[Visual neurorehabilitation of patients with cerebral damage using botulinum toxin]. / ción visual con toxina botulínica en pacientes con daño cerebral.

BACKGROUND: The neurorehabilitation of the patient with cerebral damage implies the reestablishment of the visual functions. Botulinum toxin can be considerate as a less invasive alternative for treatment. OBJECTIVE: to demonstrate the answer to the treatment using botulinum toxin of the visual motor alterations in patients with cerebral damage. METHODS: Descriptive study of patients with visual alterations associated to cerebral damage. The visual treatment included three areas: sensorial, refracting and motor under quimiodenervation with botulinum toxin, of May 2009 to May 2010. RESULTS: 48 patients were studied, age 22,4 years ± 23. The strabismus were: esotropia 52%, exotropia 39,5%, vertical 8%, nystagmus 4%. 50% of the patients had psychomotor delay. Some of the most important causes of cerebral damage were: Down syndrome, epilepsy, tumor, hydrocephalus, neuroinfection, infantile cerebral paralysis, multiple sclerosis, metabolic syndrome, cranial trauma, congenital cardiopathy, ventricular hemorrhage, cerebrovascular stroke. The dose of botulinum toxin was 8,1 UI ± 3. We registered good results in 56.5%, regular 23,9% and bad 19,5%. The global percentage of rehabilitation was 69% of correction with a r of Pearson of 0,5. DISCUSSION: Patients with cerebral damage have diverse types of visuomotor alterations, strabismus and nystagmus.Use of botulinum toxin as a paralytic muscle agent is a good alternative in these cases. CONCLUSION: The botulinum toxin is an effective option for the visual rehabilitation in patients with cerebral damage and prevents the progression of more cerebral changes secondary to strabismus.

Laser-ranibizumab treatment for retinopathy of prematurity in umbral-preumbral disease. Three years of experience.

BACKGROUND: The "Early Treatment for Retinopathy of Prematurity Cooperative" reported a failure rate of 55.2% using laser in zone 1 for treatment of retinopathy of prematurity (ROP). We need to offer better alternatives for those patients. We undertook this study to evaluate the efficacy of combined laser-ranibizumab therapy for ROP with threshold-prethreshold and "plus disease" and to study development of the newborn. METHODS: This is a prospective, experimental, longitudinal and open study including newborns of either <32 weeks of gestation or with a birth weight <1500 g, with threshold-prethreshold retinopathy or "plus disease." The effect of treatment was analyzed and development of the newborn was determined. RESULTS: We studied 34 eyes of 17 patients. Age at birth was 29.9 ± 2.6 weeks. Birth weight was 1,120 ± 253 g. The statistics demonstrated an important relationship between severity of retinopathy and early birth age, along with a high probability of threshold-prethreshold disease at 29.4 weeks of age or 1204 g birth weight. The Bayley scale reported normal development in 23.5% of cases, global retardation in 23.5%, psychomotor retardation but normal mental behavior in 29.4%, and mental retardation but normal psychomotor development in 23.5%. We demonstrated regression of retinopathy in all cases. Persistence of vascular tortuosity was present in 17.6% of cases without vascular dilatation, and vitreous membrane development was demonstrated in 11.7% of patients. CONCLUSIONS: Laser-ranibizumab treatment has allowed a better control of retinopathy for threshold-prethreshold and "plus disease" in this group of patients.

Visuomotor functions and intelligence subsequent to strabismus treatment. Second phase.

BACKGROUND: Strabismus has been related to different alterations of brain functions and learning in children. Early treatment for visuomotor functions may improve the executive areas of intelligence. We undertook this study to demonstrate changes of visuomotor function and intelligence in children after strabismus treatment. METHODS: This is a prospective study of patients with strabismus, before and after treatment. We applied the Human Figure Test, Visuomotor Bender Test, and Intelligence Test. RESULTS: We included nine children with an average age of 8.7 years (± 2.4 years). Stereopsis result was 724 arc sec. Visual acuity was 0.16 logMAR ± 0.15. Verbal intelligence was 91.1 ± 11, executive intelligence (EI) was 86.7 ± 8, and global intelligence (GI) was 91 ± 10. Correlation coefficient of EI was significantly related to stereopsis (-0.2), visual acuity (-0.1) and Bender (-0.1). GI results were higher than statistical prognosis (88.16 for x = 90). CONCLUSIONS: We demonstrated improvement in binocularity and psychoadaptive areas related to EI after strabismus and amblyopia treatment.

[Skew deviation. Strabismological diagnosis and treatment alternatives].

BACKGROUND: We undertook this study to analyze diagnostic and treatment alternatives in patients with skew deviation (SD). METHODS: This is a prospective, observational and longitudinal study of patients with SD. The study took place in a third-level medical center during the period from September 2007 to May 2008. Strabismological exploration, multidisciplinary diagnosis and treatment alternatives were analyzed. RESULTS: Ten patients presenting SD were studied. Diagnoses were multiple sclerosis, arteriovenous malformation, epilepsy, hydrocephalus, ischemic encephalopathy, cortical atrophy, hypoplasia of corpus callosum and thalamic hemorrhage. Psychomotor retardation was present in 80%. Other diagnoses were Cogan apraxia, Parinaud syndrome, see-saw nystagmus, Foville syndrome, and hemiplegic alterations. Related strabismuses were exotropia (5), esotropia (3), hypertropia (2), and dissociated vertical deviation (1). Lesions of II, III and VII cranial nerves were found. CONCLUSIONS: Complete strabological study allows a better diagnosis of the lesion and consequently relapsing disease in order to achieve a better treatment according to each patient. Optical rehabilitation and botulinum applications are especially indicated.

Desviación oblicua: diagnóstico estrabológico y alternativas de tratamiento / Skew deviation: strabismological diagnosis and treatment alternatives

Objetivo: Analizar las posibilidades de diagnóstico y tratamiento en pacientes con skew deviation (SD) o estrabismo con desviación oblicua. Material y métodos: Estudio prospectivo, observacional y longitudinal de pacientes con SD, de septiembre de 2007 a mayo de 2008. Se realizó exploración estrabológica, estudio multidisciplinario y se evaluaron alternativas terapéuticas. Resultados: Se estudiaron 10 pacientes con SD. Edad 11.5 + 13.6 años. Los diagnósticos neurológicos fueron esclerosis múltiple, malformación arteriovenosa, epilepsia, hidrocefalia, encefalopatía isquémica, atrofia cortical, hipoplasia de cuerpo calloso y hemorragia talámica. Se encontró retraso psicomotor en 80 %, además se asoció a apraxia de Cogan, síndrome de Parinaud, nistagmo en see-saw, síndrome de Foville y hemiplejía. Los estrabismos relacionados fueron exotropía en cinco, endotropía en tres, hipertropía en dos, desviación vertical disociada en uno. Se encontró lesión a II, III y VII nervios craneales. Conclusiones: El estudio estrabológico adecuado permite un mejor diagnóstico de la lesión en SD y con ello vigilar la evolución neurológica del paciente. El tratamiento debe incluir la rehabilitación óptica y el manejo del estrabismo, principalmente con toxina botulínica.

BACKGROUND: We undertook this study to analyze diagnostic and treatment alternatives in patients with skew deviation (SD). METHODS: This is a prospective, observational and longitudinal study of patients with SD. The study took place in a third-level medical center during the period from September 2007 to May 2008. Strabismological exploration, multidisciplinary diagnosis and treatment alternatives were analyzed. RESULTS: Ten patients presenting SD were studied. Diagnoses were multiple sclerosis, arteriovenous malformation, epilepsy, hydrocephalus, ischemic encephalopathy, cortical atrophy, hypoplasia of corpus callosum and thalamic hemorrhage. Psychomotor retardation was present in 80%. Other diagnoses were Cogan apraxia, Parinaud syndrome, see-saw nystagmus, Foville syndrome, and hemiplegic alterations. Related strabismuses were exotropia (5), esotropia (3), hypertropia (2), and dissociated vertical deviation (1). Lesions of II, III and VII cranial nerves were found. CONCLUSIONS: Complete strabological study allows a better diagnosis of the lesion and consequently relapsing disease in order to achieve a better treatment according to each patient. Optical rehabilitation and botulinum applications are especially indicated.

[Central nervous system abnormalities related to congenital fibrosis of extraocular muscles]. / Alteraciones del sistema nervioso central asociadas a fibrosis congénita de músculos extraoculares.

OBJECTIVE: We undertook this study to describe central nervous system (CNS) abnormalities associated with congenital cranial dysinnervation disorders (CCDD). METHODS: This was a retrospective, observational, transversal and descriptive study including patients with congenital fibrotic strabismus. We analyzed clinical files of patients from 2001 to 2006. Neurological lesions were reported. RESULTS: Restrictive strabismus was demonstrated in all cases. Sixteen patients were included: nine males and seven females. Different neurological lesions were reported: corpus callosum anomalies, severe cortipathy, epilepsy, cavum vergae, nystagmus, occipital subarachnoid cyst, and hydrocephalus. Mental retardation was reported in 56% of patients. Different malformations were reported: genital malformations, trigonocephalus, camptodactyly, mild facial hypoplasia, low set ears, and agenesis of left ear. Blepharoptosis was present in 81% of patients. The most frequent form of strabismus was exotropia (56%), hypotropia in 37.5%, hypertropia 18.7%, "A" pattern 18.7%, and esotropia in 6.25%. Affection was cranial nerve III, 93.75%; cranial nerve VI, 6.25%; cranial nerve VII, 6.25%; and lesion to cranial nerve II in eight cases (50%). CONCLUSIONS: We have suggested that failure in early stages of embryology of the CNS can lead to the development of paralytic strabismus and generate secondary fibrotic changes, not only in muscle structures but also in other orbital tissues. That is the reason why we have used the term "congenital fibrotic strabismus" to report cases included in CCDD. We have demonstrated the strong association of mental retardation and neurological alterations. Multidisciplinary rehabilitation is relevant for these patients.

Alteraciones del sistema nervioso central asociadas a fibrosis congénita de músculos extraoculares / Central nervous system abnormalities related to congenital fibrosis of extraocular muscles

Objetivo: Describir las alteraciones del sistema nervioso central asociadas a dismorfogenesias de los nervios craneales. Material y métodos: Estudio retrospectivo, observacional, transversal y descriptivo de pacientes con estrabismo por fibrosis congénita de los músculos extraoculares, atendidos entre enero de 2001 y enero de 2006. Fueron identificadas las lesiones neurológicas y se analizó su asociación. Resultados: Todos los pacientes tuvieron estrabismos fibróticos. Se incluyeron 16 pacientes, nueve hombres y siete mujeres. Las lesiones neurológicas asociadas fueron anomalías de cuerpo calloso, cortipatía severa con sordera, epilepsia, cavum vergae, nistagmo, quiste subaracnoideo occipital e hidrocefalia. Se demostró retraso psicomotor en 56 % de los pacientes. Se identificaron malformaciones congénitas como trigonocefalia, camptodactilia, hipoplasia facial, implantación baja de orejas. La ptosis palpebral se encontró en 81 % de los casos. El estrabismo más frecuente fue la exotropía (56 %) seguida de hipotropía (37.5 %), hipertropía (18.7 %), anisotropía en “A” (18.7 %) y endotropía (6.25 %). Los nervios craneales afectados fueron el III (93.75 %), VI (6.25 %) y VII (6.25 %); además, se encontró lesión a II nervio en 50 %. Conclusiones: La falla en los estadios tempranos del desarrollo del sistema nervioso central puede provocar estrabismo paralítico que secundariamente puede manifestarse como estrabismo fibrótico que afecta músculos y tejidos orbiculares, por lo que el término más apropiado sería “estrabismo fibrótico congénito como causa de dismorfogenesia de los nervios craneales”. Encontramos alta incidencia de retraso psicomotor y alteraciones neurológicas. Es importante la rehabilitación temprana y multidisciplinaria en estos pacientes.

OBJECTIVE: We undertook this study to describe central nervous system (CNS) abnormalities associated with congenital cranial dysinnervation disorders (CCDD). METHODS: This was a retrospective, observational, transversal and descriptive study including patients with congenital fibrotic strabismus. We analyzed clinical files of patients from 2001 to 2006. Neurological lesions were reported. RESULTS: Restrictive strabismus was demonstrated in all cases. Sixteen patients were included: nine males and seven females. Different neurological lesions were reported: corpus callosum anomalies, severe cortipathy, epilepsy, cavum vergae, nystagmus, occipital subarachnoid cyst, and hydrocephalus. Mental retardation was reported in 56% of patients. Different malformations were reported: genital malformations, trigonocephalus, camptodactyly, mild facial hypoplasia, low set ears, and agenesis of left ear. Blepharoptosis was present in 81% of patients. The most frequent form of strabismus was exotropia (56%), hypotropia in 37.5%, hypertropia 18.7%, "A" pattern 18.7%, and esotropia in 6.25%. Affection was cranial nerve III, 93.75%; cranial nerve VI, 6.25%; cranial nerve VII, 6.25%; and lesion to cranial nerve II in eight cases (50%). CONCLUSIONS: We have suggested that failure in early stages of embryology of the CNS can lead to the development of paralytic strabismus and generate secondary fibrotic changes, not only in muscle structures but also in other orbital tissues. That is the reason why we have used the term "congenital fibrotic strabismus" to report cases included in CCDD. We have demonstrated the strong association of mental retardation and neurological alterations. Multidisciplinary rehabilitation is relevant for these patients.

[Study of vitreoretinal dystrophies in a Mexican population]. / Estudio de las distrofias vitreorretinianas en población mexicana.

BACKGROUND: We undertook this study to demonstrate the incidence of vitreoretinal dystrophies in a Mexican population. METHODS: This was a retrospective, observational, descriptive, transverse study. We analyzed the files of patients treated at the Retina Department of a medical center for state employees (ISSSTE) from January 1991 to December 2006 to obtain the incidence of vitreoretinal dystrophies. RESULTS: We studied 36,300 patient files. We found an incidence of 0.008% for familial exudative vitreoretinal dystrophy, 0.008% for X-linked juvenile retinoschisis, 0.005% for Wagner disease and 0.005% for Goldmann-Favre disease. We present here a representative case of each type of dystrophy. CONCLUSIONS: Vitreoretinal dystrophies are uncommon diseases and are difficult to diagnose. Even though their incidence is low, the poor evolution to blindness requires identification of early signs in order to offer timely and opportune treatment.

[Study of depression and sensorial functions in children with strabismus. First phase]. / Análisis de las funciones sensoriomotoras y depresión en niños con estrabismo. Primera fase.

BACKGROUND: We undertook this study to demonstrate the visuomotor alterations, intelligence level and depression changes in children with recurrent strabismus. METHODS: Children with recurrent strabismus were studied with the Human Figure Test, Lauretta Bender Visuomotor Test, Intelligence Level of Weschler, WISC-R, and WPPSI. Complete exploration of strabismus was made. RESULTS: We included nine children aged 6.8 years (SD 2). Overfunction of oblique muscles and dissociated strabismus were related to recurrence of strabismus. Stereovision was present in five cases previous to recurrence (rate: 170 sec of arc), and three lost this with recurrence of strabismus. Psychological test determined difficulties in socialization and signs of aggression, including data on depression and "dullness." Bender Test showed relevant defects in fine hand movement, level: 5.4 (SD 1.7). Santucci evaluation for Bender was 3.83 (SD 2.1). Correlation coefficient between values was significant for Santucci evaluation and stereovision (0.89). Global Intelligence Coefficient was 88.1 (SD 12), which was subnormal and poorer in executive function (84). CONCLUSIONS: We have demonstrated relevant alterations in visuomotor abilities in patients with strabismus, especially related to stereovision deficiency, effect on learning, intelligence and depression.

Análisis de las funciones sensoriomotoras y depresión en niños con estrabismo: primera fase / Study of depression and sensorial functions in children with strabismus: first phase

BACKGROUND: We undertook this study to demonstrate the visuomotor alterations, intelligence level and depression changes in children with recurrent strabismus. METHODS: Children with recurrent strabismus were studied with the Human Figure Test, Lauretta Bender Visuomotor Test, Intelligence Level of Weschler, WISC-R, and WPPSI. Complete exploration of strabismus was made. RESULTS: We included nine children aged 6.8 years (SD 2). Overfunction of oblique muscles and dissociated strabismus were related to recurrence of strabismus. Stereovision was present in five cases previous to recurrence (rate: 170 sec of arc), and three lost this with recurrence of strabismus. Psychological test determined difficulties in socialization and signs of aggression, including data on depression and "dullness." Bender Test showed relevant defects in fine hand movement, level: 5.4 (SD 1.7). Santucci evaluation for Bender was 3.83 (SD 2.1). Correlation coefficient between values was significant for Santucci evaluation and stereovision (0.89). Global Intelligence Coefficient was 88.1 (SD 12), which was subnormal and poorer in executive function (84). CONCLUSIONS: We have demonstrated relevant alterations in visuomotor abilities in patients with strabismus, especially related to stereovision deficiency, effect on learning, intelligence and depression.

Estudio de las distrofias vitreorretinianas en población mexicana / Study of vitreoretinal dystrophies in a Mexican population

BACKGROUND: We undertook this study to demonstrate the incidence of vitreoretinal dystrophies in a Mexican population. METHODS: This was a retrospective, observational, descriptive, transverse study. We analyzed the files of patients treated at the Retina Department of a medical center for state employees (ISSSTE) from January 1991 to December 2006 to obtain the incidence of vitreoretinal dystrophies. RESULTS: We studied 36,300 patient files. We found an incidence of 0.008% for familial exudative vitreoretinal dystrophy, 0.008% for X-linked juvenile retinoschisis, 0.005% for Wagner disease and 0.005% for Goldmann-Favre disease. We present here a representative case of each type of dystrophy. CONCLUSIONS: Vitreoretinal dystrophies are uncommon diseases and are difficult to diagnose. Even though their incidence is low, the poor evolution to blindness requires identification of early signs in order to offer timely and opportune treatment.

Disfuncionalidad neuronal y psicomotora como resultado del retraso del tratamiento de la ambliopía / Neuronal and psychomotor malfunction secondary to delayed amblyopia treatment

BACKGROUND: A review of neuronal and psychomotor alterations related to delay of amblyopia treatment was carried out. METHODS: We reviewed various studies to explain the anomalies of visual cortex because of the prevalence of anomalous stimulus in patients with amblyopia. RESULTS: Visual pathways are developed embryologically. The newborn has ocular dominance columns ready to be stimulated, but visual alterations present at this time will generate neuronal changes in visual cortex. CONCLUSIONS: Delay of amblyopia treatment with anomalous visual stimulus will provoke organic changes in visual cortex, inducing alterations of brain functions depending on binocularity. Memory and learning have also been related to this condition.

[Neuronal and psychomotor malfunction secondary to delayed amblyopia treatment]. / Disfuncionalidad neuronal y psicomotora como resultado del retraso del tratamiento de la ambliopía.

BACKGROUND: A review of neuronal and psychomotor alterations related to delay of amblyopia treatment was carried out. METHODS: We reviewed various studies to explain the anomalies of visual cortex because of the prevalence of anomalous stimulus in patients with amblyopia. RESULTS: Visual pathways are developed embryologically. The newborn has ocular dominance columns ready to be stimulated, but visual alterations present at this time will generate neuronal changes in visual cortex. CONCLUSIONS: Delay of amblyopia treatment with anomalous visual stimulus will provoke organic changes in visual cortex, inducing alterations of brain functions depending on binocularity. Memory and learning have also been related to this condition.

[Strabismus-associated Parinaud syndrome]. / Síndrome de Parinaud asociado a otros estrabismos.

OBJECTIVE: We undertook this study to describe the causes of Parinaud syndrome (PS) with diplopia to determine a topographic diagnosis and prognosis. METHODS: We studied patients with PS from January 1980 to January 2004 and reviewed causes and treatment. We identified all strabismus associated with PS. RESULTS: We included 18 patients with diplopia, 6 females and 12 males. Median age was 28 years old, SD 22 (10; CI 95%). Results are strabismus related: III nerve palsy in 15 patients (79%), optical nerve damage in 8 (44.4%), VII nerve palsy in 3, IV nerve palsy 2, bilateral III nerve palsy 2, nystagmus 2, Foville syndrome 2, one-and-a-half syndrome (1). The following causes were reported: tumors (6), brain stroke (4), cranial trauma (3), neurocysticercosis (2). Orthoposition under botulinum toxin treatment was obtained in 1.72 +/- 1.1 (0.65 CI 95%). Surgery was done in nine patients, and only one patient had spontaneous resolution of diplopia and PS. CONCLUSIONS: It is important to identify the topographic diagnosis and prognosis of brain diseases such as the complete study of strabismus-related PS. In this way we can learn more about the extent of damage and can identify recurrences quickly in order to offer better control.

[Evolution of threshold retinopathy of prematurity after argon laser treatment under indirect ophthalmoscopy]. / Evolución de los pacientes con retinopatía de prematuro en estadio umbral tratados con láser de argón mediante oftalmoscopia indirecta.

BACKGROUND: We undertook this study to evaluate the long-term effects of threshold retinopathy of prematurity (ROP) treatment using Argon laser under indirect ophthalmoscopy, as well as to analyze ocular diseases in those patients. METHODS: This is a descriptive, observational, longitudinal and prospective study carried out from March 1991 to February 2005, including patients with threshold retinopathy of prematurity for treatment using Argon laser under indirect ophthalmoscopy. Related ocular diseases were also reported. Descriptive statistics were applied. RESULTS: Follow-up was maintained for 14 years, 6.50 +/- 1.39 (CI 95%, p < 0.05), and 170 patients were studied. Weight was 1216.50 +/- 152.03 g (CI 95%, p < 0.05). Retinopathy was not present in 42% (72), in stage I-III, 46% (78), and threshold stage, 12% (20). Forty eyes were treated with Argon laser. After treatment, no progressive disease was found in 92.75%. We found high myopia in 20%, macular displacement 7.5%, strabismus 35%, retinal detachment (5%), optical nerve atrophy 5%, and ocular atrophy 5%. CONCLUSIONS: We were able to demonstrate that Argon laser treatment under indirect ophthalmoscopy has been effective in the control of threshold disease. The most important related ocular diseases were strabismus and myopia. Long-term monitoring has permitted us to initiate timely treatment for ocular diseases related to prematurity.

Utilidad de la anestesia tópica en cirugía de estrabismo paralítico / Utility of topical anesthesia in paralytic strabismus surgery

Objetivo: demostrar el uso de anestesia tópica en cirugía de estrabismo paralítico. Método: Es un estudio retrospectivo, comparativo con dos grupos de pacientes mayores de 12 años de edad con estrabismos de diferentes etiologías. Grupo A: pacientes con estrabismo para corregirse bajo anestesia tópica. Grupo B: pacientes con estrabismo para corregirse bajo anestesia general. Para el uso de anestesia tópica se empleó proparacaína en gotas y midazolam intravenoso. Resultados: en grupo A se incluyeron 31 pacientes con una edad 34.1 DE (desviación estándar) 11.3 años con rangos de 18 a 56 años. Desviación 28.4 DE 15.5 dioptrías prismáticas. La cirugía más realizada fue la corrección de estrabismos verticales, y la técnica más comúnmente usada fue cirugía de dos músculos prefiriendo para el reforzamiento el plegamiento muscular. El promedio de seguimiento fue de 9.06 DE 6.3 meses. Se obtuvieron buenos resultados en 25 pacientes, 3 regular, 3 malo. El diagnóstico de estrabismo paralítico se concluyó en 17 pacientes, 8 de III nervio; 5 de IV nervio, 4 de VI nervio. Las causas del estrabismo fueron: tumoral: 6, trauma craneal: 3, aneurisma cerebral: 1, ambliopía sensorial 1, uno por cirugía de región, uno por cirugía de estrabismo bajo técnica ajustable tardía con gran reforzamiento de recto medial, trauma ocular 3 con un músculo perdido recto inferior, y un músculo perdido recto medial, endotropia congénita 7. En el grupo B se ingresaron a estudio 30 pacientes. Edad: 31.9 D.E 15.1 años, con rangos de 12 a 64 años. La desviación fue de 37.83 DE 21.8 dioptrías prismáticas, el estrabismo más operado fue la exotropia antigua especialmente consecutiva a corrección de estrabismo infantil. Se operaron mayor cantidad de músculos. El seguimiento fue de 6.03 DE 7 meses.

Objective: to demostrate the efficacy of topical anesthesia in paralitic strabismus. Method: This is a retrospective and comparative study in patients older than 12 years old, with strabismus of different etiologies. Group A: strabismus corrected under topical anesthesia. Group B: strabismus corrected under general anesthesia. For topical anesthesia we used proparacain and mydazolam. Results: group A: 31 patients, age 34.1 +/- 11.3 years old , 18-56 range. Strabismus deviation: 28.4 +/- 15.5 diopters. Vertical strabismus was the most common surgery. Two muscles technique was the most frequently used, but using tacking preferable. Follow up: 9.06 +/- 6.3 month. We obtainer good results in 20 patients, regular 3, and bad 3. Paralysis was diagnosed in 17 patients, III nerve: 8, IV nerve: 4 causes: 6 tumor, 3 cerebral trauma, 1 cerebral aneurism, 1 sensorial amblyopic, 1 posterior to pterigion surgery. 1 secondary to adjustable surgery for strabismus, 3 ocular trauma with lost muscle, 7 congenital esotropia. We didn't have complications and conversion to general was no necessary. Gruop B: 30 patients average age: 31.9 +/- 15.1 years old. Strabismus: 37.83 +/- 21.8 diopters. The most operated strabismus were old exotropias especially after infantile esotropias. We made more muscles for same quantity of deviation. Follow up: 6.03 +/- 7 months. Results for surgery: good 26, regular 3, bad 1. Conclusions: we could see the preferences for using topical anesthesia in paralysis. Results were good and we could evaluate muscles action under surgery. We could evaluate the effect of recessions in inferior oblique for paralytic strabismus, and effect of tucking in superior oblique avoiding Brown iatrogenic syndrome.

Posición compensadora de la cabeza en pacientes con lesiones de tallo cerebral / Compensatory head position in patients with brain stem injury

Objetivo: analizar los fenómenos de posición forzada de la cabeza en pacientes con daño de tallo cerebral. Métodos: se realiza una revisión de las diferentes áreas cerebrales, los estrabismos que ocurren en ella y las posiciones forzadas de la cabeza que son requeridas; se diferencia entre torticolis no compensatoria y compensatoria visual (PCC). Resultado: los pacientes con daño cerebral adoptan posiciones forzadas de la cabeza con la finalidad de resolver la diplopía, de evitar las alteraciones rotacionales de un ojo fijador en casos de parálisis o de emplear el área de visión que deja una desviación de la mirada de causa neurológica. Conclusiones: es importante diferenciar las causas de tortícolis para identificar aquellas que son compensatorias y de ser así, ofrecer tratamiento para trasladar la mirada al frente lo más posible.

Objective: to analyze causes of torticollis in patients with brain damage. Method: we made a study of strabismus related to different areas of brain damage and the head torsion related to them, and to know the difference between compensatory and no compensatory head torsion (PCC). Results: patients with brain damage can show forced head torsion to resolve diplopia, paralysis of movement or to avoid nystagmus. Conclusions: is important to differentiate causes of torticollis, identifying compensatory ones, and in such cases to offer treatment in order to displace the gaze to the best position for the patient.

Participación y neuromodulación de la corteza extraestriada en estrabismo / Participation and neuromodulation of extrastriate cortex in strabismus

Introducción: algunas manifestaciones del estrabismo comparten con la epilepsia un origen cortical. Objetivo: correlacionar los hallazgos neurofuncionales y los cambios neuroadaptativos durante el manejo de una variedad de estrabismo concerniente a la presencia de un foco epileptógeno en fase ictal. Paciente y métodos: estudio prospectivo y observacional de una paciente con "síndrome estrábico de variabilidad angular" (SEVA), en quien se aplican diversos estudios neurofisiológicos en épocas distintas: mapeo cerebral digital, tomografía computada de emisión de fotón único (SPECT), electroculografía (EOG) y filmación infrarroja. Resultados: endotropia de rango variable y supresión, que durante el tratamiento cambia transitoriamente a desviación horizontal disociada (DHD) y finalmente a endoforia compensada. El primer mapeo mostró actividad lenta y paroxística, brotes de alto voltaje y mayor potencia temporal derecha; el segundo mostró asimetría de potencia y retraso en la electrogénesis y el tercero fue normal. El primer SPECT manifestó zona focal de hiperactividad metabólica epileptógena en fase ictal en región temporal derecha y zona de hipoperfusión focalizada frontoparietal izquierda, el segundo SPECT reveló disminución de la actividad en la zona hipermetabólica y del área de la zona hipometabólica. Los EOG y la filmación mostraron durante el tratamiento mejoría de la ganancia e incomitancia horizontal. Conclusiones: se evidenció la correlación entre actividad cortical ictal y esta variedad de estrabismo, además de algunos cambios neuroadaptativos que incluyeron disminución de la actividad epileptógena, la ganancia, la incomitancia horizontal y la coherencia interhemisférica, se observó también aumento en la frecuencia y la potencia hacia las regiones posteriores del cerebro.

Introduction: some strabismic manifestations share a cortical origen with epilepsy. Objective: prospective observational study of a patient with "variable angle strabismic syndrome" (VASS) in whom several neurophysiologic studies are conducted at different times: digital cerebral mapping: single photon emission computed tomography (DVD) and finally to compensated endoforia The first mapping showed slow and paroxistic activity; spikes of high voltage and higher right temporal potency. The second mapping showed potency asymetry and electrogenesis delay. Third mapping was normal. First SPECT showed a focal zone of epileptogenic metabolic hyper-activity in ictal phase at the right temporal region and a left frontoparietal focalized hypoperfresed zone. The second SPECT showed diminished activity in the hypermetabolic zone, and diminished area of the hypometabolic zone. EOG and films showed gain and horizontal inconsistence improvement. Conclusions: a correlation was found between cortical ictal activity and this type of strabismus, besides some neuroadaptative changes that included reduced epileptogenic activity, gain, horizontal incomitance and interhemispheric coherence. A rise in frequency and potency towards posterior regions of the brain was also observed.

Síndrome de Parinaud asociado a otros estrabismos / Parinaud syndrome associated with other strabismus

Objetivo: Describir los estrabismo asociados al Síndrome de Parinaud (SP). Métodos: Se estudiaron pacientes con SP de 1998 a 2004 asociados a otros estrabismos. Resultados: Total 18 pacientes, 6 mujeres y 12 hombres. Edad: 28 años DE 22 (10; 1C 95 por ciento). Lesión al III nervio craneal en 15 pacientes (79 por ciento), II nervio: 8 pacientes (44.4 por ciento), VII nervio: 3 pacientes, hemiparesia: 3, lesión a IV nervio 2, parálisis bilateral de III nervio 2, nistagmus 2, Síndrome de foville 2, y síndrome de uno y medio 1 paciente. Causas: Accidente vascular cerebral 4, uno de ellos asociado a infarto agudo de miocardio, traumatismo cráneo-encefálico 3, tumor cerebral 6, neurocisticercosis 2. Se obtuvo ortoposición con toxina botulínica en 1.72 +/- 1.1 (0.65 IC 95) y cirugía en 9, mejoría espontánea 1. Conclusiones: Identificar el diagnóstico topográfico y pronóstico de la lesión cerebral asociada a SP es muy importante en el control y vigilancia del paciente así como para ofrecer una rehabilitación mas dirigida.

Objective: To describe the causes of Parinaud syndrome (PS) with diplopia to determine a topographic diagnosis and prognosis. Method: We studied patients with SP from January 1980 to January 2004; causes and treatment. We identified all strabismus associated to PS. Results: We included 18 patients with diplopia, 6 female and 12 male. Age: 28 years old, SD 22 (10; CI 95 percent). Related strabismus: III nerve palsy in 15 patients (79 percent), optical nerve damage in 8 (44.4 percent), VII nerve palsy in 3, IV nerve palsy 2, bilateral III nerve palsy 2, nystagmus 2, Foville syndrome 2, One and half syndrome 1. Causes: Tumor 6, brain stroke 4, cranial trauma 3, neurocisticercosis 2. Ortoposition with botulinum toxin treatment was obtained with 1.72 +/-1.1 (0.65; IC 95 percent) inyections. Surgery was done in 9 patients, only one patient had spontaneous resolution of diplopia and SP. Conclusions: To identify the topographic diagnosis and prognosis of brain diseases in PS is very important to complete the study of strabismus. In this way we can know more about of damage extension and we can identify recurrences quickly to offer a better control.

[Metabolic changes in brain cortex related with the strabismus treatment. Preliminary results with SPECT]. / Cambios metabólicos en la corteza cerebral relacionados con el tratamiento de estrabismo. Resultados preliminares con SPECT.

OBJECTIVE: Our aim was to demonstrate metabolic changes occurring in brain cortex during strabismus treatment. MATERIAL AND METHODS: Single photon emission computed tomography (SPECT) of brain was made in patient with strabismus. The study only included congenital esotropia and excluded patients with other anomalies. Strabismus treatment was carried out with botulinum toxin or surgery. Brain SPECT was done prior to and after treatment. Changes were analyzed and related with strabismus response. RESULTS: We studied three children with congenital and variable esotropia for a total of three cases. In Case 1, basal SPECT showed hypoperfusion in left frontal lobe (7.38). Response to botulinum toxin was good for correcting strabismus and obtaining binocularity from third month. Control SPECT showed correction of perfusion of frontal lobe (-1.19). With Case 2, we observed hypoactivity in left parietal area (8.59); after botulinum treatment, strabismus was corrected and binocularity was demonstrated, while control SPECT showed increase of hypoactivity levels (5.95). Finally, in Case 3, strabismus was corrected at surgery with binocularity. Basal SPECT demonstrated very important hypoactivity in right hemisphere, especially in areas 3, 4, and 5 areas (-0.7, -3.71, and -11.09, respectively); in addition, positive changes after treatment were demonstrated (9.78, 6.44, and 3.22, respectively). CONCLUSIONS: Metabolic changes in brain cortex took place in congenital esotropia with SPECT. In all cases, brain SPECT could demonstrate changes after treatment with improvement of different areas, and good response of motor and sensorial state. This apparently is the first report concerning metabolic changes of brain cortex related with strabismus under treatment, and demonstrates the importance of brain cortex in genesis, evolution, and stability of visual functions and with regard to the failure of these in patients with strabismus.