Eyeglasses for Children - a Survey of Daily Practice.

BACKGROUND: Glasses for children are recommended and prescribed by different groups of professionals. We set out to compare the prescription practices of ophthalmologists, orthoptists and optometrists/opticians in Switzerland. METHODS: Online questionnaire on the prescription and recommendation of glasses in fictitious cases of children of different ages, refractive values and symptoms. The questionnaire was sent out to members of the Swiss Ophthalmological Society, Swiss Orthoptics and Schweizerischer Berufsverband für Augenoptik und Optometrie. RESULTS: 307 questionnaires were analysed. Optometrists/opticians recommended glasses with a significantly smaller cycloplegic refraction value (p < 0.005) than did orthoptists and ophthalmologists. In the example of a 14-year-old asymptomatic child, ophthalmologists recommended glasses at + 2.64 [Dpt], orthoptists at + 2.44 [Dpt] and optometrists/opticians at + 1.32 [Dpt]. Optometrists/opticians tended to recommend slightly higher correction values in glasses than did ophthalmologists and orthoptists. CONCLUSION: In Switzerland, optometrists/opticians recommend glasses with significantly smaller cycloplegic refraction values than do orthoptists and ophthalmologists, regardless of age or symptoms described in these fictitious cases.

Malposition of Teeth and Jaws in Patients with Congenital Superior Oblique Palsy.

BACKGROUND: Patients with congenital superior oblique palsy tend to adopt a head tilt to the contralateral side to maintain binocular single vision. It has long been recognised that facial asymmetries may be caused by a head tilt. The aim of this study was to describe the effect of habitual head tilt due to congenital superior oblique palsy on dental occlusion. PATIENTS AND METHODS: The study was designed as a descriptive cohort study. Ten patients with congenital superior oblique palsy (3 female, 7 male; mean age 51.7 (y) ± 15.8 SD, ranging from 19 to 69 (y)) underwent orthodontic examination. Orthodontic findings and values for vertical, torsional and horizontal deviation measured with the Harms tangent screen and stereopsis using a random dot test were compared. RESULTS: Three orthodontic parameters were found to correlate significantly or at least as trend with orthoptic parameters. Midline deviation of the upper jaw to the face (rho = 0.623; p = 0.054) and anterior positioning of upper first molar in the sagittal plane (rho = 0.594; p = 0.07) correlate with the vertical deviation; overbite correlates with horizontal deviation measured in the primary position (rho = 0.768; p = 0.016). CONCLUSIONS: In this small study, three orthodontic parameters correlated with orthoptic findings in patients with congenital superior oblique palsy. Further studies are needed to establish whether congenital superior oblique palsy is more frequent in patients exhibiting abnormal values of these orthodontic parameters.

Long-term effect of selective laser trabeculoplasty on intraocular pressure in pseudoexfoliation glaucoma.

BACKGROUND: Selective laser trabeculoplasty has been found to be effective as an adjunct to topical medical therapy in glaucoma. This analysis examines the intraocular pressure lowering effect of laser trabeculoplasty in eyes with pseudoexfoliation on maximum medical therapy. MATERIAL AND METHODS: A retrospective chart review was undertaken of 457 eyes of which 344 underwent a 360° selective laser trabeculoplasty treatment between 2008 and 2013. 94 of these eyes had pseudoexfoliation. Intraocular pressure values were analysed in 3 monthly intervals up to 60 months after selective laser trabeculoplasty. Exclusion criteria were narrow or closed angles as well as uveitic glaucoma and previous intraocular pressure lowering surgery. RESULTS: Patients mean age was 71 years±11.0 SD, 42.7% were male. At time point 12 months after selective laser trabeculoplasty the intraocular pressure lowering effect was significantly greater in eyes with pseudoexfoliation than in eyes without pseudoexfoliation (p=0.01; Mann-Whitney test). Up to 21 months after selective laser trabeculoplasty a significant intraocular pressure reduction of 2.76 mmHg±3.72 SD compared to baseline values could be seen in eyes with pseudoexfoliation (p=0.01; Wilcoxon Test). CONCLUSIONS: In this retrospective study a significant greater intraocular pressure lowering effect of selective laser trabeculoplasty could be seen in eyes with pseudoexfoliation compared to eyes without pseudoexfoliation only at time point 12 months after selective laser trabeculoplasty. Analyses revealed no significant intraocular pressure reduction compared to baseline values after 21 months in eyes with pseudoexfoliation and after 30 months in eyes without pseudoexfoliation.

[Three horizontal muscle surgery for infantile esotropia and decompensated microtropia]. / Horizontale Dreimuskelchirurgie bei frühkindlichem Innenschielen und dekompensiertem Mikrostrabismus.

BACKGROUND: Surgical management of large-angle infantile esotropia and decompensated microtropia has been controversially debated. There seems to be a relative bias against surgery on more than two horizontal muscles to avoid overcorrections. In our study we report on the sensory and motor outcomes after three horizontal muscle surgery. Furthermore we aim to suggest a table to guide surgery amounts. PATIENTS AND METHODS: This study was a retrospective interventional cohort of 27 patients (16 female, 11 male; mean age 7.9 [years], ranging from 1 to 27 [years]) with infantile esotropia and decompensated microtropia who underwent three horizontal muscle surgery (bilateral medial rectus muscle recession and lateral rectus muscle plication) between 2005 and 2013. RESULTS: Preoperative deviation in primary position measured 30.2 [°] (mean; range 21.9 to 48.0). Postoperatively esotropia was significantly reduced to 2.6 [°] (mean; range -16.7 to 16.7). After six months deviation measured 5.5 [°] (mean, range -14.1 to 21.9). An effect of 1.63°/mm was calculated for the combined three muscle surgery. CONCLUSIONS: For the correction of large-angle infantile esotropia and decompensated microtropia three horizontal muscle surgery is associated with a high success rate. Only a very low rate of consecutive exotropia does occur.

Measurement of Optic Nerve Sheath Diameter: Differences between Methods? A Pilot Study.

BACKGROUND: Quantification of the optic nerve sheath diameter is a promising approach for the detection of elevated intracranial pressure. The comparability of current methods is unclear. The objective of this study was to assess the relationship between optic nerve sheath diameter as measured with computed tomography, magnetic resonance tomography and ultrasound in patients without known optic nerve disease or increased intracranial pressure. PATIENTS AND METHODS: 15 patients (60.8 [years]±16.73 SD; 7 female) with paranasal sinus pathology in whom computed tomography and magnetic resonance imaging were performed underwent optic nerve sheath diameter measurements by ultrasound, as well as an ophthalmological examination. Ultrasound-, computed tomography- and magnetic resonance imaging-derived maximal optic nerve sheath diameter values 3 mm behind the globe were compared. RESULTS: Optic nerve sheath diameter measured (n=30) by ultrasound (mean 6.2 [mm]±0.84 SD) was significantly (p<0.01) higher than optic nerve sheath diameter in computed tomography (5.2±1.11) or magnetic resonance imaging (5.3±1.14). There was no significant (p=0.24) difference between optic nerve sheath diameter measured in computed tomography and magnetic resonance tomography. CONCLUSIONS: The comparability of optic nerve sheath diameter measurements in patients without known optic nerve disease and assumed normal intracranial pressure appears to be given between computed tomography and magnetic resonance tomography, while comparability between ultrasound and computed tomography or magnetic resonance tomography seems to be less reliable.

Long-term efficacy of selective laser trabeculoplasty in patients on prostaglandin therapy.

BACKGROUND: The aim of the study was to analyse the efficacy of selective laser trabeculoplasty in patients on medical therapy and to evaluate a possible influence of prostaglandin therapy on intraocular pressure reduction. PATIENTS AND METHODS: A retrospective chart review was undertaken of patients with ocular hypertension or open angle glaucoma who underwent selective laser trabeculoplasty between 3/2008 and 12/2010. Data were collected preoperatively, on the day of intervention, 1 day, 1 month and then every 3 months post selective laser trabeculoplasty. The main outcome measure was mean intraocular pressure reduction. RESULTS: 109 eyes (76 on prostaglandins) were included. Mean preoperative intraocular pressure was 22.3 ± 4.5 mmHg (prostaglandin naïve) and 19.2 ± 4.8 mmHg (on prostaglandin) (p=0.003). Up to 1 year follow-up, intraocular pressure was statistically significantly reduced in both groups (p ≤ 0.019). Eyes with a higher preoperative intraocular pressure had a greater pressure reduction (Spearman rho=0.387, p=0.002). Eyes naïve to prostaglandins initially had a greater reduction in intraocular pressure, although after 1 year of follow-up the difference was no longer statistically significant. CONCLUSIONS: Selective laser trabeculoplasty significantly reduces intraocular pressure in patients already on medical therapy. A sustained influence of prostaglandin therapy on the efficacy of selective laser trabeculoplasty was not found.

Long-term efficacy of selective laser trabeculoplasty in pseudophakic patients - a "real-life" analysis.

BACKGROUND: The aim of this study was to report on the course and long-term effect of selective laser trabeculoplasty on intraocular pressure of pseudophakic patients suffering from open angle glaucoma or ocular hypertension with insufficient intraocular pressure lowering despite maximally tolerated topical and systemic intraocular pressure lowering medication. PATIENTS AND METHODS: A retrospective chart review of patients who underwent selective laser trabeculoplasty (360°) between 2008 and 2010 at the University hospital Zurich was undertaken. Intraocular pressure values before intervention, on the day of the intervention, 1 day, 1 month, 3 months and every 3 months up to 43 months after the intervention were analysed with respect to lens status. RESULTS: Out of 153 treated eyes of 111 patients (mean age 70.6 years ± 11.13 SD) 40 were pseudophakic. Mean baseline intraocular pressures were 19.00 mmHg ± 4.61 in the pseudophakic group and 20.12 mmHg ± 4.89 in the phakic group. One month after selective laser trabeculoplasty intraocular pressure reduction measured between -0.33 and -4.10 mmHg (CI 95%) in the pseudophakic group and between -3.64 and -5.58 mmHg (CI 95%) in the phakic group, the difference at this time point was significant (p=0.01). Beyond one month after selective laser trabeculoplasty there was no statistically significant difference in intraocular pressure reduction between pseudophakic and phakic patients. The mean decrease in intraocular pressure from baseline to the last follow-up of 43 months was 0.67 mmHg in the pseudophakic group and 0.25 mmHg in the phakic group (p=0.72). CONCLUSIONS: One month after selective laser trabeculoplasty pseudophakic patients showed a statistically significant diminished reduction of intraocular pressure compared to phakic patients. Later on there was no statistically significant difference in intraocular pressure reduction between pseudophakic and phakic patients. Therefore we conclude that there was no clinically relevant influence of pseudophakia on the long-term effect of selective laser trabeculoplasty.

Inferior oblique muscle anteriorization in congenital superior oblique palsy.

BACKGROUND: Inferior oblique muscle overaction of variable amounts is usually present with congenital superior oblique palsy. Inferior oblique muscle anteriorization has been described as a suitable surgical procedure in this entity. The aim of this study was to investigate the effect of inferior oblique muscle anteriorization in patients with congenital superior oblique palsy on vertical, torsional and horizontal alignment. PATIENTS AND METHODS: The study was designed as an institutional retrospective cohort study. 45 patients with congenital superior oblique palsy (15 female, 30 male; mean age 36 years ± 19.2 SD, ranging from 6 to 75 years) underwent inferior oblique muscle anteriorization between 2000 and 2010. Preoperative amounts of vertical, torsional and horizontal deviation (using Harms tangent screen), measurements of Bielschowsky head tilt phenomenon as well as stereopsis (Lang test) were compared with findings three months and one year postoperatively. RESULTS: Preoperative vertical deviation in primary position measured 10.1° (mean; range 0-19). Three months postoperatively vertical deviation was significantly reduced (p<0.001) to 4° (mean; range 0-20). After one year vertical deviation measured 3.5° (mean; range 0-15). The values three months postoperatively did not significantly differ from those one year postoperatively (p=0.46). CONCLUSIONS: Inferior oblique muscle anteriorization leads to a significant and sustained improvement of ocular alignment in patients with congenital superior oblique palsy of various degrees of severity. Thus the procedure is recommendable as a first line treatment in this clinical situation.

Early onset of acquired comitant non-accommodative esotropia in childhood.

BACKGROUND: The aim of this study was to describe the clinical characteristics and surgical outcome of acquired comitant non-accommodative esotropia without obvious cause in children with an early onset ≤ three years of age. PATIENTS AND METHODS: 24 consecutive patients (13 females) with acquired comitant non-accommodative esotropia underwent strabismus surgery. Outcome measures included amount of deviation and level of binocularity at last follow-up. RESULTS: An acute onset of strabismus was observed in 83 % of patients. Accompanying features such as diplopia, covering one eye or stumbling were observed in 40 % of the children. Cycloplegic retinoscopy revealed a mild to moderate hypermetropia in all children (mean hypermetropia + 2.2 diopters). 90.5 % of children were aligned within 8 PD of orthotropia. 81 % regained normal stereovision (Lang I/II). CONCLUSIONS: All children exhibited the typical features of acute acquired comitant esotropia (AACE) type II (Burian-Franceschetti). Collective characteristics of this form of strabismus are a comitant and relatively large deviation, mild hypermetropia, a potential of normal binocular cooperation and absence of an accommodative component and neurological pathology. Time and suddenness of strabismus onset may be less helpful in defining this entity.

Early detection of Best's disease in childhood due to ineffective orthoptic treatment.

BACKGROUND: A meticulous fundoscopy is an essential examination before administering an orthoptic occlusion therapy (patching), even in cases with a "clear indication" for patching. In this case of an 8-year-old hyperopic boy the subsequent fundoscopy revealed a bilateral maculopathy that explained the stagnation of the increase of the monocular visual acuity (VA) in spite of a correctly applied patching. HISTORY AND SIGNS: The patient was a boy (8 years old) with a history of ineffective orthoptic treatment for 15 months due to hyperopia. Complete ophthalmological examination, optical coherence tomography (Cirrus HD-OCT, Zeiss, Germany) and electro-oculography (EOG) were performed. No "everyday" symptoms were found. Best corrected VA (hyperopic) on the right was 10 / 20, on the left 8 / 20. Binocular VA was 20 / 20. 15 out of 15 Ishihara plates were identified on both sides. Orthophoria has been seen. Perimetry revealed bilateral nasal-parafoveal microscotoma. Fundoscopy showed a confined and slightly prominent yellow spot on the temporal side of the fovea. OCT revealed a subfoveal accumulation of solid material in the RPE in both eyes. EOG showed normal findings in our case. THERAPY AND OUTCOME: There was no further deterioration of VA in a follow-up time of 12 months. CONCLUSIONS: Ineffective orthoptic treatment (patching) in amblyopic children should prompt the ophthalmologist to a meticulous fundoscopy, even if done so before patching, which is highly recommended. This young patient had no "everyday" visual symptoms. Because mainly the temporal fovea on both sides was affected, he showed normal binocular VA inspite of bilateral VA reduction. The authors think that this effect is due to biretinal summation (retinal filling in).

Optic nerve compartment syndrome in a patient with optic nerve sheath meningioma.

PURPOSE: To report a patient with optic nerve (ON) sheath meningioma, unilateral optic disc swelling, and inhomogeneous cerebrospinal fluid (CSF) composition between lumbar CSF and CSF from the subarachnoid space (SAS) of the affected ON. METHODS: A 39-year-old woman presented with unilateral optic disc swelling and slight deterioration of visual function in the left eye. Extensive laboratory workup and magnetic resonance imaging (MRI) of the brain and orbits were performed. As radiotherapy was refused by the patient, ON sheath fenestration (ONSF) was offered and performed in order to stop deterioration. CSF from the SAS of the ON was sampled. RESULTS: Laboratory workup was within normal limits. MRI of the left orbit demonstrated enhancement of the dura in the precanalicular portion of the ON and distension of the SAS, most prominent in the bulbar portion of the ON. On lumbar puncture the opening pressure measured 19 (cm H2O). Compared to the lumbar CSF the CSF of the affected ON SAS showed markedly elevated measurements for albumin, IgG, and beta-trace protein. Visual function remained stable over a follow-up time of 18 months. CONCLUSIONS: Composition of CSF is considered to be homogenous throughout all CSF spaces. In this patient the authors found a marked concentration-gradient of albumin, IgG, and beta-trace protein between the CSF in the spinal canal and the CSF in the SAS of the affected ON. Based on the radiologic features of the left ON and the dissociated beta-trace protein concentrations in the CSF of the SAS of the ON and the lumbar CSF, the diagnosis of an ON sheath compartment syndrome due to an ON sheath meningioma was made.

Cerebrospinal fluid dynamics between the intracranial and the subarachnoid space of the optic nerve. Is it always bidirectional?

CSF is thought to flow continuously from the site of production in the ventricles into interconnected spaces; i.e. cisterns and subarachnoid spaces (SASs). Since the SAS of the optic nerve is defined by a cul-de-sac anatomy, it is not evident how local CSF might recycle from that region to the general SAS. The concept of free communication of CSF has recently been challenged by the description of a concentration gradient of beta-trace protein, a lipocalin-like prostaglandin d-synthase (L-PGDS), between the spinal CSF and that in the SAS of the optic nerve, indicating diminished local clearance or local overproduction of L-PGDS here. In fact, computed cisternography with a contrast agent in three patients with idiopathic intracranial hypertension and asymmetric papilloedema demonstrate a lack of contrast-loaded CSF in the SAS of the optic nerve despite it being present in the intracranial SAS, thus suggesting compartmentation of the SAS of the optic nerve. The concept of an optic nerve compartment syndrome is further supported by a concentration gradient of brain-derived L-PGDS between the spinal CSF and the CSF from the optic nerve SAS in the same patients.

The optic nerve: a new window into cerebrospinal fluid composition?

Cerebrospinal fluid (CSF) pressure and composition are generally thought to be homogeneous within small limits throughout all CSF compartments. CSF sampled during lumbar puncture therefore should be representative for all CSF compartments. On the basis of clinical findings, histology and biochemical markers, we present for the first time strong evidence that the subarachnoid spaces (SAS) of the optic nerve (ON) can become separated from other CSF compartments in certain ON disorders, thus leading to an ON sheath compartment syndrome. This may result in an abnormal concentration gradient of CSF molecular markers determined in locally sampled CSF compared with CSF taken during lumbar puncture.