The impact of stoma for bowel management after spinal cord injury.

STUDY DESIGN: Multi-centre, retrospective self-report postal survey. OBJECTIVES: To characterise spinal cord injured (SCI) individuals with a stoma, their stoma management and outcomes, to identify sources of information and support for decision making and to explore the impact of a stoma on life satisfaction. SETTING: Five UK spinal cord injury centres. METHODS: A study-specific questionnaire accompanied by self-concept, life satisfaction and mood measures, and three simple rating scales for satisfaction, impact and restriction on life were sent to all known ostomates at five participating centres. RESULTS: Respondents were 92 individuals, mean age 56 years, mean duration of injury 26 years, 91% with colostomy. Multiple sources of information were utilised in deciding on surgery; discussion with other SCI ostomates was important. Duration of bowel care, faecal incontinence, bowel-related autonomic dysreflexia, dietary manipulation and laxative use were all significantly reduced following surgery. Rectal mucous discharge was the most common and bothersome post-stoma problem. Satisfaction with stoma was high; provision of sufficient information preoperatively was important, those with ileostomy were more dependent and less satisfied. Life satisfaction and physical self-concept were both lower in this sample than in previously reported samples of SCI individuals without reported bowel difficulties or stoma. CONCLUSION: The findings of this study of self-selected respondents with a stoma for bowel management after SCI emphasised the benefits of stoma in selected individuals and the importance of timely intervention, the complexity of the associated decision-making and of preoperative counselling. The impact of bowel dysfunction on physical self-concept warrants investigation.

Emmetropisation in normal and strabismic children and the associated changes of anisometropia.

The purpose of this study was to measure whether emmetropisation failed in children who had strabismus irrespective of their refraction in infancy, and to record simultaneous changes in anisometropia. We also report how often hypermetropia increased before these children presented with esotropia. A total of 2920 infants had a cycloplegic retinoscopy at age 5-7 months and again at 42 months or when defective vision was identified. Changes of refraction in 210 children with strabismus are compared with the remaining 2710 who did not. When the spherical equivalent of the fixing eyes was > +2.75 D in infancy, hypermetropia decreased less in both eyes of those who had microtropia (p <.001) and heterotropia (p <.001) than in normal children. When it was < +2.75 D, the spherical and/or cylindrical refraction more often remained outside the 'normal' range in both eyes of those who had microtropia and heterotropia (p <.05). Emmetropisation was deficient in both eyes of at least 80% of these strabismic children irrespective of their refraction in infancy. Furthermore, in the strabismic children, the mean change of refraction was less (p <.05) in their fellow eyes than in their fixing eyes, the difference between the two eyes being on average three times greater than that in those who had normal vision. Thus, anisometropia increased in 53% of those who had strabismus but remained within normal limits (< ca. 0.75 D spherical equivalent) in 94 % of those who did not. 'Abnormal' anisometropia in infancy did not, per se, permanently affect vision because 72% of all those who had it did not have strabismus. Finally, the spherical hypermetropia of fixing eyes increased in only 35% of the children with esotropia - similar to the incidence in those who had a microtropia (p =.36). This does not obviously support the concept that increasing hypermetropia causes accommodation to increase before convergence.

Reduction of astigmatism after infancy in children who did and did not wear glasses and have strabismus.

The purpose of this study was to record and explain the changes in astigmatism as normal and strabismic infants grew. Two-hundred-and-eighty-nine hypermetropic infants were randomly allocated to wear glasses from the age of six months. Changes in astigmatism and in hypermetropia of the horizontal and vertical meridia were compared in those who did and did not wear glasses and have strabismus. Mean astigmatism decreased significantly (p < 0.001) in both eyes of normal and strabismic children, but the 'last' astigmatism was significantly (p < 0.001) larger in both eyes of those who had strabismus. There was a similar progressive decrease of hypermetropia in both meridia of both eyes within each diagnostic group, but with the exception of the vertical meridian of the non-fixating eyes (in which the difference approached statistical significance), this was significantly (p < 0.01) larger in the normal children. The consistent wear of glasses was not associated with change in both meridia of both eyes in the normal children (p < 0.005), but had no significant effect on the changes in astigmatism. Since the changes in the two meridia were proportional to the starting level, hypermetropia decreased more in the meridian which was, initially, the more hypermetropic one, and the difference between them, i.e. astigmatism, tended to disappear whether or not the child eventually had strabismus.

Effect of spectacles on changes of spherical hypermetropia in infants who did, and did not, have strabismus.

AIM: To explore why emmetropisation fails in children who have strabismus. METHODS: 289 hypermetropic infants were randomly allocated spectacles and followed. Changes in spherical hypermetropia were compared in those who had strabismus and those who did not. The effect of wearing glasses on these changes was assessed using t tests and regression analysis. RESULTS: Mean spherical hypermetropia decreased in both eyes of "normal" children (p<0.001). The consistent wearing of glasses impeded this process in both eyes (p<0.007). In the children with strabismus, there were no significant changes in either eye, irrespective of treatment (p>0. 05). CONCLUSIONS: In contrast with normal infants, neither eye of those who had strabismus emmetropised, irrespective of whether the incoming vision was clear or blurred. It is suggested that these eyes did not "recognise" the signal of blurred vision, and that they remained long sighted because they were destined to squint. Hence, the children did not squint because they were long sighted, and glasses did not prevent them squinting.

Emmetropisation and accommodation in hypermetropic children before they show signs of squint--a preliminary analysis.

1119 hypermetropic children have been followed from the age of 6 months to 3 1/2 years. Observations are reported on (i) the changes in their refraction and (ii) their accommodation. Children who eventually had either a convergent squint or a microtropia were significantly (i) less likely to have spontaneously reduced their hypermetropia, and (ii) more likely to have problems with their accommodation, than those who had no squint. These abnormalities were demonstrated in both the fixing and the non-fixing eyes. There was no obvious difference between the findings for children who had microtropia and squint. We suggest that there was a basic defect in the function, and/or the development, of the visual systems relating to both fixing and non-fixing eyes of children who had squint or microtropia; and that this defect was present before squint or microtropia were diagnosed. The question of whether this defect had a congenital or an acquired (form vision deprivation) cause is discussed.

Emmetropisation, squint, and reduced visual acuity after treatment.

In a sample of children used to assess the value of optical correction of hypermetropia from the age of 6 months the refraction of the most hypermetropic meridian frequently became less than 3.5 D as the children grew. When this occurred, the incidence of squint was significantly less (p less than 0.001) and the last known acuity after treatment was significantly better (p less than 0.001) than when it did not. This process of emmetropisation appears to have been impeded by the consistent wearing of hypermetropic spectacle correction from the age of 6 months.

Results of a randomised trial of treating abnormal hypermetropia from the age of 6 months.

Children who were abnormally hypermetropic at the age of 6 months were randomly allocated treatment with spectacles or no treatment. The eventual incidence of squint was the same in both groups (approximately 24%). The last known visual acuity of the two groups was not significantly different either. Therefore there is no indication to screen infants with a view to preventing squint/amblyopia by optical correction of hypermetropia. If, however, the children allocated treatment are divided into two subgroups--those who wore glasses consistently and those who probably or certainly did not do so--the incidence of squint was the same, but the last known acuities of those who consistently wore glasses may be better than those who did not do so. This suggests that it may yet prove possible to prevent severe amblyopia.

Factors relating to visual acuity in children who have been treated for convergent squint.

Retrospective analysis of a selected sample of children who presented with convergent squint has shown that abnormal meridional hypermetropia (3.5 D or more) at age 1 was the principal factor associated with severe amblyopia (6/24 or less) remaining after conventional treatment. Neither the reported age of onset nor delay in presentation influenced the final visual outcome.

Review of children referred from the school vision screening programme in Kettering during 1976-8.

The progress of 108 children who were identified by the vision screening programme in school as having defective vision (excluding those with puberty onset myopia) was reviewed. Treatment of these children resulted in improvement in visual acuity of the worst eye (two lines or better) for 16 children. Eighteen children had severe amblyopia (6/24 or worse). Among these the vision of only five was improved by treatment. Two thirds of the children had refractive errors in the better eye which required correction. It seems sensible to identify and treat children with bilateral refractive errors, but the need to treat children with lesser degrees of amblyopia is questioned.

Prediction of amblyopia and squint by means of refraction at age 1 year.

In this series amblyopia, uncorrectable by spectacles and occlusion, was highly likely (48%) if a child had +3.50 or more dioptres of meridional hypermetropia at age 1 year. 45% of children with this refraction also had a squint. All those who remained with severely defective acuity in spite of treatment had either +3.50 or more dioptres of meridional hypermetropia or 4 or more dioptres of meridional myopia at age 1 year. These children were identifiable in the 3.7% of the population at age 1 year who showed high refractive errors. Squint as such was not so accurately predictable. Of those children with squint 71% had less than +3.50 dioptres of meridional hypermetropia at age 1 year--an incidence of 4.4% of the population. Apart from two 'congenital myopes' only 16% of these had residual amblyopia after treatment, and their last known acuity was never less than 6/12. Astigmatism in infancy or later is not significantly associated with squint or amblyopia.

Screening for visual defects in preschoolchildren.

There is no evidence to support the suggestion that a widespread programme of vision screening at age 3 1/2 should be instituted. Some of the practical problems and defects of such a programme are outlined. If the issues raised are to be resolved by further research, identification of preschoolchildren who have visual problems will be facilitated by a screening procedure involving refraction and possibly a cover test.

A first attempt to prevent amblyopia and squint by spectacle correction of abnormal refractions from age 1 year.

Spectacle correction of unusually hypermetropic refractions from age 1 year did not reduce the incidence of squint or amblyopia, nor did it lead to a reduction in the severity of residual amblyopia after subsequent occlusion.

Acute glaucoma: results of treatment by bilateral simultaneous iridectomy, now without admission to hospital.

Medical treatment followed by bilateral simultaneous iridectomy appears to be an effective basis for managing a patient who presents with acute glaucoma. Admission to hospital is seldom necessary. There was minimal evidence that delay in starting treatment caused more sight to be lost, but as the patient's age increased the prognosis for recovery of sight in an affected eye decreased quite significantly. The long-term prognosis for the sight of an individual patient who has had prophylactic iridectomy in the unaffected eye is excellent.

Changing workload in ophthalmology: some observations from routine statistics.

Children with squints and old people with cataracts account for most of the work of ophthalmologists. Recent demographic changes have led to fewer children and more elderly patients needing treatment. So far the increased workload has been met by shortening the time patients spend in hospital, but with striking variations between districts.

Day-case cataract surgery.

The results of 501 day-case cataract extractions are presented. This is a safe way to manage an operation for which there will be an increased demand. Only 13% of these patients stated that they would have preferred to stay in hospital after surgery.