A randomised comparison of bilateral recession versus unilateral recession-resection as surgery for infantile esotropia.

OBJECTIVE: Infantile esotropia, a common form of strabismus, is treated either by bilateral recession (BR) or by unilateral recession-resection (RR). Differences in degree of alignment achieved by these two procedures have not previously been examined in a randomised controlled trial. DESIGN: Controlled, randomised multicentre trial. SETTING: 12 university clinics. PARTICIPANTS AND INTERVENTION: 124 patients were randomly assigned to either BR or RR. Standardised protocol prescribed that the total relocation of the muscles, in millimetres, was calculated by dividing the preoperative latent angle of strabismus at distance, in degrees, by 1.6. MAIN OUTCOME MEASURE: Alignment assessed as the variation of the postoperative angle of strabismus during alternating cover. RESULTS: The mean preoperative latent angle of strabismus at distance fixation was +17.2 degrees (SD 4.4) for BR and +17.5 degrees (4.0) for RR. The mean postoperative angle of strabismus at distance was +2.3 degrees (5.1) for BR and +2.9 degrees (3.5) for RR (p = 0.46 for reduction in the angle and p = 0.22 for the within-group variation). The mean reduction in the angle of strabismus was 1.41 degrees (0.45) per millimetre of muscle relocation for RR and 1.47 (0.50) for BR (p = 0.50 for reduction in the angle). Alignment was associated with postoperative binocular vision (p = 0.001) in both groups. CONCLUSIONS: No statistically significant difference was found between BR and RR as surgery for infantile esotropia.

The influence of eye muscle surgery on shape and relative orientation of displacement planes: Indirect evidence for neural control of 3D eye movements.

Is Listing's law a consequence of 2D control of eye positioning, where eye torsion is determined by the biomechanical properties of the orbit, or is it a reflection of full 3D neuronal control? This was investigated by observing the influence of a change in mechanical properties of the eye socket on 3D eye movements. The shape and relative orientation of displacement planes were measured using scleral search coils before and after operation of five patients with strabismus. The operation influenced the shape of displacement planes in both eyes of all patients. After the operation, most patients obeyed Listing's law more accurately: a monocular, surgically induced, orbital change caused binocular improvements of torsional control. The relative orientation of planes also changed, but no clear relationship was found between the type of operation and the direction of rotation. The results suggest that Listing's law is not just a result of the biomechanical properties of the eye socket, but has a neural basis.

Visual determinants of reduced performance on the Stroop color-word test in normal aging individuals.

It is unknown to what extent the performance on the Stroop color-word test is affected by reduced visual function in older individuals. We tested the impact of common deficiencies in visual function (reduced distant and close acuity, reduced contrast sensitivity, and color weakness) on Stroop performance among 821 normal individuals aged 53 and older. After adjustment for age, sex, and educational level, low contrast sensitivity was associated with more time needed on card I (word naming), red/green color weakness with slower card 2 performance (color naming), and reduced distant acuity with slower performance on card 3 (interference). Half of the age-related variance in speed performance was shared with visual function. The actual impact of reduced visual function may be underestimated in this study when some of this age-related variance in Stroop performance is mediated by visual function decrements. It is suggested that reduced visual function has differential effects on Stroop performance which need to be accounted for when the Stroop test is used both in research and in clinical settings. Stroop performance measured from older individuals with unknown visual status should be interpreted with caution.

Listing's law in strabismus and amblyopia: a preliminary report.

We investigated whether Listing's law applies in patients with diminished or no stereopsis due to strabismus or amblyopia. Eye movements of normal subjects and patients with strabismus and/or amblyopia were recorded during monocular and binocular fixation; from these data the shape and relative orientation of displacement planes were calculated. In normal subjects, monocular or binocular fixation did not influence the thickness and relative orientation of displacement planes. No differences were found between normals and the patient with amblyopia due to anisometropia. In one patient with strabismus but without amblyopia, the orientation of displacement planes depended on the fixation conditions; a coupling between horizontal vergence effort and plane orientation was observed. Patients with amblyopia and strabismus showed abnormally shaped and/or abnormally orientated displacement planes, which depended on the fixation conditions. Differences between both eyes in the shape of the planes were also observed. These results show that normal Listing behavior can be present in subjects with diminished stereopsis. They also show that normal stereopsis does not necessarily mean normal Listing behavior, suggesting that Listing's law is mainly a result of motor strategy.

The influence of visual input on the vestibulo-ocular reflex.

In order to stabilise a fixation target on the retina, eye movements have to compensate for head movements. During slow head movements visual feedback can control these eye movements. During fast movements of the head, mainly the vestibulo-ocular reflex (VOR) controls eye movements, as visual feedback is too slow. However, visual feedback is an important factor in controlling the VOR; e.g. the gain of the VOR depends on the distance of the target. This study investigates the influence of retinal image position during fast head movements. The experiments were carried out in five human subjects using scleral search coils. The adaptation of each eye individually to a change of retinal position of a target was examined during head shaking. The change in visual input was carried out by placing Fresnel prisms of different strengths in front of both eyes, thus inducing a change in retinal image position without changing the retinal slip. The results show, that both eyes make the appropriate corrections when the visual input changes, even during fast head-movements. These corrections did not influence the gain of the VOR. From these results we conclude, that retinal image position besides retinal slip has a major influence on the monocular eye movements even at high head rotation frequencies.

Asymmetrical vertical phorias indicating dissociated vertical deviation in subjects with normal binocular vision.

We measured the symmetry of phoria angles in six normal subjects. Subjects were selected on the basis of good visual acuity and stereopsis, normal binocular eye alignment and, apart from mild refraction errors, absence of ocular abnormalities. They were instructed to look at a word on a reading chart at 2 m distance. Each measurement consisted of five subsequent intervals of 5 s duration. During these five intervals viewing was binocular, with the right eye only, binocular, with the left eye only, and binocular, respectively. Each experiment consisted of twelve measurements. Eye movements were measured with scleral coils suited for measuring in horizontal, vertical and torsional directions. Five out of six subjects displayed an asymmetrical vertical phoria; one subject showed an alternating hyperphoria; four displayed a left over right vertical phoria that was largest for left eye occlusion. Only one subject showed a symmetrical vertical phoria. Both the size of the vertical phorias and the size of the asymmetries in these vertical phorias were very small: on average 0.16 +/- 0.01 and 0.17 +/- 0.01 degree, respectively. The direction of the vertical phoria asymmetries (the largest left over right was found with left eye occlusion) and the fact that asymmetries were found more often in vertical than horizontal and torsional phorias suggest that these asymmetries are related to dissociated vertical deviation. These results suggest that dissociated vertical deviation, often observed in subjects with a disruption of binocular vision early in life, reflects the enhancement of a phenomenon that is present in normal subjects as well.

Sympathetic innervation of the rat choroid: an autoradiographic tracing and immunohistochemical study.

The sympathetic innervation of the choroid was investigated by means of the anterograde tracer 3H-leucine, injected into the rostral part of the superior cervical ganglion. The tracer was autoradiographically visualized at the light- and electron-microscopic levels. Labelled unmyelinated fibres were found in the choroid and labelled terminals were observed in close proximity to the smooth muscle cells of arterioles. The labelled terminals contain granular vesicles of different size and clear vesicles; the mitochondria were of the electron-dense type and no cell-to-cell synaptic contacts were observed. In addition, tyrosine hydroxylase immunocytochemistry was performed. Immunostained terminals found in the choroid show ultrastructural features similar to those found in the tracing experiments: granular vesicles of different size, clear vesicles and electron-dense mitochondria. On the basis of previous studies and the present observations, it is concluded that the choroid has a dual innervation, a parasympathetic innervation from the pterygopalatine ganglion and a sympathetic innervation from the superior cervical ganglion. The dual innervation is most likely involved in maintaining the homeostasis of vasodilatation and vasoconstriction in the choroid.

Use of antispasmodic drugs in double contrast barium enema examination: glucagon or buscopan?

PURPOSE: To compare the spasmolytic effect of glucagon and buscopan in double contrast barium enema examination. PATIENTS AND METHODS: Three hundred and twenty-four consecutive patients referred for double contrast barium enema examination were randomly allocated to receive an intravenous injection of either 1 mg of glucagon, 20 mg of buscopan or physiological saline. The transit of the barium column from rectum to caecum, the quality of the radiographs and side effects were assessed blindly without knowledge of the injected drug. RESULTS: Antispasmodic drugs (glucagon or buscopan) resulted in better transit of the barium column to the caecum compared to placebo (Mann-Whitney: P < 0.05), but no differences occurred between glucagon and buscopan (Mann-Whitney: P > 0.05). Buscopan produced better distension of the rectosigmoid than glucagon or placebo (P < 0.05). Of 109 patients who received buscopan five complained of blurred vision afterwards. CONCLUSION: Because buscopan is less expensive and more effective in distending the colon than glucagon, it is preferred for the routine double contrast examination. However, patients should be warned about the possibility of temporary visual impairment.

Peripheral neural circuits regulating IOP? A review of its anatomical backbone.

The peripheral nervous system is classically separated into a somatic division containing both afferent and efferent pathways and an autonomic division composed of efferents only. The somatic afferent division is divided in A- and B-neurons. The B-neurons are supposed to be autonomic afferents as part of a reflex system involved in homeostasis. Recent data obtained by neuronal tracing and immunohistochemical experiments concerning the eye related peripheral nervous system endorse the existence of these peripheral reflex systems. Somatic afferents of trigeminal origin synaptically innervate parasympathetic neurons in the pterygopalatine ganglion. This probably represents a pathway mediating autonomically regulated ocular activity in response to sensory stimulation. In addition, it has been hypothesized that trigeminal sensory nerve fibres have an efferent function in response to noxious stimuli e.g. the ocular injury response. Sympathetic nerve fibres originating in the superior cervical ganglion course through the trigeminal and pterygopalatine ganglion without forming direct synaptic contacts. These fibres, however, contain clusters of vesicles suggesting some kind of interneural communication. Parasympathetic nerve fibres of pterygopalatine origin course through the ciliary ganglion. These nerve fibre terminals also contain clusters of vesicles without direct synaptic contacts. Experimental data concerning the distribution of neuropeptides revealed a more detailed knowledge of the anterior eye segment innervation. These experimental data are subject to some debate. The pros and cons of different techniques are discussed. Neural circuits regulating IOP have long been postulated. The possible role of peripheral reflex systems in the regulation of IOP is discussed.

Pre- and post-ganglionic nerve fibres of the pterygopalatine ganglion and their allocation to the eyeball of rats.

The origin, course and distribution of pre- and postganglionic neurons of the pterygopalatine ganglion (PPG) in the rat were studied using acetylcholinesterase staining, wheat germ agglutinin coupled to horseradish peroxidase (WGA-HRP) histochemistry and autoradiography. These methods were used in a selected and planned fashion to reveal details concerning the innervation of the lacrimal gland and portions of the eye. The PPG in rats consists of a rostral triangular portion and additional perikarya surrounding the distal part of the major petrosal nerve. Fibres from the superior cervical ganglion (SCG) reach the PPG via the inferior petrosal sinus. Application of WGA-HRP was made after transections: (1) rostral to the PPG; and (2) caudal to the PPG. The first of these applications labelled mainly fibres in the PPG; the second application labelled preganglionic parasympathetic brainstem neurons dorsolateral to the facial nucleus (i.e. the lacrimal nucleus), rostral cells in the SCG and trigeminal sensory fibres. WGA-HRP injections of the lacrimal gland, the conjunctiva and the anterior chamber of the eye all labelled cells in different parts of the PPG. This means that the PPG contains sensory and sympathetic nerve fibres and that the PPG has a topographical organisation along the rostrocaudal axis. Isotope injections of the PPG anterogradely labelled fibres passing through the ciliary ganglion that innervated the conjunctiva, the limbus and parts of the choroid.

The allocation of nerve fibres to the anterior eye segment and peripheral ganglia of rats. II. The sympathetic innervation.

The sympathetic innervation of the peripheral ganglia related to the eye, i.e. the trigeminal ganglion, the ciliary ganglion and the pterygopalatine ganglion, and of the anterior eye segment was studied in rats. Selective labelling of sympathetic nerves was obtained by means of injection of [3H]leucine into the superior cervical ganglion. Bundles of sympathetic nerve fibres were found in the trigeminal ganglion and the pterygopalatine ganglion but were absent in the ciliary ganglion. In addition individual sympathetic nerve fibres, which may have contacts with trigeminal ganglion cells, were found between the ganglion cell bodies all over the trigeminal ganglion indicating a sympathetic innervation of this ganglion. In the anterior eye segment, there appeared to be a sympathetic innervation of the ciliary cleft, the ciliary body and the iris. Within the ciliary body sympathetic nerve fibres innervate the central stroma and the stroma of the ciliary processes. Labelled sympathetic nerve fibres were also observed in the stroma of the iris and were most abundant in its periphery. Most sympathetic fibres reach the iris and ciliary body by way of the base of the ciliary body. Only few sympathetic fibres are present in the ciliary cleft. No sympathetic innervation of the cornea was found.

The allocation of nerve fibres to the anterior eye segment and peripheral ganglia of rats. I. The sensory innervation.

The distribution of sensory trigeminal nerve fibres in the anterior eye segment and the autonomic eye related ganglia, i.e. the parasympathetic ciliary and pterygopalatine ganglia and the sympathetic superior cervical ganglion, was studied in rats. For this the trigeminal ganglion was injected with tritiated leucine and wheat germ agglutinin coupled to horseradish peroxidase (WGA-HRP). After injection of WGA-HRP into the trigeminal ganglion, ganglion cell somata in the superior cervical and the pterygopalatine ganglion were labelled. As labelling of these cell bodies with WGA-HRP is the result of retrograde transport it must be assumed that cell bodies in these ganglia project to the trigeminal ganglion. [3H]Leucine injection into the trigeminal ganglion revealed the presence of labelled nerve fibres in the pterygopalatine ganglion and the nodose ganglion i.e. the sensory ganglion of the vagus nerve. Labelled nerve fibres were absent in the ciliary and superior cervical ganglion. As [3H]leucine labelling of nerve fibres is the result of anterograde transport exclusively, it can be concluded that trigeminal nerve fibres project to the nodose ganglion and the pterygopalatine ganglion, but not to the ciliary and superior cervical ganglion. In the retrobulbar structures, sensory nerve fibres occurred between the inferior oblique and the lateral rectus muscle and were present medial to the medial rectus muscle. Within the anterior eye segment, sensory nerve fibres were found in the cornea epithelium, stroma and adjacent to the endothelium. In addition, labelled fibres were found in the anterior stroma of the ciliary body, throughout the iris up to the pupillary border and in the conjunctiva. Most sensory nerve fibres which innervate the cornea, the iris and the ciliary body traverse the ciliary cleft.

Satellite cells as blood-ganglion cell barrier in autonomic ganglia.

In a preliminary study a difference in the uptake and transport of wheat germ agglutinin-horseradish peroxidase (WGA-HRP) between the trigeminal ganglion and the superior cervical ganglion was observed. After injection of WGA-HRP and HRP into the trigeminal ganglion, peroxidase was found in the space between the satellite cell processes and the ganglion cells. The ganglion cells showed pinocytosis and uptake of WGA-HRP and HRP. In the superior cervical ganglion WGA-HRP and HRP were found alongside the satellite cells but were absent in the space between satellite cells and ganglion cells. Intravenous injection revealed the presence of HRP in the space between sensory ganglion cells and their satellite cells of the trigeminal and nodose ganglion whereas HRP was absent in the space between autonomic ganglion cells and their satellite cells of the superior cervical, medial cervical and pterygopalatine ganglion although HRP lined the satellite cell membranes. By means of electron microscopy, satellite cell processes in the superior cervical ganglion were found to enwrap ganglion cells very tightly with a marginal space between both cell types. Satellite cells and their processes were mutually anchored by numerous tight junctions. In the trigeminal ganglion the extracellular space between ganglion cells and satellite cells was larger and satellite cells were found to be more loosely arranged around the ganglion cells. Satellite cell processes were only occasionally linked by tight junctions. It is concluded that satellite cells in autonomic ganglia comprise an effective barrier for WGA-HRP and HRP and probably large molecules in general. This barrier is absent in sensory ganglia.

The innervation of the rabbit's anterior eye segment: a retrograde tracing study.

The differential innervation of the distinct elements of the anterior segment of the rabbit eye, i.e. cornea, conjunctiva, ciliary body, iris, and trabecular meshwork, was studied using horseradish peroxidase-wheatgerm agglutinin (HRP-WGA) as a tracer. HRP-WGA was injected into the anterior chamber, the conjunctiva, or the cornea, and the animals were killed after 6 to 96 hr. The HRP-WGA localization was studied at the light and electron microscopic level. Injection into the anterior chamber led to an ubiquitous spread of the tracer in all elements of the anterior segment, resulting in a consistent retrograde labelling of neurons in the trigeminal (sensory), superior cervical (sympathetic) and ciliary (parasympathetic) ganglion. Neurons in the proximal part of the pterygopalatine ganglion (parasympathetic) were labelled only when the injected tracer was present in the conjunctiva. Varying survival times after corneal injection were used to establish restricted corneal uptake. Up to 16 hr after corneal injection, HRP-WGA was limited to the cornea and led to the exclusive labelling of neurons in the trigeminal ganglion, indicating that the central cornea has an almost exclusive sensory innervation. The trigeminal sensory neurons projecting to the cornea were restricted to a small antero-medial part of the trigeminal ganglion. Electron microscopy revealed four different cell types in the trigeminal ganglion. However, distinct elements of the anterior segment did not project to specific cell types.