Congenital cranial dysinnervation disorders (CCDD) is a new term describing a collection of non-progressive neurogenic syndromes. Initially referred to as congenital fibrosis syndrome, it was thought that the primary problem was extraocular muscular maldevelopment. Recent advancements in genetics and neuro-radiology have now determined the initial observation of fibrotic muscles is secondary to a primary lack of innervation from deficient, absent, or misguided cranial nerves. Read More
From the Eye Center, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania;
Purpose: To report four cases of early onset sixth-nerve palsy all of whom had eccentric fixation.
Methods: A retrospective case note review was undertaken of all cases presenting to the senior author's private and NHS practice with early onset sixth palsy between 2006 and 2012. As well as demographic information, details of ophthalmic, orthoptic, electrophysiological examinations, and radiological investigations that were extracted from the records. Read More
From the Neuromusculoskeletal Department, Eye Clinic, University of Florence, Florence, Italy.
Background: "Dragged-fovea diplopia syndrome" is a type of central binocular diplopia that is secondary to a foveal displacement, caused by epiretinal membranes (ERMs) or other macular diseases. Its management is difficult, because prisms are not effective.
Case Reports: Two cases of dragged-fovea diplopia syndrome were presented. Read More
Ross Eye Institute, University at Buffalo, Department of Ophthalmology, Buffalo, New York.
Background And Purpose: To assess the possibility of determining the insertion distance from the limbus of previously operated extraocular rectus muscles (EOM) with the Heidelberg Spectralis anterior segment optical coherence tomography (AS-OCT).
Patient And Method: Subjects with a history of previous strabismus surgery underwent AS-OCT of the EOM before planned additional strabismus surgery. The EOM insertion distances from the limbus were measured pre-operatively on the AS-OCT and compared to the caliper distance measured during the strabismus surgery. Read More
Background And Purpose: Early onset exodeviations in systemically and ocularly healthy young children, diagnosed at less than 1 year of age, may be of the constant, "infantile XT" type, or early X(T) type. The onset of common childhood X(T) is not clearly known. The purpose of this lecture is to discuss theories and characteristics of early onset exodeviations, and report on our observations of infantile XT and early X(T) at Children's Eye Care in Michigan. Read More
Background And Purpose: Stereoacuity measurement is a common element of pediatric ophthalmic examinations. Although the Stereo Fly Test is routinely used to establish the presence of coarse stereopsis (3000 arcsecs), it often yields a false negative "pass" due to learned responses and non-stereoscopic cues. We developed and evaluated a modified Stereo Fly Test protocol aimed at increasing sensitivity, thus reducing false negatives. Read More
Background And Purpose: Adequate cycloplegia and dilation are required for refraction and fundus exam in children. Standard practice is to instill cycloplegic drops in the inferior cul-de-sac, and this is often traumatic for children. Our study assesses the use of cyclopentolate on closed lids as a method of instillation for ensuring complete cycloplegia. Read More
Introduction And Purpose: Anisometropia, a relative difference in the refractive state of the two eyes, is common in hyperopic patients. We investigated the association between ocular dominance (sighting dominance) and refractive asymmetry in patients with hyperopia.
Methods: This retrospective study included 223 hyperopic patients with a mean age of 10. Read More
Introduction And Purpose: To investigate the level of agreement between orthoptists and medical practitioners in the comprehensive eye examination of children seen in an orthoptist-led triage clinic.
Patients And Methods: Patient records over a 6-month period were retrospectively reviewed. Those with a presenting complaint related to vision or ocular motility were triaged into the orthoptist-led clinic and included in the study. Read More
Introduction And Purpose: To compare binocular vision measurements between Chronic Fatigue Syndrome (CFS) patients and healthy controls.
Methods: Forty-one CFS patients referred by the Reference Centre for Chronic Fatigue Syndrome of the Antwerp University Hospital and forty-one healthy volunteers, matched for age and gender, underwent a complete orthoptic examination. Data of visual acuity, eye position, fusion amplitude, stereopsis, ocular motility, convergence, and accommodation were compared between both groups. Read More
Introduction And Purpose: We describe the clinical characteristics of 252 patients with unilateral superior oblique palsy who underwent strabismus surgery. We assess if a predetermined surgical strategy, based on preoperative alignment and motility measurements, was effective in treating these patients. On this basis, the patients were divided into three different treatment groups. Read More
Background And Purpose: Good surgical results following strabismus surgery depend on several factors. In this article, detailed steps for planning strabismus surgery will be reviewed for basic horizontal strabismus surgery, vertical, and oblique muscle surgeries. The thought process behind each case will be presented to help in selecting the best surgical approach to optimize postoperative results. Read More
A general property of nervous system development is that correlated activity is used to organize topographic projections. This correlated activity is typically produced by electrical coupling of adjacent neurons; however, electrical coupling is not possible for retinal ganglion cells in separate eyes that need to be precisely mapped to the same place in the brain. This forces the visual system to rely on environmental stimuli to produce the correlated activity that drives the development of binocularity, with amblyopia as necessary consequence when visual experience is abnormal. Read More
Introduction And Purpose: Most strabismus specialists use bifocals for patients with convergence excess esotropia whose distance deviation is small. While this is a popular treatment modality, there is actually no good data to indicate that this should be considered a standard of care.
Patients And Methods: In patients for whom the distance deviation is small enough to allow for the development of binocular vision, my preference is to simply observe these patients. Read More
Background And Purpose: There is a continuing debate as to whether the patient optically correctable at distance to within 8 prism diopters of perfect alignment requires treatment for persisting overconvergence at near, and if treatment is indicated, what it should be.
Patients And Methods: For the patient whose misalignment at distance is reduced to 8 or fewer prism diopters, my preference is for the full cycloplegic correction plus a bifocal in the first prescription, to discourage virtually all accommodation initially, with pull back later.
Results: Review of several reports indicates a continued lack of consensus on whether this causes disuse weakening of accommodation and premature presbyopia. Read More
The authors present three patients with idiopathic exercise-induced esotropia. The history, physical findings, and testing that led to the diagnosis are discussed. To the authors' knowledge, this is the largest series of patients with this rare condition, with this series representing half of reported patients in the literature. Read More
We report a patient who suffered consecutive cranial neuropathies where each event was immediately preceded by the use of oral PDE-5 inhibitors. A discussion of the etiology of the events including possible interaction with other medications is included. Read More
Introduction And Purpose: This paper reviews the complaints and associated symptoms/consequences of lacking essential nutrients and vitamins in our central and peripheral nervous systems. This has become important as there has been a rise in malnutrition following the increasing incidence of bariatric surgery for obesity.
Methods: A case report example involving review of the clinical presentation and treatment. Read More
Background And Purpose: The Convergence Insufficiency Symptom Survey (CISS) is a questionnaire used as an outcome measure in treatment of convergence insufficiency. The current prospective randomized trial evaluates the diagnostic specificity of the CISS.
Patients And Methods: Surveys were completed by 118 adolescent patients who presented for routine eye examinations. Read More
Introduction: There is little data validating most illiterate eye charts. Lea Symbols®, however, have been well validated in numerous studies. In this study, we compare the assessment of visual acuity employing both the Lea Symbol hanging wall Early Treatment Diabetic Retinopathy Study (ETDRS)-style chart and a similar Patti Pics® ETDRS-style chart in order to determine whether the two charts provide clinically similar data. Read More
From the Hamilton Eye Institute, Department of Ophthalmology, University of Tennessee Health and Science Center, Memphis, Tennessee; From the Department of Oncology, St. Jude Children's Research Hospital, Memphis and.
Background: Children with brain neoplasms often develop cranial nerve palsies (CNP) affecting ocular ductions. Duction deficits may improve or resolve with treatment of their intracranial disease. However, these children may be left with residual strabismus. Read More
Purpose: Thyroid eye disease (TED) frequently causes strabismus and diplopia. Though the condition involves multiple extraocular muscles in both eyes, the inferior rectus (IR) muscle is particularly susceptible. TED may be so asymmetric as to mask the involvement of the contralateral IR. Read More
Background And Purpose: When patients with intermittent exotropia show an increase in their near deviation after prolonged monocular occlusion, they have been said to have tenacious proximal fusion (TPF). That term is not adequately descriptive, since this finding can occur without the patient having been allowed to fuse. The purpose of this study is to investigate the possibility that this phenomenon is mediated by the preponderance of binasal retinal disparity and uncrossed localization that occurs with near fixation. Read More
Introduction And Purpose: To investigate the relationship between sensory dominance and ocular deviations.
Patients And Methods: Sixty-three patients were evaluated with a new device for the measurement of exclusive visibility during binocular rivalry. The patients were consisted of twenty-three with exotropia (XT), twenty with intermittent exotropia [X(T)], twenty with exophoria (XP), respectively. Read More
From the IWK Health Centre Eye Care Team, Halifax, Nova Scotia, Canada; From the Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia, Canada; From the Division of Ophthalmology, Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa.
Concepts regarding certain forms of congenital eye movement disorders have recently changed, due in large part to new genetic evidence identifying causative genes and their role in the development of extraocular muscle innervation. This group is now referred to as the Congenital Cranial Dysinnervation Disorders (CCDDs). Careful assessment of phenotypic features that include both ophthalmological and non-ophthalmological features in genetically defined individuals has led to the development of a more robust classification system. Read More
Background And Purpose: Certified orthoptists are routinely required, as a standard component of outpatient care, to examine and identify the cause of double vision described by neuro-ophthalmology and oculo-plastics patients. Peer-reviewed articles in the strabismus literature describing the significance of this role of the orthoptists, especially in more complex cases of strabismus, do exist, but are outdated. The importance of creating a differential diagnosis in the understanding of the disease process is a well-recognized component of medical education and modern medicine. Read More
Patients with motility problems due to neurodegenerative disease such as Parkinson's and its variations often present challenging cases for the orthoptist. A few "tricks of the trade" will be presented on how to make a Parkinson's patient's daily life a little easier. Read More
An esodeviation that is greater at distance than near in an adult patient requires a full sensorimotor exam to rule out any cofounding neurological conditions. Many etiologies are described in the literature to cause an esodeviation that is greater at distance than near in adult patients and some exist in conjunction with a neurological condition. However, many adult patients present to the adult strabismus clinic with no other findings on exam and have a purely benign divergence insufficiency esotropia. Read More
Divergence insufficiency esotropia, or acquired comitant esotropia that is at least 10Δ larger at distance than at near, is most often seen in older adults, and may also be known as "age-related distance esotropia." Surgical treatment is often indicated for patients who do not tolerate prism therapy, or for those with large angles of esotropia. Surgical treatments have evolved with our understanding of the disease-state. Read More
Introduction And Purpose: Symptomatic, small-angle strabismus is largely an acquired problem of adults that has previously been managed with prism spectacles. This paper will explore surgical options that are becoming increasingly popular.
Methods: The special issues that confound surgical treatment of small-angle strabismus are considered. Read More
Maculopathies affect point-to-point foveal correspondence causing diplopia. The effect that the maculopathies have on the interaction of central sensory fusion and peripheral fusion are different than the usual understanding of treatment for diplopia. This paper reviews the pathophysiology of macular diplopia, describes the binocular pathology causing the diplopia, discusses the clinical evaluation, and reviews the present treatments including some newer treatment techniques. Read More
Background And Purpose: Torsional diplopia can result in failure of fusion in an individual without a measureable strabismus. When presented with a patient with complaints of binocular diplopia, physicians and orthoptists should consider cyclovertical muscle dysfunction when the source of the complaint is not readily apparent.
Methods: A thorough review of the literature combined with the author's own personal experience in treating adult patients with strabismus was used to evaluate the different potential causes of torsional diplopia. Read More
Background And Purpose: The profession of orthoptics has been present for over 100 years and was created as a partnership with pediatric ophthalmology in an effort to provide better strabismus care to children. Orthoptists are known to improve practice efficiency, but to date, no quantitative data has been presented in the literature to support this claim. Proper utilization of an orthoptist is critical to improving practice efficiency and revenue. Read More
The year 2015 marks the 75th anniversary of the American Association of Certified Orthoptists (AACO), the second oldest orthoptic professional organization in the world. Since its inception, October 7, 1940, approximately 90% of all certified orthoptists (C.O. Read More
This is a case presentation of a 39-year-old male who presents with silent sinus syndrome. He was initially diagnosed by a neuroophthalmologist, and at first, the patient's otolaryngologist disagreed. The patient had a significant reduction in his symptoms with surgical and orthoptic intervention. Read More