Changes of saccadic eye movements in thyroid-associated ophthalmopathy.

PURPOSE: To establish whether or not the dynamics of saccadic eye movements are significantly changed in patients with different stages of thyroid-associated ophthalmopathy (TAO) and, subsequently, if analysis of saccades could serve as an additional diagnostic tool for early detection of inflammatory activity in TAO. METHODS: Thirty-seven patients with TAO and 10 age- and gender-matched control subjects were investigated. The patients were divided into four groups according to the stage of the disease: (i) early mild disease (n = 10), (ii) early severe disease (n = 11), (iii) long-standing restrictive disease (n = 10) and (iv) proven auto-immune hyperthyroidism without any signs of TAO (n = 6). Horizontal and vertical saccades with amplitudes of 10°, 20°, 30° and 40° were recorded binocularly using the induction scleral search coil technique. The two main sequence constants V(max) and C were calculated for each eye. Repeated measurement analysis of variance was carried out to test for differences between different gaze directions, eyes and groups. RESULTS: In horizontal saccades, significant differences were found between groups but not between abduction and adduction. In vertical saccades, differences between groups and the interaction between groups and up- and down-gaze saccades were significant. Compared with the control group, analysis of the main sequence curves revealed larger differences in patients of group 3 and 4 than in those of group 1 and 2. Whereas in the control group down-gaze saccades were faster than up-gaze saccades, the opposite behaviour was found in all patient groups. The largest differences were detected among those patients who had no signs of TAO (group 4). CONCLUSIONS: In this study, significant saccade differences were detected in all patients with TAO. In contrast to our earlier studies where evaluation of multiple individual saccade parameters did not reveal significant differences, analysis of the main sequence constants and mathematical reconstruction of the main sequence curves turned out to be a sensitive technique for reliable detection of subtle ocular motility changes. Significant differences were detected even in patients with auto-immune thyroiditis where no clinical signs of TAO were apparent.

Magnetic resonance imaging and ultrasound measurements of extraocular muscles in thyroid-associated ophthalmopathy at different stages of the disease.

PURPOSE: To assess extraocular muscle (EOM) involvement in thyroid-associated orbitopathy (TAO) of different stages with magnetic resonance imaging (MRI) and ultrasound techniques. METHODS: A total of 32 patients with TAO were divided into three groups according to whether they had mild active, pronounced active or longstanding inactive disease. Six patients with Graves' disease but no clinical signs of TAO and 10 healthy control subjects were also studied. Muscle volume and cross-sectional area were measured with MRI. A-scan ultrasound was used to measure muscle thickness. RESULTS: The average MRI volume and maximal cross-sectional area of the EOM were significantly larger in patients with pronounced active and longstanding inactive TAO than in control subjects. Increased average muscle thickness measured by ultrasound was found mainly in patients with longstanding disease. Muscle enlargement was seen with MRI and ultrasound in individual patients in all patient groups, including those with Graves' disease but no TAO. Bilateral muscle enlargement was revealed by MRI in about two-thirds of patients with mild active TAO and in all patients with pronounced active and longstanding inactive TAO. Bilateral involvement estimated with ultrasound was less common in all patient groups. The MRI and ultrasound findings were not well correlated in any patient group. CONCLUSIONS: Extraocular muscle enlargement was seen in all patient groups with TAO of differing levels of severity. Measurements with MRI of muscle volume or maximal cross-sectional area are considered good indicators of muscle enlargement in TAO.

Drift in ocular torsion during sustained head tilt.

PURPOSE: A head tilt towards the shoulder (roll) induces an ocular counter-roll (OCR), i.e. torsion in the opposite direction to the head. How this counter-rolled position is maintained during a static head tilt is in debate. In a previous study, we reported an OCR-increasing drift subsequent to the head tilt. This finding is in contrast to other reports where no such response was found. The primary aim of this study was to repeat the experiment during a prolonged head-tilt test and to describe the OCR characteristics. A secondary aim was to investigate the influence of spatial visual cues on OCR. METHODS: Five male subjects performed a head tilt (30 degrees ) towards the right shoulder while the eye position was recorded during a 10-minute interval. In test 1, the subjects viewed a target with no cues for spatial orientation. The same head-tilt paradigm was repeated in test 2 with a visual target with spatial cues. Two samples of data were extracted from the start and the end of the recordings for statistical analysis. RESULTS: Subsequent to the head tilt, a slow OCR-increasing drift in the opposite direction to the head roll was found in all subjects. On average, this drift lasted for 30 sec (+/- 5) in test 1 and for 55 sec (+/- 18) in test 2. The drift was then found to change its direction, i.e. the eyes were rotated in the same direction as the head roll. When measured after 10 minutes, the OCR was significantly decreased. CONCLUSIONS: The OCR during static head tilt is not constant. During the first minute there is a gradually increasing OCR. Thereafter, the amplitude of the OCR decreases gradually. These changes are influenced to some extent by spatial visual cues. Possible mechanisms are adaptive responses in otolithic afferents as well as central nervous memory functions related to the semicircular canal system.

Drift in ocular counterrolling during static head tilt.

A decreasing drift of the counter-rolled eye position (OCR) during head tilt was recently described. The underlying mechanism is not known. OCR in eleven healthy subjects was recorded (Search coil, Skalar) during a head tilt paradigm in two test conditions. The head was tilted with a velocity below (test 1) and above (test 2) detection threshold for the semicircular canals (SC) and held static for eight minutes. A significant drift of OCR was revealed in test 2 (P = .0006, ANOVA) and close to significant in test 1 (P = .07). No statistical difference was found between the two test conditions. The results suggest that the OCR drift was not caused by the SC complex merely.

Torsional and vertical eye movements during head tilt dynamic characteristics.

PURPOSE: As the first response to a Bielschowsky head tilt test (BHTT), a fast transient torsional eye movement in the same direction as the head tilt has been shown with the three-dimensional (3D)-video oculography (3D-VOG) technique, and this movement is paralleled by a transient vertical vergence shift inducing a physiological skew deviation. The purpose of the present study was to investigate these dynamic eye movements further in response to a BHTT paradigm with the magnetic search coil technique. METHODS: Ten healthy subjects performed a BHTT (15 degrees, 30 degrees, and 45 degrees) toward each shoulder while (search coil) the monocular eye and head positions were recorded. The same head tilt paradigm was repeated in a second test while (3D-VOG) the binocular eye position was recorded. RESULTS: Subsequent to the initiation of the head tilt (latency, approximately 160 ms) a rapid torsional eye movement (mean peak velocity: 40 deg/s; mean amplitude: 4 degrees) was seen in the same direction as the head movement, followed by a somewhat slower return movement. This torsion was synchronous with a vertical vergence eye movement (mean amplitude 3 degrees). The vertical vergence was always with left eye over right eye in the rightward head tilt and in head straightening from the left shoulder. In the left head tilt and in the head straightening from the right shoulder, this movement was always with the right eye over the left eye. CONCLUSIONS: A torsional and vertical vergence back-and-forth eye movement induced by a BHTT was confirmed with the search coil technique. Utricular inertia due to an interaural head translation, combined with a stimulation of the vertical semicircular canals, seems to be a plausible explanation for these eye movements.

Conjugacy of torsional eye movements in response to a head tilt paradigm.

PURPOSE: Vertically skewed eye movements are induced by head tilt toward the shoulder (roll). Because vertical and torsional eye movements are tightly coupled both mechanically and neuronally, the purpose of the present study was to investigate the conjugacy of torsional eye movements during the Bielschowsky head tilt test (BHTT). Furthermore, the purpose was to investigate the influence of different visual and viewing condition on torsional conjugacy. The issue has clinical relevance in interpreting the outcome of the BHTT. METHODS: Eye movement recordings were performed using the infrared three-dimensional video-oculography (3D-VOG) technique. Objective cycloposition of 20 healthy individuals was measured in presumed primary position and in head tilt positions of 15 degrees, 30 degrees, and 45 degrees to the right and left, respectively. The same paradigm was performed under three different viewing conditions: binocularly without spatial orientation and both binocularly and monocularly with spatial orientation. The stimulus used with spatial orientation was a photographic picture of a historic building, whereas the stimulus with no spatial cues consisted of concentric circles. RESULTS: Consistent excyclovergence occurred in all subjects in head tilt. The relative amount increased with head tilt, regardless of the visual stimulus. Maximum excyclovergence was 0.7 degrees in 45 degrees head tilt during monocular fixation. Binocular viewing enhanced the torsion conjugacy by means of vergence stability (SD), whereas spatial visual cues improved the torsional conjugacy only slightly. CONCLUSIONS: Consistent excyclovergence was induced in head tilt. A vestibular origin seems to provide a plausible explanation of the induced torsional disconjugacy, whereas visual feed-back seems plausible in explaining the better conjugacy in binocular viewing.

Wave-front analysis as screening technique for amblyogenic ametropia with and without cycloplegia.

INTRODUCTION: For many years, attempts have been made to find an easy, efficient and inexpensive method to screen children for amblyogenic ametropia. Wave-front analysis is a new way to determine the refractive state of the eye from a distance. This technique could be a useful tool for infant screening. PURPOSE: The purpose of the study was the evaluation of the efficacy of a commercially available wave-front analyzing autorefractometer (SureSight, software version 2.0, Welch Allyn, Skaneateles Falls, NY 13153, U.S.A.) in detecting amblyogenic ametropia in patients with and without cycloplegia. METHODS: 256 eyes (-28.25 D to +7.88 D spherical equivalent) of 128 patients (1-81 years) were examined with the wave-front autorefractometer under cycloplegia. Prior to this investigation, 108 eyes (-21.38 D to 75 D) of 54 of these patients (1-76 years) were refracted without cycloplegia. The readings of the wave-front autorefractometer were compared with the results of retinoscopy under cycloplegia. RESULTS: Without cycloplegia, the sensitivity in detecting any amblyogenic ametropia such as anisometropia, astigmatism, myopia or hyperopia was 94%, while the specificity was 63%. Following cycloplegia, the sensitivity decreased to 87% and the specificity increased to 80%. CONCLUSION: Wave-front analyzing refractometry is highly applicable for infant screening. At the present state of development, the efficacy in detecting amblyogenic ametropia is similar to that of other screening techniques and instruments that operate from distance. Cycloplegia enhances the sensitivity in detecting hyperopia and decreases the sensitivity in detecting astigmatism.

Assessment of ocular counterroll during head tilt using binocular video oculography.

PURPOSE: According to recent literature, the presence and the amount of true compensatory ocular counterroll is still debatable. The purpose of the current study was to assess compensatory counterroll in response to lateral head tilt using a new noninvasive recording technique, and, furthermore, to find out whether the amount of counterroll is influenced by the presence or absence of spatial orientation. METHODS: Eye movement recordings were performed using the infrared three-dimensional video oculography (3D-VOG) technique. Objective cycloposition of five healthy individuals was measured in presumed primary position and in head tilt positions of 15 degrees, 30 degrees, and 45 degrees to the right and left. The same paradigm was performed under three viewing conditions: binocularly without spatial orientation and both binocularly and monocularly with spatial orientation. RESULTS: A consistent ocular counterroll corresponding to the amount of head tilt was observed in all subjects. Maximum torsional amplitude was 10 degrees at a 45-degree head tilt. The relative amount of compensation ranged between 13% and 22% of the actual head tilt, decreasing with increasing head tilt. Compensatory counterroll and torsional conjugacy between both eyes revealed minor differences between the experimental paradigms. Incomplete cycloductional reorientation in primary position after head tilt was detected in all subjects, regardless of the stimulus. CONCLUSIONS: A consistent compensatory ocular counterroll was demonstrated in response to static lateral tilting of the head in healthy individuals. The amplitude of counterroll and the gain of compensatory cycloversion were higher than has been generally reported. Infrared 3D-VOG technique was a reliable and comfortable method for the assessment of ocular cycloduction. It can be considered to be a promising tool for advanced evaluation of disturbances of the oblique eye muscles.