) e -0,895% ± 2,23% e -1,16% ± 2,03% (p=0,77018). 31,6% dos escolares corrigidos com lentes iseicônicas e 21,1% dos escolares corrigidos com lentes oftálmicas de estoque identificaram os optotipos que sugerem estereopsia < 100 segundos de arco (p= 0,475). Em relação à preferência, 4/15 (26,7%) escolheram os óculos com lentes iseicônicas, 2/15 (13,3%) escolheram os óculos com lentes oftálmicas de estoque e para 9/15 (60%) a escolha foi indiferente. Conclusão: A aniseiconia induzida nos escolares anisometropes corrigidos com lentes iseicônicas sugeridas pelo software Aniseikonia Inspector 3 foi similar ao obtido na correção com lentes oftálmicas de estoque com curvas-base selecionadas para minimizar a diferença de tamanho interocular das imagens retínicas.

Abstract Objectives: To compare the aniseikonia and the stereopsis in school children anisometropes of the first-year of elementary school corrected with stock ophthalmic lenses with base curve selected to minimize the interocular size difference of retinal images and with size lenses suggested by the software Aniseikonia Inspector 3, and to check the preference of them for one of these forms of correction. Methods: Nineteen school children with anisometropia ≥ 1.5 D in corresponding meridians, in the use of glasses with stock ophthalmic lenses and with size lenses were evaluated for aniseikonia (software Aniseikonia Inspector 3) and stereopsis (Stereo Fly test with LEA symbols). The preference for one of the forms of correction was verified after 40-50 days of wearing glasses. Results: The mean and standard deviations of the vertical and horizontal aniseikonia in the use of glasses with stock ophthalmic lenses and with size lenses were, respectively, -1.05% ± 2.20% and-1.37% ± 2.36% (p = 0,82739) and -0.895% ± 2.23% and -1.16% ± 2.03% (p = 0,77018). 31.6% of the school children corrected with size lenses and 21.1% of the students corrected with stock ophthalmic lenses identified the optotypes that suggest stereopsis less than 100 seconds of arc (p = 0.475). Regarding the preference, 4/15 (26.7%) of the students chose the glasses with size lenses, 2/15 (13.3%) chose the glasses with stock ophthalmic lenses, and for 9/15 (60%) the choice was indifferent. Conclusion: The induced aniseikonia in school children with anisometropia corrected with size lenses suggested by the software Aniseikonia Inspector 3 was similar to that obtained in the correction with stock ophthalmic lenses with base curves selected to minimize the difference of interocular size of retinal images.

New advances in amblyopia therapy II: refractive therapies.

The treatment of anisometropic or ametropic amblyopia has traditionally enjoyed a high treatment success rate. Early initiation and consistent use of spectacle correction can completely resolve amblyopia in a majority of patients. For those with anisometropic amblyopia that fail to improve with glasses wear alone, patching or atropine penalisation can lead to equalisation of visual acuity. However, successful treatment requires full-time compliance with refractive correction and this can be a challenge for a patient population that often has one eye with good acuity without correction. Other barriers for a select population with high anisometropic  or ametropic amblyopia include rejection of glasses for various reasons including discomfort, behavioural or sensory problems, postural issues and visually significant aniseikonia. When consistent wear of optical correction proves difficult and patching/atropine remains a major obstacle, surgical correction of refractive error has proven success in achieving vision improvement. Acting as a means to achieve spectacle independence or reducing the overall needed refractive correction, refractive surgery can offer a unique treatment option for this patient population. Laser surgery, phakic intraocular lenses and clear lens exchange are three approaches to altering the refractive state of the eye. Each has documented success in improving vision, particularly in populations where glasses wear has not been possible. Surgical correction of refractive error has a risk profile greater than that of more traditional therapies. However, its use in a specific population offers the opportunity for improving visual acuity in children who otherwise have poor outcomes with glasses and patching/atropine alone.

REFRACTIVE SURGERY FOR HIGH AMETROPIES, A FEW CONCLUSIONS.

This paper presents a few clinical cases of patients with high ametropies and/or anisometropia, who underwent one or two surgical procedures in our clinic, in order to obtain independence of glasses or contact lenses. Twenty cases of high ametropies were included in our study, with or without astigmatism, with transparent lenses, who presented in our clinic for surgical treatment to correct their refractive errors. Postoperatively, we analyzed the results and took decisions for each case in particular; sometimes a second surgical procedure was needed.

[Correction of secondary anisometropia after retinal detachment and LASIK surgery]. / Corrección de anisometropía secundaria tras cirugía de desprendimiento de retina y LASIK.

CASE REPORT: A male with cylindrical anisometropia secondary to retinal detachment (RD) surgery in the right eye (OD) was referred for contact lens (CL) fitting. His refraction was OD -1.25 -2.75 x 60 degrees VA 1.0 and OS +0.25 VA 1.2. He was complaining of diplopia with spectacles. Seven years prior to the RD surgery, he had undergone LASIK without complications. The diplopia was eliminated after a CL was fitted according to his corneal topography. DISCUSSION: RD surgery can cause anisometropic refractive changes. In patients with diplopia and asthenopia, spectacles are not well tolerated. CL fitting according to post-LASIK corneal geometry succeeded in refractive correction with less anisometropic symptoms.

[Refractive surgery--possibilities to maximize postoperative visual acuity]. / Chirurgia refractiva - modalitati de optimizare vizuala postoperatorie.

Laser refractive surgery has an ascendant evolution on the context of the progress in the medical field. The functional result can be negatively influenced by residual errors, irregular astigmatism or anisometropia, situations in which rigid gas permeable (RGP) contact lenses are a successful alternative in optimizing visual acuity. The paper presents the particularities and the protocol of RGP fitting, outlining the contribution of the corneal topography in the ocular pre and post-operative evaluation.

Analyzing refractive data.

PURPOSE: To provide a general approach to the analysis of refractive data that overcomes the shortcomings of traditional treatments and can be easily adapted to most spreadsheets. SETTING: Corneal Service, Royal Liverpool Hospital, Liverpool United Kingdom, and Optometric Science Group, Rand Afrikaans University, Auckland Park, South Africa. METHOD: The basis of the analyses is the dioptric power matrix. Using a hypothetical sample of data on pre-event and post-event refractions, the calculation of the mean pre-event and post-event refractions and the effect of an event on the refractive outcome, for example the refractive surgical effect, are illustrated. The most important statistics, the mean and the variance-covariance of refractions, and the formal testing of hypotheses on the mean are provided. RESULTS: The method of analysis demonstrated how an event such as cataract surgery, occlusion treatment of amblyopia, or anisometropia can be evaluated in terms of refractive outcome. Hypothesis testing showed how the significance of this effect may be demonstrated. CONCLUSIONS: This standardized method of analyzing and reporting refractive data enables a quantitative analysis and statistical hypothesis testing of the complete refractive data. This approach has generalized applicability in a range of commonly encountered contexts such as the refractive change after cataract and refractive surgery, corneal transplantation, and treatment for amblyopia or the significance of anisometropia. The method is relatively straightforward and can be adapted to most conventional spreadsheets.

A new technique for rigid gas permeable contact lens fitting following penetrating keratoplasty.

PURPOSE: To evaluate a new, rigid gas permeable contact lens fitting technique following penetrating keratoplasty. METHODS: For the correction of postoperative anisometropia or astigmatism, a rigid gas permeable, tetra-curve contact lens with an overall diameter of 12.0 mm and a back optic zone diameter of 8.5 mm was fitted in 36 eyes of 33 patients, 7 months after penetrating keratoplasty. The contact lens back optic zone radius was selected using the videokeratography values over the elevated edges of the transplant wound (with the sutures in place). Graft clarity, visual outcome, and corneal topography were evaluated up to 3 years after surgery at intervals of 6 months. RESULTS: Throughout the follow-up period (range 6-36, mean 19.3+/-sd 11.8 months), all grafts remained clear. Mean contact lens daily wearing time averaged 13.6 (+/- sd 4.7) hours. Mean best-corrected visual acuity improved from +0.36 (+/- sd 0.18) LogMAR with spectacles to +0.11 (+/- sd 0.11) LogMAR with contact lenses (p < 0.0001). One patient was excluded from the study due to a lack of motivation and one had an adverse reaction to the stitches. CONCLUSIONS: To improve the visual performance following penetrating keratoplasty, the described fitting technique, guided by videokeratography, eased selection of the back optic zone radius of the initial trial lens. The large diameter contact lenses with a tetra-curve design were well tolerated in all patients for more than 13 hours daily.

Outcome in refractive accommodative esotropia.

AIM: To examine outcome among children with refractive accommodative esotropia. METHODS: Children with accommodative esotropia associated with hyperopia were included in the study. The features studied were ocular alignment, amblyopia, and the response to treatment, binocular single vision, requirement for surgery, and the change in refraction with age. RESULTS: 103 children with refractive accommodative esotropia were identified. Mean follow up was 4.5 years (range 2-9.5 years). 41 children (39.8%) were fully accommodative (no manifest deviation with full hyperopic correction). The remaining 62 children (60.2%) were partially accommodative. At presentation 61.2% of children were amblyopic in one eye decreasing to 15.5% at the most recent examination. Stereopsis was demonstrated in 89.3% of children at the most recent examination. Mean cycloplegic refraction (dioptres, spherical equivalent) remained stable throughout the follow up period. The mean change in refraction per year was 0.005 dioptres (D) in right eyes (95% CL -0. 0098 to 0.02) and 0.001 D in left eyes (95% CL -0.018 to 0.021). No patients were able to discard their glasses and maintain alignment. CONCLUSIONS: Most children with refractive accommodative esotropia have an excellent outcome in terms of visual acuity and binocular single vision. Current management strategies for this condition result in a marked reduction in the prevalence of amblyopia compared with the prevalence at presentation. The degree of hyperopia, however, remains unchanged with poor prospects for discontinuing glasses wear. The possibility that long term full time glasses wear impedes emmetropisation must be considered. It is also conceivable, however, that these children may behave differently with normal and be predestined to remain hyperopic.

Change in refractive anisometropia in presbyopic adults wearing monovision contact lens correction.

BACKGROUND: Researchers studying the refractive development of infant monkeys suggest that monocular refractive error changes in response to induced ametropia; specifically, slightly blurring one eye may cause a difference to develop between each eye's correction (anisometropia) when none existed before wearing the correction. The important question of whether similar changes occur in humans has not been addressed. METHODS: We compared premonovision correction and the correction after at least 12 months of monovision soft contact lens wear (artificially induced anisometropia prescribed to focus one eye for near and the other for distance so that bifocal glasses are not needed) for 62 healthy predominantly female soft contact lens wearers and (a) 62 age- and sex-matched spectacle wearers and (b) 62 age- and generally sex-matched contact lens wearers. Control patients wore corrections of like power and had similar follow-up periods. RESULTS: Development of anisometropia occurred significantly more frequently among monovision wearers than among spectacle (p = 0.043) or contact lens wearing controls (p = 0.025). Changes in anisometropia greater than or equal to 0.50 D, with amounts up to 1.25 D, occurred in 29% of monovision wearers. CONCLUSIONS: Changes in refractive correction occur for adults who have monocular blur intentionally induced with monovision contact lenses. Similar changes may also occur after refractive surgery if one eye is corrected for a different distance than the other. Care should be taken when counseling presbyopic patients so that they are aware of the possibility of inducing refractive changes after monovision correction.

Contact lens management of patients who have had unsuccessful refractive surgery.

The advent of corneal refractive surgery has, inevitably, resulted in the occasional need for contact lens fitting after surgery. For each new, developing procedure, new contact lens fitting challenges arise. The literature on contact lens use after radial keratotomy is rich and well known, but reports on the use of contact lenses after photorefractive keratectomy or laser-assisted in situ keratomileusis are few and far between. This review summarizes the prevailing clinical opinions on the contact lenses and contact lens fitting methods that are most effective after refractive surgery that results in high refractive error, irregular astigmatism, or anisometropia.

Steroid injection versus conservative treatment of anisometropia amblyopia in juvenile adnexal hemangioma.

Because of serious side effects, the indications for intralesional steroid injection of adnexal hemangiomas are unclear. Of 23 children with such lesions who were examined over a period of 9 years, 9 had no evidence of amblyopia and needed no intervention. Five required steroids intralesionally and/or systemically because of threatened occlusion of the pupillary axis. The remaining 9 were considered at risk of anisometropic amblyopia because of induced astigmatism: 5 received injections and 4 were treated with glasses and/or patching alone. The visual, refractive, and cosmetic results of the injected and conservatively managed anisometropes were similar. We recommend that steroid injection be reserved for patients with threatened occlusion of the visual axis and for those with severe astigmatism or amblyopia refractory to conservative management.

Incidencia de ambliopia en el servicio de oftalmología del Hospital San Juan de Dios / Amblyopia incidence in the Departament of opthalmology at the San Juan de Dios Hospital

Se revisaron 561 historias del Servicio de Oftalmología del Hospital San Juan de Dios de Caracas entre los años 1989-1992 con diagnóstico de ambliopia, mayores de 9 años para su último control, encontrándose 25 pacientes lo que representó el 4.45 por ciento. De ellos 14 casos estuvieron relacionados con estrabismo correspondiendo al 56 por ciento, 7 casos de anisometropia representando el 28 por ciento, 3 casos de ambliopia ex-anópsia relacionada con catarata y uno con ptosis

Contact lenses following keratoplasty.

Bandage contact lenses can be used following keratoplasty to protect the ocular surface and promote epithelial healing. Rigid gas permeable contact lenses are indicated to correct irregular astigmatism and anisometropia. The Rotterdam Eye Hospital fit 77 keratoplasty patients with contact lenses following their surgery. The methods of fitting contact lenses over the irregular or highly astigmatic surface of a graft are discussed.

La restitución de la visión binocular en las altas anisometropías: estudio en 194 casos / Restitution of binocular vision in high anisometropic eyes: 194 cases study

Se reportan los resultados de 194 altas anisometropías tratadas c.c. total mediante lentes de contacto, mayoritariamente en pacientes adultos. El alto porcentaje de éxitos alcanzados en estos pacientes, en cuanto a la curación de la ambliopía y a la restitución de la visión binocular con estereopsia, se oponen a diversos conceptos arraigados en la literatura, que se relaciona con la diferente modalidad de su corrección, con las limitaciones determinadas por la edad del paciente, y al mal pronóstico que se le atribuye tanto a su ambliopía como a la posibilidad en recuperar su visión binocular en el adulto