[Management of unilateral traumatic bulb luxation with disruption of the optic nerve]. / Interdisziplinäres Management der einseitigen traumatischen Bulbusluxation mit Abriss des N. opticus.

Luxation of the eyeball, which means that the eye protrudes between the eyelids,may occur spontaneously or as a rare sequel to major trauma to the orbital wall. It can be accompanied by a disruption of the optic nerve, which is called optic nerve avulsion. In most cases primary enucleation is performed as therapeutic treatment. In our case of a 1 1/2-year-old child bulb luxation with disruption of the optic nerve followed a relatively slight trauma,presumably a fall onto a toy. An irreversible amaurosis was diagnosed. To guarantee symmetrical growth of the orbita and face, the eyeball was replaced into the orbit under microscopic and endoscopic vision via a transnasal and transethmoidal approach.Postoperative examinations showed an exotropy with unrestricted motility of the globe and amaurosis. Five years after the trauma we found symmetrical facial development with uniform orbital cavities. The clinical features and management of globe luxation are discussed, importance of a rapid reposition of the eyeball in contrast to primary enucleation for functional, cosmetic and psychological reasons is emphasized.

[The function of Tenon's capsule revisited]. / La fonction de la capsule de Tenon revisitée.

Tenon's capsule is at the forefront of today's strabismus news. Its function as a muscle pulley was recognized by Tenon himself in 1806. Neiger, then Koornneef, and more recently Demer gave a more modern description of Tenon's capsule. The anterior or muscular part is made up of collagen, elastic, and smooth muscle fibers. It forms a sleeve around extraocular muscles from the Tenon foramen to their scleral insertion. Directly in front of the foramen, it includes a zone of strong capsular-muscular adherence, which is also solidly suspended by ocular suspension system to the periosteum of the orbit; the intermuscular membrane consolidates the adherence zones of the rectus muscles. The posterior part is simply a condensation of collagenous fibers. The function of Tenon's capsule is essential. At the place where it adheres to the muscles, the sleeve that it forms around the muscles plays the role of a pulley diverting the muscle's path, with the pulley representing the proximal functional insertion of the muscle. The position of a rectus muscle's pulley is stable during ocular movements perpendicular to the axis of this muscle because of the transversal and radial fastening of the capsular-muscular adherence zone. During movements along the muscle axis, the pulley moves with the ocular globe. In fact, it is positioned actively to accompany the ocular globe's movements. The anomalies of these pulleys can contribute to or be responsible for an extraocular muscle imbalance: a position anomaly, an instability, a displacement, or a pathological adherence of one pulley can be the cause. Surgery of Tenon's pulley has always been an integral part of extraocular muscle surgery. Any intervention on the muscular level involves, to a lesser or greater extent, the operated muscle's pulley. Different examples demonstrate this.

[Differentiation between dyslexia and ocular causes of reading disorders]. / Differenzierung zwischen Legasthenie und okulär bedingten Lesestörungen.

BACKGROUND: Dyslexia is defined as a reading and/or writing disability persisting after exclusion of organic causes. Studies show that ocular disorders, especially small refraction errors, hypoaccommodation and symptomatic heterophoria, are often not detected or treated in cases of reading and/or writing problems which were otherwise diagnosed as dyslexia. METHODS: We evaluated the data of patients referred to our department from December 1997 to March 2000 with the diagnosis of dyslexia. RESULTS: We found ocular disturbances in 28 (84.8%) out of 33 children, 26 (78.8%) showed improved reading after therapy. They had mostly accommodative problems: uncorrected hyperopia, hypoaccommodation and/or exophoria compensated by accommodative convergence (pathophoria). CONCLUSIONS: Our results underline the importance of the correction of even small refraction and/or motility errors in the presence of reading and writing difficulties.

Frequency of reading disability caused by ocular problems in 9- and 10-year-old children in a small town.

INTRODUCTION AND PURPOSE: In most children referred to our department with a diagnosis of dyslexia, we have found an ocular disorder that had not been detected during previous ophthalmologic examinations. Exophoria and/or hypoaccommodation were the most common cause. Some of these children needed eye muscle surgery to improve the reading problems. However, these patients represent a selection. Therefore, we performed a field study to determine the percentage of children with reading disability caused by ocular disorders and the percentage of children with real dyslexia in a normal population. This was made possible by an examination of most pupils in the 4th grade of the three primary schools in a small German town. The co-author and a very experienced orthoptist performed all of the examinations. RESULTS: Eighty-nine out of 127 children were examined. Of these, 16 (18%) had reading problems (2 girls and 14 boys). Most of them had accommodation problems: six (6.7%) suffered from an uncorrected hypoaccommodation, three children did not wear their prescribed glasses, one child had not been prescribed any glasses yet and one child had the wrong glasses. Two children suffered from pathophoria: one from eso- and the other from exophoria compensated by accommodative convergence. In 3 (3.4%) children no ocular cause could be found. These children may have true dyslexia. CONCLUSION: Of the 89 children examined, 16 (18%) had reading problems and only 3/16 had no detectable ophthalmologic explanation. Hypoaccommodation was the most common cause of reading problems (in 6 of 16). In most of the cases it had not been diagnosed before. In all of these children the reading ability improved markedly with the proper refractive correction, bifocals or prisms.

Ondansetron, droperidol and their combination for the prevention of post-operative vomiting in children.

In this study the antiemetic effects of droperidol, ondansetron and their combination were evaluated in 160 ASA Grade I and II children undergoing surgery for strabismus, who were randomly assigned to one of four groups: Group D received droperidol 75 micrograms kg-1, group O ondansetron 0.1 mg kg-1, group D+O received both droperidol 75 micrograms kg-1 and ondansetron 0.1 mg kg-1, and group N NaCl as placebo. Emesis within the first 24 h occurred in 95.0% of the children with placebo medication, compared with 32.5% (D), 40.0% (O) and 45.0% (D+O) in the groups with antiemetic prophylaxis. The differences between group N and all other groups were significant (P < 0.001). However, there were no statistically significant differences between the groups D, O and D+O. It is concluded that droperidol (75 micrograms kg-1) and ondansetron (0.1 mg kg-1) both significantly reduce PONV in children undergoing surgery for strabismus. Neither ondansetron, nor the combination D+O were superior to droperidol alone.

[The effect of the laryngeal mask airway on the postoperative incidence of vomiting and sore throat in children]. / Einfluss der Kehlkopfmaske auf postoperatives Erbrechen und Halsschmerzen bei Kindern.

UNLABELLED: 100 ASA I and II children, aged 4 to 14 years, and scheduled for strabismus surgery, were randomly assigned to one of the following groups: group 1 (n = 50): endotracheal tube, group 2 (n = 50): laryngeal mask airway. Apart from airway management, the anaesthesiological procedures were identical in both groups: induction with 2-3 mg/kg propofol, 0.02 mg/kg alfentanil, 0.05 mg/kg vecuronium, and 0.01 mg/kg atropine. After endotracheal intubation or insertion of the laryngeal mask, anaesthesia was continued with 6-15 mg/kg.h propofol and 10-30 micrograms/kg.h alfentanil. All patients were ventilated with N2O/O2 (2:1). No antiemetics were given, gastric contents were not aspirated. Postoperative nausea and vomiting (PONV) were recorded by 24 h, the incidence of sore throats was recorded 8, 12, and 24 h post-operatively. RESULTS: The incidence of PONV was higher in group 1 (vomiting 48% vs 32%), nausea 28% vs 16% n.s.). Group 1 children had a higher incidence of sore throats (20% vs. 12%, n.s.), of a "lump in the throat" (10% vs 4%, n.s.), hoarseness (24% vs 0%, p < 0.001) and dysarthria (10% vs 4%, n.s.). CONCLUSIONS: In children undergoing strabismus surgery, the laryngeal mask airway was superior to the endotracheal tube in terms of PONV and was associated with fewer local complications such as sore throat.

[Voluntary control of unilateral strabismus sursoadductorius]. / Willkürliche Beeinflussbarkeit des einseitigen Strabismus sursoadductorius.

BACKGROUND: Strabismus with unilateral elevation in adduction is an upward deviation of the adducting eye of unknown, not necessarily paretic origin. The term "old trochlear palsy" may be erroneous since the hypertropia is not necessarily larger in downward gaze and a causative lesion can usually not be identified. We describe here a marked voluntary influence on unilateral elevation in adduction, in situations that exclude binocular fusion. PATIENTS: Two patients with an elevation in adduction of the right eye and a positive head-tilt phenomenon, a 21-year-old and a 28-year-old man, were able to vary their vertical angle of squint at will. Even under artificial conditions that exclude binocular fusion (alternate cover test, dark-red glass test) could they change their right-over-left deviation, Patient 1 between 4 and 20 degrees and Patient 2 between 0 and 15 degrees. Under natural viewing conditions both patients had binocular vision with stereopsis that decompensated only when they looked to the left. CONCLUSIONS: We assume that our two patients had a "motor memory" that stores the muscle innervation for parallel eyes, i.e. the innervation suitable for binocular vision, and that the patients made use of or neglected this memory at will. In general, our observations suggest that a variable recourse to such a motor memory explains why, in patients with unilateral elevation in adduction, the angle of squint often changes. A voluntary access to this memory may, however, be exceptional.

[Jaensch-Brown syndrome--etiology and surgical procedure]. / Jaensch-Brown-Syndrom--Ursache und operatives Vorgehen.

BACKGROUND: The classical clinical picture of inferior oblique pseudopalsy can be caused by (1) a tight connection between the superior oblique insertion and the trochlea and (2) a thickening of the tendon restricting the passage of the tendon through the trochlea. The entity may be congenital or acquired and constant or intermittend. A spontaneous cure is possible. QUESTION AND RESULTS: We looked for the cause of the inferior oblique pseudopalsy in 41 patients operated on during the last 15 years. 31 patients had a congenital and 10 an acquired inferior oblique pseudopalsy. None of these cases had an alteration of the sheath of the superior oblique tendon. Instead we found a tight band at the posterior border of the tendon between the trochlea and the sclera in all patients with a congenital inferior oblique pseudopalsy. Resection of this band, either in toto or soley of the portion near the sclera resulted in a normalisation of the active and passive elevation in adduction. In some patients a second operation was necessary. The 'V-pattern' existing preoperatively regressed in part or completely during the 1.5 postoperatives years. A consecutive superior oblique palsy was seen in one case only. CONCLUSION: A tight band at the posterior border of the tendon between the trochlea and the sclera explains the congenital variety of the inferior oblique pseudopalsy in many cases. A thickening of the tendon restricting the passage of the tendon through the trochlea may play a role in some cases, particularly in those with a spontaneous cure, but the surgical approach used in this series of patients was not suited to verify this mechanism. NAME OF THE SYNDROME: The pathognomonic signs of the inferior oblique pseudopalsy, restriction of active and passive elevation in adduction, were first described by Jaensch in 1928 in an acquired case, and Jaensch already suggested a tight band between the trochlea and the sclera as the mechanism. Brown, in 1950, only added the congenital variety. Since we owe the first description of the inferior oblique pseudopalsy to Jaensch, his name should be included in the designation of the syndrome, i.e., it should be called "Jaensch-Brown syndrome" rather than "Brown's syndrome". The name suggested by Brown, "superior oblique tendon sheath syndrome", is no longer appropriate since the tissue surrounding the superior oblique tendon is normal.

Symptomatology, surgical therapy and postoperative results of sphenoorbital, intraorbital-intracanalicular and optic sheath meningiomas.

A series of 7 patients with optic sheath meningiomas, 3 intracanalicular and intraorbital, 2 intraosseus meningiomas of the sphenoid wing involving the optic canal, and 4 sphenoorbital meningiomas were reported. The choice of a surgical approach to the orbit was appropriate to the location and size of the tumour relative to the optic nerve. The most common complaints were proptosis, reduction of visual acuity and paresis of eye muscles. Patients with optic sheath meningiomas are threatened postoperatively by visual loss whereas the high recurrence rate has to be taken into consideration in cases of sphenoorbital meningiomas.

[The effect of propofol on vomiting after strabismus surgery in children]. / Einfluss von Propofol auf das Erbrechen nach Strabismusoperationen bei Kindern.

Strabismus surgery in children is associated with a high incidence of postoperative nausea and vomiting (PONV). METHODS. Ninety ASA class I and II children aged 6 to 16 years and scheduled for strabismus surgery were randomly assigned to one of the following groups: Group 1 (n=30):thiopentone 4-6 mg/kg i.v., halothane 0.8-1.5%, N2O--O2 2:1, no opioids, droperidol 75 micrograms/kg i.v.; Group 2 (n=30):propofol 2-3 mg/kg i.v., propofol 6-9 mg/kg.h, alfentanil 30 micrgrams/kg.h, N2O-O2 2:1, no antiemetics; Group 3 (n=30):similar to group 2, but ventilation with air and O2 2:1. All patients were mechanically ventilated during anaesthesia and gastric contents were aspirated. Recovery scores were calculated for 2 h, emetic scores for 24 h postoperatively.

[Indications and methods of surgical treatment in congenital nystagmus]. / Wskazania i metody operacyjnego leczenia wrodzonego oczoplasu.

The authors present methods of operation performed in different types of congenital nystagmus in which the amplitude and frequency of nystagmus vary in different positions of gaze. In many cases, a "neutral zone" exists in which the nystagmus is less pronounced or may even be absent. If the "neutral zone" is in the primary position of gaze, then the head position may be normal. If the neutral zone is in another position of gaze, then the patient may assume compensatory head position (CHP) to achieve optimal visual acuity. Methods of surgical treatment in these case are presented. The indications are based on measurement of compensatory head position or on amplitude of convergence in nystagmus blockage syndrome. The elimination of CHP is possible by the Anderson procedure or, in more advanced cases, by the Kestenbaum procedure and/or the artificial divergence procedure of Cüppers. Sometimes Cüppers procedure alone or in combination with recession of the muscles is indicated. Our own material and results of surgical treatment are presented in the next paper.

Surgical dampening of nystagmus in patients with achromatopsia.

Lack of cone function is one and nystagmus is the other cause of low vision in patients with rod monochromatism. The nystagmus has been assumed to be a consequence of the increased light sensitivity due to the predominance of rods. However, symptoms of patients with cone dystrophy are not very different from those observed in patients with congenital nystagmus. For example, they occasionally have a dampening of the nystagmus on fixation at near. Therefore, like in congenital nystagmus, we can elicit convergence innervation during fixation at distance with prisms base-out or with a surgically induced divergence ('artificial divergence'). This approach only works in patients with binocular function, necessary to keep the eyes aligned. The authors report on three patients with complete rod monochromatism in whom they performed an artificial divergence operation (OAD) by recessing the medial rectus muscle and resecting the lateral muscle of one eye. After surgery, the measured visual acuity was the same but the nystagmus of these patients had been considerably reduced. The patients themselves considered the effect of surgery a great improvement.

[Emesis and the oculocardiac reflex. Drug prophylaxis with droperidol and atropine in children undergoing strabismus surgery]. / Erbrechen und okulokardialer Reflex. Medikamentöse Prophylaxe mit Droperidol und Atropin bei Kindern mit Strabismusoperation.

Although droperidol is often used to prevent emesis, vomiting is still common in children undergoing strabismus surgery. METHODS. One hundred children aged 3 to 12 years admitted for strabismus surgery were enrolled in a randomised, double-blind study to investigate the influence of the timing of the administration of droperidol (75 micrograms/kg i.v.) and the effect of atropine (10 micrograms/kg i.v.) on postoperative vomiting and the occurrence of the oculocardiac reflex (OCR). Each child was prospectively assigned to one of the following groups: Group A: atropine and droperidol before the beginning of surgery (n = 25); Group B: atropine before the beginning, droperidol after completion of surgery (n = 25); Group C: no atropine, droperidol before the beginning of surgery (n = 25); Group D: no atropine, droperidol after completion of surgery (n = 25). After oral premedication with 0.4 mg/kg midazolam, anaesthesia was induced via a face mask by inhalation of halothane, nitrous oxide, and oxygen and 1 mg/kg succinylcholine was given to facilitate tracheal intubation. Gastric contents were aspirated by a gastric tube at the end of the operation. Vomiting and retching were recorded for 24 h; recovery from anaesthesia was assessed by a modified Steward score. RESULTS. The four groups were comparable regarding age, sex, body weight, duration of anaesthesia, and number of repaired eye muscles. Patients receiving droperidol before and after the end of surgery had a similar incidence of vomiting (groups A and C 60% vs. groups B and D 50%). There was no significant difference in the number of patients vomiting between groups A and B (58%) and groups C and D (52%). The incidence of the OCR was lower in the patients premedicated with atropine (18% vs. 60%, P < 0.01). There was no statistical relationship between the occurrence of the OCR and post-operative emesis. Younger children (3 to 6 years) vomited more often than older ones (7 to 12 years). The incidence of the OCR was higher in patients with more than two eye muscles repaired than in others. Recovery scores were slightly lower in patients with droperidol after completion of surgery; postoperative recovery times did not differ significantly between the study groups. CONCLUSIONS. The timing of the administration of droperidol (75 micrograms/kg) had no influence on postoperative vomiting. The application of atropine (10 micrograms/kg) prior to surgery did not influence vomiting after strabismus surgery. Atropine (10 micrograms/kg) reduced the incidence of the OCR significantly. There was no statistical relationship between the occurrence of the OCR and postoperative vomiting.

Is there a cholinergic and an adrenergic phase of the oculocardiac reflex during strabismus surgery?

We investigated the counterregulatory effect of the oculocardiac reflex (OCR) in 25 infants and children during strabismus surgery under three experimental conditions. In group 1, a series of measurements were recorded when the OCR was elicited by traction. The beat-to-beat heart rate reduction ranged from -26 to -64 beats/min (median: -46 beats/min). Constant traction increased heart rate in all patients from +23 to +50 beats/min (median: +30.5; P < 0.001). After a sudden release of the stimulation, heart rate rose further from +6 to +40 beats/min (median: +15; P < 0.001). In group 2, atropine (0.01 mg/kg) was administered 3-4 min prior to the same manipulations as in group 1. Constant traction changed heart rate from -1 to +20 beats/min (median: +4.5; P < 0.01). In group 3, a retrobulbar blockade suppressed the OCR and the counterregulation completely. These findings indicate that there is an active counterregulatory process which maintains heart rate during traction at the extraocular muscles after the bradycardic reflex has been initiated. The bradycardia and the counterregulation may be referred to as cholinergic and adrenergic phrases of the OCR. Atropine eliminates the cholinergic phase. Our study indicates that there may be receptors and afferent fibres for both phases, which can be blocked by local anaesthetics.

[The 4-prism diopter base-in test in diagnosis of exophoria with asthenopia and compensation by accommodative convergence]. / Der 4-Prismendioptrien-Basis-innen-Test in der Diagnostik von Exophorien mit Asthenopie und Kompensation über die akkommodative Konvergenz.

About 30% of our patients suffering from purely binocular asthenopia showed lower binocular than monocular visual acuity. Cover test examination revealed exophoria at near fixation, which could be regarded to be physiological. Furthermore, the Pola test as well as Graefe's prism diplopia test showed no pathological findings. When given 4 prism base-in, a better binocular acuity was achieved and exophoria at for distance fixation was revealed. Often the prisms base-in had to be increased slowly and an operative treatment was indicated in 80%. The test is described in detail and examples from typical case studies are demonstrated. The importance of the test for understanding asthenopia in cases with heterophoria is discussed.

[Droperidol versus metoclopramide. Prevention of emesis following strabismus surgery in children]. / Droperidol vs. Metoclopramid. Prophylaxe von Erbrechen nach Strabismus-Operationen bei Kindern.

Vomiting after strabismus surgery is a major problem that remains as yet unsolved, especially in children. Droperidol and metoclopramide, both known as powerful antiemetic drugs, were compared in this study. METHODS. One hundred ASA class I and II children ranging from 3 to 10 years of age were studied in a double-blind, randomised fashion. They were assigned to three groups: group D (n = 33) received 0.075 mg/kg droperidol, group M (n = 33) 0.15 mg/kg metoclopramide, and group N (n = 34) 0.1 ml/kg NaCl i.v. upon arrival in the post-anaesthesia recovery room (PARR). After oral premedication with 0.4 mg/kg midazolam, anaesthesia was induced via a face mask by inhalation of halothane, nitrous oxide, and oxygen. Barbiturates, atropine, and succinylcholine were not used; 0.05 mg/kg vecuronium was given to facilitate intubation. Gastric contents were aspirated by a gastric tube at the end of the operation. Vomiting and retching were recorded for 24 h; recovery from anaesthesia was assessed by a modified Steward score. RESULTS. The three groups were comparable regarding age, body weight, duration of anaesthesia, number of repaired eye muscles, and occurrence of the oculocardiac reflex (OCR). During the first 24 h postoperatively 21/33 (64%) patients of group D vomited, 24/33 (73%) of group M, and 33/34 (97%) of group N. The differences between groups D and N and between M and N were significant (P less than 0.01); comparison of groups D and M showed no statistical significance. Droperidol was more effective in reducing severe vomiting. Of the group N children, 47% vomited more than 6 times in 24 h compared to 18% of group M and 0% of group D. Age, sex, duration of anaesthesia, number of repaired eye muscles, and occurrence of the OCR had no influence on postoperative vomiting. Despite being administered at the end of the operation, droperidol did not prolong the patients' stay in the PARR. The post-anaesthetic scores for group D children were only slightly lower compared to groups M and N. CONCLUSIONS. Droperidol (0.075 mg/kg) and metoclopramide (0.15 mg/kg) both reduce postoperative vomiting after strabismus surgery. Droperidol seems to be more effective in reducing severe vomiting. Postoperative sedation after droperidol was not a major problem in our experience.

[Physiologic and pathologic rebound nystagmus. Description and comparison]. / Physiologischer und pathologischer Rebound-Nystagmus. Beschreibung und Vergleich.

Using a binocular, infrared charged coupled device (CCD), an eye tracker coupled with an Olivetti M24 PC (resolution up to 0.1 degrees, scanning with 80 frames/s), the eye movements of 20 normal individuals with normal visual acuity and binocular function were recorded to detect physiological endpoint (EPN) and rebound nystagmus (RN). Each subject was asked to fixate a target located in the primary position (PP) and after 5 s of recording time, to look at a target either 50 degrees to the right or left of the PP for approximately 20 s and then return for the last few seconds to the PP, EPN recordings were made with the room lights on and RN recordings were made both with the lights on and in total darkness. A forehead and chin rest with bite board were used. Twelve of the 20 subjects showed EPN and RN with the lights on. The 8 subjects that did not demonstrate EPN also showed no RN with the lights on. Recordings from all 20 subjects showed RN in darkness. No differences in amplitude were found between the abducted and adducted eyes. Although clear differences in the characteristics of gaze paretic or drug-related lateral gaze nystagmus and EPN have been found, no systematic differences in RN under lighted conditions had been observed between patients and normal subjects.