Análisis de fiabilidad y concordancia entre 5 métodos subjetivos de medición de la torsión ocular / Reliability and agreement analysis among 5 subjective methods of ocular torsion measurement

Objetivo Evaluar la fiabilidad en la medición de la torsión ocular y la concordancia de los siguientes métodos subjetivos: test de Maddox bilateral, sinoptóforo, torsionómetro de Gracis, pantalla de Harms y test de ciclodesviaciones de Awaya. Método Se seleccionaron pacientes con estrabismo vertical adquirido en la edad adulta y se realizó la medición de la torsión ocular con los 5 métodos descritos en 3 ocasiones. Al no existir un gold standard en la medición subjetiva de la torsión ocular, se eligió como prueba de referencia aquella que obtuviera mejores datos de repetibilidad. Resultados Veinticinco pacientes fueron incluidos en el estudio. Se estudió la repetibilidad de cada prueba: test de Maddox bilateral (CCI=0,783, CV=29,33%), sinoptóforo (CCI=0,976, CV=6,71%), torsionómetro de Gracis (CCI=0,937, CV=20,10%), pantalla de Harms (CCI=0,962, CV=11,86%) y test de Awaya (CCI=0,987, CV=52,58%). La prueba de referencia para comparar la concordancia fue el sinoptóforo. Se encontraron diferencias estadísticamente significativas al comparar los rangos de torsión ocular entre el sinoptóforo y el torsionómetro de Gracis (p=0,008) y entre el sinoptóforo y el test de Awaya (p=0,02). Conclusiones El test de Maddox bilateral, el sinoptóforo, el torsionómetro de Gracis y la pantalla de Harms son métodos fiables con buenos índices de reproducibilidad. Entre ellos, el sinoptóforo es el método más consistente. El test de Awaya no demostró buena fiabilidad. El test de Maddox bilateral, el torsionómetro de Gracis y la pantalla de Harms fueron métodos con buena concordancia con el sinoptóforo, que se determinó como test de referencia. El test de Awaya no demostró buena concordancia con el sinoptóforo (AU)

Objective To evaluate the reliability in the measurement of ocular torsion and the agreement of the following subjective methods: double Maddox test, synoptophore, Gracis torsionometer, Harms screen and Awaya cyclodeviation test. Method Patients with vertical strabismus acquired in adulthood were recruited and ocular torsion was measured with the 5 methods described on 3 occasions. As a gold standard test does not exist, the one that obtained the best repeatability data was chosen as the reference test. Results Twenty-five patients were included in the study. The repeatability of each test was studied: double Maddox test (ICC=0.783, CV=29.33%), synoptophore (ICC=0.976, CV=6.71%), Gracis torsionometer (ICC=0.937, CV=20.10%), Harms screen (ICC=0.962, CV=11.86%) and Awaya test (ICC=0.987, CV=52.58%). The reference test to compare the agreement was the synoptophore. Statistically significant differences were found when comparing the ocular torsion ranges between the synoptophore and the Gracis torsionometer (P=.008) and between the synoptophore and the Awaya test (P=.02). Conclusion The double Maddox test, the synoptophore, the Gracis torsionometer, and the Harms screen are reliable methods with good reproducibility indices. Among them, the synoptophore is the most consistent method. The Awaya test did not show good reliability. The bilateral Maddox test, the Gracis torsionometer, and the Harms screen were methods with good agreement with the synoptophore, which was determined as the reference test. The Awaya test did not show good agreement with the synoptophore (AU)

Reliability and agreement analysis among 5 subjective methods of ocular torsion measurement.

OBJECTIVE: To evaluate the reliability in the measurement of ocular torsion and the agreement of the following subjective methods: double Maddox test, synoptophore, Gracis torsionometer, Harms screen and Awaya cyclodeviation test. METHOD: Patients with vertical strabismus acquired in adulthood were recruited and ocular torsion was measured with the 5 methods described on three occasions. As a gold standard test does not exist, the one that obtained the best repeatability data was chosen as the reference test. RESULTS: 25 patients were included in the study. The repeatability of each test was studied: double Maddox test (ICC = 0.783, CV = 29.33%), synoptophore (ICC = 0.976, CV = 6.71%), Gracis torsionometer (ICC = 0.937, CV = 20.10%), Harms screen (ICC = 0.962, CV = 11.86%) and Awaya test (ICC = 0.987, CV = 52.58%). The reference test to compare the agreement was the synoptophore. Statistically significant differences were found when comparing the ocular torsion ranges between the synoptophore and the Gracis torsionometer (p = 0.008) and between the synoptophore and the Awaya test (p = 0.02). CONCLUSIONS: The double Maddox test, the synoptophore, the Gracis torsionometer, and the Harms screen are reliable methods with good reproducibility indices. Among them, the synoptophore is the most consistent method. The Awaya test did not show good reliability. The bilateral Maddox test, the Gracis torsionometer, and the Harms screen were methods with good agreement with the synoptophore, which was determined as the reference test. The Awaya test did not show good agreement with the synoptophore.

Study of reliability and validity of VOG Perea® and GazeLab® and calculation of the variability of their measurements. / Estudio de la fiabilidad y la validez de los videooculógrafos VOG Perea® y GazeLab® y cálculo de los márgenes de variabilidad.

OBJECTIVE: To determine the reliability and validity of VOG Perea® (VP) and GazeLab® (GL), their correlation and concordance with cover test (CT), and define the margins of variability of the measurement of angle deviation in primary position. METHODS: Forty-four orthotropic patients were included. Alternating prism CT, an examination with VP, and GL were performed. Intraclass correlation coefficient (ICC) was calculated to determine the reliability, and mean comparison was used to study validity. Correlation coefficient (R) between CT and each video-oculographer was calculated. Bland-Altman diagrams were used to determine concordance. All measurements were expressed in prismatic dioptres (PD). RESULTS: The mean horizontal deviation was -0.571 PD with CT; 0.22 PD with VP and 0.4 PD with GL. ICC was 0.246 (95% CI: [-0.402]-0.595) in GL and 0.984 [95% CI: 0.970-0.992)] in VP. Mean comparison between CT and GL was -0.9286 (CI 95%: [-1.822]-[0.0355], P=.042) and -0.8423 (95% CI: [-1.7190]-0.03450, P=.0593) for CT-VP. Correlation coefficient for VP was R=0.5704 (95% CI: 0.319-0.747, P=.0001) and R=0.4539 (95% CI: 0.174-0.666, P=.0025) for GL. Margins of variability for a single horizontal measurement in primary position with VP were±5.22 PD and±2 DP for GL. CONCLUSION: Both VP and GL are reliable and valid devices. Margins of variability for a horizontal measurement are ±5.22 PD in VP and±2 PD in GL.

Membrana amniótica en el tratamiento quirúrgico de diplopía posblefaroplastia / Amniotic membrane in the surgical treatment of post-blepharoplasty diplopia

Presentamos 2 casos consecutivos de diplopía vertical tras cirugía de blefaroplastia. Se trata de 2 mujeres de 41 y 63 años que presentaron diplopía binocular vertical tras blefaroplastia inferior bilateral con abordaje transconjuntival. La diplopía se presentó en ambos casos en el postoperatorio inmediato, siendo en uno de los casos estable y en otro progresiva. Con la sospecha de estrabismo restrictivo se planteó explorar los músculos extraoculares afectados, eliminar las adherencias y recubrimiento de los vientres musculares con membrana amniótica. La diplopía posblefaroplastia es una complicación infrecuente, pero muy grave, dadas las expectativas de estos pacientes. La literatura describe, hasta la fecha, resultados poco satisfactorios en su manejo. Consideramos que el recubrimiento muscular con membrana amniótica puede aportar mejores resultados en el manejo quirúrgico de estos pacientes, debido a su efecto antiinflamatorio y antiadherencial

Two consecutive cases are presented of vertical diplopia after blepharoplasty. They concern two women aged 41 and 63 years with vertical binocular diplopia after bilateral lower blepharoplasty using a trans-conjunctival approach. The diplopia was presented in both cases in the immediate postoperative period, being stable in one of the cases and progressive in the other. With the suspicion of restrictive strabismus, it was decided to explore the affected extra-ocular muscles, eliminate adhesions and coat the muscular bellies with amniotic membrane. Post-blepharoplasty diplopia is an uncommon, but very serious complication, given the expectations of these patients. The current literature reports unsatisfactory results in its management. In this study, it is considered that the muscular covering with amniotic membrane can provide better results in the surgical management of these patients, due to its anti-inflammatory and anti-adherence effect

Amniotic membrane in the surgical treatment of post-blepharoplasty diplopia. / Membrana amniótica en el tratamiento quirúrgico de diplopía posblefaroplastia.

Two consecutive cases are presented of vertical diplopia after blepharoplasty. They concern two women aged 41 and 63 years with vertical binocular diplopia after bilateral lower blepharoplasty using a trans-conjunctival approach. The diplopia was presented in both cases in the immediate postoperative period, being stable in one of the cases and progressive in the other. With the suspicion of restrictive strabismus, it was decided to explore the affected extra-ocular muscles, eliminate adhesions and coat the muscular bellies with amniotic membrane. Post-blepharoplasty diplopia is an uncommon, but very serious complication, given the expectations of these patients. The current literature reports unsatisfactory results in its management. In this study, it is considered that the muscular covering with amniotic membrane can provide better results in the surgical management of these patients, due to its anti-inflammatory and anti-adherence effect.

Estrabismo y diplopías tras la cirugía refractiva / Strabismus and diplopia after refractive surgery

Objetivo: Analizar los factores que pueden incidir en la descompensación del estrabismo o aparición de diplopía en pacientes sometidos a cirugía refractiva. Métodos: Estudio retrospectivo de 19 pacientes remitidos por presentar descompensación de la motilidad ocular y/o de la visión binocular tras cirugía refractiva. La edad media era 38,89 DS±10,26 años (rango 27 a 63). Catorce pacientes eran miopes, cinco hipermétropes. Cinco de ellos presentaban anisometropía intensa. En tres casos la técnica refractiva fue fotoqueratectomía refractiva, en trece de tipo Lasik, en uno LIO+Lasik y en dos LIO bilateral. Resultados: La prevalencia de diplopía poscirugía refractiva fue 0,12% (5 de los 19 procedían de nuestro centro, sobre una base de datos de 4.135 pacientes sometidos a cirugia refractiva, al realizar el estudio). Todos tenían patología binocular previa a la cirugía. Tras esta, once presentaban endoforia o endotropía, tres exoforia o exotropía, dos desviaciones verticales y tres horizontal y vertical. Las causas de descompensación fueron: factor acomodativo residual, hipercorrección refractiva en sentido hipermetrópico, inestabilidad visual, anisoagudeza, descompensación de una foria en el estrabismo del miope magno, pérdida de supresión, cambio de dominancia y presbicia. Frecuentemente varios factores actuaron simultáneamente. Conclusiones: La aparición de diplopía o estrabismo poscirugía refractiva es poco frecuente. Varios factores pueden incidir en la descompensación, fundamentalmente la hipercorrección miópica y los factores acomodativos y visuales, especialmente en edad présbita, en fuertes anisométropes y miopes magnos(AU)

Objective: To evaluate factors that may decompensate a strabismus or lead to diplopia after refractive surgery. Methods: Retrospective study of 19 patients, who presented with binocular decompensation after refractive surgery. Mean age at surgery was 38.89 SD 10.26 (27-63) years. Fourteen patients were myopic, 5 hyperopic, and 5 of them had a marked anisometropia. The photo-refractive keratectomy procedure was used in 3 cases, laser-assisted in situ keratomileusis (LASIK) in 13, posterior chamber-IOL)+LASIK in one of them, and bilateral IOL in 2 cases. Results: There was a prevalence of strabismus of 0.12%. All of our patients had a binocular pathology previous to the refractive surgery. After surgery, 11 patients had an esophoria or esotropia, 3 exophoria or exotropia, 2 vertical deviations, and 3 horizontal and vertical deviations. Several factors often worked simultaneously in the same patient, such as: residual accommodation, refractive overcorrection (hyperopia), visual instability or anisoacuity, high myopia and phoria decompensation, elimination of suppression, dominance change, and a presbyopic age. Conclusions: All of our patients had a previous binocular pathology. Binocularity may decompensate by several factors but mostly by myopic overcorrection, accommodation and visual factors, particularly in patients close to or in presbyopic age, in anisometropia and high myopia(AU)

[Use of botulinum toxin in a patient with pendular congenital nystagmus]. / Empleo de toxina botulínica en paciente con nistagmus congénito de tipo pendular.

CASE REPORT: We report the case of a 5 month-old male diagnosed with congenital nystagmus and oculocutaneous albinism. The initial examination showed pendular horizontal nystagmus with high amplitude and without blocking position or foveal fixation periods. A 2.5 IU injection of botulinum toxin was administered in the horizontal rectus muscles of both eyes in two sessions separated by 6 weeks. This led to a decrease in amplitude of nystagmus and early development of binocular visual acuity of 4.8cycles/cm. CONCLUSION: Faced with diagnosis of horizontal nystagmus in the early stages of development, and in order to avoid periods of foveal fixation, the use of botulinum toxin leads to a temporary reduction in its amplitude and an improvement in visual acuity with low complication rates. Given the possibility of spontaneous improvement described in these patients, studies are needed with longer follow-up to establish the advantage of long term treatment.

[Strabismus and diplopia after refractive surgery]. / Estrabismo y diplopías tras la cirugía refractiva.

OBJECTIVE: To evaluate factors that may decompensate a strabismus or lead to diplopia after refractive surgery. METHODS: Retrospective study of 19 patients, who presented with binocular decompensation after refractive surgery. Mean age at surgery was 38.89 SD 10.26 (27-63) years. Fourteen patients were myopic, 5 hyperopic, and 5 of them had a marked anisometropia. The photo-refractive keratectomy procedure was used in 3 cases, laser-assisted in situ keratomileusis (LASIK) in 13, posterior chamber-IOL)+LASIK in one of them, and bilateral IOL in 2 cases. RESULTS: There was a prevalence of strabismus of 0.12%. All of our patients had a binocular pathology previous to the refractive surgery. After surgery, 11 patients had an esophoria or esotropia, 3 exophoria or exotropia, 2 vertical deviations, and 3 horizontal and vertical deviations. Several factors often worked simultaneously in the same patient, such as: residual accommodation, refractive overcorrection (hyperopia), visual instability or anisoacuity, high myopia and phoria decompensation, elimination of suppression, dominance change, and a presbyopic age. CONCLUSIONS: All of our patients had a previous binocular pathology. Binocularity may decompensate by several factors but mostly by myopic overcorrection, accommodation and visual factors, particularly in patients close to or in presbyopic age, in anisometropia and high myopia.

Empleo de toxina botulínica en paciente con nistagmus congénito de tipo pendular / Use of botulinum toxin in a patient with pendular congenital nystagmus

Caso clínico: Se presenta el caso de un varón de 5 meses de edad, diagnosticado de nistagmus congénito y albinismo oculocutáneo. En la exploración inicial se evidenció un nistagmus horizontal pendular de gran amplitud sin posición de bloqueo ni períodos de fijación foveal. Se realizó una inyección de 2,5 UI de toxina botulínica en los músculos rectos horizontales de ambos ojos en dos sesiones separadas por 6 semanas permitiendo una disminución de la amplitud del nistagmus y un desarrollo inicial de la agudeza visual binocular de 4,8 ciclos/cm. Conclusión: Ante el diagnóstico de nistagmus horizontal en etapas precoces del desarrollo, de amplitud tal que impida períodos de fijación foveal, el empleo de toxina botulínica permite una disminución temporal en la amplitud del mismo y una mejoría de la agudeza visual con baja tasa de complicaciones. Ante la posibilidad descrita de mejoría espontánea de estos pacientes, especialmente durante el primer año de vida, son necesarios estudios con mayor tiempo de seguimiento para establecer la ventaja de este tratamiento a largo plazo(AU)

Case report: We report the case of a 5 month-old male diagnosed with congenital nystagmus and oculocutaneous albinism. The initial examination showed pendular horizontal nystagmus with high amplitude and without blocking position or foveal fixation periods. A 2.5 IU injection of botulinum toxin was administered in the horizontal rectus muscles of both eyes in two sessions separated by 6 weeks. This led to a decrease in amplitude of nystagmus and early development of binocular visual acuity of 4.8 cycles/cm. Conclusion: Faced with diagnosis of horizontal nystagmus in the early stages of development, and in order to avoid periods of foveal fixation, the use of botulinum toxin leads to a temporary reduction in its amplitude and an improvement in visual acuity with low complication rates. Given the possibility of spontaneous improvement described in these patients, studies are needed with longer follow-up to establish the advantage of long term treatment(AU)

[Binocular vision following refractive surgery in hyperopic patients]. / Visión binocular tras cirugía refractiva en pacientes hipermétropes.

PURPOSE: To evaluate the changes in binocular vision and ocular motility in hyperopic patients undergoing refractive surgery. METHODS: Prospective study of 31 consecutive patients who underwent bilateral refractive surgery for hyperopia between May 1999 and February 2002. The examination included best-corrected visual acuity, cycloplegic refraction, ocular motility, fusion at distance, stereopsis and fusional amplitudes, before and at one month, 3 months, 6 months, one year after surgery and annually thereafter. RESULTS: After refractive surgery, there were changes in visual acuity, residual hyperopic refractive errors, and anisometropic changes that influenced the oculomotor status. The most frequent sensory modifications were suppression at distance, with much less change in stereopsis. From the point of view of ocular motility, we found a significant tendency to esotropia in strabismic patients (p=0.003). In non-strabismic patients, we also found sensorimotor modifications, but of less intensity and with fewer consequences than in strabismic patients. Sensorial and/or motor decompensation appeared in 25% of strabismic patients, and asthenopia symptoms developed in 28.7% in the same group. CONCLUSIONS: Slight binocular modifications with no symptomatic consequences were found in patients with normal binocular vision. However ocular motility was modified towards esotropia in strabismic patients, binocular decompensation appeared in 25%, and 28.7% of them suffered from asthenopia.

Visión binocular tras cirugía refractiva en pacientes hipermétropes / Binocular vision following refractive surgery in hyperopic patients

Objetivo: Analizar si existen modificaciones de lavisión binocular y motilidad ocular en pacienteshipermétropes operados de cirugía refractiva.Métodos: Estudio prospectivo de 31 pacientes consecutivosoperados de cirugía refractiva bilateral dehipermetropía entre mayo de 1999 y febrero de2002. El protocolo de exploración incluyó la agudezavisual corregida, el error refractivo bajo cicloplejía,la motilidad ocular, la fusión en visión lejana,la estereopsis y el grado de amplitud de fusión,realizándose de nuevo al mes, 3 meses, 6 meses, unaño y en sucesivas revisiones anuales.Resultados: Tras la cirugía refractiva se han encontradoalteraciones de la agudeza visual, defectoshipermetrópicos residuales, así como cambios deanisometropía, que han influido en la situación oculomotora.El tipo de alteración sensorial más frecuentementemodificado ha sido la supresión delejos, alterándose la estereopsis en mucho menorgrado. Desde el punto de vista de motilidad ocular,en los pacientes estrábicos se ha encontrado unatendencia significativa en el sentido endotrópico(p=0,003). En los sujetos no estrábicos, aunque sehan hallado modificaciones sensoriomotoras, han sido de menor intensidad y repercusión que en lossujetos estrábicos. Un 25% de los pacientes estrábicospresentó una descompensación sensorial y/omotora, y un 28,57% del mismo grupo mostró síntomasastenópicos.Conclusiones: En los pacientes con visión binocularnormal existieron leves modificaciones binocularesque no tuvieron repercusión sintomática. Sinembargo, en los pacientes estrábicos se modificó lamotilidad ocular en sentido endotrópico, se descompensóun 25% y refirió síntomas astenópicos un28,7% de ellos

Purpose: To evaluate the changes in binocular vision and ocular motility in hyperopic patients undergoing refractive surgery. Methods: Prospective study of 31 consecutive patients who underwent bilateral refractive surgery for hyperopia between May 1999 and February 2002. The examination included best-corrected visual acuity, cycloplegic refraction, ocular motility, fusion at distance, stereopsis and fusional amplitudes, before and at one month, 3 months, 6 months, one year after surgery and annually thereafter. Results: After refractive surgery, there were changes in visual acuity, residual hyperopic refractive errors, and anisometropic changes that influenced the oculomotor status. The most frequent sensory modifications were suppression at distance, with much less change in stereopsis. From the point of view of ocular motility, we found a significant tendency to esotropia in strabismic patients (p=0.003). In non-strabismic patients, we also found sensorimotor modifications, but of less intensity and with fewer consequences than in strabismic patients. Sensorial and/or motor decompensation appeared in 25% of strabismic patients, and asthenopia symptoms developed in 28.7% in the same group. Conclusions: Slight binocular modifications with no symptomatic consequences were found in patients with normal binocular vision. However ocular motility was modified towards esotropia in strabismic patients, binocular decompensation appeared in 25%, and 28.7% of them suffered from asthenopia

Tratamiento de las parálisis del VI par de etiología traumática y tumoral mediante toxina botulínica / Treatment of the sixth nerve palsy by a traumatic or tumoral etiology using botulinum toxin

Objetivo: Valorar los resultados obtenidos en las parálisis del sexto nervio craneal de las citadas etiologías tratadas mediante toxina botulínica, y analizar los factores que pueden influir. Métodos: Se estudian 35 ojos diagnosticados de parálisis unilateral del sexto nervio, 21 de etiología traumática (grupo I) y 14 de etiología tumoral (grupo II). Todos los casos eran unilaterales. El tratamiento consistió en la inyección de toxina botulínica en el recto medial del ojo afecto, con anestesia tópica. En el grupo I, la desviación media era de 59 dioptrías, y en el grupo II de 37 dioptrías. Analizamos la desviación inicial, el inicio del tratamiento, la dosis y número de inyecciones, los efectos colaterales, el resultado final y el tiempo de seguimiento. Resultados: En el grupo I, el número medio de inyecciones fue de 1,7 y la dosis media de 10,23 unidades internacionales, con un éxito del 38 por ciento, obteniéndose mejores resultados si se inicia el tratamiento antes de los seis meses, cuanto menor es la desviación inicial y cuanto mejor es la función inicial del recto lateral. En el grupo II, el número medio de inyecciones fue de 1,5 y la dosis media de 8,21 unidades internacionales, con un éxito del 57 por ciento, sin que ninguna de las variables anteriormente citadas influyan. Conclusiones: En las parálisis de etiología traumática consideramos útil inyectar toxina antes de seis meses, el resultado dependerá de la función inicial del recto lateral y del ángulo de desviación inicial. También puede ser empleada como ayuda diagnóstica y como tratamiento crónico en aquellos pacientes que no pueden ser intervenidos por su patología de base (AU)

[Treatment of sixth nerve palsy of traumatic or tumor etiology using botulinum toxin]. / Tratamiento de las parálisis del VI par de etiología traumática y tumoral mediante toxina botulínica.

PURPOSE: To study the treatment of sixth nerve palsies of traumatic or tumoral etiologies using botulinum toxin. The factors and possible influences are analysed. METHODS: 35 patients with unilateral sixth nerve palsy are studied, 21 presenting traumatic (group I) and 14 with tumoral etiology (group II). They have been treated with botulinum toxin into the medial rectus muscle, using topical anesthesia. In group I the mean preoperative deviation was 59 diopters, in group II it was 37 diopters. The follow-up time, the initial deviation, the dose, the number of injections, the colateral effects and the final results are analyzed. RESULTS: In group I, the mean number of injections was 1.7, and the dose 10.23 international units, success was achieved in 38% of the patients, better results are obtained when treatment is injected within six months after traumatism, when less initial deviation and better initial lateral muscle function are present. In group II, the mean number of injections was 1.5 and the dose 8.21 international units, success was achieved in 57%, no influence among these factors was found. CONCLUSIONS: We consider useful to treat the traumatic palsy with botulinum toxin within six months after traumatism. The results depend on the initial deviation and the previous lateral muscle function. It is also useful as a chronic treatment and as a diagnosis procedure.