Treatment of lateral rectus paralysis by transposition of superior rectus to lateral rectus / Tratamento de paralisia de reto lateral pela transposição do reto superior para o reto lateral

ABSTRACT Objective: To evaluate the results of the surgical technique described by Crouch in the correction of lateral rectal paralysis (LR) esotropia. Methods: A study conducted of six patients with VI cranial nerve palsy, with more than three months, and associated contracture of the medial rectus muscle. The causes of paralysis varied in traumatic, congenital and neuropathic. The patients underwent surgical correction, performed with a technique consisting of the instillation of the superior rectus muscle (SR) and its suture above the insertion of the LR muscle, completed with Foster´s suture (suture joining, 8mm of the muscle insertion, the body of the SR and LR). The patients were followed for six months. Results: Five patients presented preoperative deviation between 30 and 50 prismatic diopter (PD), and one patient presented a deviation greater than 100 PD, and therefore, the patient required surgical reintervention due to residual deviation. The other five patients presented postoperative orthoppy, with better visual acuity and no vertical deviations. Conclusion: The surgery proposed by Crouch has been shown to be a good alternative to conventional techniques, such as Carlson-Jampolsky surgery, being a technically simpler procedure with good results.

RESUMO Objetivo: Avaliar resultados da técnica cirúrgica descrita por Crouch na correção de esotropia por paralisia do reto lateral (RL). Métodos: Estudo realizado com seis pacientes diagnosticados com paralisia de IV par craniano, com mais de três meses, e com contratura associada do musculo reto medial. As causas da paralisia variaram em traumática, congênita e neuropática. Os pacientes foram submetidos à correção cirúrgica, realizada com técnica que consiste na desinserção do músculo reto superior (RS) e sua sutura acima da inserção do músculo RL, completada com ponto de Foster (sutura unindo, a 8mm da inserção muscular, o corpo do RS e RL). Os pacientes foram seguidos por seis meses. Resultados: Cinco pacientes apresentaram, no pré-operatório, desvio entre 30 e 50 dioptrias prismáticas (DP), e um paciente apresentava desvio maior que 100DP, sendo, portanto o paciente que necessitou de reintervenção cirúrgica, por desvio residual. Os outros cinco pacientes apresentaram ortotropia no pós-operatório, com melhor da acuidade visual e sem desvios verticais. Conclusão: A cirurgia proposta por Crouch demostrou-se uma boa alternativa às técnicas convencionais, como cirurgia de Carlson-Jampolsky, sendo um procedimento tecnicamente mais simples e com bons resultados.

Síndrome de Goltz / Goltz's syndrome

El síndrome de Goltz, o hipoplasia dérmica focal, es un desorden multisistémico raro que involucra la piel, el sistema músculo-esquelético, los ojos, el pelo, las uñas y el riñón, entre otros, con considerable variación en los rasgos clínicos. El examen oftalmológico del caso que se presenta corresponde a una niña con microftalmia en el ojo izquierdo, obstrucción del conducto nasolagrimal en el ojo derecho y coloboma de iris y del nervio óptico del ojo microftálmico, además de esotropia sensorial. El diagnóstico fue confirmado por genética como una hipoplasia dérmica focal que, a pesar de ser poco común, debemos conocerlo para poderlo identificar si se presentara en nuestra consulta(AU)

Goltz syndrome or focal dermal hypoplasia is a rare multisystemic disorder involving the skin, the musculoskeletal system, the eyes, the hair, the nails and the kidney among others, with considerable variation in clinical features. The ophthalmological examination of the case presented in this paper shows a girl who has microphthalmia in the left eye, nasolacrimal duct obstruction in the right eye and coloboma of the iris and optic nerve in the microphthalmic eye in addition to sensory esotropia. The diagnosis was confirmed by genetic studies and it was focal dermal hypoplasia, which is a rare disease but we should learn about it to be able to identify it if some patient with the disease goes to our service(AU)

Real Stereopsis Test Using a Three-Dimensional Display with Tridef Software

PURPOSE: To investigate horizontal image disparity in three-dimensional (3-D) perception using 3-D animations in normal control patients and patients with intermittent exotropia, anisometropic amblyopia, and partially accommodative esotropia. MATERIALS AND METHODS: A total of 133 subjects were included. Stereopsis was measured using the Titmus Stereo test (Stereo Optical Inc., Chicago, IL, USA) and a 3-D stereopsis test with a 15 inch 3-D display laptop, adjusting 3-D parameters of 0 mm horizontal disparity to 15 mm horizontal disparity. RESULTS: When compared with normal controls, the average threshold of the 3-D stereopsis test was significantly reduced for esotropia patients (p<0.001) and for anisometric amblyopia patients (p<0.001), compared to normal controls. No significant difference was observed between normal controls and intermittent exotropia patients (p=0.082). The 3-D stereopsis test was correlated with the Titmus Stereo test (Spearman's rho=0.690, p<0.001). Mean difference in stereoacuity was 1.323 log seconds of arc (95% limits of agreement: 0.486 to 2.112), and 125 (92.5%) patients were within the limits of agreement. CONCLUSION: This study demonstrated that a 3-D stereopsis test with animation is highly correlated with the Titmus Stereo test; nevertheless, 3-D stereopsis with animations generates more image disparities than the conventional Titmus Stereo test. The 3-D stereopsis test is highly predictive for estimating real stereopsis in a 3-D movie theater.

Measurement of Strabismic Angle Using the Distance Krimsky Test

PURPOSE: To evaluate the correlation of the distance Krimsky test and the alternate prism cover test (APCT) for the distance deviation in patients with horizontal strabismus. METHODS: Forty patients with horizontal strabismus (20 esotropia and 20 exotropia) were included in this study. Patients with a variable angle of deviation, vertical angle over 5 prism diopters, impaired binocular vision, or poor cooperation were excluded. We instructed the patient to look a target 6 meters away, and applied a prism over the patient's dominant eye while flashing a light source 33 centimeters from the middle of both eyebrows. When the corneal light reflexes were located on the center of each cornea, we measured the angle of deviation. We defined this method as 'distance Krimsky test,' and the angle measured by this method was compared with the conventional Krimsky test and APCT at distance. We analyzed the accuracy and intra- and inter-observer reliability. RESULTS: The angle of strabismus measured by the distance Krimsky test showed a significant agreement and correlation with the deviation angle measured by the APCT. We elicited the correlation gradient between the angle measured by the distance Krimsky test and the APCT. In addition, the distance Krimsky test showed significant intra- and inter-observer reliabilities. CONCLUSIONS: The distance Krimsky test is expected to be more useful than the Krimsky test in measuring the distance angle of deviation for patients with strabismus in whom it is difficult to measure the angle of deviation using the APCT. The distance Krimsky test can be an accurate and useful test through the improvement of proficiency of examiners and the establishment of individualized normative data.

Duplicación parcial del cromosoma 4 asociada con coloboma ocular bilateral / Partial duplication of chromosome 4 in a patient with bilateral ocular coloboma

La trisomía parcial 4q es una enfermedad cromosómica rara causada por la duplicación de una porción (comúnmente la distal) del brazo largo del cromosoma 4. En la mayoría de los casos resulta de una translocación balanceada de uno de los progenitores, siendo menos frecuente la aparición de novo. Los pacientes presentan diversas características clínicas según el tamaño y sitio específico de la región comprometida. Su asociación con patologías oculares ha sido escasamente comunicada. Presentamos el primer caso de un paciente pediátrico de sexo masculino con una duplicación parcial de novo del segmento proximal del brazo largo del cromosoma 4 (4q12-q22) y coloboma bilateral de iris, retina y nervio óptico.

Partial trisomy 4q is a rare chromosomal disease. It involves duplication of a portion (particularly the distal one) of the long arm of chromosome 4. In most cases results from a balanced translocation on one single progenitor. The "de novo" appearance is less common. Depending on the size and location of duplicated genetic material, patients may have different clinical manifestations. Associated eye pathology has been scarcely informed. We report on a novel case of a male infant with a proximal "de novo" 4q12-q22 duplication and bilateral iris, retinal and optic nerve coloboma.

Use of atropine to predict the accommodative component in esotropia with hypermetropia.

This cohort study included children with esotropia and hypermetropia of ≥ +2.0 diopters (D). The deviation was measured at presentation, under atropine cycloplegia and 3 months after full refractive correction. Of 44 children with a mean age of 5.2 ± 2.4 years, 25 were males. Eighteen (41%) had fully refractive accommodative esotropia (RAE), 10 (23%) had partial accommodative esotropia (PAE), and 5 (11%) had nonaccommodative esotropia (NAE). Eleven (25%) had convergence excess (CE). Under cycloplegia, all with RAE and RAE with CE had orthotropia. There was no significant change in the deviation in the patients with NAE. The deviation under cycloplegia and that with full refractive correction in PAE and PAE with CE (with +3.0 D addition) were not different. The intraclass correlation coefficient for deviation under cycloplegia and after full refractive correction (+3.0 D addition for CE) was 0.89. It was concluded that ocular deviation under cycloplegia can help to predict the accommodative component in esotropia with hypermetropia.

A Case of Pediatric Idiopathic Intracranial Hypertension Presenting with Divergence Insufficiency

An 11-year-old female presenting diplopia only at distance was found to have comitant esotropia of 20 prism diopters (PD) at distance and normal alignment at nearer proximity. Other ocular movement, including abduction, was normal and a thorough neurologic examination was also normal. The deviation angle of esotropia was increased to 35 PD in 6 months, and a brain magnetic resonance imaging with venogram at that time demonstrated no intracranial lesion. A lumbar puncture showed increased opening pressure but the cerebrospinal fluid composition was normal. The patient was diagnosed as having idiopathic intracranial hypertension and treated with oral acetazolamide. Three months after treatment, the deviation angle decreased to 10 PD. This is a case report of divergence insufficiency in pediatric idiopathic intracranial hypertension, with an increasing deviation angle of esotropia. Although sixth cranial nerve palsy is a common neurologic manifestation in intracranial hypertension, clinicians should be aware of the possibility of divergence insufficiency. Also, ophthalmoparesis may not be apparent and typical at first presentation, as seen in this case, and therefore ophthalmologists should be aware of this fact, while conducting careful and proper evaluation, follow-up, and intervention.

Cyclic esotropia.

Cyclic esotropia is a rare condition in which esotropia alternates with binocular single vision (BSV). A five years old female child presented with the complain of acute onset infrequent squinting of left eye (L/E) for 3 years. Squinting of L/E starts in morning and persists throughout the day. The child becomes completely normal on the following morning without any residual effect. Initially there was 24 hours squinting followed by several months of non-squinting. Gradually interval is lessening. For the last 6 months, she was esotropic for 24 hours and non-esotropic for another 24 hours. She complains of no diplopia during the attack. On examination she is otherwise healthy and hypermetropic by +0.50Dsph on cycloplegic refraction with normal visual acuity (6/6, N5). She was 50 prism diopter esotropic in her left eye on esotropic day both for distant and near fixation and had alternate suppression. Ocular motility is full. Anterior and posterior segment reveals no abnormality. There is BSV with positive stereoscopic vision on Titmus test (40 sec of Arc) on non-esotropic day. This case can be treated surgically either by bilateral medial rectus recession or by recession of medial rectus and resection of lateral rectus of the eye according to the amount of esotropia on the esotropic day.

Esotropia do adulto durante o período gestacional: relato de caso / Adult esotropia during pregnancy: case report

Os autores relatam o caso de uma paciente que apresentou quadro reincidente de esotropia aguda e diplopia durante o período gestacional. Não havia história de trauma ou qualquer alteração sistêmica, excetuando-se a gravidez. Tratamento oclusivo alternado foi instituído, e após o parto houve remissão espontânea dos sinais e sintomas.

The authors report a case of a female patient who presented, for the second time, diplopia and acute esotropia during pregnancy. There was no trauma involved neither was systemic disease. The patient was treated with conventional occlusion, and, soon after delivery, the squint was resolved.

Achados oftalmológicos em pacientes com múltiplas deficiências / Ophthalmologic findings in multiple handicapped patients

OBJETIVO: Relatar os achados oftalmológicos em portadores de múltiplas deficiências. MÉTODOS: Foram estudados 274 usuários do Sistema Unico de Saúde atendidos no Departamento de Oftalmologia Pediátrica e Estrabismo da Fundação Altino Ventura (FAV), no período de junho a setembro de 2004. RESULTADOS: A freqüência dos pacientes quanto ao gênero foi de 58,5 por cento para o masculino e 41,5 por cento para o feminino. A variação das idades foi de 0,1 a 20 anos com mediana de 5. A maioria (61,3 por cento) dos pacientes apresentava boa acuidade visual, contudo 38,7 por cento apresentava baixa de visão (< 20/80). As heterotropias foram vistas em 66 pacientes (24,0 por cento). Os transtornos refracionais mais freqüentes foram astigmatismo (53,2 por cento) e hipermetropia (29,0 por cento). CONCLUSÃO: Crianças com múltiplas deficiências necessitam de diagnóstico e tratamento oftalmológico precoce, possibilitando um melhor desenvolvimento global. A integração de uma equipe multidisciplinar constituída de pediatras, oftalmologistas pediátricos e profissionais de visão subnormal pode assegurar melhor qualidade na reabilitação visual.

PURPOSE: To report the visual findings in patients with multiple handicaps. METHODS: Two hundred and seventy-four patients cared for at the Pediatric and Strabismus Ophthalmology Department of the "Fundação Altino Ventura" - Brazilian National Health System, were examined from June to September 2004. Age varied from 0.1 to 20 years with a median of 5. RESULTS: The majority of the patients (61.3 percent) presented good visual acuity; however low visual acuity (< 20/80) was observed in 38.7 percent of the patients. Heterotropias were observed in 66 patients (24.0 percent); astigmatism (53.2 percent) and hyperopia (29.0 percent) were more frequent. CONCLUSION: Children with multiple handicaps need an early ophthalmologic diagnosis and treatment for better global development. The integration of a multidisciplinary team with pediatricians, pediatric ophthalmologists and specialists in low vision, may assure a better visual rehabilitation.

Correlación entre el grado de desviación y la limitación de abducción en afección del VI nervio / Correlation between the degree of deviation and limitation of abduction in the VI nerve

Se presentan 40 casos con afección del VI nervio por diversas causas etiológicas, siendo parcial (paresial) en 26 casos y total (parálisis) en 14 casos examinados. Fueron evaluados al mes de iniciado el cuadro, enfatizando la correlación entre el grado de endodesviación con el grado de limitación de abducción, encontrando congruencia en 25 casos (62 por ciento), incongruencia por mayor endodesviación que limitación de abducción en 7 casos (18 por ciento) e incongruencia por mayor limitación de abducción que endodesviación en 8 casos (20 por ciento). Se infiere que la afección del recto lateral (grado de limitación de abducción) puede ser congruente o incongruente con el grado de hipertonia del recto medial (endodesviación).

Forty cases with VI nerve alteration caused by different ethiologic factors were studied, being 26 cases with partial alteration (paresis) and 14 with total alteration (paralysis). Clinical evaluation took place one month after the onset of the alteration, emphasizing the correlation between degree of esodeviation with degree of limitation of abduction, founding congruency in 25 cases (62 percent), incongruency by more degree of esodeviation than limitation of abduction in 7 cases (18 percent), and incongruency by more degree of limitation of abduction than esodeviation in 8 cases (20 percent). It is inferred than lateral rectus affection (limitation of abduction) may be congruent or not with the medial rectus hypertonia (esodeviation).

Case study: undiagnosed diabetic child presented with paretic noncomitant esotropia

The prevalence of type II diabetes in adults is increasing. Superimposed on that are the recent reports of the emerging problem of type II diabetes in children and adolescents. Paretic [noncomitant] esotropia, usually a result of palsy of the abducens nerve is most often seen in adults who have had cerebrovascular accidents or diabetes due to infarction, but it is rarely reported in children. It is of sudden onset and the prognosis is good since most patients recover after a period of weeks to months. A case of undiagnosed diabetic child who presented to primary health care clinic with sudden onset of abducent nerve paresis is described with the main objective of raising the awareness of primary care physician about the increasing prevalence of type II diabetes in children and their unusual presentations. The patient was very obese [BMI = 30.5] with RBS of more than 22 mmol/L and marked glucosuria, with no evidence of ketosis

Espectro clínico y evolución de la endotropía acomodativa en un grupo de pacientes chilenos / Clinical spectrum and evolution of accommodative esotropia in a group of chilean patients

Objetivos: Caracterizar los tipos de Endotropía (ET) Acomodativa y su frecuencia relativa en un grupo de pacientes portadores de ET en nuestro medio y describir su evolución clínica (por ciento de descompensación, dependencia de lentes ópticos, visión binocular final y variación de la hipermetropía acompañante). Materiales y métodos: 47 pacientes fueron seguidos por un período mínimo de 2 años y máximo de 13 (promedio: 4,6 años), evaluando la desviación con o sin corrección, refracción bajo cicloplegia, visión binocular, presencia de ambliopía y necesidad de cirugía. Resultados: Edad de inicio promedio fue 2,7 + 1,5 años. 53,2 por ciento correspondieron a ET acomodativa puras. El equivalente esférico al momento del diagnóstico fue 4,8 esf. La evolución del equivalente esférico mostró aumento de la hipermetropía hasta los 7-8 años, y luego una lenta y no significativa reducción. El alineamiento motor se mantuvo estable a través del tiempo, no observándose casos inicialmente alineados que luego se descompensaron. El 15 por ciento presentó estereopsis completa al momento del último control. El 71 por ciento no requirió cirugía y hubo 1 caso tratado de toxina botulínica. Conclusiones: En esta muestra no se produjeron cambios sensoriales en el transcurso del tiempo, así como tampoco se modificó en forma significativa la refracción, motivo por el cual los lentes no pudieron ser retirados. La cirugía es un evento infrecuente y tiene lugar en los casos de ET parcialmente acomodativa.

Botulinum A toxin therapy on esotropia in children.

A prospective descriptive study was conducted to determine the results of Botulinum Toxin Type A (BTA) injection on esotropia in children, as this may be an alternative to incisional surgery for strabismus. Between September 1998 and February 2002, eleven patients (6 boys and 5 girls) with esotropia were treated with BTA at the Department of Ophthalmology, Songklanagarin Hospital. The average ages at the time of the first and second treatments were 26.8 months (range 14-40 months) and 32.3 months (range 19-54 months), respectively. An open sky procedure was used to inject the BTA. Alignment within +/- 10 prism of orthotropia was considered a successful outcome of BTA treatment in the patients. If the result of the first injection was an incomplete paralysis and the strabismus remained undercorrected, the subsequent dose was increased up to double the initial dose. The mean deviation angle was 40.4 prism diopter (PD) before the first injection and 24.5PD before the second injection. Eight of 11 (72.7%) cases had a sucessful outcome. BTA injection in childhood esotropia may be an alternative to incisional strabismus surgery.

Correçäo cirúrgica do estrabismo horizontal em portadores de alta miopia / Surgical correction of horizontal strabismus in patients with high myopia

Objetivo: Análise dos resultados cirúrgicos da correçäo dos estrabismos horizontais em portadores de alta miopia, em pacientes do Departamento de Oftalmologia da Santa Casa de Misericórdia de Säo Paulo. Métodos: Foram estudados os prontuários de 24 pacientes esotrópicos e 17 exotrópicos, portadores de miopia maior que 6,00 DE operados para correçäo do estrabismo. Consideramos como bons resultados cirúrgicos desvios residuais entre esotropia e exotropia de 10. Resultados: Observou-se grande incidência de maus resultados entre os pacientes esotrópicos altos míopes. Conclusäo: Concluímos que existe uma tendência a piores resultados cirúrgicos nos pacientes esotrópicos com miopia maior que -6,00 DE, em comparaçäo com esotrópicos com erro refrativo entre -0,75 DE e+ 3,50 DE.

Cirugía de endotropias en el Hospital San Juan de Dios: evaluación de los resultados en cinco años / Surgery of the endothropies in the San Juan de Dios Hospital: evaluation of the results in five years

Evaluar la técnica quirúrgica empleada en las endotropias operadas en 1989 y su evolución en 5 años. Se revisaron las historias de los pacientes operados de endotropias, siguiendo los siguientes criterios: examen oftalmológico completo, segmento anterior y fondo de ojos sin lesiones, seguimiento post-operatorio mayor o igual a 6 semanas; endotropias mayores de 15 dioptrias (sin cirugía previa) y tratamiento de la ambliopía previo a la intervención

Estudio epidemiológico clínico y terapeutico de la esotropía congenita en el Instituto Nacional de Salud del Niño de Lima (noviembre 1977 a mayo 1987) / Clinical and therapeutical epidemiologic study of the congenital esotropia in the Instituto Nacional de Salud de Lima (Noviember 1977 May 1987)

Fue nuestra intención, al iniciar este trabajo, presentar una visión panorámica de la situación epidemiológica, química y terapéutica de la esotropia congénita en el Instituto Nacional de Salud del Niño de Lima-Perú, en un lapso de tiempo que alcanzó los últimos 10 años. Asimismo, el propósito de incluír un número considerable de pacientes se sustenta en la posibilidad de realizar pruebas estadísticas que fueran significativas, permitiendo conclusiones y proyectos futuros válidos. Considerando los 3 requisitos de un inicio entre los 0 y 6 meses, una medida de la desviación angular y el diagnóstico de esotropia congénita, se obtuvo un total de 864 pacientes, cuyos datos epidemiológicos, clínicos y de tratamiento fueron procesados por medio de computadora, procediéndose a continuación a aplicar en ellos las pruebas estadísticas pertinentes. Los principales resultados de allí derivados, fueron los siguientes: La isotropia congénita se distribuye por igual en ambos sexos, presenta cierta proporción de antecedentes familiares positivos, pero la literatura no describe aún el o los mecanismos de herencia. Los promedio de edad de primera consulta y de primera cirugía son tardías, y en especial la última bastante elevada con respecto a las recomendaciones de múltiples reportes; esto se aunó a bajos promedios de seguimiento, particularmente en los grupos de los no operados y tasas moderadas de abandono. las pruebas estadísticas no demostraron la existencia de diferencias entre estos valores de edades y seguimientos a largo del tiempo de estudio. Se discutió respecto a las raices socioeconómicas del problema que han determinado la trayectoria invariable antes descritas y el aspecto cultural sobre el cual incidí si ha de intentarse algún posible cambio. La medida de la desviación angular señaló un promedio significativamente mayor para el síndrome de Ciancia, siendo la prueba de Hirschberg la más usada; un análisis exhaustivo de los resultados no mostró diferencia entre los resultados generales y post-quirúrgicos, para el total de pacientes, subgrupos de errores de refacción de pacientes comprendidos en cada error de refracción y diversas características del estrabismo en estudio; esto permitió concluír que: excepto los pacientes con astigmatismo y hipermetrópico que se asociarian a una mayor proporción de edotropia monocular, ningún tipo de error de refraccirn se asocia a la esotropia congénita, reafirmando su carácter de tal, frente a la de tipo acomodativo. En la mayo