[Long-term follow-up and patient satisfaction of squint surgery with adjustable sutures]. / Ergebnisse und Patientenzufriedenheit von Schieloperationen mit nachjustierbaren Fäden im Langzeitverlauf.

OBJECTIVE: Up to now, no long-term results about squint surgery with adjustable sutures have been published although it has been practiced using the current techniques since the 1970s. The aim of the study was to analyse patient satisfaction and objective findings and to compare the results to studies about squint surgery with adjustable as well as non-adjustable sutures. METHODS: Patients who had had squint surgery with adjustable sutures more than 10 years ago were identified according to their surgical records. They were contacted and asked to fill in a questionnaire. The collective consisted in cases which appeared to be difficult in treatment, e.g., 52 % had undergone previous squint surgery. RESULTS: We could analyse answered questionnaires of 113 patients (return rate 41.9 % of all contactable patients). In 34 patients (30 %) postoperative adjustment was actually performed, in the others the suture was only knotted. 89.4 % of patients either had no problems or did not remember the procedure of adjustment or knotting, respectively, the others had slight discomfort. There were no technical problems in surgery or adjustment. After an average period of 11 years, the satisfaction was very high. The reoperation rate was 7 %. CONCLUSIONS: Squint surgery with adjustable sutures is a valuable tool in difficult strabismus cases with good long-term patient satisfaction without specific problems of surgery.

[Chronic progressive external ophthalmoplegia and Kearns-Sayre syndrome : interdisciplinary diagnosis and therapy]. / Chronisch-progressive externe Ophthalmoplegie und Kearns-Sayre-Syndrom : Interdisziplinäre Diagnostik und Therapie.

BACKGROUND: The main symptom of chronic progressive external ophthalmoplegia (CPEO) and Kearns-Sayre syndrome (KSS) are upper eyelid ptosis and a slowly progressive weakness of the extraocular muscles. Mitochondrial disorders are much more frequent than previously assumed. Because of great phenotypic variability, early diagnosis may prove to be difficult. MATERIAL AND METHODS: Retrospective analysis of 30 patients with CPEO or KSS with regard to ophthalmological and neurological findings as well as molecular genetic background. RESULTS: Twenty-seven patients presented with upper eyelid ptosis as the first clinical symptom. In 11 of these patients, ptosis was either unilateral or asymmetric. External ophthalmoplegia was present in only three patients initially; however, it developed in 27 patients in the later course of the disease. Diplopia was found to be more frequent than previously assumed. Twenty-six patients showed characteristic histological hallmarks in skeletal muscle biopsy. In 22 patients, molecular genetic testing revealed mitochondrial DNA mutations. CONCLUSIONS: Mitochondrial disorders should be included in the early differential diagnosis of patients with etiologically unclear acquired isolated unilateral or bilateral ptosis, atypical eye movement disorders, or diplopia. A correct diagnosis is mandatory for qualified counseling and the management of potentially life-threatening complications, such as cardiac involvement.

[What to do in cases of inadequate effectiveness of botulinum toxin for the treatment of eyelid cramping?]. / Was tun bei unzureichender Wirkung von Botulinumtoxin in der Behandlung von Lidkrämpfen?

In 5-15% of individuals suffering essential blepharospasm, treatment with botulinum toxin is insufficient. In these cases the following measures can be applied: increase the dose, increase or vary the injection sites, change the botulinum toxin medication, use additional oral medication, or perform surgery. Certain measures can also be carried out by the patient. In cases of hemifacial spasm, inadequate results of botulinum toxin injections are even more unusual. But for these cases, additional oral medication or the neurosurgical Janetta operation can be used.

Open-loop and closed-loop optokinetic nystagmus in squirrel monkeys (Saimiri sciureus) and in man.

Horizontal optokinetic nystagmus (OKN) was measured in 3 normal Squirrel monkeys by means of the electromagnetic search coil technique. Binocular and monocular stimulation of each eye to the left and right by moving vertical stripe patterns of 2.37 or 15 degree period were applied at angular velocities of 0.5 to 400 deg/s. After measurement of horizontal OKN under normal conditions, open-loop OKN gain was determined by monocular stimulation of an eyeball immobilized by means of retrobulbar injections of 11 units botulinum toxin (BoTx type A) and compared with the pre-injection data or with monocular stimulation of the other eye, which remained mobile. In normal Squirrel monkeys gain of optokinetic nystagmus reached values between 0.8 and 0.97 at angular velocities below 1.5 deg/s. Gain under these conditions was related to stimulus angular velocities Vs, i.e. Ge = Ve/Vs. A slightly higher gain was found for binocular than for monocular stimulation. No significant differences were found in OKN when monocular stimulation in the naso-temporal and in the temporo-nasal direction was applied. The upper cut-off angular velocity (-3 dB-point) reached values of 180-230 deg/s, significantly above those observed in man under similar stimulus conditions. Monocular optokinetic stimulation of an immobilized eye led to vigorous optokinetic nystagmus and OKAN of the other eye, whereby maximum gain (Gi = Ve/Vr) was found to be between 20 and 30 at lower retinal stimulus velocities (2-5 deg/s). Gain was related to retinal stimulus velocity Vr. Increase in Vr above 10 deg/s led to a decrease in gain with a slope of about 20 dB per decade. Measurement of gain of closed-loop OKN related to retinal stimulus velocity Vr (which was determined by the difference between Vs and Ve) led to a similar dependence of OKN as in closed-loop stimulus conditions. Differences in sensitivity between the temporal and the nasal visual hemifield stimulation evoking horizontal open-loop OKN are described. Directional selectivity appeared in these experiments. Open-loop OKN data from a human subject are reported. With highly attentive horizontal optokinetic gaze nystagmus, Ve depended on the duration of the pursuit phases of OKN. Ve accelerated with the duration of the individual slow phase of OKN and was reset by each backward saccade (of the covered mobile eye). OKN gain was considerably smaller when the subject intentionally pursued as many stripes as possible of the 1.15 degree period stripe pattern (gain related to Vr about 1.5-3).(ABSTRACT TRUNCATED AT 400 WORDS)

Hemangiopericytoma of the inner canthus.

PURPOSE: A 31-year-old woman with a mass at the left inner canthus was referred to our hospital. METHODS: Clinical examination failed to establish a diagnosis and the patient underwent an incisional biopsy. RESULTS: Histopathologic examination disclosed a hemangiopericytoma. CONCLUSIONS: Because the behavior of a hemangiopericytoma is unpredictable, this tumor should be included when making a differential diagnosis in lesions of the inner canthus.

Original papers: Electrocautery paraplical incision for Faden operation.

In case of Faden operation (Cüppers' operation) without recession of the muscle, the authors looked for a direct approach to the site where the posterior fixation sutures should be placed. They chose a paraplical incision. To prevent bleeding they used electrocautery following a surgical technique previously described. The authors performed electrocautery paraplical incision in 270 eyes of 238 patients (age ranged between 3 y and 55 y). Follow-up time was 2.4 y + 1.3. After electrocautery, preparation of the medial rectus muscle and Faden procedure (without disinsertion of the muscle) were carried out. Finally the conjunctiva was closed with single sutures. In no patient did long-term complications occur and only the following minor complications were observed intra- or perioperatively: in one patient orbital fat protruded during surgery. Postoperatively one eye had a corneal erosion and another severe eyelid edema. In another patient a swollen plica with consecutive putrid secretion was observed. In all three cases symptoms disappeared after therapy. Paraplical incision was even possible after previous strabismus surgery with limbal incision. In Faden operation without recession of the medial rectus muscle, electrocautery paraplical incision is an alternative method with minimal postoperative inflammation and minimal scarring. It allows good approach to the medial rectus muscle, with minimal intraoperative bleeding. Postoperative healing and cosmesis are good.

Botulinum toxin as a tool for testing the risk of postoperative diplopia.

If preoperative examinations indicate postoperative diplopia, we generally would dissuade a patient from a squint operation. In this situation, a reliable test for diplopia can be done by injection of Botulinum toxin into an eye-muscle. Thus a predominantly transient paresis is produced during which there is parallelism for a sufficient period of time, so that the patient has time enough to experience disturbing double vision or its absence. In all 31 patients of this study a clear decision for or against an operation was possible, only in three cases was an operation contraindicated.

Examinations on the new lang test.

The New Lang-II stereopsis test employs, as compared to the Lang-I test, smaller disparities and a less dense arrangement of random dots. In 162 subjects the authors comparatively evaluated the results of the Lang-I and Lang-II tests. Ninety percent of subjects with normal binocular vision passed both tests without making any mistake (n = 127). However, about 70% of patients with microstrabismus failed both tests (n = 35). Little difference was found between the results of both tests.

The effects of botulinum toxin on hemifacial spasm: an electrophysiologic investigation.

Forty-one patients with unilateral or bilateral facial spasm were studied by electrophysiologic examination. All patients received local treatment with botulinum toxin. In the patients and controls, the measurements of the blink reflex revealed changes that (1) may indicate a central origin of the spasm in some cases, and (2) make it likely that the trigeminal nerve influences the facial nucleus and is thus involved in the regulation of the spasm.

The Faden operation. Technical aspects and indications.

Within 15 years the Faden operation (Cüppers' operation) has proven to be a valuable tool in cases of variable angle of squint and a number of other indications. In this paper the theoretical background of the Faden effect, the indications, the operative technic as well as the results are presented.

[Essential blepharospasm : Practice-oriented therapy with botulinum toxin employing reduced treatment intervals]. / Essenzieller Blepharospasmus : Praxisnahe Therapie mit Botulinumtoxin unter Verwendung verkürzter Behandlungsintervalle.

BACKGROUND: Botulinum neurotoxin injections are a primary symptomatic treatment for blepharospasm. Injections are generally repeated every 3 months. For patients with short-term treatment effects there have therefore been long intervals without sufficient treatment effects, as reinjections have previously been avoided due to concerns of increased side effects or production of antibodies against complexing proteins. METHODS: As Xeomin® is a pure A botulinum toxin type complexing proteins are not present. We have hence decided to treat appropriate patients with injection intervals of 10 or less weeks if these patients have been suffering from psychological stress. PATIENTS: In 11 of these patients the typical patient characteristics and course of therapy were analyzed. There were no relevant adverse events. In all patients, time periods without treatment effect were shorter or no longer present. In 6 patients injection intervals could be prolonged after several injections due to the good effect. CONCLUSION: An optimized therapy of essential blepharospasm should not only take dose, dose distribution and injections site into account but also injection intervals. Reinjections could be performed if necessary after at least 6 weeks.

A randomised comparison of bilateral recession versus unilateral recession-resection as surgery for infantile esotropia.

OBJECTIVE: Infantile esotropia, a common form of strabismus, is treated either by bilateral recession (BR) or by unilateral recession-resection (RR). Differences in degree of alignment achieved by these two procedures have not previously been examined in a randomised controlled trial. DESIGN: Controlled, randomised multicentre trial. SETTING: 12 university clinics. PARTICIPANTS AND INTERVENTION: 124 patients were randomly assigned to either BR or RR. Standardised protocol prescribed that the total relocation of the muscles, in millimetres, was calculated by dividing the preoperative latent angle of strabismus at distance, in degrees, by 1.6. MAIN OUTCOME MEASURE: Alignment assessed as the variation of the postoperative angle of strabismus during alternating cover. RESULTS: The mean preoperative latent angle of strabismus at distance fixation was +17.2 degrees (SD 4.4) for BR and +17.5 degrees (4.0) for RR. The mean postoperative angle of strabismus at distance was +2.3 degrees (5.1) for BR and +2.9 degrees (3.5) for RR (p = 0.46 for reduction in the angle and p = 0.22 for the within-group variation). The mean reduction in the angle of strabismus was 1.41 degrees (0.45) per millimetre of muscle relocation for RR and 1.47 (0.50) for BR (p = 0.50 for reduction in the angle). Alignment was associated with postoperative binocular vision (p = 0.001) in both groups. CONCLUSIONS: No statistically significant difference was found between BR and RR as surgery for infantile esotropia.

Efficacy and safety of a new Botulinum Toxin Type A free of complexing proteins in the treatment of blepharospasm.

NT 201 is a new development of Botulinum Toxin Type A free of complexing proteins. In this double-blind Phase III trial, we compared the efficacy and safety of NT 201 and BOTOX in patients suffering from blepharospasm. Of 304 enrolled patients, 300 patients received study medication (intent-to-treat population), and 256 patients completed the study as planned (per-protocol population). At baseline, patients received a single injection of NT 201 or BOTOX (

[Blepharospasm treatment with botulinum toxin (follow-up)]. / Blepharospasmus-Behandlung mit Botulinus-Toxin (Verlaufsbeobachtungen).

Within a period of 14 months 73 patients with idiopathic blepharospasm which could not be treated satisfactorily by any other form of therapy were treated by injections of botulin toxin. In 55 cases the follow-up period was sufficiently long to permit an evaluation. Thirty-five patients were temporarily completely free of complaints; in one patient there was no improvement. In the remaining cases there was a slight to distinct reduction in symptoms, which often cause severe suffering. The full effect of the drug lasted between 1 and 27 weeks (average 7.5 weeks). No systemic side-effects were observed; local side-effects (subcutaneous bleeding during injection, slight ptosis, intermittent diplopia) seen in 6 cases were of very minor significance.

[Stereoscopic vision in reduced visual acuity]. / Stereosehen bei vermindertem Visus.

Like other authors, we observed a number of cases with relatively good stereoscopic acuity despite poor visual acuity among patients with primary microstrabism. In order to analyze this observation experimentally the patients' visual acuity was reduced monocularly and binocularly, by means of semitransparent membranes of increasing density, to 0.3 and 0.1, and stereoscopic visual acuity was then examined using the Titmus and TNO tests. Both tests showed that in most cases stereoscopic vision was only moderately reduced, and in some cases not at all.