Abstract: Purpose To investigate heterotropia, heterophoria, head posture, nystagmus, stereo acuity, ocular motility and near point of convergence (NPC) in children with hydrocephalus treated surgically before 1 year of age. In addition, the effects of being born with hydrocephalus, the effect of the etiology of hydrocephalus, number of shunt revisions and the size of the ventricles on these variables were studied. Methods A population-based study was performed in 75 children and the results were compared with the results of an age- and sex-matched group (comp group) (n = 140). Results Heterotropia 68.9% (comp group 3.6%; p < 0.001), abnormal head posture 41.3% (comp group 0; p < 0.001), nystagmus 44.0% (comp group 0; p < 0.001), stereo acuity ≤60″ 33.8% (comp group 97.1%; p < 0.001) and ocular motility defects 69.7% (comp group 0.7%; p < 0.001) were more common among children with hydrocephalus than in the comparison group. Children with overt hydrocephalus at birth had significantly more heterotropia (p = 0.0006)...

Abstract: Background: The Vision Screener® is a new, commercial version of the Power Refractor, an off-axis, hand-held video refractor to screen for amblyogenic refractive errors. The aim of our study was to determine the reproducibility of the measurements, compare them to cycloplegic refraction, and evaluate the sensitivity and specificity for the detection of amblyogenic refractive errors. Patients and Methods: Included in the study were 161 preschool children, age 0.5–7.2 years without manifest strabismus > 10°, who attended the outpatient clinic. After three measurements with the Vision Screener (version 4.3.15) and one measurement with +3 dpt glasses, the child underwent cycloplegic refraction. Results: The reproducibility of the three non-cycloplegic measurements was ± 0.5 dpt in 85% and ± 1 dpt in more than 95% of the children. Accommodation reduced the manifest hyperopia that could be measured with the Vision Screener by up to 3 dpt in some children. Compliance with the +3 dpt glasses increased from 20% in...

Abstract: The aim of this study was to investigate the spatial and temporal distortions that occur in strabismic and anisometropic amblyopic vision. Twelve subjects with strabismic (n = 4), anisometropic (n = 4), mixed amblyopia (n = 3) and bilateral refractive amblyopia (n = 1) were asked to describe and sketch their subjective percept of different geometrical patterns, as seen with their amblyopic eye. Based on their descriptions, computer-animated patterns were generated, which were then validated by the subjects. Both spatial distortions and temporal instability were perceived mainly by strabismic and strabismic-anisometropic amblyopes. Temporal instability occurred mainly at high spatial frequencies. Our data suggest that strabismus, in addition to amblyopia, is needed to elicit significant spatial and temporal distortions. The occurrence of these distortions may be related to the early history of each subject.

Abstract: Ocular neuromyotonia is an uncommon disorder resulting from episodic involuntary discharge of ocular motor nerves producing sustained contraction of their respective ocular muscles. Ocular neuromyotonia manifests in brief spells of diplopia occurring spontaneously or after eccentric gaze holding. In most cases, ocular neuromyotonia follows months or years after radiotherapy to the sellar and parasellar region and involves the oculomotor nerve. We report two unusual cases of abducens nerve ocular neuromyotonia that followed radiation therapy of tumors in areas other than the sellar or parasellar region.

Abstract: Aims To identify the predictors for motor outcome and response to surgical treatment of primary exotropia. Setting Taunton and Somerset Hospital, Somerset, United Kingdom. Study type Retrospective analysis of the surgical treatment of primary exotropia performed in our department over a period of 12 years from April 1991 to May 2003. Methods Case-notes of the patients who had surgical treatment for primary exotropia for the specified period were identified by a hospital computer database (MDI coding). All case-notes were reviewed and the following data were recorded and used for statistical analysis: age at the time of surgery, type and severity of exotropia, presence of amblyopia, AV pattern and vertical deviation, the level of stereopsis, type of surgery, and motor and cosmetic results. The surgical outcome was determined as good motor outcome if tropia was within 10 PD of orthotropia. The response to surgery was derived from the difference between the preoperative and postoperative angle of deviation f...

Abstract: Botulinum toxin has been used extensively in strabismus management. However, less is published regarding its use in small-angled manifest deviations or decompensating heterophorias, where an alternative to surgery is required. The aim of this review is to look at the use and effectiveness of botulinum toxin in managing small-angled manifest deviations, both constant and intermittent, and decompensating heterophorias. These types of strabismus can prove difficult to manage, as the angle present is often too small for surgery to be advised, but it may still cause a cosmetic or symptom-producing problem. A search of the English speaking literature was undertaken using Medline facilities as well as a limited manual search of non-Medline journals and transactions.A brief overview is provided for mechanisms of action, complications and dose effects, and diagnostic and therapeutic uses of botulinum toxin. The main reported complications are those of ptosis, induced vertical deviation and subconjunctival haemorrh...

Abstract: Purpose To describe the clinical features of patients from the Arabian Peninsula with Duane retraction syndrome (DRS). Methods Retrospective chart review of patients referred to the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia from 1982 to 2003 with a diagnosis of DRS. Patients having had prior strabismus surgery were excluded. Results Of 404 DRS patients, 347 (86%) were unilateral, 57 (14%) were bilateral, and 111 (27%) had amblyopia. There were 221 (55%) females and 182 (45%) males. The Huber classification was as follows: 315 (78%) Type I, 16 (4%) Type II, and 77 (19%) Type III. Of the 57 bilateral cases, 25 (44%) were female and 32 (56%) were male. Discussion Overall, the clinical features of DRS patients referred to a Riyadh eye hospital are similar to those reported in series throughout the world. However, our referred bilateral DRS patients are more commonly male. The clinical features of bilateral DRS deserve further worldwide study.

Abstract: Purpose Suturing is a time-consuming process and patients may suffer from sutures because of discomfort and tearing. This prospective study was done to determine the efficacy of an available commercial fibrin sealant for conjunctival wound closure following extraocular muscle surgery for strabismus. Methods Fibrin sealant (Beriplast®) was used in 48 conjunctival wounds of 25 patients with strabismus during the period February 2004 to May 2005. There were 12 males and 13 females, whose mean age was 9.3 years. Results No allergic reactions, chemosis or infections were seen, but suturing was necessary a day after surgery in 3 wounds of 2 cases (3/48 eyes, 6%). All conjunctival wounds were healed at the end of the second week. Conclusion The use of Beriplast® for conjunctival wound closure is an effective method that is easy to apply and should be considered a solution in strabismus surgical practice.

Abstract: Background Orbital cellulitis after strabismus surgery is uncommon, may cause blindness and may lead to death. Very few cases have been described in detail due to the low incidence of this complication. Methods We report the first case of orbital cellulitis following Faden operation on the medial rectus muscle. We believe that the infection was due to asymptomatic ethmoid sinusitis. Our case is compared with other cases previously reported. Results A two-year-old boy was surgically treated for residual esotropia after two botulinum toxin A injections. Two days after surgery, signs of orbital cellulitis developed in his right orbit. CT-scan disclosed right ethmoid sinusitis that spread to the orbit after surgery. After intravenous antibiotic treatment, the infection resolved with full restoration of visual acuity and ocular motility. Conclusion Despite adequate measures to prevent infection, orbital cellulitis may complicate strabismus surgery. Patients must be instructed to recognize early symptoms of thi...

Abstract: Purpose This study investigated the ultrastructural changes in extraocular muscles under which radioactive plaques had been placed for the treatment of uveal melanoma. Methods At the time of plaque removal, biopsies were taken from four horizontal recti that had been left in situ over plaques and from one lateral rectus muscle that had been disinserted before brachytherapy. Normal lateral recti from enucleated eyes were used as controls. Iodine-125 seeds were used with a mean total activity of 54.04 mCi, remaining for an average of 149.62 hours over the sclera. Results Muscles that had been left in situ over the radioactive plaques demonstrated a focal decrease in muscular tissue and increased fibroblasts and collagen. Electron microscopy showed increased collagen, loss of sarcoplasmic reticulum and swollen mitochondria. The disinserted muscle in the plaque group appeared unaffected. Conclusions Despite the theoretical shielding properties of plaques, leaving an extraocular muscle over the plaque may lead...

Abstract: Purpose To determine the outcome of patients treated for residual symptomatic hyperdeviations, in a tertiary referral centre, following a previous weakening procedure of the ipsilateral Inferior Oblique (IO) muscle in Superior Oblique (SO) palsy. Methods A retrospective review of 37 patients seen over 6 years at one institution who had remained symptomatic from a SO palsy despite having had an initial weakening procedure to their ipsilateral IO (myectomy or recession). Median age was 19 years (range 3 to 56 years). Information recorded included pre- and postoperative deviation and ocular motility findings, preoperative symptoms, findings at the time of surgery, and outcome. Results Nine patients underwent repeat weakening surgery (disinsertion) on the ipsilateral IO only. Thirteen patients underwent strengthening surgery on the ipsilateral SO only. Nine patients had surgery on both the ipsilateral IO and SO. Six patients had surgery on the ipsilateral IO with either horizontal or vertical rectus surgery. ...

Abstract: Introduction Amyloidosis is a multi-system disease characterised by the intracellular deposition of β-pleated sheets of amyloid. It can involve the eye, orbit and ocular adnexae. Method We describe a case of a 58-year-old woman presenting to the eye department with external ophthalmoplegia, including the findings of various investigations. The spectrum of ocular amyloidosis is discussed. Conclusion Amyloidosis may be the underlying diagnosis in some cases of external ophthalmoplegia with findings atypical to other systemic disease.

Abstract: We report the case of a 20-year-old female who developed progressive esotropia, which was associated with low myopia and restricted extraocular movements.

Abstract: Disrupted stereovision is a feature that accompanies strabismus. This study uses an fMRI adaptation paradigm to assess the amount of cortical binocularity in subjects with normal or impaired stereopsis. We present data from a pilot study of two normally-sighted and one stereodeficient subject with alternating fixation. We adapted one eye to diagonally oriented sinusoidal gratings and tested either the same (monocular test) or the other eye (interocular transfer), using either the same or an orthogonal orientation. In normally-sighted subjects, we observed monocular adaptation but only weak interocular transfer in the striate cortex, whereas in the extrastriate cortex we found strong monocular as well as interocular adaptation. In the stereodeficient subject, monocular adaptation but no interocular transfer was obtained in the extrastriate cortex. These results suggest that impaired stereopsis is related to reduced interocular transfer of adaptation at higher levels of the cortical visual pathway.

Abstract: The visual performance test () measures the time required to find an object within the visual field. Black icons of high contrast are superimposed on a scenic background of low contrast in one of 11 positions in random order. The subject's task is to find the search icon on the CRT screen as rapidly as possible. This test was administered binocularly in 38 patients with homonymous visual field defects. The aim of the test was to identify those patients who had not adapted themselves to their visual handicap, and to quantify the effect, in these patients, of training of compensational search saccades (; ; ). The results show that the visual performance test reflects the practical abilities of these patients and that it may monitor the benefit of visual rehabilitation training in patients with functional restrictions in daily life.

Abstract: Purpose To assess the reproducibility of measurements of visual acuity in both the upper and lower range of visual acuity. Materials and methods The retroilluminated ETDRS 1 and ETDRS 2 charts (Precision Vision) were used for measurement of visual acuity. Both charts use the same letters. The sequence of the charts followed a pseudorandomized protocol. The examination distance was 4.0 m. When the visual acuity was below 0.16 or 0.03, then the examination distance was reduced to 1 m or 0.4 m, respectively, using an appropriate near correction. Visual acuity measurements obtained during the same session with both charts were compared. A total of 100 patients (age 8–90 years; median 60.5) with various eye disorders, including 39 with amblyopia due to strabismus, were tested in addition to 13 healthy volunteers (age 18–33 years; median 24). At least 3 out of 5 optotypes per line had to be correctly identified to pass this line. Wrong answers were monitored. The interpolated logMAR score was calculated. In the...

Abstract: The authors report the results of a retrospective review of patients who underwent nasal transposition of the vertical rectus muscles between 1997 and 2004 Eight patients were identified, 4 males and 4 females There was an average age at surgery of 37 years, with a range from 8 to 79 years The aetiologies included 6 patients with trauma to their medial rectus (4 following endoscopic sinus surgery) and 2 patients with paralytic medial rectus muscles secondary to 3rd nerve palsy All patients underwent whole tendon transposition of the superior and inferior rectus muscles, with resection of both muscles in 7 cases, before reattachment adjacent to the upper and lower borders of the medial rectus, respectively One patient had a reduced amount of resection and this was combined with inferior oblique disinsertion and traction sutures All patients had a reduction in deviation in the primary position and in 5 patients there was some improvement in adduction A consequence of surgery was a degree of limitatio

Abstract: Purpose The aim of this study was to investigate the amblyopia treatment trends of Australian orthoptists and to identify variations or consistencies amongst treatment patterns. Methods A questionnaire was distributed to all orthoptists who attended an annual national scientific conference. This questionnaire consisted of four case vignettes of amblyopic patients. Each was presented with a series of multiple-choice questions that orthoptists were required to answer. Results The questionnaire was completed by 46 orthoptists. Large diversity between orthoptists in their treatment application was found. This related mostly to the intensity of occlusion treatment. Conclusion Treatment variability continues to exist between orthoptists. Further investigations evaluating the clinical decision making processes of clinicians in prescribing amblyopia treatment may help us to better understand the determinants that are considered when prescribing treatment. This would be useful in establishing best-practice guidelines.

Abstract: Case report of a 15-year-old girl presenting with a left-sided Duane's retraction syndrome (DURS) in combination with ipsilateral retinal coloboma and contralateral microphthalmia. Abduction limitation as well as narrowing of the palpebral fissure and globe retraction during attempted adduction (type I DURS) was demonstrated in the left eye. Additionally, a retinal coloboma was observed in the nasal inferior quadrant of the left eye. No other somatic or developmental abnormalities were observed and karyotypic analysis was normal. This is the first case of non-syndromic unilateral DURS associated with a contralateral major ocular malformation. This unusual clinical combination probably arose from the embryonic action of an eye-specific disruptor.

Abstract: Dark vergence is a resting position of vergence, measured in a dark visual field to eliminate fusional, accommodative, and proximal stimuli. Dark vergence differs among subjects: the average subject converges to a viewing distance of about 1 m, while the inter-individual range is from infinity to about 40 cm. This paper reviews previous ergonomic studies on dark vergence in relation to asthenopic complaints that occur when working at near computer screens: subjects with distant dark vergence exert more convergence and experience stronger asthenopic complaints than subjects with near dark vergence. The dissociated phoria, a common clinical measure of resting vergence, is only weakly correlated with asthenopic complaints, probably because of accommodative influences that cause the difference between dark vergence and dissociated phoria.

Abstract: Aim: The aim of this study was to investigate the influence of single ocular muscle weakness on smooth pursuit eye movements. Methods: Infrared video recordings of horizontal and vertical eye movements were obtained from 14 adult patients with either unilateral abducens nerve palsy or trochlear nerve palsy. During the recordings, subsequent series of horizontal, vertical and oblique ramp stimuli of 10°/s constant target velocity and ±10° amplitude were presented under monocular viewing conditions. Results: In both forms of ocular nerve palsies, similar changes of pursuit eye movements were observed in the pulling plane of the paretic muscles. The movements of the covered paretic eye showed the lowest amplitude and gain values as well as the lowest numbers of catch-up saccades. The highest amplitude and gain values were calculated from the movements of the covered sound eye. The highest numbers of saccades, however, were produced by the fixating paretic eye. Conclusions: We conclude that the fixating paret...

Abstract: Spatial distortions in amblyopic vision can be captured by subjective reports or by a point-by-point mapping of the central part of the visual field. In this study, we developed a series of algorithms that provide a fine-grain mapping of the amblyopic percept. These algorithms can be applied to any real-world image. The images created based on these algorithms can be compared with the subjective percept of each amblyope.

Abstract: Performance in the visual environment was evaluated with a central fixation or a search target in 11 positions within 34° on a CRT, superimposed on a landscape. Reaction times were recorded. We examined 24 patients aged 26–83, with lesions of the visual pathways and homonymous visual field defects, and 18 normal subjects aged 23–79. This simple test takes about 1 minute in normal subjects and four or more minutes in neurological patients. The test may be used to quantify saccadic adaptation to disability from homonymous field defects and to monitor the training effects of visual rehabilitation.

Abstract: Purpose We examined the effects of the Harada-Ito procedure on static and dynamic alignment in an adult with acquired bilateral superior oblique palsy (SOP). Methods 3D eye movements were recorded before and six weeks after a bilateral Harada-Ito procedure. Superior oblique muscle (SOM) size and contractility were assessed with orbital imaging. Results On MRI, the left SOM was smaller than the right. Little contractile thickening was present in down gaze for either eye. Preoperatively, the patient had a hypertropia: 1.9° right hypertropia (at down 20°, left 20°) and 6.4° left hypertropia (at down 20°, right 20°). Postoperatively, the vertical tropia in all positions was < 1°. Listing's primary position rotated toward straight ahead for the RE but was unchanged for the LE. Postoperatively, for 40° upward saccades peak dynamic intrasaccadic extorsion decreased by 2.2–3.2° for both eyes and for 40° downward saccades by 2.3–3.6° for the RE but was unchanged for the LE. Saccade conjugacy improved and post-sacc...

Abstract: Background Congenital fibrosis of the extraocular muscles includes a wide spectrum of phenotypically heterogeneous disorders involving a single or multiple muscles. Methods We present a case of congenital fibrosis of the inferior rectus associated with ipsilateral high myopia. First we tried to treat the hypotropia with inferior rectus weakening and superior rectus strengthening procedures, but this failed, so we proceeded with an ocular sling with fascia lata and a vertical Hummelsheim procedure. Results Hypotropia improved completely after the last operation and some degree of upward movement appeared. Conclusion It seems that in a highly myopic globe with fibrotic muscles, classical methods for the correction of deviation may have poor response and more innovative procedures may be required to correct the deviation.

Abstract: Objective To analyze the hypothesis that a reduction in sensitivity of the nasal visual hemifield would lead to an increase in the nasotemporal asymmetry of the visual field in patients under two years of age with early-onset convergent strabismus in comparison with normal patients. Methods Both eyes of 66 patients—33 esotropes and 33 normals - were studied. Patients' age ranged from 7 to 30 years. The examination consisted of a static perimetry using the Humphrey field analyzer 700 Series' Sita Standard program. Results An accentuation of the nasotemporal asymmetry was seen in the 33 esotropes and was related to an evident decrease of sensitivity in the most peripheral of the points studied along the horizontal meridian of the visual field. The quantitative sum of values of sensitivity of these points showed an average reduction of −15.71% in relation to the normal patients. Conclusion There was a clear accentuation of the nasotemporal asymmetry of sensitivity in esotropes when compared to normal patient...

Abstract: Aim To evaluate the usability and reliability of three different visual acuity (VA) testing procedures using Landolt C's in 8 positions with a semi-automated computer program in school children. Methods 100 school children (median 7 years, 59 boys and 41 girls) were included; only the better eye was tested. We used the semi-automated computer program CORVIS®.VT in a forced choice method. Three different test strategies were employed, each two times: A) DIN, B) Standard-Staircase and C) Best-PEST procedure with sequences A, B, C or A, C, B. Results Average testing time was 100s ± 45 (DIN), 59s ± 36 (Staircase) and 77s ± 25 (Best-PEST). The mean VA estimated with DIN was equivalent to that with the Best-PEST procedure. However, the mean VA with Standard-Staircase was one line less. In DIN, 76% of the retest scores were within 0.1 logMAR unit of the initial test score (Staircase: 72%, Best-PEST 73%). The 95% confidence interval of test-retest reliability was calculated to be −0.05 ± 0.24 logMAR in DIN, +0.02...

Abstract: Writing this dissertation was motivated by the treatise of DONDERS about the movements of the human eye (Donders, 1848; Donders & Blanken, 1999). DONDERS was the first to reject the entire theory, proven by the most eminent men, regarding eye movements around three axes: the vertical, horizontal, and longitudinal, and presented a different concept of ocular movement. Earlier, TOURTUAL (1840) had hesitated to agree with all of these previous conclusions and RUETE (1845, 1999), who took into account the after-image, had denied the correctness of the theory, originally introduced by HUECK (Hueck, 1838, 2000), that the vertical eye axes, by virtue of the oblique muscles, remain vertical even when the head tilts to the side. In order to define the limitations of this work right at the beginning: It is my intent to reexamine the observations and experiments with which HUECK tried to prove the correctness of this rotation, but not to reexamine everything that he has dared to conclude. I also wish to examine the after-image (which DONDERS wants to be the pivotal point of the entire argument) and its observed positions as well as the argumentative strength of the position of the vertical meridian of the retina. After an excellent presentation of the anatomical location and position of the eye muscles, HUECK attempted to prove that a rotation around the longitudinal axis could come about by virtue of the oblique eye muscles. In my view, a difficulty that speaks against this rotation around the longitudinal axis is that in some axis positions, the oblique muscles run in an oblique angle to the longitudinal axis. The only correct statement about the attempt by HUECK is that he used an assumption that in itself lacks proof and must actually be considered wrong (I anticipate the observation). HUECK believes that he can refute the above objection with the observation that the rectus muscles, superior as well as inferior, still rotate the eyes upwards and downwards around the horizontal axis although they are attached in an oblique angle to the human eyeball, and in an even more oblique angle in birds, amphibians, and especially in frogs. The note that immediately follows HUECK’S above effort I communicate to my readers in full because of the importance it has gained among experts. It reads: Accepted 15 February 2007. ∗The thin fascicle of Gudden’s dissertation was available for study in the Bayerische Staatsbibliothek, Munich, and in the library of the Psychiatrische Klinik und Poliklinik, Ludwig-Maximilians-Universität. Only the latter copy contained the illustrations. The Latin text contains several sections in German (presented in italics in the English translation). The curriculum vitae from the appendix has been omitted since it was recently reproduced in full (along with page 6 of the dissertation and with the doctoral diploma) in a comprehensive Gudden biography (Hippius & Steinberg 2007). For the scientific context of his dissertation see a brief overview (Danek 2006) as well as a detailed account of 19th century ocular motor research (Simonsz & Den Tonkelaar 1990).

Abstract: Purpose To determine angle kappa values in strabismic individuals by means of a synoptophore. Methods One hundred-and-eight strabismic subjects and 102 healthy subjects who served as a control group were enrolled in the study. A complete ophthalmologic examination, including determination of refractive status, best-corrected visual acuity measurement, slit-lamp biomicroscopic anterior segment evaluation, intraocular pressure measurements with a Goldmann applanation tonometer, and dilated fundus examination, was done on all study participants. Orthoptic examination included Krimsky prism reflex test, prism cover test, and duction tests. Strabismic patients were grouped into two categories according to their deviation types: exotropic and esotropic. A synoptophore (Clement Clarke, London, England) with a specially designed slide (Maddox test slide series A White Binding No: 16; Clement Clarke, London, England) was used to measure angle kappa. Results Of the 108 strabismic patients, 62 were males and 46 were...