Consecutive strabismus after infantile nystagmus syndrome surgery and potential risk factors.

PURPOSE: The aim of this study is to evaluate the incidence of consecutive strabismus after infantile nystagmus surgery and its potential risk factors. METHODS: A retrospective study including 89 patients was conducted. Patients presented infantile nystagmus (idiopathic or ocular disease-associated nystagmus) without previous or coincidental strabismus. Sex, age at surgery, amblyopia, botulinum toxin (BT) injection before surgery, spherical equivalent, anisometropia, surgery procedure (Anderson's or retroequatorial recessions of four horizontal recti), and follow-up were analyzed. Kaplan-Meier and univariate Cox regression were performed. RESULTS: The median age at surgery was 5 years. The median follow-up was 36 months. The incidence of consecutive strabismus was 11.2%. There were eight patients with exotropia and two patients with esotropia. Consecutive strabismus was associated with severe bilateral amblyopia (p = 0.036), previous treatment with BT injection (p = 0.025), and large recessions of the four horizontal muscles (p = 0.001). The hazard ratio for patients with severe bilateral amblyopia was 5.4 (95% CI 1.1-25.8), and for patients previously treated with BT was 6.1 (1.3-29.3). The survival rate was 95.4% at 6 months and 88.5% at 3 years. CONCLUSION: Severe bilateral amblyopia, previous BT treatment, and type of surgery seem to be associated with consecutive strabismus after infantile nystagmus surgery. Most cases appear within the first months after surgery.

[Intermittent exotropia: bilateral lateral rectus recession treatment and long term results]. / Exotropías intermitentes: tratamiento mediante retroinserción bilateral de rectos laterales y resultado a largo plazo.

PURPOSE: To describe the long-term surgical outcomes of bilateral lateral rectus recession in patients with intermittent exotropia. METHODS: Retrospective review of 18 patients diagnosed with intermittent exotropia between 1995 and 2005 who underwent surgical treatment in the Ramon y Cajal Hospital. RESULTS: Of the 18 patients with intermittent exotropia, 50% were basic subtype. All of them underwent bilateral lateral rectus recession, associated with a previous failed botulinum toxin injection in 8 of them. Satisfactory results (less than 10 PD orthophoria) were obtained in 68.2% of the patients after a 4.5-year follow-up period. CONCLUSIONS: Bilateral lateral rectus recession is an effective and stable surgical procedure in the long-term motor control of intermittent exotropia, especially in basic subtype. Previous injection of botulinum toxin did not affect the results.

[Treatment of the comitant adquired esotropia residual deviation]. / Tratamiento de la desviación residual en la endotropía comitante adquirida.

PURPOSE: To review the therapeutic options in the management of residual esotropia, particularly focusing on the effectiveness of botulinum toxin. METHODS: Retrospective study of cases of post-surgical residual esotropia treated in our hospital from January 1999 to January 2008. Visual acuity and motor outcomes were analysed in the patients who received botulinum toxin injection. RESULTS: Of the 200 cases reviewed, 91% of the patients had a new surgery, 5% of patients refused any treatment, while 8 patients (4%) received botulinum toxin injection. Visual acuity (Snellen) before surgery, before toxin and after toxin injection in the right eye was 0.77 (SD 0.2), 0.86 (SD 0.2) and 0.97 (SD 0.2), respectively, and in the left eye: 0.76 (SD 0.1), 0.91 (SD 0.09) and 0.97 (SD 0.2), respectively. The percentage net change in the angle of deviation at far and near distance after toxin injection in the last follow-up was 41.66% and 10%, respectively. The mean follow-up after botulinum toxin injenction was 30.8 months. The success rate (ocular alignment in primary eye position) after toxin at the end of follow-up was 75%. CONCLUSIONS: Residual esotropia may be managed with further surgery or with botulinum toxin injection. The first option is more common, but in selected cases botulinum toxin injection may provide very successful outcomes with a low incidence of complications.

Global and regional cortical thinning in first-episode psychosis patients: relationships with clinical and cognitive features.

BACKGROUND: The thickness of the cortical mantle is a sensitive measure for identifying alterations in cortical structure. We aimed to explore whether first episode schizophrenia patients already show a significant cortical thinning and whether cortical thickness anomalies may significantly influence clinical and cognitive features. METHOD: We investigated regional changes in cortical thickness in a large and heterogeneous sample of schizophrenia spectrum patients (n=142) at their first break of the illness and healthy controls (n=83). Magnetic resonance imaging brain scans (1.5 T) were obtained and images were analyzed by using brains2. The contribution of sociodemographic, cognitive and clinical characterictics was investigated. RESULTS: Patients showed a significant total cortical thinning (F=17.55, d=-0.62, p<0.001) and there was a diffuse pattern of reduced thickness (encompassing frontal, temporal and parietal cortices) (all p's<0.001, d's>0.53). No significant group×gender interactions were observed (all p's>0.15). There were no significant associations between the clinical and pre-morbid variables and cortical thickness measurements (all r's<0.12). A weak significant negative correlation between attention and total (r=-0.24, p=0.021) and parietal cortical thickness (r=-0.27, p=0.009) was found in patients (thicker cortex was associated with lower attention). Our data revealed a similar pattern of cortical thickness changes related to age in patients and controls. CONCLUSIONS: Cortical thinning is independent of gender, age, age of onset and duration of the illness and does not seem to significantly influence clinical and functional symptomatology. These findings support a primary neurodevelopment disorder affecting the normal cerebral cortex development in schizophrenia.

Prognostic value of cognitive functioning for global functional recovery in first-episode schizophrenia.

BACKGROUND: It has become widely accepted that cognitive deficits in schizophrenia are related to functional outcome. However, it remains to be seen whether these associations are relevant for predicting which cases will have a global functional recovery. In this study, we attempt to determine whether global functional recovery (integrating social and occupational outcomes) after first-episode schizophrenia (FES) can be predicted by cognitive variables. METHOD: A total of 131 FES patients with functional deficits (n=97) and functional recovery (n=34) as determined at 1-year follow-up were examined. Neuropsychological, sociodemographic, pre-morbid and clinical data at baseline were analysed using independent groups comparisons and a logistic regression method. RESULTS: Sustained attention and negative symptoms emerged as significant predictors of good global functional outcome. Although the model revealed a high accuracy (91%) in the classification of patients with functional deficits, it was unacceptably low (26%) in the classification of patients with global functional recovery. CONCLUSIONS: The limitations found in the prediction of a favourable global functional outcome may well be an indication for a need to address the role of other factors not commonly included in longitudinal studies of long-term outcomes in schizophrenia.

Construct validity of the Trail Making Test: role of task-switching, working memory, inhibition/interference control, and visuomotor abilities.

The aim of this study was to clarify which cognitive mechanisms underlie Trail Making Test (TMT) direct and derived scores. A comprehensive review of the literature on the topic was carried out to clarify which cognitive factors had been related to TMT performance. Following the review, we explored the relative contribution from working memory, inhibition/interference control, task-switching ability, and visuomotor speed to TMT performance. Forty-one healthy old subjects participated in the study and performed a battery of neuropsychological tests including the TMT, the Digit Symbol subtest [Wechsler Adult Intelligence Scale (Third Version) (WAIS-III)], a Finger Tapping Test, the Digits Forward and Backward subtests (WAIS-III), Stroop Test, and a task-switching paradigm inspired in the Wisconsin Card Sorting Test. Correlation and regression analyses were used in order to clarify the joint and unique contributions from different cognitive factors to the prediction of TMT scores. The results suggest that TMT-A requires mainly visuoperceptual abilities, TMT-B reflects primarily working memory and secondarily task-switching ability, while B-A minimizes visuoperceptual and working memory demands, providing a relatively pure indicator of executive control abilities.

[Surgical treatment of Duane's syndrome type I by recession of the medial rectus of the affected eye and faden operation of the contralateral medial rectus]. / Tratamiento quirúrgico del síndrome de Duane, tipo I mediante retroinserción del recto medial del lado afecto y faden del recto medial contralateral.

PURPOSE: Different surgical approaches have been described for the treatment of Duane's syndrome. The purpose of our study is to report the results of patients undergoing recession of the medial rectus (MR) muscle of the affected eye and placement of contralateral MR faden posterior fixation sutures. METHODS: Retrospective study of 11 patients treated by a 4-7 mm recession of the MR of the affected eye and 13 mm faden posterior fixation suture of the contralateral MR in order to correct abnormal head position and esotropia in primary position. RESULTS: After surgery, there was no torticolis in 81.8% of patients, with less than 10 degrees of torticolis in the remainder. In all patients, postoperative esotropia was less than 5 prismatic dioptres. CONCLUSION: This is a safe and effective procedure in Duane's syndrome type I to treat moderate esotropia and torticolis.

Cannabis abuse is associated with decision-making impairment among first-episode patients with schizophrenia-spectrum psychosis.

BACKGROUND: Cannabis use appears to be a risk factor for schizophrenia. Moreover, cannabis abusers show impaired decision-making capacities, linked to the orbitofrontal cortex (OFC). Although there is substantial evidence that first-episode schizophrenia patients show impairments in cognitive tasks associated with the dorsolateral prefrontal cortex (DLPFC), it is not clear whether decision making is impaired at schizophrenia onset. In this study, we examined the association between antecedents of cannabis abuse and cognitive impairment in cognitive tasks associated with the DLPFC and the OFC in a sample of first-episode patients with schizophrenia-spectrum disorders. METHOD: One hundred and thirty-two patients experiencing their first episode of a schizophrenia-spectrum psychosis were assessed with a cognitive battery including DLPFC-related tasks [backward digits, verbal fluency (FAS) and the Trail Making Test (TMT)] and an OFC-related task [the Iowa Gambling Task (GT)]. Performance on these tasks was compared between patients who had and had not abused cannabis before their psychosis onset. RESULTS: No differences were observed between the two groups on the performance of any of the DLPFC-related tasks. However, patients who had abused cannabis before their psychosis onset showed a poorer total performance on the gambling task and a lower improvement on the performance of the task compared to no-abusers. CONCLUSIONS: Pre-psychotic cannabis abuse is associated with decision-making impairment, but not working memory and executive function impairment, among first-episode patients with a schizophrenia-spectrum psychosis. Further studies are needed to examine the direction of causality of this impairment; that is, does the impairment make the patients abuse cannabis, or does cannabis abuse cause the impairment?

Pretreatment predictors of cognitive deficits in early psychosis.

BACKGROUND: Predicting cognitive deficits in early psychosis may well be crucial to identify those individuals most in need of receiving intensive intervention. As yet, however, the identification of potential pretreatment predictors for cognitive performance has been hampered by inconsistent findings across studies. We aimed to examine the associations of functional and clinical pretreatment variables with cognitive functioning after a first psychotic episode. METHOD: One hundred and thirty-one patients experiencing first-episode psychosis were assessed for psychopathology, pre-morbid functioning, duration of illness, age of onset, and family history of psychosis and neurocognitive functioning. Multiple regression analyses were conducted for six basic cognitive dimensions known to be affected in this population: verbal learning, verbal memory, verbal comprehensive abilities, executive functioning, motor dexterity and sustained attention. RESULTS: Pre-morbid functioning was the main predictor for five out of the six basic cognitive domains. Pre-morbid social adjustment difficulties were associated with worse performance in executive functioning, motor dexterity and sustained attention. Academic functioning was associated with verbal comprehension, and verbal learning and memory. Gender, age of onset, duration of untreated psychosis, and family history of psychosis had no or limited value as predictors of neurocognitive outcome. CONCLUSIONS: Poor pre-morbid functioning was related to a worse performance in the six basic cognitive dimensions evaluated; however, this accounted for only a small amount of the explained variance. Cognitive impairment is a prominent feature in patients with early psychosis regardless of favorable prognostic features such as short duration of illness, female gender, later age of onset, and non-family history of psychosis.

Trail Making Test in traumatic brain injury, schizophrenia, and normal ageing: sample comparisons and normative data.

The Trail Making Test (TMT) has been a useful assessment tool to investigate executive function. Several studies have recently improved the existing TMT norms by mean of large samples of healthy individuals stratified by a number of demographic variables from different populations. In contrast, criticisms have been raised about the utility of norms from healthy samples to detect changes across time in clinical samples where TMT performance used to be altered. In addition, few studies have compared groups of patients with deficits in TMT performance, making it difficult to decide whether a single set of norms is sufficient to assess different clinical populations. We provide normative data from three large samples of patients with traumatic brain injury (TBI) (n=90), schizophrenia spectrum disorders (n=127), and healthy Spanish speakers (n=223). Differences between healthy participants and patients in all TMT direct (TMT-A, TMT-B) and derived (B-A, B:A, B-A/A) scores were found. TMT performance was poorer in TBI patients than in schizophrenia patients except for the B:A and B-A/A scores, suggesting a similar underlying executive deficit. Normal ageing impaired both direct and derived TMT indices, as revealed by lower scores in the healthy elderly group (55-80 years old) as compared with young (16-24) and middle-aged (25-54) healthy participants. Three different sets of norms stratified by age, education, or both are presented for clinical use. Recommendations on TMT scores are made for future research.

Cognitive therapy in early psychosis and "at risk mental state".

Evidence suggests that the early course of psychosis might be important in the long term outcome of the disease. Moreover, pharmacological treatment has important limitations in this population which has increased the interest in the combination of psychological and biological treatments. Recently, cognitive therapy has been modified and applied to the field of psychosis. For decades several studies have shown its effectiveness in the treatment of psychotic symptoms which has led to formulate new and more comprehensive cognitive treatments for early psychosis. These new cognitive approaches have been assessed in clinical trials. In the same way, the study of the pre-psychotic phase and prevention of illness is becoming important. Two aspects are especially relevant in this regards: the possibility of prospective detection of patients at risk of developing psychosis and the search for adequate treatments in this phase. Recent studies concerning early and pre-onset psychosis cognitive treatment are reviewed by the authors.

Terapia cognitiva en psicosis de inicio reciente y "estado mental de riesgo" / Cognitive therapy in early psychosis and "at risk mental state"

Diferentes investigaciones sugieren que las fases tempranas de las psicosis pueden tener una influencia decisiva en el curso posterior de la enfermedad. Además, el tratamiento farmacológico plantea importantes limitaciones en esta población, aspecto que ha favorecido el interés por la combinación de tratamientos psicológicos y biológicos. La terapia cognitiva ha sido adaptada y aplicada al campo de la psicosis. La evidencia que sugiere desde hace décadas su eficacia en el tratamiento de síntomas psicóticos ha llevado al desarrollo de modelos de tratamiento cognitivo más complejos, de variado enfoque terapéutico y a la evaluación de su eficacia en estudios controlados. Este interés también se ha extendido al estudio de las fases prepsicóticas y a la posibilidad de prevención de la enfermedad. Dos aspectos adquieren especial relevancia en este ámbito: la posibilidad de detección prospectiva de individuos en estado de riesgo de desarrollar psicosis y la provisión de tratamientos adecuados en estas circunstancias. Los autores revisan la literatura reciente relativa al tratamiento cognitivo de fases tempranas de las psicosis y estado mental de riesgo

Evidence suggests that the early course of psychosis might be important in the long term outcome of the disease. Moreover, pharmacological treatment has important limitations in this population which has increased the interest in the combination of psychological and biological treatments. Recently, cognitive therapy has been modified and applied to the field of psychosis. For decades several studies have shown its effectiveness in the treatment of psychotic symptoms which has led to formulate new and more comprehensive cognitive treatments for early psychosis. These new cognitive approaches have been assessed in clinical trials. In the same way, the study of the pre-psychotic phase and prevention of illness is becoming important. Two aspects are especially relevant in this regards: the possibility of prospective detection of patients at risk of developing psychosis and the search for adequate treatments in this phase. Recent studies concerning early and pre-onset psychosis cognitive treatment are reviewed by the authors

[Differential diagnosis among depressive pseudodementia, frontal dementia and subcortical dementia: a case report]. / Diagnóstico diferencial entre seudodemencia depresiva, demencia frontal y demencia subcortical: estudio de un caso.

Among the clinical entities that show cognitive impairments it may sometimes be difficult to reach a diagnosis. That is the case with the differential diagnosis among depressive pseudodementia, subcortical dementia without motor symptoms and predominantly frontal-mesial frontotemporal dementia. This current paper presents one clinical case that illustrates such difficulties. In the first place, clinical, neuropsychological and neuroimaging features as well as common features of these three disorders are described, after which the case, and evolution of the diagnostic process are described.

Diagnóstico diferencial entre seudodemencia depresiva, demencia frontal y demencia subcortical: estudio de un caso / Differential diagnosis among depressive pseudodementia, frontal dementia and subcortical dementia: a case report

Entre las entidades clínicas que muestran alteraciones cognitivas a veces puede ser difícil alcanzar un diagnóstico. Tal es el caso con el diagnóstico diferencial entre la seudodemencia depresiva, la demencia subcortical sin síntomas motores y la demencia frontotemporal de predominio frontal-mesial. En el presente artículo se presenta un caso clínico que ilustra estas dificultades. Primero se describen las características clínicas, neuropsicológicas y de neuroimagen y los rasgos comunes de estos tres trastornos para después presentar el caso y la evolución del proceso diagnóstico (AU)

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[Strabismus surgery of the myopic patient under topical anaesthesia]. / Cirugía del estrabismo del miope magno bajo anestesia tópica.

PURPOSE: To study the epidemiological characteristics and the results of strabismus surgery of high myopic patients under topical anaesthesia. METHOD: Retrospective study of nine high myopic patients with restrictive myopic myopathy (RMM) that underwent surgery in the last year and with a minimum follow-up of at least 6 months following surgery. Clinical findings, alteration of the extrinsic ocular motility (EOM) and response to surgical treatment were evaluated in each case. RESULTS: RMM was more frequent in women, average age was 46 years and average refractive error was 14 diopters. Diplopia was the most frequent reason for consultation, followed by the wish to undergo surgery because of an aesthetically unacceptable strabismus. High myopia was the most frequent etiology. One case was secondary to decompensated fourth cranial nerve palsy. The alteration of the EOM more frequently observed was endotropia associated with hypotropia. The recurrence rate of the deviation was 44%, occurring generally in the immediate postoperative period. In these cases botulinum toxin is a valid treatment option. CONCLUSIONS: Topical anaesthesia offers undoubted advantages for a better adjustment of diplopia in RMM surgery. During the intraoperative adjustment it is convenient to overcorrect the horizontal deviation and to undercorrect the vertical deviation.

Cirugía del estrabismo del miope magno bajo anestesia tópica / Strabismus surgery of the myopic patient under topical anaesthesia

Objetivo: Estudiar las características epidemiológicas y los resultados del estrabismo del paciente miope magno sometido a cirugía muscular mediante anestesia tópica. Método: Estudio retrospectivo de nueve pacientes miopes magnos con miopatía restrictiva miópica (MRM) operados en el último año y con un seguimiento posquirúrgico de al menos 6 meses. Se evaluaron los datos clínicos así como la alteración de la motilidad ocular extrínseca (MOE) y la respuesta al tratamiento quirúrgico empleado en cada uno de ellos. Resultados: La MRM fue más frecuente en mujeres, la edad media fue de 46 años y el defecto refractivo medio de 14 dioptrías. El motivo de consulta más frecuente fue la diplopía seguido del deseo de operarse de un estrabismo estéticamente inaceptable. La etiología más frecuente fue la miopía y sólo un caso fue secundario a una parálisis del IV par craneal descompensada. La alteración de la MOE más frecuentemente encontrada fue la endotropía asociada a hipotropía. La tasa de recidiva de la desviación fue de un 44 por ciento, ocurriendo ésta generalmente en el postoperatorio inmediato. En estos casos la toxina botulínica es una opción válida de tratamiento. Conclusiones: La anestesia tópica ofrece indudables ventajas para un mejor ajuste de la diplopía en la cirugía de la MRM. Durante el ajuste intraoperatorio es conveniente hipercorregir la desviación horizontal e hipocorregir la vertical (AU)

[Diagnostic and therapeutic approaches in oculomotor paralyses]. / Abordaje diagnóstico y terapéutico de las parálisis oculomotoras.

OBJECTIVES: We wish to unify current criteria regarding oculomotor paralysis (POM). Based on our experience, we have designed a diagnostic-therapeutic protocol which permits an early approach, especially since botulinum toxin has been used for treatment. DEVELOPMENT: To make things easier to understand, we start with the concept of POM, including the physiopathogenic description of phenomena secondary to eye movements. Then we consider the aetiological-topographical incidence and assess the overall causes of POM and the relative frequency of the involvement of the different cranial oculomotor nerves. Finally, we consider each cranial nerve more fully from two different angles: the aetiologic-topographic diagnosis and therapeutic attitudes. CONCLUSIONS: The current approach to POM should include a systematic study to classify the disorder as isolated, associated with other neurological causes or of some other type (metabolic, auto-immune, etc). Satisfactory early treatment should include consideration of infilbration with botulinum toxin in all paresis or paralysis presenting with contractures. In cases of total paralysis the contractures may occur within a week of onset of the condition. In partial paralyses close follow-up of three parameters evolution of the degree of ocular deviation, limitation of movement and exploration of passive movements makes it possible to determine the best moment to treat the contracture by injection of botulinum toxin: This treatment resolves or improves the diplopia, with recovery of oculomotor equilibrium, when it is given during the acute phase.

Utilización de la toxina botulínica en el retratamiento del estrabismo

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