Nonparalytic Strabismus Research Articles

Investigation of the Perception of Three-Dimensional Geometric Figures from the Rotational Movement of Their Two-Dimensional Image in Children with Ophthalmopathology

Manifestations of the illusion of a three-dimensional structure appearing when rotating a flat projection of a three-dimensional object (structure from motion (SfM)) were studied in three groups of children aged 7 to 17 years: 1) 40 children of the control group with orthotropy, the normal state of visual functions (including binocular and stereovision) and fundus; 2) 33 children with non-paralytic strabismus and normal fundus condition; 3) 50 children with non-paralytic strabismus on the background of congenital partial atrophy of the optic nerve (PAON). As a test image, we used the figure of a hexagon with diagonals passing through its center, presented in binocular and monocular observation conditions in the form of a still image, and when it rotates at a speed of 5, 10, 15, 20, 30, 40 rpm. It was shown that the perception of a three-dimensional structure in the form of a cube is possible with a stationary presentation of a test image in 2–3% of children of both the control group and groups of children with strabismus in binocular and monocular observation conditions. When rotating the test image in both binocular and monocular observation conditions, the number of children who perceived the cube in all groups increased with increasing image rotation speed, reached maximum values at 15–30 rpm and significantly decreased at 40 rpm. In the control group, during the transition from binocular observation conditions to monocular, the number of children perceiving the image as a cube significantly increases at rotational speeds of 5 rpm (p = 0.023), 10 rpm (p = 0.005), 20 rpm (p = 0.002) and 30 rpm (p = 0.001). In groups of children with strabismus (both on the background of normal fundus and on the background of PAON), binocular and monocular indicators were statistically comparable (р 0.05). Comparison of indicators in different groups demonstrated a greater number of children perceiving a three-dimensional figure in the control group than in both groups of children with strabismus at certain speeds of rotation of the test image (from 10 to 20 rpm). In groups of children with strabismus on the background of normal fundus and children with strabismus on the background of PAON, binocular and monocular indicators are statistically comparable for all image rotation speeds. There was no significant dependence of the nature of the perception of the test image on age in all the studied groups of children. Thus, along with the general patterns of SfM manifestations in children of the studied groups, differences were revealed due to the nature of the interaction of monocular and binocular mechanisms of spatial perception in normal and ophthalmopathology. Thus, the SfM study can be used to evaluate the effects of depth and force relations of the monocular and binocular mechanisms of spatial perception in normal and ophthalmopathology.

Lateral Phenotypes in Children with Ophthalmopathology

The work is devoted to one of the most relevant problems of ophthalmology and neurophysiology which is the study of interhemispheric interactions in children with ophthalmopathology.The purpose of this work is to study lateral phenotypes in children with ophthalmopathology.Patients and methods. 374 6–15 years old children were observed: 1) 160 children with non-paralytic strabismus; 2) 111 children with organic pathology of the retina and the optic nerve; 3) 103 children of the control group (without ophthalmopathology). The lateral phenotype (LP) was determined according to the scheme “dominant hand — dominant ear — dominant eye”.Results. Different LP ratios were obtained in the examined groups of children (p < 0.001). The ratio of right-handers / left-handers / ambidextrous children was most uniform in the group of children with non-paralytic strabismus (43,8 / 22,5 / 33,7 %). In the group of children with organic ophthalmopathology it was “shifted” to the right-hand side (65,8 / 10,8 / 23,4 %). In the control group the number of left-handers was minimal, and the number of ambidextrous was maximal (51,4 / 3,9 / 44,7).Conclusion. It was found that children with organic ophthalmopathology are characterized by the most pronounced predominance of right-sided LP, and children with non-paralytic strabismus are characterized by a relatively uniform distribution of right-sided, left-sided and symmetrical LP. The identified features may reflect increased left-hemispheric activity in children with organic ophthalmopathology and adaptivecompensatory increase in right-hemispheric activity in children with non-paralytic strabismus.

The Results of Studying Spatial Perception in Children with Ophthalmopathology Using the Technique of Copying Taylor’s and Rey–Osterrieth’s Figures

The work is devoted to one of the actual problems of ophthalmology — the study of spatial perception in children with ophthalmopathology.Purpose of the work is to study the characteristics of spatial perception in children with ophthalmopathology using the technique of copying Taylor’s and Rey–Osterrieth’s figures.Patients and methods. 284 children aged 6 to 8 years were observed: 1) 135 children with operated convergent non-paralytic strabismus; 2) 53 children with organic pathology of the retina and optic nerve; 3) 96 children of the control group (without ophthalmopathology). The characteristics of spatial perception were evaluated according to the results of copying complex geometric figures — Taylor’s (with a right hand) and Rey–Osterrieth’s (with a left hand).Results. It is found that the distinguishing particularities of the group of children with non-paralytic strabismus are the smaller number of children copying the figures starting from the whole contour (using a deductive strategy) and the reduced quality of drawing compared to those in the group of children without ophthalmopathology. It is also shown that in children with organic ophthalmopathology these features relate to copying Rey–Osterrieth’s figure to a greater degree than copying Taylor’s figure, which may reflect a shift in interhemispheric relations in them towards more pronounced left-hemisphere activity.Conclusion. Thus, the method used in the work is informative, allows to identify the features of spatial perception in children with different ophthalmopathology and conduct a comparative analysis of its characteristics.

Strabismus outcomes after surgery: the nationwide SOS France study.

To describe the types of strabismus operated on, the surgical procedures performed, and the 2-year reoperation rate in France. Entire population 5-year cross-sectional analysis of a national medico-administrative database in France between January 2013 and December 2017 included all patients who underwent a first strabismus surgery, with a 2-year follow-up. Patient identification was based on the diagnostic codes of the 10th International Classification of Diseases and surgical procedures on the codes of the Common Classification of Medical Acts. A subgroup analysis comparing non-paralytic and paralytic strabismus was performed. Among the 56,654 patients included (women: 50.8%), 26,892 (47.5%) patients were under 10years old. Overall, 52,711 (93%) were diagnosed with non-paralytic strabismus and 3,943 (7%) with paralytic strabismus. Among the non-paralytics, the most frequent diagnosis was esotropia (21,282, 37.6%), followed by exotropia (14,392, 25.4%) and vertical strabismus (2,017, 3.6%). Among the paralytics, fourth cranial nerve palsy (1,499, 2.6%) was more frequent than sixth cranial nerve palsy (691, 1.2%) and third cranial nerve palsy (431, 0.8%). The 2-year reoperation rate was 7.7% (4,362 patients), the lowest for non-paralytic (7.4%) and the highest for paralytic (11.4%). This first French population-based study about strabismus will contribute to the evaluation of practices at a national level and permit comparisons between countries. Although the 2-year reoperation rate was found to be 1 out of 13 patients, it should be interpreted with caution. Long-term follow-up is still warranted due to considerable variability of the type and severity of strabismus as well as surgical practices.

Динамика межполушарных отношений в результате функционального лечения у детей с оперированным содружественным косоглазием

Purpose. To study the dynamics of interhemispheric interactions in children with friendly strabismus as a result of functional treatment. Material and methods. The study included 135 children aged 6 to 8 (average 6.8±0.1) years with convergent non-paralytic operated strabismus in combination with hypermetropic refraction and 96 children of the same age in the control group (average 7.1±0.1 years) without ophthalmic pathology. In children with strabismus, the leading hand and dominant eye were determined before and after functional treatment. Characteristics of spatial perception were evaluated by copying of complex geometric shapes which were Taylor's (right-handed) and Ray-Osterritz's (lefthanded). Results. After functional treatment in the group of children with non-paralytic strabismus, along with improved binocular functions and improved performance of the Taylor and Ray-Osterritz tests, there was an increase in the number of ambidextrous children and a significant decrease in the number of left-handers (p<0.001). Conclusion. The increase in the number of symmetrical lateral phenotypes against the background of improved binocular functions and spatial perception characteristics as a result of functional treatment of children with non-paralytic strabismus indicates an improvement of their interhemispheric interactions and can be an additional criterion for the ef fectiveness of treatment. Key words: lateral phenotypes, interhemispheric asymmetry, functional treatment of strabismus

Results of Using Different Modes of Presentation of Stereostimuli in the Study of Stereo Vision in Normal Children and in Children with Non-Paralytic Strabismus without Functional Scotoma

The work is devoted to one of the actual problems of current ophthalmology — creating effective methods of studying stereovision.The purpose — comparative analysis of the capability of stereoperception under conditions of using different regimes of alternating presentation of stereo stimuli with different characteristics in children with strabismus and in children without ophthalmopathology.Patients and methods. 294 school children — 167 children of the control group (without ophthalmopathology) and 127 children with non-paralytic strabismus without functional scotoma (FSS) were observed. We used stereostimuli with different characteristics in the following regimes of presentation: 1) the regime of simple monocular alternating (alternate presentation of an image for the right and left eye); 2) the regime having an “empty” interval (black background) between monocular phases; 3) the regime having a binocular phase (a binocular image containing details corresponding to the stimuli for the right eye and the left eye) between monocular phases.Results. It was found that the majority of children with non-paralytic strabismus, who are incapable of stereoperception with the classic Fly-test and Lang-test, can perceive the stereoeffect with alternating presentation of stereostimuli within individual ranges of durations of monocular phases, a binocular phase and an “empty” interval. In children of the control group when switching from the simple alternation regime to the “empty” interval regime the maximal durations of monocular phases, which preserved the stereoeffect, decreased and when switching to the binocular phase regime they significantly increased. In children with strabismus linear images are simpler for stereoperception than random-dot images as well as in children of the control group (p < 0.001); stimuli creating the effect of the frontoparallel separation of details get perceived better than those creating the decline effect or the turning effect (p < 0.001); stimuli creating the effect of the vertical stripes decline get perceived better than those creating the effect of the horizontal stripes turning (p < 0.001). However, as opposed to the children of the control group, in children with strabismus the stereoeffect gets formed better under conditions of the peripheral localization of linear details than under conditions of the central one.Conclusion. Using computer programs with different regimes of alternating presentation of stereostimuli with certain characteristics allows to effectively evaluate individual capability of stereoperception which is necessary for the personalized approach to the selection of visual stimuli and stimuli presentation regimes in functional treatment of patients with non-paralytic strabismus.

Results of Using Alternating Presentation of Stereostimuli in Children with Functional Scotoma in Non-Paralytic Strabismus

The work is devoted to one of the actual problems of modern strabismology — the study of the ability to stereo perception in children with non-paralytic strabismus.Purpose: to study the capability to stereovision with alternating presentation of stereostimuli in children with functional scotoma in non-paralytic strabismus.Patients and methods. 113 children with functional scotoma (FS) in non-paralytic strabismus were observed. We used stereostimuli with different characteristics in the following regimes of presentation: 1) the regime of simple monocular alternating (alternate presentation of an image for the right eye and the left eye); 2) the regime having an “empty” interval (black background) between monocular phases; 3) the regime having a binocular phase (a binocular image containing details corresponding to the stimuli for the right eye and the left eye) between monocular phases.Results. It was found that in 23 (20,3 %) children, the ability to stereo perception was completely absent. All these children had stable total FS (monocular vision). In the remaining 90 children (with unstable or regional FS), the ability to stereo perception was shown with some stimuli in some modes of their alternating presentation. For stimuli with a central arrangement of linear parts, the stereo effect was possible when they were presented in an alternating mode with an “empty” interval lasting from 20 to 70 ms in combination with the duration of monocular phases from 30 to 90 ms. For stimuli with a peripheral arrangement of linear elements, 22.1 % of children were able to stereo perception not only in the “empty” interval mode, but also in the simple alternation mode. At the same time, the greatest number of children capable of stereo perception was detected when using the mode with an “empty” interval of 30–60 ms and a duration of monocular phases of 40–60 ms. With random-dot stimuli, none of the children in this group were capable of stereo perception.Conclusion. Our results suggest that even in patients with FS in non-paralytic strabismus, stereo perception is possible under the conditions of alternating presentation of stimuli with certain characteristics. In this case, the most likely appearance of a stereo effect with stimuli containing peripheral linear elements that create a stereo effect when presented in an alternating mode with an empty interval between monocular phases.

Characteristics of diplopia in a pediatric population

To evaluate the characteristics of diplopia in children at a single tertiary eye care center. The medical records of patients with diplopia onset at age 18 years or younger presenting during the period 2015-2018 were reviewed retrospectively. Demographic information, clinical characteristics, diagnoses, treatment, and outcome data were collected. The exact χ2 test was used to compare groups and select post hoc analyses were performed using the Fisher exact or exact χ2 tests. A total of 244 patients (average age, 12.2 years at presentation) were included. The most common clinical diagnoses were nonparalytic strabismus (49.2%), trauma (9.4%), and cranial nerve palsies (9%). There was no statistically significant difference in median age of diplopia onset in those with nonparalytic strabismus, cranial nerve palsies, and vision- or life-threatening conditions. There was a statistically significant difference in timing of onset of diplopia at presentation in vision- or life-threatening conditions compared to nonparalytic strabismus (P < 0.0001) and cranial nerve palsies (P = 0.01) and for neurologic symptoms in vision- or life- threatening conditions compared to nonparalytic strabismus (P = 0.032) and cranial nerve palsies (P = 0.0051). In patients with more than one neurologic symptom, the majority (58.3%) had a vision- or life-threatening condition. Initial interventions included observation (28.7%), prisms (18.4%), updating refractive correction (14.3%), and strabismus surgery (11.1%). In patients with follow-up data, 5.3% had resolution of diplopia prior to their clinic visit, and 46.6% had resolution after initial intervention. In our study cohort, most children who presented with diplopia had nonemergent conditions. In those with life-threatening conditions, diplopia tended to have an acute onset and associated neurologic signs and visual symptoms.

Using of Hypercorrection in Diagnostics and Functional Treatment of Children with Strabismus

Conjunctival lymphomas are predominantly extranodal B-cell non-Hodgkin’s lymphomas (NHL), most of them are MALT-lymphomas originating from the mucosa-associated lymphoid tissue. The paper is devoted to the study of the feasibility of using hypercorrection in the functional treatment of children with non-paralytic strabismus.The purpose of this work is evaluation of the effectiveness of hypercorrection in the diagnosis and functional treatment of children with non-paralytic strabismus. Patients and methods. We observed 166 school-age children with friendly strabismus: 140 children with esotropia (134 children with hypermetropic refraction and 6 children with myopic refraction) and 26 children with exotropia (17 children with myopic refraction and 9 children with hypermetropic refraction). The control group of children included 151 school-age children with ametropia without strabismus: 110 children with hypermetropia and 41 children with myopia. Optimal optical correction, accommodation and visual acuity were studied under monocular observation conditions and then under bifixation control using a binarimeter at different distances from the eyes (0.5, 1, and 5 m).Results. In children with esotropia and hypermetropic refraction, the most favorable conditions for the formation of a binocular visual image (BVI) were created using hypercorrection (average values from 2.4 ± 0.06 to 2.8 ± 0.06 D for different distances from the eyes). Children with exotropia and myopic refraction also needed hypercorrection to form BVI (Me = 2.5 [Q1 = 2.0; Q3 = 3.0] D at all distances from the eyes). At the same time, a strong positive correlation was found between the deviation value and the hypercorrection value necessary for the formation of BVI in children with both esotropia and exotropua (r = 0.85, p &lt; 0.001 and r = 0.8, p &lt; 0.001, respectively). In children with “inappropriate” refraction (myopic with esotropia and hypermetropic — with exotropia), BVI was easier to occur and better maintained under hypocorrection by an average of 1.75 ± 0.06 d. In the control group of children, the maximum visual acuity under the control of BVI was observed with the strength of correcting lenses 0.5 D less compared to monocular conditions of the study.Conclusion. The effectiveness of using hypercorrection in children with non-paralytic strabismus and “appropriate” refraction for the formation of BVI on a binarimeter is shown. In this case, the value of hypercorrection has a direct dependence on the value of deviation, which is consistent with the principles of accommodation-convergent synkinesia. In children with non-paralytic strabismus and “inappropriate” refraction, more favorable conditions for the formation of BVI are created when using hypocorrection. The result of functional treatment on a binarimeter with an individual selection of optimal optics for performing exercises is an improvement of accommodation, binocular and stereo vision, an increase of fusion reserves and visual acuity.

Application of the Modified Вagolini Test in the Diagnosis of Binocular Vision Disorders

The work is devoted to one of the most actual problems of current strabismology — the development of effective ways to study binocular vision.The purpose — to study the effectiveness of the developed modification of the Bagolini test in the diagnostics of binocular disorders.Patients and methods. 240 patients with non-paralytic strabismus aged from 6 to 17 (on average 10.8 ± 0.24) years were observed. There were 190 patients with converging strabismus and 50 patients with diverging strabismus. The control group consisted of 180 children aged also from 6 to 17 (on average 10.9 ± 0.3) years without ophthalmopathology. All children were examined for the character of vision using a Worth-test, the classic Bagolini test (CTB), and the developed modified Bagolini test (MTB). If the patient has a strabismus angle, the study was performed in two variants: without prismatic deviation compensation (under the subjective angle of strabismus — SU) and under full prismatic compensation (under the objective angle of strabismus — OU). For qualitative assessment of binocular vision with MTB, static presentation of the test image was used, for quantitative assessment — alternating (alternate presentation of details corresponding to the right and left eyes).Results. The qualitative evaluation data obtained with the help of MTB made it possible to differentiate patients with non-permanent regional functional scotoma of suppression (FSP) and patients with stable bifoveal fusion among children with binocular vision by color test, and to distinguish patients with regional stable FSP and total FSP among children with monocular vision by color test. In the study under SU, the sensitivity of the method was 97.8 % and specificity 96.2 %, under OU — 96.6 % and 92.7 %, correspondingly. Using quantitative evaluation, it was found that the minimum duration of monocular phases required to eliminate functional inhibition in children with total FSP is twice as long as in children with regional FSP (z = 6,303, df 52, p &lt; 0.001 according to the Mann — Whitney criterion).Conclusion. Thus, the modified Bagolini test developed by us is an effective way of qualitative and quantitative assessment of the state of binocular vision. The method has a high sensitivity and specificity, combines the capabilities of anaglyphic and phase haploscopy, and can be used for a personalized approach to the selection of conditions and modes of functional correction of binocular disorders, as well as for monitoring binocular vision during treatment.

Результаты использования альтернирующего предъявления стимулов в ортоптическом лечении у детей

Purpose. To evaluate the results in the use of different modes for alternating presentation of stimuli in the orthoptic treatment of strabismus in children. Material and methods. The study included 41 patients with a nonparalytic strabismus (30 children with esotropy and 11 children with exotropy) aged from 7 to 16 years. For additional studies of binocular functions, we used a modified Bagolini test and our own stereo-test created for the conditions of anaglyph separation of visual fields. During the first examination the results with all the used stereo-tests (the Flytest, the Lang-test, and the stereo image that we created) were negative. Besides to the static presentation of test images, three different modes of alternating presentation of stimuli were used: 1) with consecutive monocular presentation of visual stimuli corresponding to the right and left eye; 2) with the presence of an empty interval between monocular phases; 3) with the presence of a binocular phase between monocular phases. The duration of the monocular and binocular phases, as well as the empty interval, was regulated by the researcher. Depending on the results of the examination, an optimal mode of alternative presentation of stimuli for the orthoptic tr eatment was selected individually. Results. In the duration of the monocular phase 50 ms in combination with the duration of an empty interval 50 ms, the majority of children (32 of 41) with strabismus were able to have stereovision. As a result of orthoptic exercises, the number of patients capable of bifoveal fusion increased from 24.4% to 48.8%. Stereovision appeared in 39% of children according to the Fly-test and in some cases according to the Lang-test. In all children with moderate amblyopia the visual acuity increased on average from 0.23±0.01 to 0.52±0.05 (p<0.001), in children with mild amblyopia the visual acuity increased on average from 0.66±0.02 to 0.93±0.01 (p<0.001). A reduction of the strabismus angle or an elimination of postsurgical microdeviation occur in one-third of children. Conclusion. The proposed method for the study of binocular functions in patients with strabismus allows to evaluate the ability to the bifoveal fusion and stereo perception not only with static presentation of visual stimuli, but also with the use of different modes of their alternating presentation. The most favorable mode for the elimination of functional inhibition is the mode of alternating presentation of stimuli with the presence of an empty interval not less than 50 ms between the monocular phases, which are also not less than 50 ms. This mode with the combination of monocular phase duration and empty interval duration in the range from 30 to 60 ms creates the most favorable conditions for the appearance of the stereo effect in the majority of the patients. The use of optimal individually chosen regime of alternating presentation of the stimuli allows to improve significantly the binocular functions, to increase the visual acuity, and in some cases to reduce the angle of strabismus or to eliminate postsurgical microdeviations.

The Management of Childhood Intracranial Tumours and the Role of the Ophthalmologist

ABSTRACTObjective: This study looked at a single paediatric neuro-oncology centre’s experience of childhood intracranial tumours seen in the ophthalmology clinic over an approximately five-year period. This was used to analyse the role of the ophthalmologist in their long term follow up.Methods: A database was compiled of all children discussed at the neuro-oncology multi-disciplinary team (MDT) meeting between January 2012 and April 2017. All children who had an intracranial tumour determined by histology or suspected on neuro-imaging, who had also been seen in the ophthalmology clinic, were included. A retrospective case review was performed to create a record for each child.Results: The database contained 129 children of which 82 (64%) were boys and 47 (36%) were girls. Of these 89 (69%) had a histological diagnosis and 40 (31%) had a tumour suspected on neuroimaging. The most common tumour locations were the posterior fossa (n = 54, 42%), diencephalon (n = 20, 16%) and the visual pathways (n = 17, 13%). Papilloedema at first presentation was only found in 39 (30%) children. The most common other neuro-ophthalmic manifestations were non-paralytic strabismus (n=33), sixth nerve palsy (n=19) and seventh nerve palsy (n=12). Non-paralytic strabismus was a presenting symptom in only one case. There were 13 ophthalmic surgical procedures required for these children, the most common being strabismus surgery.Conclusion: We report the types and locations of paediatric intracranial tumours seen in the ophthalmology clinic as well as their neuro-ophthalmic manifestations. Only 30% presented with papilloedema and approximately 10% required an ophthalmic surgical procedure.

Outcome of Unilateral Inferior Oblique Recession

The aim of this study was to analyze the outcome of unilateral inferior oblique (IO) recession in patients with unilateral or asymmetrical IO overaction in terms of effectiveness, stability, and undesired effects. Fifteen patients with nonparalytic strabismus who underwent unilateral IO recession for unilateral or asymmetric IO overaction and horizontal muscle surgery were included in this study. Nine patients demonstrated asymmetric bilateral IO overaction, whereas 6 had unilateral overaction. All patients underwent IO recession to the Scheie Parks point in one eye, along with conventional horizontal muscle surgery. Clinical outcome assessment included changes in oblique muscle dysfunction in both eyes. Changes in horizontal deviation, V pattern, vertical deviation, and excyclotorsion were also studied. Satisfactory outcome in terms of oblique muscle function, V pattern, vertical deviation, and cyclodeviation was achieved in all patients with unilateral IO overaction and 7 (77%) patients with bilateral IO overaction. Increased IO overaction in the other eye was noted in 2 patients. Satisfactory outcome in patients with bilateral overaction was related to degree of asymmetry in IO overaction between the 2 eyes. Unilateral IO recession is effective in patients with unilateral IO overaction and selected patients with largely asymmetrical bilateral IO overaction.

Leptomeninges as the first and only dissemination site of colorectal cancer

Dear Editor, Colorectal cancer (CRC) is one of the most common cancer types in the world, ranked second in developed countries for both genders, with the incidence of around 70–80 per population of 100,000. CRC disseminates most frequently to liver, lung, and bones, whereas it is rather rare in other organs. The incidence of colorectal adenocarcinoma dissemination to the leptomeninges is not estimated and seems to be quite rare. We report a case of a woman with CRC and the disease dissemination to the leptomeninges as the first and only dissemination site. A 61-year-old woman presented to the infectious diseases emergency room with a one-month history of fatigue, fever, photophobia, and mild headache that progressed to severe headache and vertigo. All of these symptoms appeared shortly after a mild conjunctivitis on both eyes that was treated with tobramycin eye-drops. The patient also emphasized a 1-year history of strabismus of the right eye and substantial weight loss of about 12 kg in a period of several months. She had no history of malignancies or any other serious diseases. Fifteen years ago, she had cataract surgery with a plastic lens implemented in her left eye. Physical examination, except for nonparalytic convergent strabismus of the right eye, was unremarkable with no clinical signs of meningitis. Body temperature was 38.0°C. Upon admission to the infectious diseases ward, a lumbar puncture was performed. The cerebrospinal fluid (CSF) analysis showed hypercellular sterile CSF with predominantly adenocarcinoma cells of unknown origin with elevated total protein level (64.5 g/dL) and low glucose level (1.9 mmol/L—33% of the blood level). The contrast-enhanced computed tomography (CECT) of the brain, made in order to enlighten this finding, did not find any pathological substrate except mild maxillary sinusitis on the left. Computed tomography (CT) of the abdomen was performed thereafter, and a large tumor mass in the ascending colon was found, though the patient had no symptoms or clinical signs of gastrointestinal obstruction. No lesions elsewhere in the abdomen were detected. Chest X-ray examination was normal. Thereafter, the patient was referred to the gastroenterology ward. Physical examination on admission to the gastroenterology ward showed moderate pain on deep palpation in the right iliac region and nonparalytic convergent strabismus of the right eye with hypermature cataract of the same eye. Neurological examination revealed no evidence of motor dysfunction or sensory changes including pathologic reflexes, except the aforementioned convergent strabismus, photophobia, and vertigo. The complete blood count revealed mild anemia with hemoglobin concentration of 114 g/L. Laboratory serum examination results showed high cholesterol (7.56 mmol/L) and triglyceride (2.84 mmol/L) level, increased gamma glutamyl-transpeptidase (90 U/L) and low concentration of iron (2.5 μmol/L). Blood coagulation was also slightly impaired with prothrombin time of 0.93 INR, fibrinogen of 5.8 g/L, and prolonged fibrinolysis. Additionally, C-reactive protein of 31.1 mg/L was detected. Tumor marker carbohydrate antigen 19-9 was highly increased (>1,000 kIU/L) with carcinoembryonic Int J Colorectal Dis (2009) 24:355–356 DOI 10.1007/s00384-008-0560-7

Specialized Surgical Procedures for Management of Cranial Nerve Palsies

Background and PurposeSurgical correction of cranial nerve palsies involves balancing unequal muscle forces. Conventional recess/resect techniques used in non-paralytic strabismus may not be sufficient. Special surgical procedures are available that may improve outcomes.MethodsLiterature review and the author's experience.ResultsThe surgical goal of re-establishing ocular alignment and restoring a functional diplopia-free field depends upon the degree of muscle paralysis and the number of muscles involved. A recess/resect/adjustable suture technique used to correct a single paretic (weakened) muscle may afford the patient complete or nearly complete function. A single totally paralyzed muscle may require additional procedures such as a transposition. However, the best possible outcome will still compromise ocular rotations and the diplopia-free field. Multiple muscle involvement complicates the issue even further. Other specialized procedures may be required. The outcome, at best, may be alignment in the primary position with a minimal range of binocular function.ConclusionA variety of specialized techniques are available to the strabismus surgeon in designing a successful treatment plan for cranial nerve palsies. In general, the success of surgery for paretic muscles will be more favorable than for paralyzed muscles. With careful attention to diagnosis and surgical planning, favorable outcomes can be maximized.

Ophthalmic manifestations of tuberous sclerosis: a population based study

BACKGROUND/AIMSTuberous sclerosis complex (TSC) has retinal and non-retinal ophthalmic manifestations. This study was designed to determine the prevalence of the ophthalmic manifestations and of refractive errors in a population of...

Complex limbal choristomas in linear nevus sebaceous syndrome

Objective This study aimed to describe the clinical and histopathologic findings in four patients with complex limbal choristomas associated with linear nevus sebaceous syndrome (LNSS), a rare disorder including nevus sebaceous, seizures, and mental retardation, and often accompanied by ocular anomalies. Design Small observational case series. Methods A retrospective review of the clinical and histopathologic records of four patients. Results Each of four patients had complex limbal choristomas in the setting of clinical and histopathologic LNSS. The limbal choristomas were multiple in three patients and bilateral in two patients. Most choristomas involved the superotemporal limbus (6 of 10), although nasal (3 of 10) and inferior (1 of 10) limbal tumors also were present. Three patients had significant corneal astigmatism or involvement of the central cornea requiring surgical removal of their choristomas, one accompanied by a lamellar keratoplasty and another accompanied by two consecutive penetrating keratoplasties. Each graft eventually vascularized, reducing vision. One patient’s vision was limited by amblyopia and another by occipital cortical dysgenesis with visual impairment. Histopathologic examination of the excised choristomas showed foci of lacrimal gland (3 of 4 patients), adipose tissue (3 of 4), neural tissue (1 of 4), cartilage (1 of 4), lymphoid follicles (1 of 4), skin adnexal tissue (1 of 4), and smooth muscle (1 of 4). Other associated ocular findings included an eyelid mass (1 of 4), colobomas of the eyelid (3 of 4), colobomas of the choroid and retina (2 of 4), nonparalytic strabismus (2 of 4), scleral ectasia (1 of 4), partial oculomotor palsy with ptosis and anisocoria (1 of 4), microphthalmia (1 of 4), and cortical visual impairment (1 of 4). Conclusions Complex limbal choristomas, although rare, can occur in the setting of LNSS and can be associated with multiple ocular and systemic abnormalities. Visual prognosis appears poor in most cases despite aggressive management.

Congenital corneal anesthesia in children with the vacterl association

To describe ocular manifestations in patients with the VACTERL (vertebral, anal, cardiovascular, tracheoesophageal, renal, and limb defects) association. We reviewed the medical records of patients with the VACTERL association who had undergone treatment for amblyopia at the orthoptic department. A striking similarity was found in three unrelated children, who, in addition to clinical manifestations of VACTERL association, showed total corneal anesthesia of one or both eyes that had resulted in recurrent corneal erosions, keratitis, and permanent corneal opacities. Other ocular manifestations included nonparalytic strabismus, anisometropia, and amblyopia. Congenital corneal anesthesia may be part of the VACTERL association.

Oculomotor and nystagmus tests in subjects with strabismus.

Smooth pursuit (SP) and saccades (SC) as well as nystagmus were recorded with electro-oculography in 21 healthy subjects with manifest non-paralytic strabismus. A normal SP function under binocular conditions could be recorded in 67% of the subjects and complementary monocular recordings increased the figure to 81%. The corresponding figure for the SC test was 38 and 67%, respectively. However, a minority of the subjects presented a normal test result under both binocular and monocular conditions. Spontaneous nystagmus and/or nystagmus after headshaking was present in 67%. These findings may indicate that subjects with strabismus have a combination of a 'subclinical' vestibular and oculomotor dysfunction.

Eye position and electromyographic observation of squint eyes under general anesthesia.

The position of eyes under general anesthesia was measured in different groups of nonparalytic strabismus. Almost all patients with esotropia or hyperactive inferior oblique muscle showed divergent eye positions while patients with exotropia showed no consistent trend. The eye position of patients with lid ptosis without squint, which served as a control group, were divergent in all cases. Electromyographic observation of the medial rectus muscle under the same condition of anesthesia revealed that muscle discharge disappeared almost completely at the stage at which the eyes were in a well-stabilized position.