Brazilian guideline for pediatric cycloplegia and mydriasis / Diretrizes brasileiras para cicloplegia e midríase em crianças

ABSTRACT Cycloplegia is crucial for reliable pediatric ophthalmology examinations. This document provides a re­commendation for pediatric cycloplegia and mydriasis for Brazilian ophthalmologists. This article was developed based on literature reviews; the clinical experience of Brazilian specialists, as obtained through questionnaires; and the consensus of the Expert Committee of the Brazilian Pediatric Ophthalmology Society. According to the best evidence and formulations available in Brazil, this committee recommends the use of one drop of 1% cyclopentolate plus one drop of 1% tropicamide in children older than 6 months and two drops of 1% tropicamide 0-5 minutes apart for those younger than 6 months. Mydriasis may be increased by a single drop of 2.5% phenylephrine. For retinopathy of prematurity screening, the recommendation is 0.5% or 1% tropicamide, administered two or three times, 5 minutes apart, and 2.5% phenylephrine, used preferably once. In all scenarios, we recommend the use of a prior drop of 0.5% proxymetacaine.

RESUMO A cicloplegia é crucial para um exame oftalmológico pediátrico acurado. Este documento visa a fornecer uma recomendação para cicloplegia e midríase pediátrica para oftalmologistas brasileiros. Foi desenvolvido com base em revisão literária, na experiência clínica de especialistas brasileiros, por meio de questionários, e no consenso do comitê de especialistas da Sociedade Brasileira de Oftalmologia Pediátrica (SBOP). De acordo com as melhores evidências, este comitê recomenda o uso de uma gota de ciclopentolato 1%, mais uma gota de tropicamida 1% em crianças maiores de 6 meses e duas gotas de tropicamida 1% com intervalo de 0-5 minutos para menores de 6 meses. A midríase pode ser potencializada por uma gota de fenilefrina 2,5%. Para o rastreamento da retinopatia da prematuridade, a recomendação é tropicamida 0,5 ou 1%, duas ou três vezes, com 5 minutos de intervalo, e 2,5% de fenilefrina, preferencialmente uma vez. O uso prévio de proxymetacaína 0,5% é sempre recomendado.

Brazilian guideline for pediatric cycloplegia and mydriasis.

Cycloplegia is crucial for reliable pediatric ophthalmology examinations. This document provides a re-commendation for pediatric cycloplegia and mydriasis for Brazilian ophthalmologists. This article was developed based on literature reviews; the clinical experience of Brazilian specialists, as obtained through questionnaires; and the consensus of the Expert Committee of the Brazilian Pediatric Ophthalmology Society. According to the best evidence and formulations available in Brazil, this committee recommends the use of one drop of 1% cyclopentolate plus one drop of 1% tropicamide in children older than 6 months and two drops of 1% tropicamide 0-5 minutes apart for those younger than 6 months. Mydriasis may be increased by a single drop of 2.5% phenylephrine. For retinopathy of prematurity screening, the recommendation is 0.5% or 1% tropicamide, administered two or three times, 5 minutes apart, and 2.5% phenylephrine, used preferably once. In all scenarios, we recommend the use of a prior drop of 0.5% proxymetacaine.

Plication versus Resection in Horizontal Strabismus Surgery: A Systematic Review with Meta-Analysis.

PURPOSE: The purpose of this review was to compare the efficacy of rectus muscle plication versus resection on the treatment of horizontal strabismus and to evaluate the exodrift after each technique. METHODS: A research was performed in Latin American and Caribbean Literature on Health Sciences (LILACS); MEDLINE; and Cochrane Central Register of Controlled Trial (CENTRAL). The database was searched by 30 June 2019. The selection was restricted to articles published in English, Spanish, or Portuguese. There were no date restrictions in the search. A minimum mean follow-up of six months was required to access the primary outcomes. Motor alignment success was defined as postprocedure deviation within 10 prism diopters (PD) of orthotropia. RESULTS: Seven studies were eligible for inclusion. The grouped success rate after plication was 66% (95% CI = [43%-89%]), and the grouped success rate after resection was 68% (95% CI = [43%-89%]). High heterogeneity was observed between the estimations. There was no difference between the mean amount of deviation corrected in prism diopters, when using the mixed-model approach (SMD = 0.12; 95% CI = -0.2-0.44; p=0.45). The undercorrection rates were also analyzed. The combined odds ratio was 1.37 (95% CI = 0.59-3.16; p=0.462), and there was no statistical significance. CONCLUSION: Plication of horizontal extraocular muscles reveals to be an alternative to resection in strabismus surgery, with similar results. Exodrift is observed after plication and after resection in the treatment of exotropia, but randomized clinical trials are necessary to analyze and compare the follow-up.

Surgical results of strabismus correction in patients with myelomeningocele.

PURPOSE: Myelomeningocele is one of the most common birth defects. It is associated with severe neurological deficiencies, and ocular changes, such as strabismus, are very common. The purpose of this study was to describe indications for strabismus surgery in patients with myelomeningocele and to evaluate the results achieved with surgical correction. METHODS: We retrospectively reviewed records of all patients with myelomeningocele who underwent surgery for strabismus correction in a 5-year period in an institution for disabled children. RESULTS: The main indications for strabismus surgery were esotropia and A-pattern anisotropia. Excellent surgical results were achieved in 60.9% of patients, satisfactory in 12.2%, and unsatisfactory in 26.9%. CONCLUSION: Patients with myelomeningocele and strabismus had a high incidence of esotropia and A-pattern anisotropia. Strabismus surgery in these patients had an elevated percentage of excellent and satisfactory results, not only for the ocular deviation, but also for improvement of head posture.

Surgical results of strabismus correction in patients with myelomeningocele / Resultados cirúrgicos da correção do estrabismo em pacientes com mielomeningocele

Purpose: Myelomeningocele is one of the most common birth defects. It is associated with severe neurological deficiencies, and ocular changes, such as strabismus, are very common. The purpose of this study was to describe indications for strabismus surgery in patients with myelomeningocele and to evaluate the results achieved with surgical correction. Methods: We retrospectively reviewed records of all patients with myelomeningocele who underwent surgery for strabismus correction in a 5-year period in an institution for disabled children. Results: The main indications for strabismus surgery were esotropia and A-pattern anisotropia. Excellent surgical results were achieved in 60.9% of patients, satisfactory in 12.2%, and unsatisfactory in 26.9%. Conclusion: Patients with myelomeningocele and strabismus had a high incidence of esotropia and A-pattern anisotropia. Strabismus surgery in these patients had an elevated percentage of excellent and satisfactory results, not only for the ocular deviation, but also for improvement of head posture. .

Objetivo: A mielomeningocele é um dos mais frequentes defeitos do nascimento e está associada a disfunções neurológicas severas. Alterações oculares como estrabismo são muito comuns nesses pacientes. O objetivo deste estudo foi descrever as principais indicações de cirurgia de estrabismo em pacientes com mielomeningocele e avaliar os resultados atingidos com a correção cirúrgica. Métodos: Foi realizado estudo restrospectivo com revisão de prontuários de todos os pacientes com mielomeningocele submetidos à cirurgia para correção de estrabismo em um período de 5 anos em uma instituição de assistência a crianças deficientes. Resultados: As principais indicações para cirurgia de estrabismo foram esotropia e anisotropia com padrão em A. Resultados cirúrgicos excelentes foram alcançados em 60,9% dos pacientes, satisfatórios em 12,2% e insatisfatórios em 26,9%. Conclusão: Pacientes com mielomeningocele e estrabismo têm uma alta incidência de esotropia e anisotropia com padrão em A. A cirurgia de estrabismo nesta população teve uma elevada porcentagem de resultados excelentes e satisfatórios, não somente em relação ao desvio ocular, mas também na melhora na posição viciosa de cabeça .

Teratogen exposure and congenital ocular abnormalities in Brazilian patients with Möbius sequence.

Purpose: To assess the sociodemographic profiles, teratogen exposures, and ocular congenital abnormalities in Brazilian patients with Möbius sequence. Method: Forty-four patients were recruited from the Brazilian Möbius Sequence Society. This cross-section comprised 41 patients (age, mean ± standard deviation, 9.0 ± 5.5 years) who fulfilled the inclusion criteria. The parent or caregiver answered a questionnaire regarding sociodemographic data and pregnancy history. Patients underwent ophthalmological assessments. They were subdivided into groups according to misoprostol exposure during pregnancy, and the two groups were compared. Results: Mothers/caregivers reported unplanned pregnancies in 36 (88%) cases. Of these, 19 (53%) used misoprostol during their first trimesters. A stable marital status tended to be more frequent in the unexposed group (P=0.051). Incomplete elementary school education was reported by two (11%) mothers in the exposed group and by three (14%) mothers in the unexposed group (P=0.538). The mothers' gestational exposures to cocaine, marijuana, alcohol, and cigarettes were similar in both groups (P=0.297, P=0.297, P=0.428, and P=0.444, respectively). One (5%) case of Rubella infection during pregnancy was found in the unexposed group. The main malformations in the exposed and unexposed groups were the following: strabismus (72% and 77%, respectively), lack of emotional tearing (47% and 36%, respectively), and lagophthalmos (32% and 41%, respectively). Conclusion: Stable marital statuses tended to be more frequent among mothers that did not take misoprostol during pregnancy. Exposures to other teratogens and the main ocular abnormalities were similar in both groups.

Amniotic membrane for reducing the formation of adhesions in strabismus surgery: experimental study in rabbits.

PURPOSE: To evaluate the effect of amniotic membrane in reducing inflammation, fibrosis, adhesion formation, and ocular motility restrictions following strabismus surgery. METHODS: In the first stage of this prospective, randomized study, 17 rabbits underwent superior rectus muscle recession in both eyes. Surgery was performed in the same manner, but human amniotic membrane was placed over the muscle without sutures in the right eye after recession. After 15 days, the rabbits were killed and their orbits were exenterated and evaluated histopathologically to quantify tissue inflammation and fibrosis. In the second stage, 5 rabbits underwent the same procedure but were killed after 30 days. A dynamometer was used to measure the force required to displace all eyes. RESULTS: At 15 days postoperatively, eyes with amniotic membrane exhibited an increased inflammatory response and less fibrosis than eyes without amniotic membrane. At 30 days postoperatively, eyes with amniotic membrane continued to exhibit increased inflammation and less fibrosis than eyes without amniotic membrane. In the dynamometer test, more force was needed to displace eyes without amniotic membrane after 15 days, but there was no significant difference between the forces required at 30 days. CONCLUSIONS: Human amniotic membrane in rabbits led to an increase in the inflammatory process and a decrease in fibrosis formation following strabismus surgery.

Teratogen exposure and congenital ocular abnormalities in Brazilian patients with Möbius sequence / Exposição à teratógenos e anormalidades oculares congênitas em pacientes brasileiros portadores da sequência de Möbius

Purpose: To assess the sociodemographic profiles, teratogen exposures, and ocular congenital abnormalities in Brazilian patients with Möbius sequence. Method: Forty-four patients were recruited from the Brazilian Möbius Sequence Society. This cross-section comprised 41 patients (age, mean ± standard deviation, 9.0 ± 5.5 years) who fulfilled the inclusion criteria. The parent or caregiver answered a questionnaire regarding sociodemographic data and pregnancy history. Patients underwent ophthalmological assessments. They were subdivided into groups according to misoprostol exposure during pregnancy, and the two groups were compared. Results: Mothers/caregivers reported unplanned pregnancies in 36 (88%) cases. Of these, 19 (53%) used misoprostol during their first trimesters. A stable marital status tended to be more frequent in the unexposed group (P=0.051). Incomplete elementary school education was reported by two (11%) mothers in the exposed group and by three (14%) mothers in the unexposed group (P=0.538). The mothers' gestational exposures to cocaine, marijuana, alcohol, and cigarettes were similar in both groups (P=0.297, P=0.297, P=0.428, and P=0.444, respectively). One (5%) case of Rubella infection during pregnancy was found in the unexposed group. The main malformations in the exposed and unexposed groups were the following: strabismus (72% and 77%, respectively), lack of emotional tearing (47% and 36%, respectively), and lagophthalmos (32% and 41%, respectively). Conclusion: Stable marital statuses tended to be more frequent among mothers that did not take misoprostol during pregnancy. Exposures to other teratogens and the main ocular abnormalities were similar in both groups. .

Objetivo: Descrever o perfil sóciodemográfico, exposição à teratógenos e anormalidades oculares congênitas em pacientes brasileiros portadores da sequência de Möbius Método: Quarenta e quatro pacientes recrutados da Sociedade Brasileira de Sequência de Möbius foram examinados. Este estudo transversal incluiu 41 pacientes que preencheram os critérios de inclusão do estudo (média das idades: 9,0 ± 5,5 anos). Mãe/responsável dos pacientes responderam a um questionário sobre perfil sóciodemográfico e história gestacional. Foi realizado exame oftalmológico de todos os pacientes. Eles foram agrupados em dois grupos de acordo com a exposição ao misoprostol durante a gestação e seus dados foram comparados. Resultados: Mães/responsáveis referiram gravidez indesejada em 36 (88%) dos casos. Destas, 19 (53%) fizeram uso de misoprostol no primeiro trimestre de gestação. Houve uma tendência do grupo de mães não expostas ao misoprostol de terem um estado civil estável (P=0,051). Duas (11%) mães do grupo de expostas ao misoprostol relataram primeiro grau incompleto e três (14%) do grupo de não expostas (P=0,538). A exposição das mães à cocaína, maconha, álcool e cigarro foi similar em ambos os grupos (P=0,297, P=0,297, P=0,428, P=0,444, respectivamente). Houve um caso (5%) de Rubéola no grupo de mães não expostas. As principais malformações associadas nos pacientes expostos e não expostos foram, respectivamente: estrabismo (72% e 77%), e diminuição da lágrima emocional (47% e 36%) e lagoftalmia (32% and 41%). Conclusão: Estado civil estável foi mais frequente em mães que não fizeram uso de misoprostol durante a gestação. Exposição à outros ...

Prevalence of refractive errors in Möbius sequence.

PURPOSE: To assess the prevalence of refractive errors in Möbius sequence. METHODS: This study was carried out during the Annual Meeting of the Brazilian Möbius Society in November 2008. Forty-four patients diagnosed with the Möbius sequence were submitted to a comprehensive assessment, on the following specialties: ophthalmology, neurology, genetics, psychiatry, psychology and dentistry. Forty-three patients were cooperative and able to undertake the ophthalmological examination. Twenty-two (51.2 %) were male and 21 (48.8%) were female. The average age was 8.3 years (from 2 to 17 years). The visual acuity was evaluated using a retro-illuminated logMAR chart in cooperative patients. All children were submitted to exams on ocular motility, cyclopegic refraction, and fundus examination. RESULTS: From the total of 85 eyes, using the spherical equivalent, the major of the eyes (57.6%) were emmetropics (>-0.50 D and <+2.00 D). The prevalence of astigmatism greater than or equal to 0.75 D was 40%. CONCLUSION: The prevalence of refractive errors, by the spherical equivalent, was 42.4% in this studied group.

Prevalence of refractive errors in Möbius sequence / Prevalência de erros refrativos na sequência de Möbius

PURPOSE: To assess the prevalence of refractive errors in Möbius sequence. METHODS: This study was carried out during the Annual Meeting of the Brazilian Möbius Society in November 2008. Forty-four patients diagnosed with the Möbius sequence were submitted to a comprehensive assessment, on the following specialties: ophthalmology, neurology, genetics, psychiatry, psychology and dentistry. Forty-three patients were cooperative and able to undertake the ophthalmological examination. Twenty-two (51.2 %) were male and 21 (48.8%) were female. The average age was 8.3 years (from 2 to 17 years). The visual acuity was evaluated using a retro-illuminated logMAR chart in cooperative patients. All children were submitted to exams on ocular motility, cyclopegic refraction, and fundus examination. RESULTS: From the total of 85 eyes, using the spherical equivalent, the major of the eyes (57.6%) were emmetropics (>-0.50 D and <+2.00 D). The prevalence of astigmatism greater than or equal to 0.75 D was 40%. CONCLUSION: The prevalence of refractive errors, by the spherical equivalent, was 42.4% in this studied group.

OBJETIVO: Avaliar a prevalência de erros refrativos em crianças portadoras da sequência de Möbius. MÉTODOS: Trabalho realizado durante o encontro anual da Associação Möbius do Brasil (AMoB) em novembro de 2008. Quarenta e quatro pacientes com diagnóstico de sequência de Möbius foram submetidos a avaliação multidisciplinar: oftalmológica, neurológica, genética, psiquiátrica, psicológica e odontológica. Quarenta e três pacientes colaboraram com exame oftalmológico. Vinte e dois (51,2 %) eram do sexo masculino e 21 (48,8 %) do sexo feminino. A idade média foi de 8,3 anos (2 a 17 anos). A medida da acuidade visual foi realizada com tabela logMAR retro-iluminada, nos pacientes que colaboravam. Todas as crianças foram submetidas a exame da motilidade ocular, refração sob cicloplegia e fundo de olho. RESULTADOS: Do total de 85 olhos estudados, usando o equivalente esférico, a maioria dos olhos (57,6%) são emétropes (>-0,50 D e <+2,00 D). A prevalência de astigmatismo maior que 0,75D foi 40%. CONCLUSÃO: A prevalência de erros refrativos, pelo equivalente esférico, no grupo estudado foi de 42,4%.

Bupivacaine and botulinum toxin to treat comitant strabismus.

PURPOSE: To evaluate the change in ocular motility and muscle thickness measured with ultrasonography after intramuscular injection of bupivacaine and botulinum toxin A. METHODS: Eight patients (five female) were enrolled to measure ocular motility prior and 1, 7, 30 and 180 days after one injection of 2 ml of 1.5% bupivacaine and 2.5 U of botulinum toxin A in agonist and antagonist muscles, respectively, of eight amblyopic eyes. Muscle thickness was measured prior and on days 1, 7 and 30 after injection using 10-MHz ultrasonography (eyelid technique). RESULTS: Mean change in alignment was 10 prism diopters after 180 days (n=6). An average increase of 1.01 mm in muscle thickness was observed after 30 days of bupivacaine injection and 0.28 mm increase was observed after botulinum toxin A injection, as measured by ultrasonography. Lateral rectus muscles injected with bupivacaine had a mean increase of 1.5 mm in muscle thickness. CONCLUSION: In this study, a change in ocular motility was observed after 180 days of intramuscular injection of bupivacaine and botulinum toxin in horizontal extraocular muscles. Overall, there was an increase of muscle thickness in both botulinum toxin A and bupivacaine injected muscles after 30 days of injection when measured by ultrasonography. This change was more pronounced on lateral rectus muscles after bupivacaine injection.

Bupivacaine and botulinum toxin to treat comitant strabismus / Bupivacaína e toxina botulínica para tratamento de estrabismo comitante

PURPOSE: To evaluate the change in ocular motility and muscle thickness measured with ultrasonography after intramuscular injection of bupivacaine and botulinum toxin A. METHODS: Eight patients (five female) were enrolled to measure ocular motility prior and 1, 7, 30 and 180 days after one injection of 2 ml of 1.5% bupivacaine and 2.5 U of botulinum toxin A in agonist and antagonist muscles, respectively, of eight amblyopic eyes. Muscle thickness was measured prior and on days 1, 7 and 30 after injection using 10-MHz ultrasonography (eyelid technique). RESULTS: Mean change in alignment was 10 prism diopters after 180 days (n=6). An average increase of 1.01 mm in muscle thickness was observed after 30 days of bupivacaine injection and 0.28 mm increase was observed after botulinum toxin A injection, as measured by ultrasonography. Lateral rectus muscles injected with bupivacaine had a mean increase of 1.5 mm in muscle thickness. CONCLUSION: In this study, a change in ocular motility was observed after 180 days of intramuscular injection of bupivacaine and botulinum toxin in horizontal extraocular muscles. Overall, there was an increase of muscle thickness in both botulinum toxinum A and bupivacaine injected muscles after 30 days of injection when measured by ultrasonography. This change was more pronounced on lateral rectus muscles after bupivacaine injection.

OBJETIVO: Avaliar a mudança na motilidade ocular e espessura dos músculos medida por ultrassonografia após injeção intramuscular de bupivacaína e toxina botulínica tipo A. MÉTODOS: Oito pacientes (5 mulheres) foram incluidos para avaliar a mudança na motilidade ocular antes e após 1, 7, 30 e 180 dias da injeção de 2 ml de bupivacaína 1,5% e 2,5 U de toxina botulínica tipo A nos músculos agonista e antagonista, respectivamente, de 8 olhos amblíopes. A espessura muscular foi medida antes após 1, 7, 30 dias da injeção através de ultrassonografia ocular 10-MHz (técnica palpebral). RESULTADOS: A média de mudança no alinhamento ocular foi igual a 10 dioptrias prismáticas após 180 dias (n=6). Foi observado um aumento médio de 1,01 mm na espessura muscular após 30 dias da injeção de bupivacaína e 0,28 mm após a injeção de toxina botulínica A medido pela ultrassonografia. Os músculos reto laterais injetados com bupivacaína tiveram um aumento médio de 1,5 mm na sua espessura. CONCLUSÃO: Neste estudo, observou-se uma mudança no alinhamento ocular após 180 dias de injeção intramuscular de bupivacaína e toxina botulínica A. Em geral, houve um aumento da espessura muscular de ambos os grupos de músculos injetados com toxina botulínica A e com bupivacaína após 30 dias da injeção. Essa mudança foi mais pronunciada nos músculos retos laterais após a injeção de bupivacaína.

Yamada's surgery for treatment of myopic strabismus fixus.

PURPOSE: Myopic strabismus fixus is characterized by acquired progressive esotropia and hypotropia associated with restricted elevation and abduction. Treatment is difficult, with recurrence of the large-angle esotropia even after surgery. The aim of this study was to describe two cases of myopic strabismus fixus successfully treated with Yamada's surgical technique. METHODS: Two patients with myopic strabismus fixus were submitted to hemitransposition of the superior rectus (SR) and lateral rectus (LR) muscles with scleral fixation at 7 mm from the limbus. In one patient, the hemitransposition was associated with ipsilateral MR muscle recess as described by Yamada, while in the other, botox injection into the MR muscle was performed. In both cases Yamada's procedure was associated with 4 mm resection of the hemitransposed portions of the SR and LR muscles to increase the muscular tonus and then improve surgical effects. RESULTS: The patient submitted to the MR recess presented with satisfactory ocular alignment after 6 months postoperative. The other patient submitted to botox injection at the MR muscle presented recurrent esotropia after 3 months. RM recess was then performed and an excellent ocular alignment was achieved. CONCLUSIONS: Yamada's surgical technique can provide acceptable ocular alignment in cases of myopic strabismus fixus. The surgical effects can be potentialized with resection of the hemitransposed portions of the SR and LR muscles. In addition, we demonstrated that botulinum toxin injection at the RM muscle is not an effective treatment in these cases.

[Botulinum toxin treatment for horizontal strabismus in children with cerebral palsy]. / Toxina botulínica no tratamento de estrabismo horizontal em crianças com paralisia cerebral.

UNLABELLED: To evaluate the efficacy of botulinum toxin injection in the treatment of horizontal strabismus in children with cerebral palsy. METHODS: A group of 24 patients, age 6 - 156 months, with cerebral palsy and horizontal strabismus (17 esotropias ranging from 25 to 45 PD and 7 exotropias ranging from 20 to 45 PD) were treated with botulinum toxin (34 medial rectus and 14 lateral rectus muscles). The children underwent full ophthalmic examination. The injection treatment was performed after sedation using Mendonça's forceps. The follow-up was done after 7 days, 15 days and monthly. Deviation less or equal of 10 PD after 6 months of follow-up was considered successful. However, if patients did not achieve this result a second application could be performed. RESULTS: In the group of esotropia (n=17) 47.1% had successful results with only one application after two years of follow-up. All of these patients had previous deviation less than or equal to 35 PD. In the exotropia group a single injection was not sufficient to achieve successful result. The side effects included: subconjutival hemorrhage in 4 (16.7%) patients, transient vertical deviation in 4 (16.7%) and transient ptosis in 22 (91.7%). CONCLUSION: The use of botulinum toxin was a good alternative in the treatment of children with cerebral palsy and esotropia.

Toxina botulínica no tratamento de estrabismo horizontal em crianças com paralisia cerebral / Botulinum toxin treatment for horizontal strabismus in children with cerebral palsy

OBJETIVO: Avaliar a eficácia da toxina botulínica no tratamento de estrabismo horizontal em crianças com paralisia cerebral. MÉTODOS: Um grupo de 24 pacientes com paralisia cerebral e estrabismo horizontal (17 esotropias variando de 25delta a 45delta e 7 exotropias variando de 20delta a 45delta), com idades variando entre 6 a 156 meses, foram tratadas com toxina botulínica (34 músculos retos mediais e 14 retos laterais). As crianças foram submetidas a exame oftalmológico completo. A injeção de toxina, utilizando-se a pinça de Mendonça, foi realizada sob sedação. O seguimento foi realizado mediante avaliação aos 7 dias, 15 dias e a seguir mensalmente. O resultado foi considerado bom quando se obteve desvio < 10delta após seis meses de seguimento. Caso o resultado não fosse satisfatório uma segunda aplicação poderia ser realizada. RESULTADOS: No grupo das esotropias, no seguimento de dois anos (n=17) 47,1 por cento tiveram bons resultados, com apenas uma aplicação de toxina botulínica. Todos estes pacientes tinham desvio prévio < 35delta. No grupo das exotropias, após a primeira aplicação, não foi encontrado qualquer resultado satisfatório no sexto mês de seguimento. Os efeitos colaterais foram: hemorragia subconjuntival em 4 pacientes (16,7 por cento), desvio vertical transitório em 4 pacientes (16,7 por cento) e blefaroptose transitória em 22 (91,7 por cento). CONCLUSÕES: O uso da toxina botulínica pode ser considerado como boa alternativa de tratamento em crianças com diagnóstico de paralisia cerebral e esotropia.

PURPOSE: To evaluate the efficacy of botulinum toxin injection in the treatment of horizontal strabismus in children with cerebral palsy. METHODS: A group of 24 patients, age 6 - 156 months, with cerebral palsy and horizontal strabismus (17 esotropias ranging from 25 to 45 PD and 7 exotropias ranging from 20 to 45 PD) were treated with botulinum toxin (34 medial rectus and 14 lateral rectus muscles). The children underwent full ophthalmic examination. The injection treatment was performed after sedation using Mendonça's forceps. The follow-up was done after 7 days, 15 days and monthly. Deviation less or equal of 10 PD after 6 months of follow-up was considered successful. However, if patients did not achieve this result a second application could be performed. RESULTS: In the group of esotropia (n=17) 47.1 percent had successful results with only one application after two years of follow-up. All of these patients had previous deviation less than or equal to 35 PD. In the exotropia group a single injection was not sufficient to achieve successful result. The side effects included: subconjutival hemorrhage in 4 (16.7 percent) patients, transient vertical deviation in 4 (16.7 percent) and transient ptosis in 22 (91.7 percent). CONCLUSION: The use of botulinum toxin was a good alternative in the treatment of children with cerebral palsy and esotropia.

[Electromyograph assistance and Mendonça's forceps--a comparison between two methods of botulinum toxin A injection into the extraocular muscle]. / Comparação entre os métodos de injeção de toxina botulínica em músculo ocular externo com o uso do eletromiógrafo e com o uso da pinça de Mendonça.

PURPOSE: To compare two methods of botulinum toxin A (BTA) injection into the extraocular muscle (EOM): the electromyographically (EMG) guided injection and the injection using Mendonça's forceps. METHODS: Twenty-nine (29) patients with strabismus and low visual acuity in one eye were examined at the Department of Ophthalmology of UNIFESP. They were divided into 2 groups -- group I with 17 patients receiving the botulinum toxin A injection using Mendonça's forceps, and group II with 12 patients receiving the toxin with electromyographical guidance. The patients of both groups were examined on the 7th and 14th day after intervention and the outcome of both methods of botulinum toxin A injection were compared. Friedman and Mann-Whitney correlation tests were used in the statistical analysis of the data. RESULTS: Although the follow-up examinations on the 7th and 14th days showed a different behavior between both methods, there was no statistically significant difference between the mean values of the correction attained in both groups at the end of this study. CONCLUSION: No statistically significant difference was shown between the two groups. Mendonça's forceps can be a safe alternative to electromyography to locate an extraocular muscle for botulinum toxin A injection.

Comparação entre os métodos de injeção de toxina botulínica em músculo ocular externo com o uso do eletromiógrafo e com o uso da pinça de Mendonça / Electromyograph assistance and Mendonça's forceps - a comparison between two methods of botulinum toxin A injection into the extraocular muscle

OBJETIVO: Comparar dois métodos de aplicação de toxina botulínica A (TBA) em músculo ocular externo: com auxílio de eletromiógrafo (EMG) e com a pinça de Mendonça. MÉTODOS: Foram analisados no Departamento de Oftalmologia da UNIFESP 29 pacientes que apresentavam estrabismo e baixa acuidade visual em um olho. Foram divididos em dois grupos: grupo I - 17 pacientes que receberam a toxina botulínica A por meio de injeção com auxílio da pinça de Mendonça e grupo II - 12 pacientes que receberam a toxina botulínica A por injeção guiada pelo eletromiógrafo. Os pacientes dos dois grupos foram avaliados no 7º e no 14º dia após aplicação. Compararam-se os resultados dos dois grupos neste período de tempo. Os testes de correlação de Friedman e Mann-Whitney foram usados para análise estatística. RESULTADOS: Houve diferença estatística entre as médias de desvio pré-aplicação e em pelo menos um período (7º ou 14º dia) após aplicação, tanto no grupo dos pacientes em que foi utilizada a pinça, quanto no grupo de pacientes em que foi utilizado o eletromiógrafo. Não houve diferença estatística dos desvios pré-aplicação e pós-aplicação entre os dois grupos. CONCLUSAO: Os dois métodos de aplicação da toxina botulínica A são equivalentes e portanto, o uso da pinça de Mendonça pode ser método alternativo ao uso do eletromiógrafo, para guiar a injeção de toxina botulínica A.

Toxina botulínica no tratamento de estrabismo horizontal em crianças com paralisia cerebral / Botulinum toxin treatment for horizontal strabismus in children with cerebral palsy

Objetivo: Avaliar a eficácia da toxina botulínica no tratamento de estrabismo horizontal em crianças com paralisia cerebral. Métodos: Um grupo de 24 pacientes com paralisia cerebral e estrabismo horizontal (17 endotropias variando de 25 a 45 e sete exotropias variando de 20 a 45), com idades variando entre seis a 156 meses, sendo 15 (62,5 por cento) do sexo masculino e nove (37,5 por cento) do sexo feminino, foram tratadas com toxina botulínica (34 músculos retos mediais e 14 retos laterais). As crianças foram submetidas a exame oftalmológico completo. A dose da droga utilizada em cada músculo variou de 2,0 U a 6,0 U. A injeção de toxina, utilizando-se a pinça de Mendonça, foi realizada sob sedação (anestesia inalatória com máscara de sevoflurano 4 a 5 por cento). 0 seguimento foi realizado através de avaliação aos sete dias, 15 dias e a seguir mensalmente. 0 resultado foi considerado bom quando se obteve desvio <_ a 10 após seis meses de seguimento. Caso o resultado não fosse satisfatório uma segunda aplicação poderia ser realizada. Resultados: No grupo das endotropias, no seguimento de dois anos (n=10) 70 por cento tiveram bons resultados, com apenas uma aplicação de toxina botulínica. Todos estes pacientes tinham desvio prévio <_ 35. No grupo das exotropias, após a primeira aplicação, não foi encontrado qualquer resultado satisfatório no sexto mês de seguimento. Os efeitos colaterais foram: hemorragia subconjuntival em 4 pacientes (16,7 por cento), desvio vertical transitório em 4 (16,7 por cento) e blefaroptose transitória em 22 (91,7 por cento). Na medida da fenda palpebral, pré e pós-aplicação de toxina botulínica foi encontrada diferença estatisticamente significante. Conclusões: 0 uso da toxina botulínica pode ser considerado como uma boa alternativa de tratamento em crianças com diagnóstico de paralisia cerebral e desvio horizontal. Neste estudo a exemplo do que se observa na literatura, os resultados obtidos no grupo das endotropias foi melhor do que aqueles do grupo das exotropias, principalmente quando o desvio prévio era...

Ambliopia anisometrópica / Anisometropic amblyopia

Os autores estudaram 79 casos de pacientes portadores de anisometropia e relacionaram severidade da anisometropia com graus de ambliopia, tipos de erros refrativos, posiçäo dos olhos e os resultados finais do tratamento. Foi observado um maior número de pacientes com ausência de ambliopia 11 (33,3/100) nos casos de anisometropia pequena. Como resultado relacionado à acuidade visual, tivemos: 17 (21,5/100) com resultado classificado como ótimo, 25 (31,6/100) como melhor, 1 (1,3/100) como pior e 11 (13,9/100) como inalterado. Os autores enfatizaram a necessidade da detecçäo precoce da ambliopia e da orientaçäo aos pais