Convergencia ocular, simetría facial y corporal en niños de 5 a 12 años con mordidas cruzadas / Ocular convergence, facial and body symmetry in children from 5 to 12 years old affected by crossbite

RESUMEN Introducción: el cuerpo humano se mantiene en bipedestación gracias al equilibrio existente entre distintos planos quinesiológicos, la alteración de uno de ellos supondrá un desajuste de todo el conjunto. La mordida cruzada es una maloclusión frecuente en la práctica diaria, la cual precisa de un diagnóstico y plan de tratamiento precoz, pues las modificaciones que provoca a diferentes niveles se incrementan con la edad, lo que produce importantes asimetrías que pueden expresarse facial y corporalmente. Objetivo: determinar la convergencia ocular, la simetría facial y corporal en los niños de 5 a 12 años de edad afectados por mordidas cruzadas de las escuelas primarias de la zona urbana del municipio de Quemado de Güines. Métodos: se realizó un estudio descriptivo de corte transversal en las escuelas primarias de la zona urbana del municipio de Quemado de Güines en el período comprendido desde noviembre de 2014 hasta junio de 2016. Se seleccionó una muestra no probabilística que incluyó pacientes de 5 a 12 años con diagnóstico de mordida cruzada, los cuales no habían recibido tratamiento ortodóncico previo y fueron autorizados por sus padres o tutores para participar en el estudio. Resultados: predominaron los niños de 8 años de edad (40%). Solo 3 niños no mostraron trastorno de la convergencia ocular. Por otra parte, 5 niños fueron simétricos (simetría facial), y en relación a la simetría corporal: solamente 2 niños eran simétricos Conclusiones: se determinó que existe una significativa relación entre las mordidas cruzadas, la convergencia ocular y la simetría facial y corporal.

ABSTRACT Introduction: the human body remains standing thanks to the existing balance between different kinesiological planes; the alteration of one of them will suppose a mismatch in all body's structures. Crossbite is a frequent malocclusion in daily practice, which requires an early diagnosis and treatment plan, since the modifications it causes at different levels increase with age, which produces important asymmetries that can be expressed facially and bodily. Objective: to determine ocular convergence, facial and body symmetry in children affected by crossbites, aged 5 to 12 years and belonging to primary schools from the urban area of Quemado de Güines municipality. Methods: a cross-sectional descriptive study was carried out in primary schools from the urban area of Quemado de Güines municipality from November 2014 to June 2016. A non-probabilistic sample that included patients aged 5 to 12 years, diagnosed with crossbite, who were authorized to participate in the study by their parents or guardians and had not received previous orthodontic treatment was selected. Results: 8-year-old children predominated (40%). Only 3 children showed no ocular convergence disorder. On the other hand, 5 children were symmetric (facial symmetry), and in relation to body symmetry: only 2 children were symmetric. Conclusions: a significant relationship among crossbites, ocular convergence, facial and body symmetry was determined.

Relación de la desalineación postural y la convergencia ocular con los trastornos temporomandibulares / Relationship of postural misalignment and ocular convergence to temporomandibular disorders / Relação de desalinhamento postural e convergência ocular com desordens temporomandibulares

Introducción: los trastornos temporomandibulares son unas condiciones dolorosas o disfuncionales en los músculos masticadores o en la articulación temporomandibular con síntomas y signos complejos y variados que influyen negativamente en la calidad de vida. La evidencia científica es ambigua al querer relacionar la postura corporal con la presencia o ausencia de esta alteración. El objetivo es determinar la relación entre la postura de las cinturas escapular y pelviana y la convergencia ocular con los trastornos temporomandibulares. Materiales y métodos: se realizó una investigación observacional, correlacional, prospectiva, transversal. La población estaba constituida por 146 pacientes de 18 a 47 años que acudieron al servicio de odontología del Hospital Honorio Delgado Espinoza y que cumplieron con los criterios de elegibilidad. Se empleó el índice de Helkimo modificado por Maglione para la evaluación de los trastornos temporomandibulares, y para la postura de las cinturas escapular y pelviana y la convergencia ocular se empleó el protocolo de evaluación clínica del Dr. Dupas de la Universidad de Lille (Francia). Resultados: 91.1 % presentaron trastornos temporomandibulares; 86.3 %, disfunción leve; 4.8 %, disfunción moderada, con un predominio femenino, en un 67.8 %. Las manifestaciones clínicas resultantes fueron desviación mandibular, ruidos articulares y limitación de movimiento mandibular moderado. La relación entre la no alineación de las cinturas escapular y pelviana con los trastornos temporomandibulares fue altamente significativa y no se encontró relación con la convergencia ocular. Conclusiones: se evidenció una relación estadística altamente significativa entre los trastornos tempo-romandibulares y la postura alterada de las cinturas señaladas. No se encontró relación con la hipoconvergencia ocular

Introduction: Temporomandibular disorders are a set of painful and/or dysfunctional conditions of the chewing muscles and/or in the temporomandibular joint. They involve complex and varied symptoms and signs that negatively influence the quality of life. The scientific evidence is ambiguous regarding relating body posture with the presence or absence of the involved alterations. The objective of this study is to determine the relationship between the posture of the shoulder girdle, pelvic girdle, and ocular convergence with temporomandibular disorders. Materials and methods: An observational, cor-relational, prospective, cross-sectional investigation was conducted. The population consisted of 146 patients aged 18 to 47 years who attended the dental service of the Hospital Honorio Delgado Espinoza and met the eligibility criteria. The Helkimo index modified by Maglione was used for the evaluation of temporomandibular disorders. The posture of the shoulder girdle, pelvis, and ocular convergence were evaluated using the clinical evaluation protocol of Dr. Dupas of the University of Lille-France. Results: There was a total of 91.1% presented temporomandibular disorders. These included 86.3% with mild dysfunction and 4.8% with moderate dysfunction. There was a female predominance (67.8%). The outstanding clinical manifestations were mandibular deviation, joint noises, and moderate mandibular movement limitation. The relationship between pelvic girdle and shoulder girdle nonalignment with temporomandibular disorders was highly significant. No relationship was found with ocular conver-gence. Conclusions: A highly significant statistical relationship was found between the temporomandib-ular disorders and the altered postures of the shoulder girdle and pelvis. No relationship was found with ocular hypoconvergence

Introdução: as disfunções temporomandibulares são um conjunto de condições dolorosas ou disfun-cionais dos músculos da mastigação ou da articulação temporomandibular com sintomas e sinais com-plexos e variados que influenciam negativamente na qualidade de vida. As evidências científicas são ambíguas ao relacionar a postura corporal com a presença ou ausência desta alteração. O objetivo é determinar a relação entre a postura da cintura escapular, cintura pélvica e convergência ocular com as disfunções temporomandibulares. Materiais e métodos: foi realizada uma investigação observacio-nal, correlacional, prospectiva e transversal. A população foi constituída por 146 pacientes com idades entre 18 e 47 anos que frequentaram o serviço de odontologia do Hospital Honorio Delgado Espinoza e que preencheram os critérios de elegibilidade. O índice de Helkimo modificado por Maglione foi uti-lizado para a avaliação das disfunções temporomandibulares, já para a postura da cintura escapular, cintura pélvica e convergência ocular, foi utilizado o protocolo de avaliação clínica do Dr. Dupas da Universidade de Lille-França. Resultados: 91.1% apresentavam disfunção temporomandibular, 86.3% disfunção leve, 4.8% disfunção moderada com predomínio do sexo feminino em 67.8%. As manifestações clínicas marcantes foram desvio mandibular, ruídos articulares e limitação moderada dos movimentos mandibulares. A relação entre o não alinhamento da cintura escapular e da cintura pélvica com as disfunções temporomandibulares foi altamente significativa e nenhuma relação foi encontrada com a convergência ocular. Conclusões: foi evidenciada relação estatística altamente significativa entre disfun-ção temporomandibular e postura alterada da cintura escapular e cintura pélvica. Nenhuma relação foi encontrada com a hipoconvergência ocular

Intermittent exotropia evaluation using the propedeutics proposed by Kushner: a 25-year study / Avaliação de exotropia intermitente usando propedêutica proposta por Kushner: estudo de 25 anos

ABSTRACT Purpose: To evaluate the clinical and surgical impacts of phenomena that could occur in intermittent exotropia. Methods: The medical records of intermittent exotropia cases from 1991 to 2014 were retrospectively reviewed. All patients underwent a series of measures, including a protocol to assess monocular occlusion based on the propedeutics proposed by Kushner. Results: Outdoor sensitivity was observed in 31% of patients with an undercorrection rate of 44% vs. 18% of cases with no outdoor sensitivity. After 1 h of monocular occlusion, 41% of all patients achieved an increase in deviation with an undercorrection rate of 40%, whereas 25% did not. Conclusion: The results show the importance of complete propedeutics, since there is a higher rate of late undercorrection in cases with outdoor sensitivity and increased deviation after occlusion.

RESUMO Objetivo: Avaliar os impactos clínico e cirúrgico dos fenômenos que podem ocorrer na exotropia intermitente. Métodos: Os prontuários de casos de exotropia intermitente de 1991 a 2014 foram revisados retrospectivamente. Todos os pacientes foram submetidos a uma serie de medidas incluindo o protocolo com oclusão monocular com base na propedêutica proposta por Kushner. Resultados: Outdoor sensitivity foi observada em 31% dos pacientes com taxa de subcorreção de 44% vs. 18% dos casos sem outdoor sensitivity. Após 1 hora de oclusão monocular, 41% de todos os pacientes apresentaram um aumento no desvio com uma taxa de subcorreção 40%, enquanto 25% não. Conclusão: Os resultados demonstram a importância da propedêutica completa, uma vez que há maior taxa de subcorreção tardia nos casos de outdoor sensitivity e maior desvio após a oclusão.

Sintomas visuais e insuficiência de convergência em docentes universitários / Visual symptoms and convergence insufficiency in university teachers

Resumo Objetivo: Investigar a prevalência de desconforto visual e insuficiência de convergência (IC) em docentes universitários. Métodos: Tratar-se de um estudo transversal, com 60 docentes de ambos os sexos, tendo sido utilizado o questionário Convergence Insufficiency Symptom Survey, validado para a população brasileira. Resultados: Dos docentes entrevistados 55,0% eram do sexo feminino. 48,3% responderam dedicar menos que duas horas por dia à leitura, sendo que 40,0% dos entrevistados disseram que fazem pausas de 30 minutos à uma hora durante a leitura e 63,3% afirmaram passar entre 2 a 5 horas por dia em frente ao computador. Em relação à investigação sobre as doenças do sistema visual, 25,0% relataram apresentar miopia, sendo que 55,0% dos indivíduos usam óculos e destes 41,7% o usam com frequência. Quanto à investigação da prevalência de insuficiência de convergência, obteve-se frequência de (1,8) %. Conclusão: Constatou-se que a maioria dos entrevistados se apresentou com desconforto visual e uma pequena porcentagem foram acometidos pela IC.

Abstract Objective: To investigate the prevalence of visual discomfort and convergence failure in professors. Methods: A cross-sectional study was done, consisting of 60 teachers of both sexes, of the Centro Universitário FAG, which used the Convergence Insufficiency Symptom Survey, validated for the Brazilian population. Results: Of those surveyed 55.0% are female. 48.3% respondents spend less than two hours a day reading, with 40.0% of respondents said they do 30-minute breaks for one hour during reading and 63.3% said they spend between 2-5 hours a day in front of the computer. With regard to research on diseases of the visual system, 25.0% reported having myopia, with 55.0% of individuals use these glasses and 41.7% use it frequently. The research of the prevalence of convergence insufficiency, gave an average of 12.4(1.8) %. Conclusion: It was found that most respondents presented with visual discomfort and small percentages were affected by CI.

Distância interpupilar e convergência na população présbita / Interpupillary distance and convergence in the presbyopic population

Objetivo:Determinar as medidas da distância interpupilar (DIP) e convergência ocular na população présbita com pupilômetro de reflexo corneano.Métodos:Cento e sessenta pacientes, com idades entre 41 e 85 anos, sendo 66 do sexo masculino e 94 do sexo feminino, foram avaliados com medida da DIP longe e de perto com PRC.Resultados:A média da idade foi de 55,9 ± 11,5 anos, com DIP média de 65,02 ± 2,78 e 62,47 ± 3,15mm para o sexo masculino e feminino, respectivamente. A média da convergência foi de 5,00 ± 0,5mm. Houve forte correlação direta entre o aumento da DIP e a convergência.Conclusão:Este estudo sugere que a DIP média é pouco menor na população présbita feminina e que existe variação da convergência de acordo com a DIP do paciente.

Objective:To determine the measurements of interpupillary distance (IPD) and ocular convergence in the presbyopic population with corneal reflex pupillometer.Methods:160 subjects (66 males and 94 females) aged 41 to 85 years have their measurements of IPD done - far and near - by CRP method.Results:The mean age was 55.9 ± 11.5 years; the average IPD was 65.02 ± 2.78 and 62.47 ± 3.15 mm for male and female respectively. Also, the average convergence was 5.00 ± 0.5 mm. There was a strong direct correlation between the increase in IPD and convergence.Conclusions:This study suggests that the average IPD is slightly smaller in presbyopic female population, and there is variation in the convergence according to the IPD of the subject.

A new unity for angular measurements in strabismus / Uma nova unidade para medidas angulares no estrabismo

The practical advantages of quantifying an angle by a ratio of linear lengths instead of arcs of circles has led to the definition of the prism-diopter, a conventional unity for numbering prisms and measuring strabismic deviations. However, a major inconvenience of using prism-diopter unities to express angular measurements is the non-linearity of the scale, which reaches an infinite value for the angle of 90º, then becomes negative, with decreasing magnitudes for increasing angles between 90º and 180º. As a consequence, arithmetical operations and comparisons of angles measured by such unities present errors of very great magnitudes. In order to retain the advantages of defining an angle by straight line dimensions but to diminish the severe inconveniences of this method, a new definition of the prism-diopter is proposed. Here, instead of defining the prism-diopter by the asymmetrical condition, the conception of this new unity is based on a geometrically symmetrical condition; that of the relationship of an isosceles triangle (where the leg is perpendicular to the bisector of the angle and the bisector itself ). The condition of symmetry for the definition of the new unity represents a conceptual advance because it reproduces the already well accepted, conventional criteria for quantifying the value of a prism, that of its minimum deviation. Furthermore, it corresponds to the most commonly observed clinical conditions of binocular balance. The absolute differences between the unitary values of the prism-diopter and that of the new unity are negligible (0.0025%), but the scale of values expressed by the new unity is closer to the ideal scale of angular measurements. (With the new unity, the infinite value is only reached for an angle of 180º and the errors due to arithmetical operations are much smaller.) Numerical examples showing the advantages of using the new unity of angular measurements instead of the prism-diopter are presented. A mathematical generalization of the modifying concept (partition of an angle) with which the new unity is based is also provided.

As vantagens práticas de quantificação de um ângulo pela relação de comprimentos lineares em lugar dos de arcos de círculos propiciaram a definição da dioptria- prismática, uma unidade convencional de numeração dos prismas e de medições do estrabismo. Entretanto, um grande inconveniente do uso das dioptrias- -prismáticas para exprimir medidas angulares é a não-linearidade da escala, que alcança um valor infinito para o ângulo de 90º e passa a valores negativos e com magnitudes decrescentes para ângulos crescentes entre 90º e 180º. Como consequência, operações aritméticas e comparações de ângulos com medidas angulares expressas com tais unidades apresentam erros de magnitude muito grande. Para manutenção das vantagens de definição de um ângulo pela dimensão de distâncias retas, mas reduzindo os graves inconvenientes dessa escolha, propõe-se uma nova definição para a dioptria-prismática. Ao invés da condição assimétrica pela qual a dioptria-prismática é definida, a concepção dessa nova unidade é baseada em uma condição geometricamente simétrica, a das relações de um triângulo isósceles (o cateto perpendicular à bissetriz do ângulo e essa própria bissetriz). Essa condição de simetria para a definição da nova unidade corresponde a um avanço conceitual, por reproduzir o critério convencional, já bem aceito, de quantificação do valor do prisma, o de seu desvio mínimo, além de corresponder às condições clínicas de exame do equilíbrio binocular comumente usadas. A diferença absoluta entre os valores unitários da dioptria-prismática e o da nova unidade é negligenciável (0,0025%) mas a escala dos valores expressos pela nova unidade é mais próxima da escala ideal de medidas angulares. (Com a nova unidade, o valor infinito é apenas alcançado para um ângulo de 180º e os erros devidos às operações aritméticas são muito menores.) Dão-se exemplos numéricos mostrando as vantagens de uso da nova unidade de medidas angulares em lugar da dioptria-prismática. Apresenta-se, também, uma generalização matemática do conceito de modificação (partição de um ângulo) pelo qual a nova unidade é baseada.

Changes in the Accommodation-convergence Relationship after the Artisan Phakic Intraocular Lens Implantation for Myopic Patients

PURPOSE: To evaluate the change of accommodation-convergence parameters after implantation of Artisan phakic intraocular lens (PIOL). METHODS: Prospective study for the patients with the Artisan PIOL implantation was performed. A total of 37 patients (3 males and 34 females) enrolled the study. Preoperatively, convergence amplitude, the stimulus accommodative convergence per unit of accommodation (AC/A) ratio and the near point of convergence (NPC) were evaluated. After the Artisan PIOL implantation, the identical evaluations were repeated at 1 week, 1, 3, and 6 months after the surgery. RESULTS: Mean age was 24.3 +/- 4.8 years old, and preoperative refractive error was -8.92 +/- 4.13 diopters (D). After the implantation, mean refractive errors significantly decreased to within +/-1.00 D, and noticeable complications were not found. The convergence amplitude and the stimulus AC/A ratio increased 1 month after the surgery, but progressively stabilized afterward to near preoperative values. NPC didn't show any significant change over follow-up period up to 6 months. CONCLUSIONS: These results regarding implantation of the Artisan PIOL revealed the increase of accommodation-convergence relationship within first 1 month after the surgery, but progressive stabilization was noted during follow-up periods.

Long-term Follow-up of Acute Isolated Accommodation Insufficiency

PURPOSE: To define the long-term results of accommodation insufficiency and to investigate the correlation between accommodation insufficiency and other factors including near point of convergence (NPC), age, and refractive errors. METHODS: From January 2008 to December 2009, 11 patients with acute near vision disturbance and remote near point of accommodation (NPA) were evaluated. Full ophthalmologic examinations, including best corrected visual acuity, manifest refraction and prism cover tests were performed. Accommodation ability was measured by NPA using the push-up method. We compared accommodation insufficiency and factors including age, refractive errors and NPC. We also investigated the recovery from loss of accommodation in patients. RESULTS: Mean age of patients was 20 years (range, 9 to 34 years). Five of the 11 patients were female. Mean refractive error was -0.6 diopters (range, -3.5 to +0.25 diopters) and 8 of 11 patients (73%) had emmetropia (+0.50 to -0.50 diopters). No abnormalities were found in brain imaging tests. Refractive errors were not correlated with NPA or NPC (rho = 0.148, p = 0.511; rho = 0.319, p = 0.339; respectively). The correlation between age and NPA was not significant (rho = -395, p = 0.069). However, the correlation between age and NPC was negative (rho = -0.508, p = 0.016). Three of 11 patients were lost to follow-up, and 6 of 8 patients had permanent insufficiency of accommodation. CONCLUSIONS: Accommodation insufficiency is most common in emmetropia, however, refractive errors and age are not correlated with accommodation insufficiency. Dysfunction of accommodation can be permanent in the isolated accommodation insufficiency.

Long-term Follow-up of Acute Isolated Accommodation Insufficiency

PURPOSE: To define the long-term results of accommodation insufficiency and to investigate the correlation between accommodation insufficiency and other factors including near point of convergence (NPC), age, and refractive errors. METHODS: From January 2008 to December 2009, 11 patients with acute near vision disturbance and remote near point of accommodation (NPA) were evaluated. Full ophthalmologic examinations, including best corrected visual acuity, manifest refraction and prism cover tests were performed. Accommodation ability was measured by NPA using the push-up method. We compared accommodation insufficiency and factors including age, refractive errors and NPC. We also investigated the recovery from loss of accommodation in patients. RESULTS: Mean age of patients was 20 years (range, 9 to 34 years). Five of the 11 patients were female. Mean refractive error was -0.6 diopters (range, -3.5 to +0.25 diopters) and 8 of 11 patients (73%) had emmetropia (+0.50 to -0.50 diopters). No abnormalities were found in brain imaging tests. Refractive errors were not correlated with NPA or NPC (rho = 0.148, p = 0.511; rho = 0.319, p = 0.339; respectively). The correlation between age and NPA was not significant (rho = -395, p = 0.069). However, the correlation between age and NPC was negative (rho = -0.508, p = 0.016). Three of 11 patients were lost to follow-up, and 6 of 8 patients had permanent insufficiency of accommodation. CONCLUSIONS: Accommodation insufficiency is most common in emmetropia, however, refractive errors and age are not correlated with accommodation insufficiency. Dysfunction of accommodation can be permanent in the isolated accommodation insufficiency.

Impacto del entrenamiento visual en las vergencias de pacientes présbitas / Impact of visual training in presbyopic patients’ convergences

El motivo del disconfort en pacientes présbitas puede deberse a una disfunción en las habilidades de vergencia, que no compensan de forma eficiente la posición fórica en visión cercana. Objetivo: determinar el impacto del entrenamiento visual en los rangos de vergencias de pacientes présbitas. Materiales y métodos: se incluyeron 54 sujetos présbitas corregidos. Se formaron dos grupos de 27 pacientes; el grupo de intervención se sometió a un programa de entrenamiento de vergencias durante diez semanas. Se midieron los rangos de vergencias fusionales negativas y positivas, la relación acomodación-convergencia acomodativa, la distancia en centímetros del punto próximo de convergencia y las forias lateral y vertical en visión cercana con el método de Von Graefe y el grado de disconfort visual. Resultados: la pueba t de Student confirmó que existe significancia (p < 0,005) en el grupo de intervención entre: a) el valor del disconfort inicial y el valor final y b) los valores de ruptura y recobro de la vergencia positiva. La media inicial de los valores de ruptura fue de 19,70 dioptrías prismáticas y la final de 26,07 y de 4,48 a 13,33 dioptrías prismáticas en el recobro. El valor de la media del punto próximo de convergencia inicial en el grupo de intervención fue de 15,63 centímetros y el final de 6,28 centímetros. La variación en la media del AC/A inicial y final del grupo de intervención fue de 1,1 dioptrías prismáticas. Conclusiones: el entrenamiento visual tiene impacto sobre las vergencias positivas, normaliza el punto próximo de convergencia y disminuye el disconfort visual.

The reason for the discomfort in presbyopic patients may be due to dysfunction in the skills of convergence, which may not efficiently compensate for the phoric position in near vision. Objective: To determine the impact of visual training in the ranges of convergences of presbyopic patients. Materials and methods: 54 subjects with presbyopic correction. Groups of 27 patients were formed. The intervention group underwent a convergence training program for ten weeks. Negative and positive convergence fusions, the accommodation-convergence ratio, the distance in centimeters from the next point of convergence and lateral and vertical phorias for near vision were measured using the Von Graefe method and the degree of visual discomfort. Results: The student test confirmed that there is significance (p <0.005) in the intervention group between: a) the value of the initial discomfort and the final value, and b) the values of breakdown and recovery of the positive convergence. The mean values of rupture were 19.70 prism diopters initially, and 26.07 at the end, and 4.48 to 13.33 prism diopters in the recovery. The value of the near point of convergence measured in the initial intervention group was 15.63 centimeters and in at the end it was 6.28 centimeters. The variation in initial and final AC/A measurement of the intervention group was 1.1 prism diopters. Conclusions: The visual training has a positive impact on convergences, normalizes the near point of convergence and reduces visual discomfort.

Modificación de la relación acomodación por convergencia acomodativa (AC/A), en respuesta adiferentes lentes estímulo / Modification of the accommodative-convergence over accommodation

La cantidad de acomodación que es modificada por acción de la convergencia se denomina la relación AC/A y puede influir en la magnitud de la desviación ocular, en el diagnóstico del estado sensorial y motor, y en el plan de tratamiento del paciente; existen discrepancias en si la medida del AC/A gradiente es igual con otras respuestas acomodativas. Objetivo: determinar si la relación AC/A gradiente estímulo presentaba una respuesta similar al emplear diferentes lentes estímulos. Materiales y métodos: fueron evaluados 132 sujetos a los cuales se midió la heteroforia habitual e inducida con lentes estímulo de +3,00, +2,00, +1,00, -1,00, -2,00 y -3,00 dioptrías, usando la técnica de Thorington, con una carta modificada de forias (para 0,33 m). Resultados: el promedio del AC/A gradiente para el lente estímulo fue de +3,00 (1,39), +2,00 (1,67), +1,00 (1,84), -1,00(1,42), -2,00 (1,48), -1,00 (1,42), y el AC/A pendiente (AC/Ap 1,49); la comparación del AC/A nomostró diferencias significativas (ANOVA, p = 0,0132), pero sí una mayor variabilidad en los resultadoscon los lentes de +/- 1,00D (COA ±2,98 y ±2,56). Conclusiones: el AC/A gradiente estímulo en promedio fue similar cuando se calculó con los diferentes lentes, pero la variabilidad en los datos indica que debería ser medido y calculado con base en varios estímulos de acomodación.

The amount of accommodation modified by convergence is called the AC/A ratio and it can affect the magnitude of ocular deviation in the sensory and motor state diagnosis, as well as in the patient’s treatment plan. There are some disagreements on whether the measurement of the AC/A gradient is the same with other accommodative responses. Objective: To determine if the gradient stimulus AC/A ratio had a similar response when using different stimulus lenses. Materials and methods: One hundred and thirty-two (132) individuals were evaluated, who had regular and induced heterophoria with +3.00, +2.00, +1.00, -1.00, -2.00 and -3.00 dioptry stimulus lenses measured through the Thorington technique, with a modified phoria card (for 0.33 m). Results:The mean gradient AC/A for the stimulus lens was +3.00 (1.39), +2.00 (1.67), +1.00 (1.84), -1.00(1.42), -2.00 (1.48), -1.00 (1.42), and the slope AC/A ratio (AC/Ap1.49). The comparison of the AC/A did not show any significant differences (ANOVA p=0.0132), but a higher variability in the results with the +/-1.00D (COA ±2.98 and ±2.56) lenses. Conclusions: The mean gradient stimulus AC/A was similar when calculated with the different lenses, but the variability of the information indicates that it should be measured and calculated with several accommodation stimuli.

Effectiveness of Home-Based Pencil Push-ups (HBPP) for Patients with Symptomatic Convergence Insufficiency

PURPOSE: To report the effectiveness of home-based pencil push-ups (HBPP) therapy for patients with symptomatic convergence insufficiency. METHODS: Data was collected prospectively on 16 patients who were diagnosed with convergence insufficiency beginning in January 2009. The study group was composed of ten male and six female patients. The duration of symptoms, refractive error, distant and near deviation angles, and near point of convergence (NPC) prior to and after 12 weeks of HBPP therapy were measured in all patients. RESULTS: The mean age of the patients was 19.3 years. The mean deviation angle of exophoria was 3 prism diopters (PD) at distant and 11.2 PD at near. The mean value of NPC prior to HBPP therapy was 36.3 cm; however, the near point of accommodation was within the normal range. After 12 weeks of HBPP therapy, the mean deviation angle of exophoria decreased to orthophoric at distant and 4 PD at near. The mean value of NPC decreased to 14.4 cm. CONCLUSIONS: Twelve weeks of HBPP therapy appears to be an easy, cost-free and effective therapy for patients with symptomatic convergence insufficiency.

Cambios en la relación acomodación convergencia AC/A en el valor de las forias después de cirugía refractiva Lasik / Changes of the convergence accomodation relation (A/CA) and the forias in patiens before and after refractive surgery Lasik

Objetivo: determinar cambios significativos de la relación acomodación convergencia (AC/A) y las forias en pacientes antes y después de cirugía refractiva con técnica Lasik. Metodología: se realizó un estudio prospectivo para una muestra poblacional de veinte pacientes (cuarenta ojos) sometidos a cirugía refractiva, evaluados ortópticamente en Optiláser en Bogotá. Se determinó como criterio de inclusión haber sido valorado ortópticamente antes y después de la cirugía refractiva. Se evaluaron condiciones motoras, sensoriales, signos, síntomas, agudeza visual, AC/A, forias con cover test y con varilla de maddox. Resultados: en la medida de las forias se observa qué tanto para Cover Test como para Varilla de Maddox no se presentan cambios estadísticamente significativos entre el pre y el posquirúrgico. La relación AC/A calculada con el método de la Heteroforia tuvo valores similares antes y después de la cirugía refractiva; estadísticamente, no se observan cambios significativos, pues se mantuvieron los valores normales en un promedio de 55 por ciento (once pacientes) y 65 por ciento (trece), respectivamente. En cuanto a los pacientes con ACA bajo, se observó que antes de la cirugía había 45 por ciento (nueve pacientes) y después de la cirugía 65 por ciento (seis pacientes). Cabe resaltar que un paciente (5 por ciento) que presentaba foria antes de la cirugía se descompensó en el posquirúrgico, lo que generó tropia en visión próxima y, por ende, imposibilidad en la realización de la valoración de ACA. Conclusiones: la relación acomodación convergencia en pacientes sometidos a cirugía refractiva no presenta cambios significativos, con respecto a su condición inicial. El cover test y la varilla de Maddox reportan diferencias, encontrándose mayor alteración en los valores de las forias en la varilla de Maddox; es decir, que con el método disociante se evidenció un mayor valor de ésta y se encontró una variación significativa con respecto al valor encontrado con el método habitual.

The objetive of the study was to determine significant changes of the convergence accomodation relation (A/CA) and the forias in patiens before and after refractive surgery. Methodos: 40 eyes was submitted to refractive surgery, evaluated by ortoptic in a refractive center OPTILASER. Conditions such as motored, sensorial, signs, symptoms, visual a harpness, AC/A, binocular vision were evaluated with cover test and with maddox rod. Results: in the measures of forias, it is observed that so much for cover test as for maddox rod, there are not significant statistically changes between the pre and the postsurgical pursuit.The relation AC/A calculated with the method of the heteroforia, had similar values before and after the refractive surgery, statistically there are not significant changes observed; therefore the normal values were maintained in an average of 55 percent (11 patients) and 65 percent (13) respectively. As for the patiens with ACA is observed that before the surgery there was 45 percent ( 9 patients) and after the surgery 65 percent (6 patients). It fits to stand out that 1 patient (5 percent) that presented foria before the surgery, is descompensated in the postsurgical treatment generating strabismus in near vision and therefore impossibility in the execution of the appraisal of ACA. Conclusions: the convergence accomodation (AC/A) relation in patients submitted to refractive surgery does not present significant changes, with respect to its initial condition. The cover test and the Maddox rod report differences finding greater alteration in the values of the forias in the maddox rod; that is to say that withthe dissociate method was shown a greater value of the same one, finding a significant variation with respectto the value found with the habitual method.

Parálisis de convergencia / Convergence pals

La parálisis de convergencia se caracteriza por la imposibilidad de la convergencia en la mirada próxima, con diplopía horizontal cruzada a partir de 1 metro, con aducción normal. La parálisis de la convergencia es una condición distinta de la insuficiencia de la convergencia y normalmente secundaria a una lesión intracraneal. Acude paciente de 12 años de edad por presentar diplopía horizontal de cerca ± 1 metro de 3 meses de evolución, cefalea, lagrimeo y fotofobia. La impresión diagnóstica fue parálisis de convergencia. En los estudios neurológicos solo se encontró implantación baja de las amígdalas cerebrales. Aún no se precisa la etiología aunque se recoge el antecedente de un traumatismo craneal sin relevancia por la familia

The convergence paralysis is characterized by impossible convergence in the near sight, with crossed horizontal diplopia at one meter distance and normal adduction. The convergence paralysis is a condition different from the inadequate convergence and usually secondary to intracranial lesion. A 12-years old patient went to the hospital because he had suffered horizontal diplopia in near sight (± 1 meter) for 3 months, migraine, watering and photophobia. The definitive diagnosis was convergence paralysis. In the neurological studies, the low placing of the tonsils of cerebellum was the only finding. The etiology of this disorder is not determined yet; although there is some history of head trauma to which the family did not pay enough attention

Insuficiencia de convergencia en adulto prepresbita: caso clínico / Convergence insufficiency in a pre-presbyopic: clinical case

Se presenta un caso de un paciente preprésbita con una insuficiencia de convergencia severa con sintomatología marcada en tareas de cerca. Se realizó terapia visual mediante el entrenamiento de la convergencia acomodativa, con lo cual se logró una visión binocular eficaz, sin síntomas y con un excelente resultado en el tiempo. Por esta razón, se enfatiza en realizar un examen visual completo de los pacientes, dar el diagnóstico apropiado y determinar la mejor opción de tratamiento que conlleve a solucionar su motivo de consulta independientemente de la edad. Además, se resalta la importancia de analizar clínicamente cuánto se podría influir de manera favorable en diferir el momento de inicio de prescripción de cerca. Como lo menciona Lara (2001), muchos escritores sugieren que las disfunciones binoculares no estrábicas son muy comunes en la práctica optométrica, y aunque los datos de prevalencia son muy variados, en la experiencia clínica se observa que la insuficiencia de convergencia es una de las más frecuentes y quizá de las más ignoradas a nivel de la consulta en adultos. Cuando se trata de un paciente présbita o preprésbita con diagnóstico de insuficiencia de convergencia, puede surgir la duda de la eficacia de la terapia visual, debido al compromiso normal de la acomodación en esta edad. Sin duda, son numerosos los casos que a diario acuden con sintomatología justificada por una disfunción binocular y no por presbicia propiamente. Muchos de ellos son corregidos prematuramente con lentes positivos afectando de manera negativa su condiciónde acomodación.

This is a case report of a prepresbiopic patient with severe CI (convergence Insufficiency) and noticeable symptomatology in near work tasks.The patient underwent visual training of the accommodative convergence, improving his binocular vision without symptoms with excellent result in time. Its important to make a complete evaluation to patients, have an appropriate diagnosis and determine the best treatment option according to the complaints and age. By the mean of the case report, we highlight the importance of the clinical analysis of how positive can be the influence of the treatment in the retarding of the use of near prescription. Lara (2001), as many authors suggest that binocular dysfunctions (no strabismus) are very common in the optometric practice, the prevalence statistics is very variable but the clinical experience has showed that CI is one of the most frequent and sometimes is ignored in adult patients. In prepresbiopic patients with CI, there are some doubts about the efficiency of the visual therapy, due the physiological fails of the accommodation in this age. However, there are many cases coming to consultation day by day with symptoms justified by a binocular dysfunction and not precisely by the presbiopia. Many of this patients are corrected early with near addition , wich can affect negatively their accommodative condition.

Relación entre el a/ca medido con el método del gradiente y el de las heteroforias en pereira / Relation between the a/ca measured by the gradient and the heterophorias method in pereira

Introducción:el presente estudio busca determinar los valores promedio y la correlación de la razón A/CA, mediante evaluación con el método del gradiente y el de las heteroforias.El A/CA promedio con el método del gradiente y de las heteroforias fue de 1:3.15 y 1:4.89 respectivamente.Métodos:se calculó el A/CA con el método del gradiente empleando lentes de +1.00, -1.00, -2.00 y -3.00 dioptrías.Para medir las heteroforias habituales e inducidas se empleó el método de Von Graefe con los prismas de Risley en el foropter y se acomodó un hilera de letras que subtendían una AV para VL de 20/40 y para cerca (0.4m) de 20/30 en el rotochart.Se evaluó la distancia interpupilar para visión próxima empleando un transiluminador ubicado a 40cm y centrando la reglilla con la primera imagen de Purkinge para cada ojo Resultados:la correlación del A/CA evaluado con ambos fue de 0.162 (Spearman), y con la primera técnica entre los diferentes lentes estímulo fue mejor entre -2.00 y 3.00 D (r=0.771) y más deficiente con +1.00 y -1.00 D (r=0.149).La distancia interpupilar promedio fue de 60 mm y la correlación con el A/CA Heteroforias fue muy deficiente (r=0.292).Conclusiones:se encontraron valores promedio inferiores a los citados por la literatura con ambas técnicas; poca correlación entre los dos métodos y variabilidad en los resultados con el método del gradiente, al emplear diferentes lentes estímulo; el menor valor promedio hallado con el método de las heteroforias se deba a la menor distancia interpupilar...

Evaluation of subjective and objective cyclodeviation following oblique muscle weakening procedures.

PURPOSE: To evaluate the subjective and objective cyclodeviational changes following different weakening procedures on superior and inferior oblique muscles. DESIGN: Comparative case series. MATERIALS AND METHODS: In a prospective institution based study, 16 cases of A pattern horizontal strabismus having superior oblique overaction were randomized to superior oblique weakening procedures: either silicon expander or translational-recession. Similarly, 20 cases of V pattern horizontal strabismus with inferior oblique overaction were randomized for inferior oblique weakening procedures: either 10 mm Fink's recession or modified Elliot and Nankin's anteropositioning. Cyclodeviation was assessed subjectively with the synoptophore and objectively using the fundus photograph before surgery and 3 months postoperatively. Change in cyclodeviation was measured by subjective and objective methods. The index of surgical effect (ISE) was defined as the net torsional change postoperatively. RESULTS: The difference between the extorsional change induced by the two superior oblique procedures, silicone expander (-6 degrees ) and translational recession (-11.3 degrees), was statistically significant (P=0.001). Translational recession caused more extorsional change (ISE=296%) than silicone expander surgery (ISE=107%). The two inferior oblique weakening procedures, Fink's recession (+2.5 degrees) and modified Elliot and Nankin's anteropositioning (+4.7 degrees) produced equitable amount of intorsional shift with no statistical difference (P=0.93). Objective measurements were significantly more than the subjective measurements. CONCLUSIONS: Different weakening procedures on oblique muscles produce different changes in cyclodeviation, which persists even up to 3 months. Subjective cyclodeviation is less than the objective measurements indicating partial compensation by sensorial adaptations.

El examen analítico y su importancia clínica método de análisis gráfico / The analytic exam and its clinical importance graphic analysis method

Los métodos Analíticos determinan la exactitud de la refracción, la relación de la acomodación –convergencia y establece los limites de la Zona de visión clara, sencilla y binocular. La zona de confort o zona de trabajo se ve afectada por las siguientes categorías: Disminución de la visión: como son los defectos refractivos y funcionales (hipermetropía, miopía, astigmatismo, ambliopía, estrabismo). Fatiga Visual: alteraciones de la relación de acomodación convergencia, y disminución de la amplitud de fusión de acomodación, llevando consigo dificultad de atención y concentración en el trabajo debido a la fatiga visual que se presenta. Infantes con problemas de aprendizaje y falencias en lecto-escritua. Padres y docentes que remiten a los niños en edad escolar para tratamientos psicológicos sin preveer que el rendimiento académico del el niño, no está asociado a factores relacionados con su personalidad y relación con su entorno, si no que por el contrario su bajo nivel de aprendizaje es consecuencia de su incorfort visual. Procesos pre y post Quirúrgicos de Cirugia Refractiva. Es normal encontrar en el motivo de consulta de estos pacientes el inconfort visual para lejos y cerca, reportando emborronamiento, visión doble, exagerada molestia a la luz, ardor, afectando su zona de trabajo de vision clara, sencilla y binocular.El examen Analítico comprende tres puntos esenciales, examen Refractivo, examen Gráfico y disposición. Por medio del Análisis Gráfico, se demuestra clínicamente el estado de la visión binocular, en la cual se estudia la zona de trabajo identificando que exista, visión clara, simple y confortable.

The analytical methods determine the accuracy ofrefraction, relation accommodation-convergenceand establish the limits of the clear, simple andbinocular vision zone. The comfort zone or workingzone is affected by the following categories: visiondecrease is caused by refractive and functionaldefects (hypermetropia, myopia, astigmatism,amblyopia, and strabismus). Visual fatigue is causedby alterations in the relation accommodationconvergenceand decrease in the amplitude ofaccommodation fusion causing difficulty inattention and concentration in work. Children withlearning problems and reading and writing mistakes:Parents and teachers send school age children topsychological treatments without thinking thatthe academic performance is not associated topersonality aspects and environmental relations,but, on the contrary, their learning low level is aconsequence of their visual discomfort. Pre and postsurgical processes of refractive surgery: in patientsconsultation is normal to find visual discomfort forfar and near vision, blurred vision, double vision,exaggerated discomfort to light, ardor, which affecttheir working clear, simple and binocular visionzone. The analytical exam includes three essentialpoints: refractive examination, graphic examinationand disposition. The graphic analysis clinicallyshows the state of binocular vision, where theworking zone is studied, and identifies the existenceof clear, simple and comfortable vision.

study of relationship between binocular vision and near point of convergence while near vision

Binocular vision anomalies are the most common visual problems that are along with several symptoms such as headache, asthenopia, and pain in the eyes, intermittent diplopia, intermittent blur vision, print swimming and other symptoms. Because of high prevalence of these anomalies a regular examination and visual screening program including on some tests for assessment and determination of these anomalies is necessary. The aim of this study was assessment of relationship between near point of convergence [NPC] and near binocular vision symptoms. In this cross sectional study 124 students of different majors in paramedical and health faculty of Mashhad University of medical sciences that had inclusion criteria were studied. The subjects were selected using simple random sampling. The subjects were divided to two groups [with and without symptoms] according to their own reporting. Visual acuity, refractive errors and NPC were determined using snellen chart, retinoscopy [cyclopentolat 1% if necessary] and small isolated letter [E] of approximately 20/30 [6/9] size from snellen reduced chart. The data were analyzed by SPSS version 13 using descriptive and analytical [Mann-Withney test and ROC curve] statistics. The subjects were 60% [75] female and 40% [49] males. In this study 61.1% [82] and 33.9% [42] of subjects were with and without symptom respectively. The mean of NPC in with and without symptoms group were 11.7 +/- 6.01 and 8.4 +/- 3.95 centimeters respectively. The difference in near point of convergence was statistically significant in the two groups. The cut-off point of NPC was determined 9.5 cm using ROC curve. According to high prevalence of binocular vision anomalies especially in students, determination of NPC has an important role in differentiation of symptomatic from asymptomatic subjects. Hence, NPC is suggested to be evaluated specially in persons that have long near vision tasks. Cut-off point 9.5 cm is suggested to binocular vision screening