Avaliação do colírio de brimonidina 0,2% em comparação à nafazolina 0,025% + feniramina 0,3% nas cirurgias de estrabismo / Evaluation of 0.2% brimonidine eye drops compared to 0.025% naphazoline + 0.3% pheniramine in strabismus surgery

RESUMO Objetivo: Avaliar o efeito do colírio de brimonidina 0,2% na redução da hiperemia e do sangramento ocular durante as cirurgias de estrabismo, em comparação com o colírio de nafazolina 0,025% + feniramina 0,3%. Métodos: Foram avaliados 14 pacientes com estrabismo e indicação de correção cirúrgica bilateral. Foi instilado antes do procedimento, de forma aleatória, um colírio em cada olho dos pacientes avaliados. A análise subjetiva da hiperemia conjuntival e do sangramento perioperatório foi realizada de forma duplo-cega, por dois cirurgiões. A avaliação objetiva do nível de hiperemia conjuntival foi realizada por análise das imagens obtidas por meio do software ImageJ®. Resultados: A análise de modelos multivariados de efeito misto indicou diferenças estatisticamente significantes entre os grupos em relação à hiperemia (avaliador 2) e ao sangramento intraoperatório (avaliadores 1 e 2), com maiores escores nos casos tratados com colírio de nafazolina + feniramina. Entretanto, não houve diferença estatística na análise objetiva realizada por meio da saturação de cores obtidas pelo programa ImageJ®. Conclusão: O colírio de brimonidina pode ser superior ao colírio de nafazolina + feniramina na redução do sangramento, levando-se em conta apenas a análise subjetiva.

ABSTRACT Objective: To evaluate the effect of 0.2% brimonidine eye drops in reducing hyperemia and ocular bleeding during strabismus surgeries, in comparison with 0.025% naphazoline + 0.3% pheniramine eye drops. Methods: Fourteen patients with strabismus and indication for bilateral surgical correction were evaluated. Before the procedure, the eye drops were instilled randomly in each eye of the evaluated patients. The subjective analysis of conjunctival hyperemia and perioperative bleeding was performed in a double-blind manner, by 02 surgeons. The objective assessment of the level of conjunctival hyperemia was performed by analyzing the images obtained using the ImageJ® software. Results: The analysis of multivariate mixed effect models indicated statistically significant differences between the groups in relation to hyperemia (rater 2) and intraoperative bleeding (raters 1 and 2) with higher scores in cases treated with naphazoline + pheniramine eye drops. However, there were no statistically significant differences in the objective analysis of color saturation obtained by the ImageJ® program. Conclusion: Brimonidine eye drops may be superior to naphazoline + pheniramine eye drops in reducing bleeding, taking into account the subjective analysis only.

Botulinum toxin A for the treatment of strabismus in children with neurological impairment / Toxına botulínica tipo A para o tratamento de estrabısmo em crianças neurologicamente comprometidas

ABSTRACT Purposes: To assess the efficacy of botulinum toxin A injection in the treatment of strabismus in patients with neurological impairment and evaluate the factors associated with treatment success. Methods: The study included 50 patients with strabismus and neurological impairment. In all children, botulinum toxin injection was performed into the appropriate extraocular muscle. The relationship between demographic features, clinical characteristics, and treatment success were analyzed. Results: In the study group, 34 patients had esotropia, and 16 patients had exotropia. As neurological problems, 36 patients had cerebral palsy, and 14 had hydrocephalus. The average follow-up period was 15.3 ± 7.3 months. The mean number of injections was 1.4 ± 0.6. The mean angle of deviation was 42.5 ± 13.2 PD before the treatment, which decreased to 12.8 ± 11.9 PD after the treatment. Successful motor alignment (orthotropia within 10 PD) was achieved in 60% of the patients. Binary logistic regression analysis revealed that esotropic misalignment and shorter duration of strabismus was significantly associated with treatment success in the study group. Patients with esotropia and lower angles of misalignment were more likely to be treated with a single injection. Conclusion: The use of botulinum toxin A for the treatment of strabismus in children with neurological impairment is a good alternative to conventional surgical therapy with a lower risk of overcorrection. The treatment outcome is better in esodeviations and shorter duration of strabismus, implying an advantage of early treatment.

RESUMO Objetivos: Avaliar a eficácia do uso de toxina bo-tulínica tipo A no tratamento do estrabismo em pacientes com comprometimento neurológico e avaliar os fatores associados ao sucesso do tratamento. Métodos: Cinquenta pacientes com estrabismo e comprometimento neurológico foram incluídos no estudo. Em todas as crianças, a toxina botulínica tipo A foi injetada no músculo extraocular apropriado. A relação entre características demográficas, características clínicas e o sucesso do tratamento foram analisadas. Resultados: No grupo de estudo, 34 pacientes tiveram esotropia e 16 pacientes tiveram exotropia, sendo trinta e seis pacientes com paralisia cerebral e 14 pacientes com hidrocefalia. O tempo médio de acompanhamento foi de 15,3 ± 7,3 meses. O número médio de aplicações foi de 1,4 ± 0,6. O ângulo de desvio médio foi de 42,5 ± 13,2 DP antes do tratamento e diminuiu para 12,8 ± 11,9 DP após o tratamento. Alinhamento motor bem sucedido (ortotropia dentro de 10 DP) foi alcançado em 60% dos pacientes. A análise de regressão logística binária revelou que o desalinhamento esotrópico e uma menor duração do estrabismo foram significativamente associados ao sucesso do tratamento no grupo de estudo. Pacientes esotrópicos com ângulos de desalinhamento menores são mais propensos a serem tratados com uma única aplicação. Conclusão: O uso da toxina botulínica tipo A para o tratamento de estrabismo em crianças com comprometimento neurológico é uma boa alternativa para a terapia cirúrgica convencional com menor risco de hipercorreção. O resultado do tratamento é melhor em exodesvios e em pacientes com estrabismo de menor duração, implicando em vantagem para o tratamento precoce.

Cirugía monocular de 4 músculos extraoculares para la exotropía monocular de gran ángulo / Unilateral four muscle surgery for extra-large monocular exotropia

Introducción La exotropía recurrente es común después de cirugía para exotropía sensorial monocular constante de gran ángulo. La cirugía generalmente se limita al ojo afectado. El debilitamiento simultáneo de los músculos oblicuos ipsilaterales puede mejorar el efecto de la cirugía de los músculos rectos horizontales al disminuir las fuerzas de abducción. Presentamos los resultados de la cirugía simultánea de debilitamiento de los músculos oblicuos combinados con cirugía del músculo recto horizontal ipsilateral con exotropía monocular constante superior a 35 dioptrías prismáticas (DP). Métodos Serie retrospectiva en casos de retroinserción unilateral del recto lateral combinada con resección del recto medial, y debilitamiento simultáneo de ambos músculos oblicuos ipsilaterales. La medida de resultado fue la alineación ocular en la posición primaria. Resultados Se incluyeron 12 ojos de 12 pacientes. La exotropía preoperatoria mejoró de 57,9±15,1DP (rango 35-80; mediana 60) a 3,3±5,5 (rango 0-16; mediana 0) postoperatoriamente (p<0,005). Dos (66%) pacientes con desviación vertical preexistente tuvieron una resolución de su desalineación vertical postoperatoriamente. En el último seguimiento postoperatorio, el 92% de los pacientes tenían una exodesviación de 10DP o menos y 7 (58%) midieron ortotropía. La abducción postoperatoria midió −0,6±1(0 a −3) y la aducción −0,4±0,7 (0 a −2). Conclusión El debilitamiento de los músculos oblicuos puede mejorar el efecto de la cirugía de los músculos rectos horizontales al disminuir las fuerzas de abducción en casos de exotropía monocular de gran ángulo. Como ventaja adicional, la cirugía del músculo oblicuo se puede utilizar simultáneamente para abordar las desviaciones verticales asociadas (AU)

Introduction Recurrent exotropia is common following surgery for monocular large angle constant sensory exotropia. Surgery is usually limited to operations on the affected eye. Simultaneous oblique weakening surgery may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting forces. We report the results of simultaneous oblique muscle weakening procedures combined with ipsilateral horizontal rectus muscle surgery constant monocular exotropia greater than 35 prism diopters (PD). Methods Retrospective case series of patients who underwent unilateral lateral rectus recession combined with medial rectus muscle resection and simultaneous weakening of both ipsilateral oblique muscles. Primary outcome measure was ocular alignment in primary position. Results Twelve eyes of 12 patients were included. The mean preoperative exotropia improved from 57.9±15.1 (range 35–80; median 60PD) to 3.3±5.5 (range 0–16; median 0PD) postoperatively (p<0.005). Two (66%) patients with a pre-existing vertical deviation had resolution of their vertical misalignment postoperatively. At the last postoperative follow up 92% of the patients had an exodeviation of 10PD or less (range 0–16PD median 0PD), and 7 (58%) measured near and distance orthotropia. Postoperative abduction measured −0.6±1 (0 to −3) and adduction −0.4±0.7 (0 to −2). Conclusion Weakening the ipsilateral oblique muscles may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting vectorial forces when operating for a large angle monocular exotropia. As an additional potential advantage, oblique muscle surgery may be used simultaneously to address associated vertical deviations (AU)

Unilateral four muscle surgery for extra-large monocular exotropia.

INTRODUCTION: Recurrent exotropia is common following surgery for monocular large angle constant sensory exotropia. Surgery is usually limited to operations on the affected eye. Simultaneous oblique weakening surgery may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting forces. We report the results of simultaneous oblique muscle weakening procedures combined with ipsilateral horizontal rectus muscle surgery constant monocular exotropia greater than 35 prism diopters (PD). METHODS: Retrospective case series of patients who underwent unilateral lateral rectus recession combined with medial rectus muscle resection and simultaneous weakening of both ipsilateral oblique muscles. Primary outcome measure was ocular alignment in primary position. RESULTS: Twelve eyes of 12 patients were included. The mean preoperative exotropia improved from 57.9 ±â€¯15.1 (range 35-80; median 60 PD) to 3.3 ±â€¯5.5 (range 0-16; median 0 PD) postoperatively (p < 0.005). Two of 3 patients with a pre-existing vertical deviation had resolution of their vertical misalignment postoperatively. At the last postoperative follow up 92% of the patients had an exodeviation of 10 PD or less (range 0-16 PD median 0 PD), and 7 (58%) measured near and distance orthotropia. Postoperative abduction measured -0.6 ±â€¯1 (0 to -3) and adduction -0.4 ±â€¯0.7 (0 to -2). CONCLUSION: Weakening the ipsilateral oblique muscles may enhance the effect of the horizontal rectus muscles surgery by decreasing the abducting vectorial forces when operating for a large angle monocular exotropia. As an additional potential advantage, oblique muscle surgery may be used simultaneously to address associated vertical deviations.

Clinical correlation between automated vision screening under cycloplegia and retinoscopy in young children / Correlação clínica entre triagem visual automatizada sob cicloplegia e retinoscopia em crianças pequenas

ABSTRACT Purpose: To evaluate the clinical performance of the Spot Vision Screener and establish clinical correlations between automated screening and retinoscopy following induction of cycloplegia in preverbal children. Methods: In this prospective, cross-sectional study, children aged 6-36 months were evaluated using the Spot Vision Screener. A complete ophthalmologic examination, including cycloplegic refraction assessment, was performed, followed by repeat spot vision screening and retinoscopy in all cases to establish correlations regarding hypermetropia, myopia, and astigmatism following induction of induction cycloplegia. Results: The study included 185 children. The sensitivity of the automated screener after cycloplegia was 100% (95%CI: 85.18-100%), and specificity was 87.04% (95%CI: 80.87-91.79%). Positive and negative predictive values were 52.27% (42.36-62.01%) and 100%, respectively. Compared to retinoscopy, the Spot Vision Screener overestimated spherical values by 0.62 D (95%CI: 0.56-0.69) in the right eye and by 0.60 (95%CI: 0.54-0.66) in the left eye and cylindrical values by -0.38 D in the right eye (95%CI: -0.42--0.33) and by -0.39 D in the left eye (95%CI: -0.43--0.34). For overall spherical and cylindrical values, the difference was 0.61 D (95%CI: 0.57-0.65) and -0.38 D (95%CI: -0.41--0.35) in the left and right eyes, respectively. Conclusion: A substantial correlation was found between retinoscopy and objective data captured by the device. This shows that technology can be used in conjunction, reaching a more accurate diagnosis and identifying amblyopia risk factors as early as possible. Photoscreening may make a difference at the population level for early screening and intervention.

RESUMO Objetivo: Avaliar o desempenho clínico do Spot Vision Screener e estabelecer correlações clínicas entre a triagem automatizada e a retinoscopia após indução de cicloplegia em crianças pré-verbais. Métodos: Neste estudo transversal prospectivo, crianças de 6 a 36 meses foram avaliadas usando o Spot Vision Screener. O exame oftalmológico completo, incluindo refração cicloplégica, foi então realizado, seguido de repetição da triagem automatizada e retinoscopia em todos os casos, a fim de estabelecer correlações quanto à hipermetropia, miopia e astigmatismo após a indução de cicloplegia. Resultados: O estudo incluiu 185 crianças. A sensibilidade do dispositivo de triagem automática após cicloplegia foi de 100% (IC 95%: 85,18-100%) e a especificidade foi de 87,04% (IC 95%: 80,87-91,79%). Os valores preditivos positivos e negativos foram de 52,27% (42,36 - 62,01%) e 100%, respectivamente. Em comparação com a retinoscopia, o Spot Vision Screener superestimou os valores esféricos em 0,62 D (IC 95%: 0,56 - 0,69) no olho direito e em 0,60 (IC 95%: 0,54 - 0,66) no olho esquerdo e os valores cilíndricos em -0,38 D (IC 95%: -0,42 a -0,33) no olho direito e por -0,39 D (IC 95%: -0,43 a -0,34) no olho esquerdo. A diferença para os valores esféricos e cilíndricos de forma geral foi de 0,61 D (IC 95%: 0,57 - 0,65) e -0,38 D (IC 95%: -0,41 a -0,35), respectivamente. Conclusão: Foi encontrada correlação substancial entre a retinoscopia e os dados objetivos captados pelo dispositivo. Isso mostra que a tecnologia pode ser usada em conjunto, contribuindo para um diagnóstico mais preciso e identificando os fatores de risco de ambliopia o mais precocemente possível. A técnica automatizada pode fazer a diferença em nível populacional para triagem e intervenção precoce.

Simultaneous posterior eyelid ptosis repair and strabismus surgery: a single-stage approach / Cirurgia reparadora simultânea de blefaroptose posterior e de estrabismo: abordagem de estágio único

ABSTRACT Purpose: Blepharoptosis with coexisting strabismus can be observed in adults, and both these conditions affect cosmetic appearance and have psychosocial effects. Both also commonly require surgery, which is typically performed using a sequential approach. This study aimed to evaluate the efficacy of simultaneous Müller's muscle-conjunctival resection with or without tarsectomy and strabismus surgery in adult patients with ptosis and coexisting strabismus. Methods: Patients with ptosis and coexisting strabismus who underwent simultaneous Müller's muscle-conjunctival resection with or without tarsectomy and horizontal strabismus surgery were retrospectively evaluated. Analysis included measurement of the angle of deviation in prism diopters, margin reflex distance, eyelid height asymmetry, and complications following surgery. Success of Müller's muscle-conjunctival resection with or without tarsectomy was defined as a margin reflex distance of ≥3.5 and ≤5 mm with a difference between the two upper eyelids of <1 mm. Strabismus success was defined as alignment with ±10 prism diopters of orthotropia. Results: The patients comprised three women and five men with a mean age of 37.12 years (range, 22-62 years). The strabismus stage of the surgery was performed first in all patients. Upper eyelid symmetry outcomes were assessed as perfect (<0.5 mm) in four patients and good (≥0.5 mm, <1 mm) in four patients. Success of Müller's muscle-conjunctival resection with or without tarsectomy was achieved in six of eight patients (75%), and strabismus success was achieved in all patients. No revision eyelid or strabismus surgery was required following simultaneous surgery in any of the patients. Conclusion: Müller's muscle-conjunctival resection with or without tarsectomy combined with strabismus surgery may be an alternative approach for use in patients with ptosis and coexisting strabismus.

RESUMO Objetivo: Blefaroptose e estrabismo podem ser coexistentes em adultos e ambos afetam a aparência estética e o domínio psicossocial. Ambos também geralmente requerem cirurgia, realizada tradicionalmente em uma abordagem sequencial. O objetivo do presente estudo foi avaliar a eficácia da execução simultânea da ressecção musculoconjuntival de Müller, com ou sem cirurgia de tarsectomia, e da cirurgia de estrabismo em pacientes adultos com ptose e estrabismo coexistentes. Métodos: Foram retrospectivamente avaliados pacientes com ptose e estrabismo coexistentes submetidos simultaneamente à ressecção musculoconjuntival de Müller, com ou sem tarsectomia, e à cirurgia de estrabismo horizontal. A análise incluiu a mensuração do ângulo de desvio das dioptrias de prisma, a distância do reflexo à margem, a assimetria da altura palpebral e quaisquer complicações após a cirurgia. A ressecção musculoconjuntival de Müller, com ou sem sucesso na tarsectomia, foi considerada bem-sucedida com uma distância reflexo-margem medindo entre 3,5 e 5 mm, e uma diferença entre as duas pálpebras superiores menor que 1 mm. O sucesso da cirurgia de estrabismo foi definido como um alinhamento com ± 10 dioptrias prismáticas de ortotropia. Resultados: Os pacientes foram 3 mulheres e 5 homens, com média de idade de 37,12 anos (faixa de 22 a 62 anos). A parte de estrabismo da cirurgia foi realizada primeiro em todos os pacientes. Os resultados da simetria palpebral superior foram avaliados como perfeitos (<0,5 mm) em 4 pacientes, bons (≥0,5 mm, <1 mm) em 4 pacientes e regulares (≥1 mm) em nenhum. A ressecção musculoconjuntival de Müller, com ou sem sucesso na tarsectomia, teve sucesso em 6 dos 8 pacientes (75%) e a intervenção para o estrabismo foi bem-sucedida em todos os pacientes. Não foi necessária cirurgia de revisão da pálpebra ou do estrabismo após a cirurgia simultânea em nenhum paciente. Conclusão: A ressecção musculoconjuntival de Müller, com ou sem tarsectomia, pode ser combinada com a cirurgia de estrabismo em uma abordagem alternativa para pacientes com ptose e estrabismo coexistentes.

Entrenamiento quirúrgico con fantomas en cirugía de estrabismo / Surgical training with phantoms in strabismus surgery

Antecedentes y objetivo La simulación en el aprendizaje quirúrgico responde a necesidades éticas y pragmáticas. Nuestro propósito es describir los efectos sobre las habilidades quirúrgicas de la realización de un taller de entrenamiento quirúrgico en cirugía de estrabismo con fantomas. La preocupación por la seguridad del paciente obliga a plantearse el empleo de simuladores (virtuales y físicos tridimensionales) y modelos animales permite al aspirante practicar sin riesgos los procedimientos antes de enfrentarse a un caso real. Material y métodos Realización de un taller con contenido teórico previo y práctica real con fantomas diseñados para simular cirugía de estrabismo (globo ocular, 6 músculos, conjuntiva, párpado y cápsula de Tenon insertados en cráneo) de dimensiones anatómicas reales. Encuesta de satisfacción y evaluación subjetiva de aprendizaje por parte del alumno y del tutor experto según el modelo de evaluación de Kirkpatrick. Resultados Completaron la encuesta 100% de los 26 alumnos asistentes a dos cursos (15 alumnos en un curso y 11 alumnos en otro curso) y 100% de los tres tutores que participaron en ambos cursos; 20 eran médicos residentes y 20 especialistas en oftalmología. La satisfacción global de los alumnos fue de 8,2 (± 0,68). Conclusiones Según los resultados de la encuesta de evaluación de acciones formativas de Kirkpatrick, la percepción de alumnos y tutores es que el entrenamiento con fantomas en cirugía de estrabismo puede ayudar a mejorar las habilidades necesarias para una práctica segura e independiente. Siendo el objetivo último mejorar la seguridad del paciente (AU)

Background and purpose Simulation in surgical learning responds to ethical and pragmatic needs. Our purpose is to describe the effects on surgical skills of conducting a surgical training workshop on strabismus surgery with phantoms. Concern for patient safety makes it necessary to consider the use of simulators (virtual and three-dimensional physical) and animal models that allow the applicant to safely practice the procedures before facing a real case. Material and methods Realization of a workshop with previous theoretical content and real practice with phantoms designed to simulate strabismus surgery (eyeball, six muscles, conjunctiva, eyelid and Tenon capsule inserted in the skull) of real anatomical dimensions. Satisfaction survey and subjective evaluation of learning by the student and the expert tutor according to the Kirkpatrick evaluation model. Results 100% of the 26 students attending two courses (15 students in one course and 11 students in another course) and 100% of the three tutors who participated in both courses completed the survey. Twenty were resident doctors and 20 specialists in ophthalmology. The overall satisfaction of the students was 8.2 (± 0.68). Conclusions According to the results of the Kirkpatrick training actions evaluation survey, the perception of students and tutors is that training with phantoms in strabismus surgery can help improve the skills necessary for safe and independent practice. The ultimate goal being to improve patient safety (AU)

Factores del estrabismo incomitante para mejorar el pronóstico de los casos / Factors of incomitant strabismus to improve the prognosis of cases / Fatores no estrabismo incomitante para melhorar o prognóstico dos casos

El estrabismo es una alteración de la visión binocular, es decir, la pérdida de paralelismo de los ejes visuales. Las personas que padecen estrabismo presentan disminución de la profundidad visual y percepción de dimensionalidad. Se estima que este padecimiento ocular, afecta alrededor del 2 al 4 % de la población infantil. La clasificación de los estrabismos y su misma definición han sido parte de un debate mundial durante años. La edad de aparición, el ángulo de desviación, el ojo desviado, y la magnitud del ángulo en distancia de enfoque tambien; sin embargo, siempre debe confirmarse con exámenes más exhaustivos luego de un primer diagnóstico realizado por un profesional de la salud visual. Objetivo. Identificar las características de los estrabismos incomitantes, formas de diagnóstico, clasificación y factores para poder manejarlos específicamente y mejorar el pronóstico del caso. Metodología. Se realizó una síntesis de la información disponible de literatura sobre el estrabismo incomitante a través de un análisis bibliográfico donde se empleó descriptores de búsqueda para lo cual se revisaron las bases de datos: Google académico y Proquest Prisma. Se realizó el análisis de referencias desde el año 2010 al 2020 y como resultado se obtuvieron 34 referencias que describen una clasificación de estrabismos, tipo de diagnóstico y tratamiento. Conclusión. Se considera fundamental aumentar la conciencia pública sobre el tema del diagnóstico temprano de afectaciones oculares para generar medidas de prevención que busquen atenuar la ocurrencia de esta alteración. Delimitar el tipo de estrabismo incomitante podría evitar consecuencias irreparables para el paciente.

Strabismus is an alteration of binocular vision, that is, the loss of parallelism of the visual axes. People suffering from strabismus have decreased visual depth and dimensionality perception. It is estimated that this ocular condition affects about 2 to 4% of the child population. The classification of strabismus and its very definition have been part of a worldwide debate for years. The age of onset, the angle of deviation, the deviating eye, and the magnitude of the angle in focusing distance as well; however, it should always be confirmed with more exhaustive examinations after a first diagnosis by an eye care professional. Objective. To identify the characteristics of incomitant strabismus, ways of diagnosis, classification and factors to be able to manage them specifically and improve the prognosis of the case. Methodology. A synthesis of the information available in the literature on incomitant strabismus was made through a bibliographic analysis using search descriptors for which the following databases were reviewed: Google Scholar and Proquest Prisma. The analysis of references from 2010 to 2020 was carried out and as a result 34 references were obtained describing a classification of strabismus, type of diagnosis and treatment. Conclusion. It is considered essential to increase public awareness on the issue of early diagnosis of ocular disorders in order to generate preventive measures that seek to mitigate the occurrence of this disorder. Delimiting the type of incomitant strabismus could avoid irreparable consequences for the patient.

O estrabismo é um distúrbio da visão binocular, ou seja, a perda do paralelismo dos eixos visuais. As pessoas que sofrem de estrabismo têm uma percepção de profundidade e dimensionalidade visual reduzida. Estima-se que essa condição ocular afete cerca de 2 a 4% da população infantil. A classificação do estrabismo e sua própria definição têm sido parte de um debate mundial há anos. A idade de início, o ângulo de desvio, o olho desviado e a magnitude do ângulo na distância de focalização também; no entanto, devem sempre ser confirmados por exames adicionais após um primeiro diagnóstico feito por um oftalmologista. Objetivo. Identificar as características do estrabismo incomitante, as formas de diagnóstico, a classificação e os fatores para poder tratá-los especificamente e melhorar o prognóstico do caso. Metodologia. Foi feita uma síntese das informações disponíveis na literatura sobre estrabismo incomitante por meio de uma análise bibliográfica usando descritores de pesquisa para os quais foram revisados os seguintes bancos de dados: Google Scholar e Proquest Prisma. A análise das referências de 2010 a 2020 foi realizada e, como resultado, foram obtidas 34 referências que descrevem a classificação do estrabismo, o tipo de diagnóstico e o tratamento. Conclusões. Considera-se essencial aumentar a conscientização pública sobre a questão do diagnóstico precoce de distúrbios oculares para gerar medidas preventivas que busquem mitigar a ocorrência desse distúrbio. Delimitar o tipo de estrabismo incomitante poderia evitar consequências irreparáveis para o paciente.

Surgical training with phantoms in strabismus surgery.

BACKGROUND AND PURPOSE: Simulation in surgical learning responds to ethical and pragmatic needs. Our purpose is to describe the effects on surgical skills of conducting a surgical training workshop on strabismus surgery with phantoms. Concern for patient safety makes it necessary to consider the use of simulators (virtual and three-dimensional physical) and animal models that allow the applicant to safely practice the procedures before facing a real case. MATERIAL AND METHODS: Realization of a workshop with previous theoretical content and real practice with phantoms designed to simulate strabismus surgery (eyeball, 6 muscles, conjunctiva, eyelid and tenon capsule inserted in the skull) of real anatomical dimensions. Satisfaction survey and subjective evaluation of learning by the student and the expert tutor according to the Kirkpatrick evaluation model. RESULTS: Total, 100% of the 26 students attending two courses (15 students in one course and 11 students in another course) and 100% of the 3 tutors who participated in both courses completed the survey. 20 were resident doctors and 20 specialists in ophthalmology. The overall satisfaction of the students was 8.2 (±0.68). CONCLUSIONS: According to the results of the Kirkpatrick training actions evaluation survey, the perception of students and tutors is that training with phantoms in strabismus surgery can help improve the skills necessary for safe and independent practice. The ultimate goal being to improve patient safety.

Traducción y adaptación transcultural de la escala AS-20 para medir la calidad de vida en adultos con estrabismo en Colombia, prueba piloto / Translation and transcultural adaptation of the AS-20 scale to measure quality of life in adults with strabismus in Colombia, a pilot study

Antecedentes El estrabismo genera un impacto psicosocial negativo en los pacientes adultos, afectando aspectos como la autopercepción y la calidad de vida. No existe en Colombia una escala que permita medir dicho impacto. Objetivo Realizar la traducción y adaptación transcultural del instrumento AS-20 al español colombiano, para medición de la calidad de vida en pacientes adultos con estrabismo en Colombia. Materiales y métodos Prueba piloto de un estudio de corte transversal de traducción, traducción inversa y adaptación del instrumento de medición tipo escala de calidad de vida AS-20 de su idioma original en pacientes adultos con estrabismo en Bogotá, Colombia. Resultados Dieciséis pacientes fueron evaluados. El rango de edad fue entre 18 y 68 años, con un promedio de 41 años. La escala fue respondida en una media de tiempo de 10,62min. Se reportó dificultad en 3 individuos para la comprensión de 2 ítems (preguntas 8 y 14), los cuales se ajustaron, resolviendo la dificultad. Conclusión Se realizó la traducción y prueba piloto de la escala AS-20 a español colombiano identificando y corrigiendo los problemas de traducción en la prueba. Este es el primer paso del proceso de adaptación transcultural. Con base en los resultados, la validación y adaptación transcultural se puede finalizar en un próximo estudio (AU)

Background Strabismus generates a negative psychosocial impact on adult patients, affecting aspects such as self-perception and quality of life. There is no scale in Colombian Spanish that measures these impacts. Objective To carry out the translation and cross-cultural adaptation of the AS-20 instrument into Colombian Spanish, for measuring the quality of life in adult patients with strabismus in Colombia. Materials and methods Pilot test of a cross-sectional study for the translation, reverse translation, and cross-cultural adaptation of the AS-20 instrument from its original language, English, to Colombian Spanish, in adult patients with strabismus in Bogotá, Colombia. Results Sixteen patients were assessed. The age range was between 18 and 68 years with a mean age of 41 years. The scale was answered in an average time of 10.62min. Difficulty was reported in 3 individuals for understanding 2 items (questions 8 and 14), which were resolved. Conclusion The translation and pilot test of AS-20 scale into Colombian Spanish was carried out, identifying and solving translational difficulties. It is the first step in the cross-cultural adaptation process. Based on the results, the validation and cross-cultural adaptation can be completed in a future study (AU)

Doble recubrimiento con membrana amniótica en estrabismo restrictivo / Double covering with amniotic membrane in restrictive strabismus

El manejo del estrabismo restrictivo sigue siendo un problema no resuelto hoy en día.Se presenta un caso de estrabismo restrictivo posquirúrgico severo tras una cirugía de exotropía consecutiva. Describimos a continuación el manejo exitoso mediante una técnica que consiste en envolver el músculo afectado con membrana amniótica o «wrap» en la que añadimos un segundo injerto de membrana amniótica en la reconstrucción de la superficie ocular. (AU)

The management of restrictive strabismus remains an unresolved problem today.A case of severe restrictive strabismus after a consecutive exotropia surgery is presented. We describe the exitosus managment through a technique consist of wrapping with amniotic membrane the affected muscle where we add a second amniotic membraneA graft in the reconstruction of the ocular surface. (AU)

Translation and transcultural adaptation of the AS-20 scale to measure quality of life in adults with strabismus in Colombia, a pilot study.

BACKGROUND: Strabismus generates a negative psychosocial impact on adult patients, affecting aspects such as self-perception and quality of life. There is no scale in Colombian Spanish that measures these impacts. OBJECTIVE: To carry out the translation and cross-cultural adaptation of the AS-20 instrument into Colombian Spanish. MATERIALS AND METHODS: Pilot test of a cross-sectional Study for the translation, reverse translation, and cross-cultural the AS-20 instrument from its original language, English, to Colombian Spanish, in adult patients with strabismus in Bogotá, Colombia. RESULTS: 16 patients were assessed. The age range was between 18 and 68 years with a mean age of 41 years. The scale was answered in an average time of 10.62min. Difficulty was reported in three individuals for understanding two items (questions 8 and 14), which were resolved. CONCLUSION: The translation and pilot test of AS-20 scale into Colombian Spanish was carried out, identifying and solving translational difficulties. Is the first step in the cross-cultural adaptation process. Based on the results, the validation and cross-cultural adaptation can be completed in a future study.

Double covering with amniotic membrane in restrictive strabismus.

A case of severe restrictive strabismus after a consecutive exotropia surgery is presented. We describe the exitous managment through a technique consist of wrapping with amniotic membrane (AM) the affected muscle where we add a second AM graft in the reconstruction of the ocular Surface.

Translation and validation of a questionnaire on the impact of strabismus on the quality of life of patients / Tradução e validação de um questionário sobre impacto na qualidade de vida em pacientes com estrabismo

ABSTRACT Objective: To translate and validate the Adult Strabismus Quality of Life Questionnaire into Brazilian Portuguese. Methods: A cross-sectional study for linguistic and cross-cultural validation of the Adult Strabismus Quality of Life Questionnaire in order to assess the quality of life in patients with strabismus. We have followed previous published guidelines on translation process to ensure the equivalence between the original and translated versions. The final version was applied in a pilot study to evaluate concordance and its reliability and reproducibility as a tool to be used in future studies. Results: The translation and counter translation processes of the Adult Strabismus Quality of Life Questionnaire were conducted according to preestablished protocols. The analysis of the results obtained in the test-retest application of the questionnaire in a sample of 30 participants revealed a correlation coefficient of 0.67, which was deemed satisfactory for the validation process of this tool. Conclusion: The Adult Strabismus Quality of Life Questionnaire was translated and validated according to preestablished protocols. The referred questionnaire has been used in studies worldwide, so this process will enable its application to better understand the impact of strabismus in patients' quality of life in the Brazilian population.

RESUMO Objetivo: Traduzir e validar o questionário Adult Strabismus Quality of Life Questionnaire (AS-20) para o português brasileiro. Métodos: Estudo transversal para validação linguística e transcultural do questionário Adult Strabismus Quality of Life Questionnaire (AS-20) para avaliação da qualidade de vida em pacientes com estrabismo. Foram seguidas as diretrizes já publicadas sobre o processo de tradução, para garantir a equivalência entre as versões original e traduzida. A versão final foi aplicada em um estudo-piloto para avaliar a concordância e sua confiabilidade e reprodutibilidade, como ferramenta a ser utilizada em estudos futuros. Resultados: Os processos de tradução e contratradução do questionário Adult Strabismus Quality of Life Questionnaire (AS-20) foram realizados de acordo com protocolos preestabelecidos. A análise dos resultados obtidos na aplicação teste-reteste do questionário em uma amostra de 30 participantes revelou coeficiente de correlação de 0,67, que foi considerado satisfatório para o processo de validação desse instrumento. Conclusão: O questionário Adult Strabismus Quality of Life Questionnaire (AS-20) foi traduzido e validado de acordo com protocolos preestabelecidos. O referido questionário vem sendo utilizado em estudos ao redor do mundo e, portanto, esse processo possibilitará sua aplicação para melhor compreensão do impacto do estrabismo na qualidade de vida dos pacientes da população brasileira.

Ambulatory surgery for strabism and its relationship with the different techniques / Cirugía ambulatoria del estrabismo y su relación con las diferentes técnicas

Objective: To assess the functionality and usefulness of ambulatory surgery in pediatric patients operated on for strabismus, as well as the incidence of postoperative complications or hospital admission. Material and methods: A descriptive observational retrospective study was carried out with 92 patients operated on at a tertiary hospital between January 2017 and December 2018. Results: Most patients were ASA I. A laryngeal mask was used in 69.6 % of patients with a prevalence of use of sevoflurane (in 94.6 % of patients) and muscle relaxant (rocuronium in 96.7 % of patients). From the point of view of strabismus surgery, 72.8 % of patients presented with horizontal strabismus, and were esotropias. Most of them with 2 muscles intervened and undergoing surgery for the first time. 21.7 % of patients, presented with other types of strabismus such as IV nerve palsy, Duane or Brown Syndrome. With regard to the results, the admission rate was 4.3 %. In the immediate postoperative period in the Postanesthesic Care Unit (PACU), they did not present with pain and only 6.5 % of the patients suffered Postoperative nausea or vomiting (PONV). Regarding the presence of complications (pain, significant discomfort, tearing, difficulty opening the eyes…), in the ophthalmology consultation on the first postoperative day, they were noted in 2.2 % of the patients. Conclusion: Uniformity criteria such as handling by the same surgeon and the same anesthetic protocol have been essential. Regarding the results, we observed that the number of surgeries performed, the type of strabismus and certain techniques such as Faden, had an effect on the presence of pain. In our study, the low complication rate and low admission rate confirm the success of the ambulatory surgery for this type of surgery (AU)

Objetivo: Evaluar el funcionamiento y utilidad de la cirugía mayor ambulatoria (CMA) en pacientes pediátricos intervenidos de estrabismo, así como la incidencia de complicaciones postoperatorias o ingreso hospitalario. Material y métodos: Se ha realizado un estudio retrospectivo observacional descriptivo, con 92 pacientes intervenidos en el Hospital Álvaro Cunqueiro de Vigo; entre enero de 2017 y diciembre de 2018. Resultados: La mayor parte de los pacientes eran ASA I. Se utilizó mascarilla laríngea en el 69,6 % con prevalencia de empleo de sevoflurano (94,6 %) y relajante muscular (rocuronio en un 96,7 %) Desde el punto de vista de la cirugía estrabológica, el 72,8 % de los pacientes presentaron estrabismo horizontal, tratándose en su mayoría de una primera intervención, endotropias y afectación de hasta dos músculos. El 21,7 % de los pacientes presentaron otros tipos de estrabismo como: paresia IV, síndrome de Duane o Brown, etc. En cuanto a los resultados, la tasa de ingresos fue de un 4,3 %. En el postoperatorio inmediato en la CMA, no presentaron dolor y solo el 6,5% de los pacientes presentaros náuseas o vómitos. En cuanto a la presencia de complicaciones, en la consulta oftalmológica en el primer día postoperatorio (dolor, molestias importantes, lagrimeo, dificultad apertura ocular, etc.), fueron recogidas en un 2,2 % de los pacientes. Conclusión: Han resultado esenciales unos criterios de uniformidad como el manejo por el mismo cirujano y un mismo protocolo anestésico. En cuanto a los resultados, observamos influencia en la presencia de dolor según el número de intervenciones, tipo de estrabismo o técnicas (como Faden). En nuestro estudio, la baja tasa de complicaciones y baja tasa de ingreso confirman el éxito de la CMA para este tipo de intervenciones (AU)

Two birds, one stone: a surgical approach for third nerve palsy with aberrant regeneration / Tratamento cirúrgico de paralisia de terceiro nervo craniano com regeneração aberrante

ABSTRACT Aberrant regeneration in third nerve palsies, linking medial rectus contraction to the levator palpebrae muscle, is a great opportunity for surgical planning to address both the ptosis and horizontal deviation in a single procedure. We report a case of severe ptosis associated with exotropia that was successfully corrected with a single horizontal strabismus surgery owing to aberrant regeneration and discuss the basis underlying the surgical planning.

RESUMO A regeneração aberrante nas paralisias do terceiro nervo, ligando a contração do reto medial ao músculo levantador da pálpebra, é uma grande oportunidade para fazer um planejamento cirúrgico para tratar tanto a ptose quanto o desvio horizontal em um procedimento único. Relatamos uma ptose grave associada à exotropia corrigida com sucesso com uma única cirurgia de estrabismo horizontal devido à regeneração aberrante e discutimos as bases do planejamento cirúrgico.

Isolated abducens nerve palsy associated with coronavirus disease: an 8-month follow-up / Paresia isolada do nervo abducente associada ao COVID-19: 8 meses de seguimento

ABSTRACT We report the case of a previously healthy 48-year-old man who developed an isolated abducens nerve palsy 18 days after presenting with coronavirus disease (COVID-19) confirmed by reverse transcriptase polymerase chain reaction. His main complaint at arrival was double vision. Ocular examination revealed a sixth cranial nerve palsy in the left eye. The incomitant esotropia at arrival was 30 prism diopters. Abduction was markedly limited, while adduction was normal in the left eye. The patient underwent complete clinical, neurological, and neuroimaging investigations, including cerebrospinal fluid sample analysis to rule out infectious causes. A conservative approach with orthoptic therapy and Fresnel prism was opted. Eight months after the onset of COVID-19, regression of the strabismus was observed, and the patient reported complete recovery of the diplopia. This case suggests that isolated abducens nerve palsy caused by severe acute respiratory syndrome coronavirus 2 infection may improve with a conservative approach.

RESUMO Reportamos o caso de homem previamente hígido, 48 anos, com paralisia isolada do nervo abducente 18 dias após infecção pelo novo coronavírus (COVID-19) confirmada por reação cadeia polimerase de transcriptase reversa. A principal queixa do paciente na admissão era diplopia. O exame ocular revelou paralisia do sexto nervo craniano do olho esquerdo. Esotropia incomitante no exame inicial media 30 dioptrias prismáticas. Abdução estava limitada com adução completa no olho esquerdo. O paciente foi submetido a investigação clínica e neurológica com exame de neuroimagem, incluindo análise de amostra do líquido cefalorraquidiano para descartar causas infecciosas. Optou-se por abordagem conservadora com terapia ortóptica e prisma de Fresnel. Oito meses após a infecção pelo COVID-19, o paciente evoluiu com regressão do estrabismo e informou recuperação completa do quadro. Este relato sugere que paralisia isolada do nervo abducente causada por SARS-CoV-2 pode melhorar com abordagem conservadora.

¿Cómo realizamos el cribado visual en Atención Primaria? / How is vision screening performed in primary care?

Introducción: la ambliopía es la causa más común de pérdida de visión prevenible en los países desarrollados. Dicha prevención depende de una detección y tratamiento precoces mediante un adecuado cribado visual en la infancia. Nuestro objetivo es describir la situación del cribado visual en Atención Primaria en España y su relación con la formación de los profesionales. Material y métodos: estudio observacional descriptivo mediante encuesta telemática a los pediatras de Atención Primaria acerca de sus conocimientos sobre el desarrollo visual y las técnicas de cribado, material y formación al respecto. Análisis estadístico descriptivo y univariado en busca de relación entre la formación recibida y sus conocimientos. Resultados: el 79,3% de los participantes acierta más de la mitad de las preguntas teóricas. El 82,8% tiene optotipos estandarizados y el 30,7%, el test de Lang. El 72,7% conoce la distancia óptima y el 76,6% la altura óptima para explorar la agudeza visual con optotipos. El 50%, 68,3% y 44,5% realiza el reflejo rojo, el test de Hirschberg y el Cover test en las revisiones indicadas, respectivamente. Más del 90% conoce los criterios de derivación al oftalmólogo. El 3,1% ha recibido formación institucional y el 54,8% autónoma. Existen diferencias en la puntuación obtenida entre los profesionales según la formación recibida. Conclusiones: se detectan aspectos a mejorar. Se debe explorar el reflejo rojo en todas las revisiones del lactante y la alineación ocular desde los 6 meses, así como disponer y mejorar la utilización del test de Lang y de optotipos estandarizados. Existe relación entre un mayor nivel de conocimientos teóricos y prácticos y la formación recibida (AU)

Introduction: amblyopia is the most frequent cause of preventable vision loss in developed countries. Its prevention depends on early detection and treatment through adequate vision screening in childhood. Our objective was to describe the current situation in vision screening at the primary care level in Spain and its association with the training of professionals.Material and methods: observational descriptive study via a remote survey of primary care paediatricians of their knowledge on visual development and vision screening techniques, equipment and training. We conducted a statistical descriptive and univariate analysis to assess the association between the training received and the level of knowledge. Results: of all respondents, 79.3% answered the theoretical questions correction, 82.8% had standardised optotypes and 30.7% used the Lang test. Also, 72.7% knew the adequate distance and 76.6% the optimal height to assess visual acuity with optotypes. Fifty percent used the red reflex test, 68.3% the Hirschberg test and 44.5% the cover test in the appropriate check-ups. As regards training, 3.1% received it from their institutions, and 54.8% independently. Over 90% knew the criteria for referral to the ophthalmologist. We found differences in the scores of the respondents based on the training received.Conclusion: we identified opportunities for improvement: the red reflex test should be performed during all infant check-ups and ocular alignment checked from 6 months, and the Lang test and standardised optotypes should be available and their use improved. Higher levels of theoretical and practical knowledge are positively correlated with the amount of training received by health professionals. (AU)

Eficacia y seguridad de la sutura ajustable en estrabismos horizontales: estudio comparativo de niños frente a adultos / Efficacy and safety of adjustable suture in horizontal strabismus: Comparative study of children versus adults

Objetivo Los procedimientos con sutura ajustable permiten abordar la imprevisibilidad de algunos resultados postoperatorios en la cirugía de estrabismo. El propósito del estudio fue comparar la efectividad de la sutura ajustable y no ajustable en el tratamiento del estrabismo horizontal en niños y en adultos. Método Estudio prospectivo en el que se incluyeron pacientes sometidos a cirugía de estrabismo para la corrección de un estrabismo horizontal con sutura colgante fija (grupo de sutura no ajustable) y sutura ajustable. Se registraron la agudeza visual, la ambliopía, la desviación, la afectación de los músculos oblicuos, las cirugías previas, el nistagmo, la necesidad de ajuste y las complicaciones. Las variables se registraron en el postoperatorio inmediato, a la semana y a los 3 y 6meses. Resultados Se incluyeron 186 pacientes: 157 (84,4%) con sutura ajustable y 29 (15,6%) con sutura no ajustable, de los cuales 119 eran niños y 67 eran adultos. En el postoperatorio, 19 niños (16,0%) y 19 adultos (28,4%) requirieron un ajuste (p=0,044). De 157 pacientes con sutura ajustable, se ajustó al 20% (32/157). El éxito tras el ajuste fue superior para la sutura ajustable (91,72% vs 79,31%; p=0,043) y se mantuvo los 6meses (p<0,05). La cirugía previa (p=0,004) y la exotropía (p=0,018) se relacionaron con la necesidad de ajuste. Conclusiones Un 20% de pacientes con estrabismo horizontal se pueden beneficiar de un ajuste postoperatorio para mejorar el resultado quirúrgico. La sutura ajustable mostró ser superior frente a la sutura colgante fija y supone una excelente opción quirúrgica tanto en niños como en adultos (AU)

Objective Adjustable suture procedures allow addressing the unpredictability of some postoperative results in strabismus surgery. The purpose of the study was to compare the effectiveness of adjustable and non-adjustable suture in the treatment of horizontal strabismus in children and adults. Methods Prospective study including patients undergoing strabismus surgery to correct horizontal strabismus with fixed hanging suture (non-adjustable suture group) and adjustable suture. Visual acuity, amblyopia, deviation, oblique muscle involvement, previous surgeries, nystagmus, need for adjustment, and complications were recorded. The variables were recorded in the immediate postoperative period, at one week and at 3 and 6months. Results 186 patients were included: 157 (84.4%) with adjustable suture and 29 (15.6%) with non-adjustable suture, of which 119 were children and 67 were adults. Postoperatively, 19 children (16.0%) and 19 adults (28.4%) required adjustment (P=.044). Of 157 patients with adjustable suture, it was adjusted in 20% (32/157). Success after adjustment was higher for adjustable suture (91.72% vs 79.31%; P=.043) and remained for 6months (P<.05). Previous surgery (P=.004) and exotropia (P=.018) correlated with the need for adjustment. Conclusions 20% of patients with horizontal strabismus can benefit from a postoperative adjustment to improve the surgical result. The adjustable suture was shown to be superior to the fixed hanging suture and is an excellent surgical option, both in children and adults (AU)

Efficacy and safety of adjustable suture in horizontal strabismus: Comparative study of children versus adults.

OBJECTIVE: Adjustable suture procedures allow addressing the unpredictability of some postoperative results in strabismus surgery. The purpose of the study was to compare the effectiveness of adjustable and non-adjustable suture in the treatment of horizontal strabismus in children and adults. METHODS: Prospective study including patients undergoing strabismus surgery to correct horizontal strabismus with fixed hanging suture (non-adjustable suture group) and adjustable suture. Visual acuity, amblyopia, deviation, oblique muscle involvement, previous surgeries, nystagmus, need for adjustment, and complications were recorded. The variables were recorded in the immediate postoperative period, at one week and at 3 and 6 months. RESULTS: 186 patients were included: 157 (84.4%) with adjustable suture and 29 (15.6%) with non-adjustable suture, of which 119 were children and 67 were adults. Postoperatively, 19 children (16.0%) and 19 adults (28.4%) required adjustment (p = 0.044). Of 157 patients with adjustable suture, it was adjusted in 20% (32/157). Success after adjustment was higher for adjustable suture (91.72% vs 79.31%; p = 0.043) and remained for 6 months (p < 0.05). Previous surgery (p = 0.004) and exotropia (p = 0.018) correlated with the need for adjustment. CONCLUSIONS: 20% of patients with horizontal strabismus can benefit from a postoperative adjustment to improve the surgical result. The adjustable suture was shown to be superior to the fixed hanging suture and is an excellent surgical option, both in children and adults.