Orthoptic Examination Research Articles

Prevalence and etiology of amblyopia of children in Yaoundé (Cameroon), aged 5-15 years

To determine the frequency of amblyopia and identify its causes in a population of children aged 5-15 years in Cameroon. This retrospective study examined the files of children aged 5-15 years seen in a private eye clinic in Yaounde from January 2008 through December 2010. The subjects underwent a complete ophthalmic examination including assessment of the best corrected visual acuity on a LogMAR chart, cycloplegic refraction measurements, and an orthoptic examination. The slit-lamp microscope and eye fundus examinations made it possible to rule out organic diseases. Statistical analysis was performed with Epi Info software, version 3.5.3, to analyze the the frequency and laterality of amblyopia according to age, sex, and refractive errors. Twenty-eight of the 314 patients studied had amblyopia, for a frequency of 8.9 % in the study population and 10.3 % in the subjects with ametropia (n = 271). The average age of children with amblyopia was 9.9 + / - 3 years. The frequency of amblyopia was higher among boys, but the difference was not statistically significant (p=0.3679). In order of frequency, the causes were refractive errors, for 93 % (26/28) of the children, and strabismus for 7 % (2/28). Astigmatism was the most frequent cause of ametropic amblyopia. Amblyopia had an anisometropic origin in 43 % (12/28) of cases. It was unilateral in 39.2 % (11/28) and bilateral in 61 % (17/28) of cases, severe in 18 %, moderate in 18 %, and mild in 64 %. Ten percent of the subjects in our series had amblyopia, mainly due to refractive errors. Amblyopia was most frequently bilateral and mild. A systematic ophthalmological examination in childhood could provide early detection and management of refractive errors that cause ocular morbidity.

Ophthalmic findings in Angelman syndrome

To provide detailed information about opthalmological findings in a group of patients with Angelman syndrome (AS). Consecutive patients with a genetically confirmed diagnosis of AS were submitted to ophthalmic and orthoptic examinations. Strabismus, visual acuity, cycloplegic refraction, and iris and fundus pigmentation were evaluated. Parents were also examined to compare the extent of fundus pigmentation. A total of 34 patients were identified, representing 3 genetic classes: deletion, uniparental disomy, and mutation. Ametropia >1 D was present in 97% of cases: myopia in 9%, hyperopia in 76%, and astigmatism in 94%. Myopia and anisometropia were found only in the genetic deletion group. Strabismus, most frequently exotropia, was found in 24 patients (75%). Ocular hypopigmentation was observed in 18 subjects (53%), with choroidal involvement in 3 cases and isolated iris involvement in 4. Hypopigmentation was observed in all of the 3 genetic classes. Ophthalmic alterations in AS were observed more frequently than has been previously reported, except for ocular hypopigmentation, which was observed less frequently.

Horizontal and Vertical Angle Kappa

The aim of this study is to report the geometric range of angle kappa formation in patients with and without strabismus. This is a retrospective study of three patients with angle kappa in different planes. Routine eye examinations, including visual acuity, slit-lamp examination, and ophthalmoscopy, were performed. A thorough orthoptic examination revealed a notable difference between the prism and alternate-cover test and the Hirschberg measurements. The first patient exhibited a bilateral vertical angle kappa into opposite directions due to retinochoroidal scars. Two other patients presented with horizontal angle kappa deviations. In one patient a true accommodative esotropia was exaggerated by a right negative angle kappa. The other patient had a pseudoexotropia due to bilateral positive angle kappa. Macular ectopia was noted in all cases. The patients herein reported demonstrate a marked variability of angle kappa occurrence in the horizontal and vertical plane. The angle kappa can exaggerate or conceal the size of the true heterotropia.

The use of modern imaging techniques in the diagnosis and treatment planning of patients with orbital floor fractures

SummaryBackgroundOcular motility impairment associated with orbital trauma may have several causes and manifest with various clinical symptoms. In some cases orbital reconstructive surgery can be very challenging and the results are often unsatisfactory. The use of modern imaging techniques aids proper diagnosis and surgical planning.Case ReportThe authors present the case of a 29-year-old male who sustained trauma to the left orbit. Orthoptic examination revealed limited supra- and infraduction of the left eye. The patient reported diplopia in upgaze and downgaze with primary position spared. Dynamic magnetic resonance imaging (dMRI) was performed, which revealed restriction of the left inferior rectus muscle in its central section. A patient-specific anatomical model was prepared on the basis of 3-dimensional computed tomography (CT) study of the intact orbit, which was used to prepare a custom pre-bent titanium mesh implant. The patient underwent reconstructive surgery of the orbital floor.ConclusionsModern imaging techniques such as dMRI and 3-dimensional CT reconstruction allow us to better understand the pathophysiology of orbital floor fractures and to precisely plan surgical treatment.

The base-to-base induced-tropia prism test for detection of amblyopia: A pilot study

To investigate the accuracy of the base-to-base prism test (BBPT), which entails inducing an esotropia with the use of base-in prisms before each eye, in the diagnosis of amblyopia. Participants were consecutive patients recruited from a pediatric ophthalmology practice who were able to perform logMAR acuity testing. All participants underwent an orthoptic examination, including logMAR visual acuity testing, and a sensorimotor evaluation. Patients with an interocular difference of 2 or more lines were considered to have amblyopia. Fixation preference was assessed by use of both the vertical fixation test and the BBPT. The agreement between the BBPT and visual acuity was analyzed and compared with the agreement between the vertical fixation test and visual acuity. Fifty-one consecutive patients aged 4 to 17 (mean, 9.8 years; SD ± 3.4) were included, of whom 11 were diagnosed with amblyopia. Kappa analysis showed moderate but significant agreement between the BBPT and logMAR (κ = 0.453, p = 0.001), whereas the vertical fixation test demonstrated only a fair agreement (κ = 0.254, p = 0.061). The overall sensitivity for the BBPT was 72.7% (95% confidence interval [95% CI], 43.4%-90.3%) but only 40% for the vertical fixation test (95% CI, 16.8%-69.7%). For the BBPT, specificity was 80% (95% CI, 65.2%-89.5%); for the vertical fixation test, 78% (95% CI, 63.3%-88.0%). The BBPT appears to be more sensitive than the vertical fixation test for detecting amblyopia in our patient population. The 2 tests had similar specificity.

Evaluation of factors influencing distance stereoacuity on Frisby–Davis Distance Test (FD2) in intermittent exotropia

AimTo evaluate the factors affecting the restoration of stereoacuity after surgery in cases of intermittent exotropia.MethodsThirty consecutive patients of intermittent exotropia X (T) scheduled for surgical intervention underwent preoperative evaluation,...

Detektion amblyogener Risikofaktoren mit dem Vision Screener S 04

The Vision Screener® (Plusoptix) was developed for the recognition of amblyogenic refractive errors without cycloplegia. The aim of this study was to evaluate the sensitivity and specitifity for the detection of amblygenic refractive errors in preschool children. Furthermore it was investigated whether small angle strabismus as another cause for amblyopia could be detected by manual evaluation of corneal reflex images on printouts. 83 children aged between 0.5 and 6 years without strabismus had undergone 3 measurements without cycloplegia with the Vision Screener before cyclplegic retinoscopy was performed. In a second group of 72 children with orthotropia or a manifest strabismus < 10° the position of the eyes without correction was evaluated in a complete orthoptic and ophthalmological examination. Three measurements with the Vision Screener were performed in non-cycloplegic status. The centre of the "cloud of viewing directions" was determined on print-outs and the distance to the points of origin (middle of pupil) measured for each eye. The sum of distances of right and left eyes was taken for determination of total deviation and the assymetry was calculated by the difference of distances of the right and left eyes. There was a total sensitivity of 75% (specifity 91%) for amblyogenic refractive error (prevalence: astigmatism 22%, hyperopia 6%, anisometropia 6%). A change of threshold criteria increased the total sensitivity to 86% and 93%, whereas specifity was lowered to 80% and 76%, respectively. Eight children showed a manifest strabismus. In 75% of these cases the determined deviation of corneal reflex images in the horizontal direction was outside of the normal range; analysis of asymmetry showed an abnormal result in 37.5% of the cases. The examination using the Vision Screener may detect refractive errors and partially small angle strabismus as amblyogenic risk factors; however, additional tests should be added for screening examinations. An ophthalmological examination including cycloplegic retinoscopy cannot be replaced. Despite acceptable sensitivity and specifity the major portion of positively screened children will be without pathological findings at cycloplegic controls, because the amount of "false-positive" results exceeds the amount of "true-positive" results based on a prevalence of 5% for amblyopia.

Evaluation of new quality of life questionnaire in children with strabismus and amblyopia before and after re‐education

Abstract Purpose To evaluate a new quality of life questionnaire in children presenting a strabismus with abnormal retinal correspondence and amblyopia before and after reeducation. Methods Twenty children of a mean age of 4,2 yo (range 2‐7yo) were included with a strabismus with 3 type deviations. They presented amblyopia of at least 2 lines VA. They underwent a complete ocular and orthoptic examination with binocular quantification. At the consultation, parents and child completed a self‐administered questionnaire of quality of life. The questionnaire has three major items including a total of 10 criterions. Criterions were quoted by 4 colors corresponding to a score (from 0 to 30) reflecting the daily activity. Children were treated with optical correction, eye‐patching and orthoptic reeducation as needed. Six months after, examination and questionnaire was completed again to appreciate the progression of the children capacities. Results Of the twenty children, 16 presented an esotropia, 4 an exotropia and 10 an isolated or associated vertical hypertropia. The mean rate of the questionnaire at baseline was 18. The twenty patients who presented an amblyopia had an improvement of VA after treatment. After 6 months, rate of all questionnaires was improved with a mean score of 25. Conclusion Very few QOL questionnaires had been developed and even more in ophthalmology. This questionnaire appears simple to complete for parents and children, it can also be a basis to evaluate the progress of amblyopia reeducation.

The Efficacy of Vertical Rectus Transposition and Its Modalities in Patients with Abducens Nerve Palsy

Patients with VIth nerve palsy that does not resolve within 6 months should undergo surgery. The most common procedure used in such cases is transposition of a whole or a part of a vertical rectus muscle combined or not with a resection of the lateral rectus muscle. Commonly, a simultaneous recession of medial rectus muscle with or without prior injection of botulinum toxin is performed. The aim of our study was to evaluate the results of vertical rectus transposition performed in patients with abducens nerve palsy. Nine cases of abducens nerve palsy ware retrospectively analyzed. All patients underwent full ophthalmic and orthoptic examination before and after surgery. All patients underwent vertical rectus muscle transposition to the lateral rectus insertion in the affected eye. Additional procedures included Jensen procedure, botulinum toxin injection, resection of the lateral rectus, recession of the medial rectus on the same side with or without adjustable sutures, and Foster modification of lateral rectus posterior fixation. In all cases, we found a varying degree of postoperative improvement. There was a significant reduction in the strabismus angle for distance and near, increase in abduction of the affected eye, and broadening of the field of binocular single vision. The vertical rectus muscle transposition technique is a safe and successful method of treatment in abducens nerve palsy. Its use together with additional procedures and modifications allows one to achieve orthophoria, improvement of abduction, and larger field of binocular single vision.

Congenital Cataract

Congenital cataract has a high amblyogenic potential and is an important subject in pediatric opthalmology. Because of amblyopia risk, congenital cataracts require an early diagnosis.Bilateral congenital cataract is genetic in at least 25% of cases. In contrast, unilateral congenital cataract is usually sporadic. The mode of inheritance is mostly autosomal dominant but autosomal recessive and X-linked modes also occur. Metabolic cataract may be diagnosed biochemically. Because of the anatomical dimensions being smaller and the tissue structures being softer and more elastic in the young patient, surgery of paediatric cataracts represents a special challenge for the ophthalmic surgeon. The evolution of paediatric cataract surgery continues, with many adult cataract surgical techniques being applied to children with minor technical adjustments. Intraocular lenses have helped to provide better anatomic and functional outcome for cataract surgery in children. More and more, surgeons are implanting intraocular lenses in younger children. One of the most widely reported technologic advances in 2004-2005 was the use of hydrofobic acrylic intraocular lenses in children. Predicting axial growth, and refractive change that accompanies it, is one of the major remaining challances for the long- term care of children who have had cataract surgery. Due to the increased inflammatory reaction postoperatively, a minimally traumatic operation, intensive occlusion therapy and optimal correction with glasses or contact lenses are also necessary. Orthoptic follow-up examinations are also important for the long-term result.In this review, a short information about diagnosis and management of congenital cataract is presented.

Ophthalmic, clinical and visual electrophysiological findings in children born to mothers prescribed substitute methadone in pregnancy

Background and aimsThere are growing concerns regarding visual outcome of infants exposed to opiates (including substitute methadone) and/or benzodiazepines in utero. We describe the combined ophthalmology and visual electrophysiology findings...

Horizontal lang two-pencil test as a screening test for stereopsis and binocularity

Purpose:To assess the horizontal Lang two-pencil test as a bedside test to detect gross stereopsis.Materials and Methods:Eighty-four strabismic subjects divided into two groups based on the amount of deviation, and 40 normal subjects were studied. Sensory status examination including binocularity and stereopsis were evaluated with Bagolini, Titmus test and the Netherlands organisation for applied scientific research (TNO), Randot, synoptophore and horizontal Lang two-pencil test.Results:The subjects in the group with smaller deviation showed better performance on all the four stereo tests and over 90% demonstrated presence of fusion. When compared to TNO and Randot for determining presence of stereopsis, the horizontal Lang two-pencil test demonstrated sensitivity of 100% and 83.9%, specificity of 77.8% and 73.7%, and negative predictive value of 100% and 100% respectively. It also showed 100% specificity as a test for binocularity when compared with the Bagolini striated glass test.Conclusion:Horizontal Lang two-pencil test, an easily performed test with a high sensitivity and negative predictive value can be used as a screening test to detect gross stereopsis and binocularity.

Refractive surgery in patients with accommodative and non-accommodative strabismus: 1-year prospective follow-up

AimTo determine the efficacy and safety of keratorefractive surgery in patients with accommodative and non-accommodative strabismus in a prospective study.MethodsPreoperative assessment included uncorrected (UCVA) and best-corrected visual acuity (BCVA), manifest...

Consecutive exotropia after surgical treatment of childhood esotropia: a 40-year follow-up study

To determine the incidence of consecutive exotropia (XT) following successful surgical correction of childhood esotropia (ET) and identify factors associated with its development. This is a retrospective study of 85 patients with ET, aged 2-24, who underwent strabismus surgery by a single surgeon between 1958 and 1969 in Sweden, until they were successfully aligned to ET within 10 prism dioptre, after primary or reoperation(s). The charts of these patients were reviewed, and data regarding age at onset of strabismus, surgery performed and outcome were recorded. The patients were recalled for a complete orthoptic examination in 2001-2003. The incidence of consecutive XT in this cohort was 21% (18/85). Patients who had undergone multiple surgeries had a higher risk of developing consecutive XT compared to those successfully aligned with one surgery (p = 0.00036). Restriction of adduction and convergence postoperatively was associated with a high risk of consecutive XT (p = 0.0437). The incidence of consecutive XT did not vary with the level of visual acuity in the operated eye (p = 0.6428). Age of onset, age at surgery and amount of surgery did not appear to influence the risk for developing consecutive XT (p > 0.05). This 40-year postoperative follow-up of patients with childhood ET who underwent strabismus surgery by a single surgeon in Sweden showed that multiple surgeries and presence of postoperative adduction deficit were the most important factors influencing the incidence of consecutive XT after surgery. Presence of uncorrected amblyopia did not alter the prognosis for long-term development of consecutive XT.

Accuracy of venous blood oxygen pressure depends on arterial blood oxygen pressure

One hundred and two patients with anisohypermetropic amblyopia without strabismus were studied. Microstrabismus was excluded by detailed orthoptic examinations including visuscopy and Cüppers9 bifoveal correspondence test. Treatment consisted in wearing correcting glasses and part-time or full-time patching of the nonamblyopic eye. In patients with dense amblyopia patching of the amblyopic eye was done and Cüppers9 after-image method of pleoptic therapy was instituted as the initial procedure. When visual acuity improved sufficiently by this therapy, patching was used on the nonamblyopic eye. Sixty-five (63.7%) patients showed 2 lines or more improvement on the Snellen chart. Though young children (6 to 12 years) improved their visual acuity more often than those aged 13 to 20 years, a considerable number of patients (50.0%) in the older age group improved their visual acuity after therapy. The improvement in visual acuity was accompanied by improved stereoacuity in 49.0% of the patients. It is therefore suggested that every effort should be made to treat these patients even after the age of 12 years.

Ophthalmological screening of a paediatric cochlear implant population: a retrospective analysis and 12-year follow-up

To determine the nature and prevalence of ophthalmological findings for a cohort of children in a paediatric cochlear implant program and to assist the clinician in devising an investigative plan for this population. Retrospective medical record review of children who underwent multichannel cochlear implantation at a tertiary care hospital between February 1996 and July 2008. In all, 141 children (mean age 28 months, range 16 months to 9 years) had complete medical record documentation consisting of orthoptic and opthalmological examination, including cycloplegic refraction. A total of 59 children (41.8%) had ocular abnormalities with refractive errors being the most common abnormality. Hypermetropia was the most common refractive error and was found in 21 children (14.8%). Strabismus was found in six patients, with constant esotropia being the most common. Ocular pathology (excluding refractive or muscle abnormalities) were found in nine patients (6.3%). Three patients had syndromes associated with ocular findings including Waardenburg and Usher syndrome. During the follow-up period, 14 children were fitted with prescription lenses, 3 had strabismus surgery, and 2 underwent ptosis. Routine orthoptic and ophthalmologic examination can be beneficial in the initial evaluation of children assessed for cochlear implants. Electroretinography is useful in evaluating children with unexplained congenital sensorineural hearing loss, suggestive symptoms including night blindness, unexplained reduction in visual acuity, or delayed motor milestones. Routine yearly follow-up may aid in the detection of changing refractive errors and the possibility of later-onset retinal degeneration.

Evaluation of Refraction in a Statistically Significant Sample: Changes According to Age and Strabismus

To assess possible refractive changes according to age and strabismus in a statistically significant cohort. A population-based sample of 12,534 subjects 0.5 to 20 years old, examined between 2004 and 2006, was tested. Each subject received a complete orthoptic examination, including spherocylindrical streak retinoscopy in cycloplegia. Patients were divided into those with orthophoria (7,784) and those with strabismus (4,750), and the latter group was further divided into those with esodeviation (3,026) and those with exodeviation (1,724). A statistical analysis of the spherical equivalent, astigmatism, and anisometropia was performed with an independent samples t test or one-way analysis of variance. The percentage of patients with a mean spherical equivalent within +/- 1 and +/- 2 standard deviations was greater than 68% and 95%, respectively. The mean spherical equivalent of the total sample was 1.62 diopters (D) (+/- 2.88). The mean spherical equivalent was 1.10 +/- 2.94 D in the orthophoria group, 3.22 +/- 2.29 D in the esodeviation group, and 1.13 +/- 2.50 D in the exodeviation group (one-way analysis of variance; P = .000). Age-related changes in the mean spherical equivalent showed a clear and steady myopic shift, reaching mean myopic refraction at 12 to 14 years in both the total sample and the orthophoria and exodeviation groups. It assumed a more constant trend, with no myopic swing, in the esodeviation group (P = .000). Mean astigmatism was less in patients with less than 1.00 D anisometropia (0.83 +/- 0.92 D) than in those with 1.00 D or greater anisometropia (1.42 +/- 1.18 D) (t test; P = .0001). Both the age-related trend in the spherical equivalent and the high hyperopic values of the distribution peak in patients with esodeviation confirm the importance of the hypermetropic refractive component. The statistically significantly higher incidence of astigmatism in patients with 1.00 D or greater ametropia highlights its incidence in amblyopia.

Acquired restrictive strabismus and high axial myopia: diagnosis and management

Objective: This paper documents the clinical, ultrasound, magnetic resonance imaging (MRI), and anatomic characteristics of 6 patients with esohypotropia and high axial myopia. The results of strabismus surgery performed on these patients are evaluated. Study Design: Retrospective cohort study. Participants: Six patients with esohypotropia and high axial myopia were selected from the practice of the second author (Michael Flanders). Methods: We extracted the history and data from the preoperative and postoperative ophthalmic and orthoptic examinations, recorded the surgical procedures, and tabulated the postoperative results. A- and B-scans, orbital MRI images, and photo documentation were obtained for all patients. Supramaximal recession and resection on the horizontal rectus muscles, using adjustable sutures, was performed in all patients. A surgical outcome was deemed successful if, in primary position, postoperative horizontal ocular alignment measured 15 prism diopters (PD) or less and (or) if diplopia was eliminated. Results: Echographic and MRI findings demonstrated an enlarged globe in all cases. Globe flattening on the orbital walls was found in 5 cases. Lateral rectus depression was visualized on MRI images in 4 cases. Surgical success was obtained in all patients. The average preoperative primary position esotropia measured 60 PD (25 to 90 PD) and the esodeviation after surgery was 7.0 PD (0 to 15 PD). Ductions were also improved. Conclusions: Different surgical approaches to realignment of eyes with high myopia and esohypotropia have been attempted. In this study, supramaximal amounts of recession and resection on the rectus muscles provided satisfactory results.

Synergistic divergence: a distinct ocular motility dysinnervation pattern.

To summarize the clinical, neuroradiologic, and genetic observations in a group of patients with unilateral synergistic divergence (SD). Five unrelated patients with unilateral SD underwent ophthalmic and orthoptic examinations; three of them also had magnetic resonance imaging of the brain and orbits. Three patients underwent genetic evaluation of genes known to affect ocular motility: KIF21A, PHOX2A, HOXA1, and ROBO3. The patients did not meet the clinical criteria for CFEOM types 1, 2, or 3. Each patient had severe adduction weakness on the affected side and large-angle exotropia in primary gaze that increased on attempted contralateral gaze because of anomalous abduction. Magnetic resonance imaging revealed a much smaller medial rectus muscle in the involved SD orbit. Oculomotor cranial nerves were present in the one patient imaged appropriately. Genetic sequencing in three patients revealed no mutations in KIF21A, PHOX2A, HOXA1, or ROBO3. SD should be classified as a distinct congenital ocular motility pattern within congenital cranial dysinnervation disorders. It may be caused by denervation of the medial rectus with dysinnervation of the ipsilateral lateral rectus by the oculomotor nerve precipitated by genetic abnormalities (some currently identified) or by local environmental, teratogenic, or epigenetic disturbances.

Long-term follow-up of children with benign abducens nerve palsy

Benign abducens nerve palsy is rare in childhood. Diagnosis is made by exclusion, and the severe underlying pathologies have to be ruled out. The aim of our study was to present the largest single-center series of patients with the longest period of follow-up to confirm the benign nature of this entity. We carried out a retrospective study of 12 consecutive children with benign abducens nerve palsy. All children underwent a careful orthoptic and ophthalmic examination during acute presentation and follow-up. Painless palsies were associated with a preceding infection or immunization in five patients. The left eye was affected in nine children and no bilateral case was found. No sex differences were seen. Recovery was observed within 6 months in all cases, and ipsilateral recurrences occurred in three children. Three children required strabismus surgery. None of the patients developed long-term recurrences or neurological abnormalities during a mean follow-up of more than 9 years. Our data support earlier findings, such as painless and predominately left-sided occurrence, spontaneous recovery within 6 months, and ipsilateral recurrence. In contrast to much of the literature, we did not find a female preponderance. Exclusion of severe causes and close follow-up is mandatory for these patients. As none of the patients developed long-term recurrences or neurological sequelae, this entity can be regarded as a benign condition without malignant associations or complications.