Long-Term Outcome and Recurrence of Abnormal Head Posture after Surgery in Patients with Nystagmus

PURPOSE: To evaluate the long-term outcome and recurrence of abnormal head posture after modified Kestenbaum surgery in patients with nystagmus. METHODS: The medical records of 46 patients who underwent modified Kestenbaum procedure in horizontal recti muscles for nystagmus with abnormal head turn were retrospectively reviewed. We assessed the effect of surgery by comparing preoperative and postoperative clinical data such as visual acuity (log MAR) and degree of head turn. A reoperation or abnormal head turn of 10degrees or more at final visit were defined as recurrence. Patients were divided into 2 groups according to the presence of recurrence or reoperation. Clinical factors associated with recurrence or reoperation were compared between the 2 groups. RESULTS: The mean visual acuity was 0.38 in the better eye and 0.42 in the worse eye before surgery, which improved to 0.15 and 0.21 after surgery (each p < 0.001), with a mean follow-up period of 124 months. The mean degree of head turn was 41.41degrees preoperatively and was changed to 2.61degrees postoperatively (p < 0.001). The recurrence rate was 23.9% and the reoperation rate was 10.9%. Mental retardation, amblyopia, preoperative visual acuity, degree of head turn, and presence of strabismus were not associated with recurrence or reoperation. The mean age at first surgery was significantly lower in the reoperation group (p = 0.009). The mean visual acuity in the better eye at postoperative 6 months and in better and worse eyes at postoperative 1 year was significantly worse in the reoperation group (p = 0.034, 0.012 and 0.009, respectively). CONCLUSIONS: The visual acuity and head turn was improved after modified Kestenbaum surgery in patients with nystagmus and abnormal head posture. The reoperation rates were associated with earlier age of first operation and worse postoperative visual acuity. However, further prospective studies are necessary to clarify these factors.

The Effects of Part-Time Occlusion Therapy Shortened to One or Two Hours in Intermittent Exotropia

PURPOSE: To evaluate the compliance level of therapy and the change in exo-angle after 1 or 2 hours of part-time occlusion therapy in intermittent exotropia. METHODS: This retrospective study included 97 patients with intermittent exotropia who were followed-up for more than 6 months after their initial visit. We evaluated the exo-angle and prescribed either 1 hour or 2 hours of part-time occlusion therapy for the fixating eye. After 6 months, the exo-angle was reevaluated and compliance was examined. Patients were divided into 2 groups according to the occlusion therapy time: the 1-hour patching group (33 patients) and the 2-hour patching group (64 patients). Compliance and deviation angle were retrospectively reviewed and compared between the 2 groups. We evaluated the exo-angle of patients with compliance over 50% (1-hour patching group (31 patients), 2-hour patching group (51 patients)). RESULTS: The mean exo-angles on the first visit were 22.61 +/- 5.78 PD (prism diopters) at distance and 22.88 +/- 8.11 PD at close-range in the 1-hour patching group, and 26.17 +/- 4.55 PD at distance and 25.27 +/- 8.54 PD at close-range in the 2-hour patching group. The proportion of patients with compliance over 50% was higher in the 1-hour patching group (93.94%) than in the 2-hour patching group (79.69%, p = 0.013). There were significant decreases in distant and close- range deviation angles after part-time occlusion in patients with compliance over 50% in both groups (1-hour patching group distant p = 0.042, close-range p = 0.002; 2-hour patching group distant p < 0.001, close-range p < 0.001). The magnitude of deviation angle decrease was not statistically significant between the 2 groups (ANCOVA; distant p = 0.461, near p = 0.761). CONCLUSIONS: One or 2 hours of part-time occlusion therapy in intermittent exotropia provided beneficial effects, including decreasing the deviation angle. The magnitude of deviation angle decrease, however, was not different between the 2 times of therapy. Compliance was higher in the 1-hour part-time occlusion therapy group. Therefore, 1-hour part-time occlusion therapy could be effective in patients with poor cooperation.

Influence of Watching 3D Television on Refractive Error in Children with Exodeviation

PURPOSE: To investigate the effects of watching three-dimensional (3D) television (TV) on the angle of deviation and refractive error in children with exodeviation. METHODS: Twenty-three volunteers with exodeviation, aged 6 to 12 years, without any ocular abnormalities other than refractive error and exodeviation were recruited for this study. The subjects watched 3D TV for 50 minutes at a viewing distance of 2.8 meters. The image disparity of 3D contents was -1 to 1 degree. Refractive errors were measured before and immediately after watching TV and after a 10-minute rest. The changes in angle of deviation were also obtained. Refractive errors and angle of deviation before and after watching 3D TV were compared. RESULTS: The mean age of the subjects was 9.30 +/- 1.58 years. The mean baseline angle of deviation was 13.04 +/- 5.25 (6-30) prism diopters (PD), which did not change significantly immediately after watching 3D TV and after a 10-minute rest (p = 0.452). The mean refractive errors were -2.15 +/- 1.55 D in the right eye and -2.06 +/- 1.55 D in the left eye before and changed to -2.14 +/- 1.57 D and -2.11 +/- 1.45 D, respectively, immediately after watching 3D TV. After a 10 minute rest, the mean refractive errors were 2.14 +/- 1.53 D in the right eye and -2.07 +/- 1.53 D in the left eye. All changes in refractive errors were not statistically significant (p = 0.991 in right eye, 0.495 in left eye). The amount of myopic shift in both eyes immediately after watching 3D TV was correlated with the angle of exodeviation (r = 0.468, p = 0.024). However, the correlation disappeared after a 10-minute rest (r = 0.345, p = 0.107). CONCLUSIONS: Watching properly made 3D contents on 3D TV for 50 minutes at more than 2.8 meters of viewing distance did not affect the refractive error in children with exodeviation. Further studies on the relationship between the amount of myopic shift and the angle of exodeviation are necessary.

A Study of Ocular Disease and Treatment in Patients with Developmental Disability

PURPOSE: To evaluate ocular abnormalities in children with developmental disability and to find out whether any correlation exists between developmental disability and surgical outcome. METHODS: Totally 43 patients with the diagnosis of developmental disability were enrolled in this retrospective study. RESULTS: Mean follow-up was 4.54 +/- 2.35 year. 20 patients had exodeviation, 15 patients had esodeviation, 10 patients had dissociated vertical deviation and 4 patients had dyskinetic strabismus. 21 patients had surgery and the mean deviation angle was decreased from 36.67 +/- 15.70 PD to 5.33 +/- 5.93 PD in exotropia and 56.25 +/- 8.54 PD to 5.75 +/- 4.65 PD in esotropia. Refractive error was found in 33 patients (88.4%). 26 patients (60.5%) had monocular amblyopia and 17 patients (65.38%) showed improvement of visual acuity after treatment. CONCLUSIONS: Exotropia is the most common type strabismus in patients with developmental disability and dyskinetic strabismus is found in cerebral palsy. Strabismus Surgery for patients with stable angle deviation and amblyopia treatment is effective in children with developmental disability. However decision for surgery should be made after a long follow up period.

The Surgical Outcome of Intermittent Exotropia with Type Conversion Subsequent to Preoperative Part-Time Occlusion Therapy

PURPOSE: To evaluate the effects of converted intermittent exotropia type with part-time occlusion therapy on final postoperative outcomes. METHODS: The present study included 140 consecutive intermittent exotropia patients. On the patient's first visit, the type of intermittent exotropia was determined according to the deviation angle. After preoperative part-time occlusion therapy, the type of intermittent exotropia was reevaluated. The surgical success rates of each group was compared retrospectively according to the converted type. RESULTS: At the first visit, the basic type was the most prevalent (n = 112), followed by convergence insufficiency type (n = 18) and pseudo-divergence excess type (n = 10). Mean deviation angle on the first visit was 25.42 +/- 6.05 PD at distance and 26.19 +/- 8.20 PD at near. There were significant changes in near deviation angle after part-time occlusion in patients with the basic and convergence insufficiency types (p = 0.045, 0.03, respectively). Twenty-seven patients who had converted from basic type to pseudo-divergence excess type and from convergence insufficiency type to basic type showed better surgical success rate (89%) than other patients (69%) (p = 0.033). CONCLUSIONS: Part-time occlusion therapy converts the type of intermittent exotropia by reducing near deviation angle and is related to a better surgical success rate.

Treatment of Exotropia Caused by Lost Medial Rectus Muscle

PURPOSE: We report three patients with large angle exotropia had lost medial rectus muscle (MR) and who attained good alignment postoperatively. METHODS: Patient 1 was a 51-year-old female with a history of strabismus surgery done at 10 years of age. Exotropia of 80 prism diopter (PD) gradually developed with limitation of adduction in the right eye. Patient 2 was a 52-year-old male with fixed exotropia of 95 PD in his left eye, which became blind after a severe contusion injury. The third patient was a 46-year-old male who had MR of the right eye cut during endoscopic sinus surgery. Severe limitation of adduction followed with exotropia of 50 PD. We could not find MR in any of the three patients and noted severe adhesion between eyeball and Tenon's capsule. Ocular movement was severely limited horizontally and even vertically. RESULTS: Postoperatively Patient 1 showed orthophoria in follow-up of 2 years. Patient 2 had 16PD of exotropia in follow-up of 13 months, which was cosmetically acceptable. Patient 3 obtained orthophoria after surgery and developed 10 degrees of left head turning to avoid diplopia. CONCLUSIONS: When a patient shows longstanding large angle exotropia with limitation of adduction, we may consider the MR loss. A reasonable treatment may be to align the eyes cosmetically in primary position by weakening the abducting power and suturing the anterior part of nasal Tenon's capsule to the MR insertion site after adhesiolysis.

Early Surgery before 4 years of Age in Intermittent Exotropia

PURPOSE: We performed this study to evaluate the occurrence of consecutive esotropia after early surgery in the patients with intermittent exotropia less than 4 years of age. METHODS: We analyzed the surgical results of 37 patients who underwent surgery before 4 years of age retrospectively. They were followed up at least more than 1 year after surgery. The orthophoria was defined as an exophoria of 0 to 12PD or an esophoria of 0 to 5PD after surgery. The consecutive esotropia was defined as an esodeviation lasting more than 3 months that needed surgical correction due to sensorial deterioration. RESULTS: Preoperative angle of exodeviation at distance ranged from 20PD to 60PD (mean 35.1 +/- 9.2PD). Twenty-seven of 37 patients (75.7%) showed orthophoria after surgery in 1 year follow-up and 20 of 31 patients (64.5%) in 2 years follow-up. Five patients (13.5%) showed recurrence and 4 patients (10.8%) consecutive esotropia. Immediate postoperative overcorrection was 14.1 +/- 8.7PD(0-30) in patients who were orthophoric after postoperative follow-up more than 2 years. The rate of consecutive esotropia was high in patients with an exo-angle of 30PD or more and a large amount of recession of lateral recti more than 7mm. CONCLUSIONS: This study revealed that consecutive esotropia after early surgery for intermittent exotropia less than 4 years of age was noted to the 10.8%.

Intermittent Exotropia Associated with Simulated Superior Oblique Palsy

PURPOSE: To obtain guideline of diagnosis and treatment when hyperdeviation associated with intermittent exotropia shows symptoms similar to superior oblique palsy (SOP). METHODS: We reviewed the charts retrospectively in 27 patients showing simulated SOP in intermittent exotropia, in which hyperdeviation in primary gaze and 10PD or more by Bielschowsky head tilt test were present. Overaction of Inferior oblique, (IOOA) dysfunction of superior oblique, and forveal extorsion more than +2 were excluded including reoperation and head tilt history. All patients were undergone horizontal muscle surgery only. The postoperative changes of deviation were analyzed at postoperative one day, one month, six month, and one year. RESULTS: Average amount of distant horizontal deviation in primary gaze was 32.3+/-9.58PD. Hyperdeviation was 3.8+/-2.52PD. Degree of IOOA averaged +1.18 in hypertropic eye, and +1.06 in hypotropic eye. Only 10 patients (37%) had foveal extorsion less than +2 in degree. Average vertical deviation of hypertropic eye side was 12.7+/-2.93PD on head tilt test. After horizontal surgery only, the amount of hyperdeviation decreased to 1.3PD at 1st day. On head tilt test, hyperdeviation was almost eliminated showing 0.6PD on the hypertropic side and 0.1PD on the contralateral eye at one month. All patients were aligned up to the follow-up of one year. CONCLUSIONS: To differentiate simulated SOP from intermittent exotropia with hyperdeviation, none of head tilt history, mild foveal extorsion, mild oblique dysfunction less than +3, double Maddox rod test, and forced duction test are important guidelines. Horizontal muscle surgery is only needed to remove exodeviation and hyperdeviation.

The position of eye and head for measurement of lateral incomitancy in intermittent exotropes

PURPOSE: To determine proper position of lateral gazes and angle of head turn for the measuring lateral incomitancy in intermittent exotropia. METHODS: Twenty-five Korean intermittent exotropes with exoangle more than 25 prism diopters (PD) and 25 orthophoric people were taken. Three lateral gazes were proposed: position A, when the lateral limbus of the abducted eye was off the lateral canthus; position B, when touched the lateral canthus; and position C when was hidden behind the lateral canthus. The angle of deviation and head turn were measured at each position. In the most comfortable position which subjects selected, the length from lateral canthus to lateral limbus (lateral cantho-limbal distance) of the abducted eye was measured. RESULTS: 23 patients of each group selected that position A was the most comfortable. At position A, the mean of cantho-limbal distance in exotropes was 1.19mm at the right lateral gaze and 1.04 mm at left, people with orthophoria showed larger values in both gazes. The average amount of head turn was 24.1 degrees at the right lateral gaze and 24.3 degrees at the left at position A, 27.5 degrees and 34.1 degrees at position B, 27.6 degrees and 33.7degrees at position C. The average angle of exodeviation was 27.4 PD in the primary gaze. It was 21.7 PD in the right lateral gaze and 20.3 PD in the left lateral gaze at position A, 17.9 PD and 17.5 PD at position B, and 9.0 PD and 8.6 PD at position C. CONCLUSIONS: In the measurement of lateral exo-angle to evaluate lateral incomitancy in intermittent exotropia, the most appropriate position of eye and head turn turned to be when the lateral limbus of the abducted eye is about 1mm apart from the lateral canthus with head turn of 25degrees laterally.

A Case of Bilateral Duane's Retraction Syndrome Associated with Goldenhar's Syndrome

PURPOSE: Duane's retraction syndrome is a congenital eye movement disorder caused by innervational disturbance. It is rare that Duane's retraction syndrome is associated with Goldenhar's syndrome which shows systemic congenital malformations. We report a case of bilateral Duane's retraction syndrome associated with Goldenhar's syndrome, which was treated with strabismus surgery and excision of epibulbar lipodermoid. METHODS: A 14-month-old boy with exotropia showed severe limitation of adduction, mild limitation of abduction, globe retraction and palpabral fissure narrowing on attempted adduction in both eyes. He also had a diffuse small epibulabar mass under the lateral conjunctiva in the left eye. The angle of exodeviation was 45PD on alternate prism cover and uncover test. He had had cleft lip, multiple skin tags on the face and preauricular appendages since birth and undergone an operation for these abnormalities at age of 4 months. Bilateral 7.5mm recession of the lateral recti and excisional biopsy of epibulbar mass of the left eye were performed. RESULTS: A case of Duane's retraction syndrome associated with Goldenhar's syndrome was found. The patient obtained orthophoria in his primary gaze after bilateral recession of lateral recti. The epibulbar mass was consistent with lipodermoid on pathologic examination.

Influence of Orbit Size and Interorbital Distance on Development and Outcome of Surgery for Intermittent Exotropia

PURPOSE: To evaluate the influence of orbital size and interorbital distance on the development and recurrence of intermittent exotropia. METHODS: We selected 55 intermittent exotropes(group A), 30 esotropes (group B), and 30 normal children(group C). Width and height of orbit, inner interorbital distance (IIOD), and outer interorbital distance (OIOD) in both orbits were measured with skull A-P(Anterior-Posterior) roentgenogram, and orbital index (IIOD/OIOD X 100) was calculated. The cephalometric results of the 6 recurrent exotropes and the 6 consecutive esotropes in group A were analyzed too. RESULTS: There is no significant difference in orbital height and orbital length among 3 groups. The IIOD was 25.0+/-3.86 mm in group A, 21.9+/-3.95 mm in group B, and 22.7+/-4.34 mm in group C. Mean OIOD was 100.3+/-9.75 mm in group A, 97.0+/-8.96 mm in group B, and 98.4+/-5.61 mm in group C. Orbital index was not different with the increase of age (p=0.23). It was greater in group A (25.0+/-2.79) than that in group B (22.9+/-2.66) and group C (23.1+/-2.79) (p<0.05). Orbital index of the orthophoric children after strabismus surgery in group A was 24.7+/-2.99. It was greatest in the 6 recurrent extropes (25.2+/-2.00) and was smallest in 6 the consecutive esotropes (23.5+/-1.69) CONCLUSIONS: Intermittent exotropia is more prevalenat in subjects with longer IIOD and greater OI, and esotropia is more prevalent in subjects with shorter IIOD and lower OI. The possibility of recurrence after surgery was high in patients with greater OI, and the possiibility of consecutive esotropia was high in patients with low orbital index.

Sensory Testing for Binocular Suppression in Accommodative Esotropes

It is important to detect binocular suppression of pediatric strabismic patients, especially in accommodative esotropes and intermittent exotropes. However, it may take a long time and false results may be obtained in young children. In order to examine binocular suppression, we selected 103 accommodative esotropes with binocular suppression. Vectograph test, Worth 4 dot test, and 4 prism base-out test were performed at distance, and Worth 4 dot test, TNO test, and Bagolini test at near. Titmus fly test and Randot stereotest were administerd to know the relationship between stereoacuity and suppression. In detecting binocular suppression, the true rate of vectogram was 95%, which was the highest result of all tests and 4 prism base-out test was the next with 88% of the true rate. The stereoacuity was increased in proportional to the absence of suppression. The vectographic porject test was the easiest and the most accurate test to identify normal fusion or binocular suppression at distance in young strabismic children. The accuracy will be increased in the combination with 4 prism base-out test. Therefore the vectograph also can be used in the screening of small amount of deviation, monocular amblyopia and low vision in kindergarten and elementary school.

Dissociated Vertical Deviation after Correction of Infantile Esotropia

Dissociated vrtical deviation(DVD) is frequently associated with infantile esotropia. It is hard to find DVD before surgery for esodeviation, and usually found after surgery. We studied the occurrence of DVD in 176 patients who had had horizontal rectus muscle surgery for the correction of infantile esotropia and followed up for 6 months or more. DVD was seen in 78 patients(44.3%), preoperatively in 27 patients(34.6%) and postoperatively in 51 patients(65.4%). Among 51 patients with DVD after surgery, DVD occurred in 24.0% of patients with preoperative angle of esodeviation less than 50 PD and in 44.6% of patients with preoperative angle of esodeviation more than 51 PD(P0.05). Inferior oblique overaction(IOOA) was accompanied with DVD in 71.8% and occurred without DVD in 28.6%. This study revealed postoperative DVD developed more in large angle esotropia such as deviation angle greater than 51 PD, and IOOA was frequently accompanied. The result suggests that in large angle infantile esotropia with mild IOOA and DVD or fundus extorsion we may need the preventive correction of DVD and IOOA.

The Influence of the Vertical Location of VDT Screen on the Ocular Dryness

The fatigue of eye is much caused by eye dryness during VDT work. We performed this study to find out whether eye dryness is reduced wit the computer screen which is placed lower than primary gaze during VDT work. Forty people without eye disease were selected. One VDT screen was placed 5degreesabove the primary gaze(5degreesup screen) and the other 25degreesbelow the primary gaze(25degreesdown screen). We measured the frequency of blinking and vertical palpebral fissure height, at rest and while they enjoyed an interesting computer game for 20 minutes. Tear film break-up time(BUT) was also measured at rest, during and immediately after computer game. At rest, the average frequency of blinking was 22.35+/-6.28/min and BUT was 10.20+/-2.63 seconds. During VDT work with 5degreesup screen, the measurements were significantly decreased to 7.48+/-3.43/min and 5.38+/-1.43/min, respectively. These, however, were improved with 25degreesdown screen showing 10.05+/-4.59/min and 7.00+/-1.55 second(p>0.01). The average vertical palpebral fissure height was 6.49+/-1.07mm at rest, and 9.49+/-1.26mm with 5degreesup screen. With 25degreesdown screen, this was 7.69+/-1.01mm and narrower than the measurement with 5degreesup screen(p>0.01). This study reveals that the visual fatigue from the ocular dryness will be improved with the computer screen placed 25degreeslower than primary gaze and laid adeqately back like in reading position.

Clinical Assessment of Partially Accommodative Esotropia

We studied 49 patients who showed partially accommodative esotropia retrospectively. They were glasses for accommodative component and underwent surgery for nonaccommodative one. The mean value of refractive error was +4.41 +/- 2.04 D. The mean deviation angle of accommodative component was 20.78 +/- 12.59 PD (prism diopter), and the one of non-accommodative component was 30.45 +/- 15.12 PD. Mild amblyopia was shown in 58% of these patients. The DVD or IOOA was infrequently accompanied in these patients. Stereopsis was much improved after straightening eyes. Deterioration was noticed in 14% of the patients. The longer the duration between onset and the time at straightening eyes, and the earlier the onset of deviation, the more deterioration was noticed. This study revealed that the characteristics of partially accommodative esotropia was similar to the accommodative esotropia.

Clinical Assessment of Partially Accommodative Esotropia

We studied 49 patients who showed partially accommodative esotropia retrospectively. They were glasses for accommodative component and underwent surgery for nonaccommodative one. The mean value of refractive error was +4.41 +/- 2.04 D. The mean deviation angle of accommodative component was 20.78 +/- 12.59 PD (prism diopter), and the one of non-accommodative component was 30.45 +/- 15.12 PD. Mild amblyopia was shown in 58% of these patients. The DVD or IOOA was infrequently accompanied in these patients. Stereopsis was much improved after straightening eyes. Deterioration was noticed in 14% of the patients. The longer the duration between onset and the time at straightening eyes, and the earlier the onset of deviation, the more deterioration was noticed. This study revealed that the characteristics of partially accommodative esotropia was similar to the accommodative esotropia.

Analysis and Treatment of Axial Ametropic AnisPmetropia

Anisometropia is caused by axial ametropia and refractive ametropia. Almost all anisometropia in children are known to be caused by axial ametropia. Axial ametropic anisometropia is corrected by the spectacles by Knapp's rule. We experienced 41 patients with anisometropia, in whom the relationship between the difference in axial length in each eye(x) and the difference in refractive error in each eye(y) was linear, y = -0.00758+2.18554x. According to this approximate regression formula, 27 patients(66%) showed axial ametropic anisometropia and 14 patients(34%) showed refractive ametropic anisometropia. Twenty three(85%) out of 27 patients had had amalyopia. Ten patients(83%) at the age of 9 or less improved their visual acuity after amblyopia treatment, but only 4 patients(36%) older than 9 showed mild improvement. In authors' experience, axial ametropic anisometropia can be corrected by spectacles with full amount of refractive error and by proper amblyopia treatment. It is important to diagnose and treat the axial ametropic anisometropia in early childhood, however even in the patients older than 9 years old the visual prognosis is not so hopeless if treated with fully corrected spectacles and proper amblyopia treatment.

Insertion of Horizontal Rectus Muscles in Strabismus

An anatomical evaluation of the limbus-insertion distance and width at insertion of the horizontal rectus muscle had been measured on enuclated eyes from normal adult cadavers by several authors. We measured the variation in the limbus-insertion distance and width of 214 horizontal rectus muscles in 111 strabismus patients, composed of 38 esotropes and 73 exotropes. We also evaluated their relation to strabismus. The results were as follows: 1. The average limbus-insertion distance of medial rectus was 4.38 +/- 0.45 mm and lateral rectus was 5.56 +/- 0.84 mm and the average width of medial rectus at insertion was 9.19 +/- 0.78 mm and that of lateral was 8.32 +/- 1.00 mm. 2. The largest values for limbus-insertion distance and width of medial rectus were found in esotropes in the 8 to 13 years old age group(9.76 +/- 0.12 mm and 4.53 +/- 0.44 mm respectively), and those of lateral rectus in exotropes in the 13 to 18 years old age group(8.66 +/- 0.95mm and 6.09 +/- 0.45mm respectively). 3. The limbus-insertion distance and width at insertion was larger in male than in female and it was especially significant in the medial rectus muscle of esotropes(p<0.001). 4. The limbus-insertion distance and width tended to be larger in horizontal deviation greater than 40 delta. as compared to those of 40 delta or less.

The Evaluation and Treatment of Superior Oblique Muscle Palsy

Superior oblique palsy is the most common isolated palsy of an extraocular muscle and the most frequent cause of vertical strabismus. Patients with superior oblique palsy are frequently symptomatic from diplopia, anomalous head postures and loss of binocular vision, and showed hyperdeviation in primary position on the prism cover test, positive three step test and unilateral oblique muscle dysfunction on version. The surgical treatment of superior oblique palsy is very important because it not only prevents musculoskeletal changes from occurring in the face and neck by the elimination of abnormal head postures, but also corrects hypertropia and excydotropia in the primary position and preserves and improves stereopsis. The author had 52 patients of unilateral superior oblique palsy treated with superior oblique tucking, weakening of inferior oblique (recession, and denervation and extirpation of inferior oblique), recession of contralateral inferior rectus and ipsilateral superior oblique recession. The results were as follows. Children under 10 years of age were 71.2% of the patients. The average amount of hyperdeviaiton in primary position was 24.0 delta with range of 4 to 70 delta. Maddox double rod test was performed in 22 patients who understood it and all of them showed excyclodeviation of either eye. The range was 2 to 10 degrees with average of 5.2 degrees. Stereopsis was present in 77.1% of all the patients, in 91.3% of superior oblique palsy alone combined with horizontal strabismus before surgery. Following inferior oblique weakening procedure, the mean correction of hyperdeviation in primary position was 15.7 delta by 10 mm recession, 20.4 delta by 14 mm recession and 38.3 delta by denervation and extirpation of inferior oblique muscle.

Clinical Assessment of Accommodative Esotropia

Accommodative esodeviation is the result of either the need to clear the blurred vision caused by hypermetropia or a high accommodative convergence to accommodation(AC/A) ratio. In 1958, Parks showed that there were three origins of accommodative convergence to accommodation(AC/A), and a combination of the two. The authors experienced 71 cases of accommodative esotropia which were treated with hyperopic glasses, executive bifocals, and surgery on nonaccommodative component. Accommodative esotropia was subdivided into 3 types as refractive, nonrefractive and combined type. The refractive type was 59.1%, nonrtfractive type 8.5%, and combined type 32.4%. Among all 71cases, partially accommodative esotropia was 32.4%. The onset was at the age between 2 and 4 years in 50.8%. In most cases the sphero-equivalent of refractive error was +4.00 to less than +6.00 D in the refractive type with a normal AC/A ratio, less than +2.00 D in the nonrefractive type with a high AC/A ratio, and +2.00 to less than +4.00 D in the combined type with a high AC/A ratio. The cases with a normal AC/A ratio showed more hypermetropia. The amount of esodeviation controlled by hyperopic glasses was 24.4 to 25.0 delta at distance; by executive bifocals 26.2 delta in the nonrefractive type and 18.6 delta in the combined type at near. Stereoacuity was tested in 34 cases who understood the test, was better in the refractive type with normal AC/A ratio than in nonrefractive and combined type with a high AC/A ratio, and was absent in 26.4%. In many cases without stereopsis, the interval between onset and institution of therapy was too long and the age at treatment was too old. The longer the eyes are not aligned the greater chance for the development of amblyopia and sensory motor misalignant. Therefore early recognition and early initiation of treatment should be emphasized.