Treatment Of Strabismus Research Articles

Polytetrafluoroethylene (Goretex®) for muscle elongation in the surgical treatment of strabismus with restricted motility

Repeated strabismus surgery as well as eye muscle fibrosis in various forms of strabismus, can be followed by restriction of the motility of the eye. Tendon elongation may be necessary if further improvement of the deviation and duction of the eye muscle is to be achieved. We used polytetrafluoroethylene (Goretex) and looked at its user comfort, compatibility and dose-rate relationship. Three patients with consecutive exotropia after repeated operations for congenital esotropia, two patients with VI nerve palsy and residual head turn after combined convergence operation and one child with congenital fibrosis syndrome underwent muscle tendon elongation with Goretex (7-15 mm) of either the medial or the lateral rectus muscle, which had already been resected and/or recessed in former surgeries. Forced duction under general anaesthesia was restricted in all patients. The correction of the deviation in primary position (deviation at distance + 3 degrees to - 4 degrees and at near - 1 degrees to - 8 degrees ) and in side gaze was satisfactory and motility was clearly improved. There were no postoperative complications (infection, shrinkage, scarring) and the postoperative results in terms of the angle of deviation and the improvement in motility remained stable for 1-6 years. Polytetrafluoroethylene (Goretex) is a good material with which to resolve complicated cases of strabismus in which muscle tendon elongation for bulbus restriction is necessary.

Surgical treatment of diplopia with thyroid associated ophthalmopathy

目的 探讨手术治疗甲状腺相关眼病导致限制性斜视的特点与疗效.方法对14例(16条眼肌)甲状腺相关眼病致限制性斜视行眼外肌后徙术或断键术,其中下直肌后退术7条;内直肌后退术3条;上直肌后退术3条,断腱术1条;外直肌后退术2条.结果术后随访时间3～9月(平均5.6月),所有患者术后水平及向下注视时复视症状消失,眼位基本正常.结论手术是治疗甲状腺相关眼病所致限制性斜视的有效方法。

Extraocular Muscle Imaging in Complex Strabismus

Abnormalities of extraocular muscle are an unusual cause of complex strabismus. The traditional evaluation based on clinical examinations is insufficient for the interpretation of incomitant motility disorders resulting from extraocular muscle anomalies. Extraocular muscle imaging by computed x-ray tomography (CT) or magnetic resonance imaging (MRI) can provide useful information for diagnosis, pathophysiology, and treatment of complex strabismus. Five cases of complex strabismus resulting from congenital anomalies of the extraocular muscles and their successful evaluation using extraocular muscle imaging are described. Orbital CT or MRI scan was obtained in five patients who had unusual incomitant strabismus. It confirmed the diagnosis of the absence of the medial rectus muscle, accessory lateral rectus muscle, atrophy of the inferior or both superior and medial rectus muscles, and abnormal thickening of the levator palpebrae superioris and superior rectus muscle. Extraocular muscle imaging is a useful technique for evaluating anatomic abnormalities. It should be considered when evaluating patients with atypical strabismus.

Botulinum Toxin Treatment of Extraocular Muscles in Rabbits Results in Increased Myofiber Remodeling

Botulinum toxin A (Botox) is commonly used for strabismus treatment. Although other muscles atrophy after intramuscular injection with Botox, extraocular muscles (EOMs) do not. A continuous process of myonuclear addition in normal uninjured adult myofibers in rabbit EOMs was studied. In this study, the effect of Botox-induced muscle paralysis on myofiber remodeling in adult EOMs was examined. The superior rectus muscles of adult rabbits were each injected with 5 units of Botox. The contralateral muscle received injections of saline only. Bromodeoxyuridine (BrdU) was administered for various periods after Botox treatment, followed by various BrdU-free periods. Myonuclear addition, the number of BrdU-positive satellite cells, and the number of MyoD-positive satellite cells were quantified, as were alterations in expression of immature myosins. Intramuscular injection of Botox resulted in a significant increase in both the number of BrdU-positive myonuclei and satellite cells. MyoD expression in both satellite cells and myonuclei was significantly increased after Botox injection in EOMs. In Botox-treated EOMs, an increased number of myofibers positive for the neonatal myosin heavy chain (MyHC) isoform was detected in the orbital layer. Botox-induced EOM paralysis resulted in a significant short-term increase in satellite cell activation and myonuclear addition in single myofibers in adult rabbit EOMs compared with control muscles. The appearance of MyoD-positive myonuclei suggests that protein synthesis becomes upregulated after Botox injection, and this, in turn, may help explain the minimal effects on myofiber size in EOMs after Botox injection. Understanding the effect of Botox on satellite cell activation and myonuclear addition in existing myofibers may suggest new ways to maximize the clinical effectiveness of Botox in patients with strabismus.

Diagnosis and treatment of traumatic incomitant strabismus

目的 探讨外伤所致非共同性斜视的诊断和治疗方法.方法临床收集外伤所致非共同性斜视25例,在常规的斜视检查基础上,辅以CT、MRI以进行诊断.采取药物保守治疗、手术治疗及配三棱镜等方式进行矫正.结果治疗后所有病例的眼位偏斜、眼球运动障碍、复视及代偿头位均有不同程度的改善.结论外伤所致的非共同性斜视应根据病情选择适当的治疗方法,不仅可改善斜视,而且一定程度上达到功能改善目的。

Evaluation of Mitomycin C in Reducing Postoperative Adhesions in Strabismus Surgery

The aim of this study was to evaluate the efficacy of mitomycin C in reducing postoperative adhesions following strabismus surgery. This study was a prospective, single-center, interventional case series. We randomized 14 patients with restrictive strabismus to the mitomycin C group (7 patients) or to the control group (7 patients). We used mitomycin C intraoperatively for 5 min at a concentration of 0.2 mg/mL in the mitomycin group after adhesion release. We compared postoperative results using the forced duction test. Compared to the control group, the mitomycin C group exhibited a better range of passive duction at all postoperative follow-up times; however, mitomycin C did not completely eliminate the problem of postoperative adhesions. Patients receiving mitomycin C did not report any complications during this study. The intraoperative application of mitomycin C is a safe and effective adjunct to surgery in the treatment of restrictive strabismus.

Botulinum toxin type A injections: Adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases

Botulinum toxin type A (BTA) (Botox) received Food and Drug Administration (FDA) approval for therapeutic treatment of strabismus and blepharospasm in 1989, cervical dystonia in 2000, and cosmetic treatment of glabellar wrinkles (Botox Cosmetic) in 2002. In 2002 alone there were approximately 1.1 to 1.6 million patients using cosmetic BTA. Our objective was to review adverse event (AE) reporting to the FDA after BTA administration. We reviewed all (therapeutic and cosmetic use) serious (per FDA regulations) AEs reported to the FDA for the 13.5 years since licensure of the product (December 1989-May 2003) and nonserious AEs reported from December 2001 to November 2002. AEs are reported to the FDA through the MedWatch system. We reviewed 1437 AE reports; 406 followed therapeutic use of BTA (217 serious and 189 nonserious) and 1031 followed cosmetic use (36 serious and 995 nonserious). Reported AEs occurred predominantly in female patients, with a median age of 50 years. In the year December 2001 to November 2002, when both serious and nonserious reports were evaluated, the proportion of reports classified as serious was 33-fold higher for therapeutic than for cosmetic cases. The 217 serious AEs reported in therapeutic cases involved a wide spectrum of events and included all 28 reported deaths. Among cosmetic users, no deaths were reported and, of the 36 serious AEs, 30 were included as possible complications in the FDA-approved label. The remaining 6 serious AEs did not display a pattern suggesting a common causal relationship to BTA. Among the 995 cosmetic cases reported to have nonserious AEs, most commonly noted were lack of effect (623, 63%), injection site reaction (190, 19%), and ptosis (111, 11%). Serious AEs were more likely to be reported for therapeutic than for cosmetic use, which may be related to higher doses, complicated underlying diseases, or both. Among cosmetic cases, few serious AEs were reported, and these were predominantly events that were previously recognized in clinical trials of BTA for the labeled use. This study is limited primarily by the incomplete nature of AE reporting by clinicians. Numerous departures from FDA-approved recommendations for drug dose, dilution, handling, site of injection, and storage were noted in these AE reports.

Does Botulinum Toxin Have a Role in the Management of Myofascial Pain?

Does Botulinum Toxin Have a Role in the Management of Myofascial Pain?

Ophthalmic Sequelae of Crouzon Syndrome

To document the frequency of ophthalmic sequelae in patients with Crouzon syndrome before the influence of craniofacial surgery. Retrospective observational case series. Seventy-one consecutive patients with a clinical diagnosis of Crouzon syndrome assessed before craniofacial or ophthalmic surgery at the Australian Craniofacial Unit between 1984 and 2000. Review of clinical records with documentation of patient age, gender, visual acuity, refractive error, diagnosis of amblyopia, squint, eye movement dysfunction, nystagmus, fundus examination, examination of the anterior segment, interpupillary distance, and intercanthal distance. The frequency of ophthalmic signs and visual impairment, defined as a visual acuity of 6/12 or less. Visual impairment in at least 1 eye occurred in 35% of patients and was bilateral in 9%. The most common cause of visual impairment was amblyopia, which was present in 21% of patients, followed by optic atrophy in 7%. Ametropia occurred in 77% of patients; 57% had hypermetropia of > or =+2 diopters (D) and 20% had myopia of > or =-0.5 D. Strabismus occurred in 39% of patients. Although exposure keratopathy was observed in 15% of patients, this complication was well managed and caused no reduction in visual acuity. Early detection to reduce amblyopia by correction of refractive errors, timely treatment of strabismus, and patching should be a priority for ophthalmologists and a goal of the craniofacial teams managing patients with Crouzon syndrome. Optic atrophy remains an important cause of visual impairment in these patients before decompressive craniectomy.

The surgical treatment of paralytic strabismus in children

目的 探讨儿童麻痹性斜视依不同的发病原因和临床特点进行手术选择的原则.方法分析病例病史资料及治疗结果.3～12岁麻痹性斜视58例.根据术前三棱镜和/或同视机检查的结果,采用减弱拮抗肌、加强麻痹肌或减弱其配偶肌的方法进行手术.结果儿童麻痹性斜视占同期住院儿童斜视患者的21.30%,其中上斜肌麻痹23例、外直肌麻痹11例、内直肌麻痹9例、上直肌麻痹6例、下直肌和下斜肌麻痹各2例、DVD合并双上斜肌麻痹1例、双上直肌麻痹1例、双下转肌麻痹1例、双上转肌麻痹2例.手术治疗临床治愈40例(69.00%)、好转18例(31.00%).结论儿童麻痹性斜视根据病因及类型,选择不同的手术方法,可获得满意的手术结果。

Management of Bladder, Prostatic and Pelvic Floor Disorders with Botulinum Neurotoxin

Since its introduction in the late 1970s for the treatment of strabismus and blepharospasm, botulinum toxin (BoNT) has been increasingly used in the interventional treatment of several other disorders characterized by excessive or inappropriate muscle contractions. The use of this pluripotential agent has extended to a plethora of conditions including: focal dystonia; spasticity; inappropriate contraction in most sphincters of the body such as those associated with spasmodic dysphonia, esophageal achalasia, chronic anal fissure, and vaginismus; eye movement disorders; other hyperkinetic disorders including tics and tremors; autonomic disorders such as hyperhidrosis; genitourinary disorders such as overactive and neurogenic bladder, non-bacterial prostatitis and benign prostatic hyperplasia; and aesthetically undesirable hyperfunctional facial lines. In addition, BoNT is being investigated for the control of the pain, and for the management of tension or migraine headaches and myofascial pain syndrome. BoNT injections have several advantages over drugs and surgical therapies in the management of intractable or chronic disease. Systemic pharmacologic effects are rare; permanent destruction of tissue does not occur. Graded degrees of relaxation may be achieved by varying the dose injected; most adverse effects are transient. Finally, patient acceptance is high. In this paper, clinical experience over the last years with BoNT in urological impaired patients will be illustrated. Moreover, this paper presents current data on the use of BoNT to treat pelvic floor disorders.

Tratamento cirúrgico do estrabismo: avaliação técnico-econômica

To evaluate, from the economic and technical point of view, the surgical treatment of strabismus. A retrospective survey of available consecutive medical charts from the Altino Ventura Foundation-Recife/PE, Brazil was performed. Data on 100 patients who underwent strabismus surgery (from January of 2001 to February of 2003) and 100 patients who underwent cataract surgery (January of 2003) were analyzed. The times to performed these surgical procedures were observed. The times to accomplish strabismus surgeries were compared to those of cataract surgeries. In addition the variability of time among different strabismus surgeries was also observed. Surgical mean time for strabismus correction was longer than that for cataract surgery (77.3+/-27.6 min versus 58.3+/-12.7 min; p<0.0001). A significant variability in time to accomplish strabismus surgeries was also observed. In the case of intervention in up to two muscles, mean time was less than in the case of intervention in more than two muscles (66.0+/-16.6 min versus 97.5+/-31.7 min; p<0.0001). Longer surgical time of strabismus surgeries as compared to cataract surgeries gives support to the idea that the medical remuneration for strabismus surgery should be, at least, equivalent to that of cataract surgery. In addition, the fact of surgical mean time being so variable, suggests that this procedure should have a different remuneration.

Does Botulinum Toxin Have a Role in the Treatment of Secondary Strabismus?

Methods: We reviewed the Toxin Clinic database over a 20-year period, identifying patients with strabismus secondary to permanent or temporary impairment of vision. Results: Five hundred-and-three patients who fulfilled our criteria were treated with Botulinum toxin. There were 301 males and 202 females, with a mean age at treatment of 35 years (range 6–86). Three hundred-and-eighty-three patients (76%) had exotropia, 114 (22.5%) had esotropia and 6 (1.5%) had vertical strabismus. Reduced vision secondary to trauma accounted for 45% (227) of patients. Other causes were congenital anomalies 121 (24%), refractive error 30 (6%), retinal detachment 20 (4%), senile cataract 24 (5%), corneal problems 19 (4%), glaucoma 10 (2%) and other 52 (10%). One hundred-and-ninety-three (38%) were aphakic. One thousand-four-hundred-and-fifty-seven injections were given, with a range of 1–50 per patient. Ninety-nine (20%) patients were managed with continued toxin treatment. Two hundred-and-eighteen patients (43%) proceeded to surgery. Forty patients (8%) required no further treatment as they regained binocularity by injection alone. Conclusions: Botulinum toxin appears to have a role in the treatment of secondary strabismus, since only 3% (14) failed to obtain any reduction in their angle. It was well tolerated, with no permanent side effects. Only 22 (4%) patients developed ptosis.

Update in the Diagnosis and Treatment of Strabismus

Update in the Diagnosis and Treatment of Strabismus

Pharmacological approaches for the treatment of strabismus

Strabismus is an eye movement disorder characterized by misalignment of the eyes and affects 1-5% of preschool-aged children. Lack of successful treatment in children may result in amblyopia, a lasting visual impairment.Current treatments to realign the eyes include surgery and botulinum toxin (Botox). We are working to develop two potential alternative treatments. The first uses muscle-specific immunotoxins, such as ricin-MAb35 where ricin is conjugated to a monoclonal antibody to the nicotinic acetylcholine receptor. We show that this significantly weakens the treated muscle, and our studies indicate that its muscle-weakening effects last up to 24 weeks after a single injection. The second strategy uses known myogenic growth factors, such as insulin-like growth factor (IGF), to strengthen an underacting muscle. A single injection of IGF-II resulted in significant increases in muscle force generation. Our studies thus far confirm that these agents can significantly alter muscle force generation, and we are actively pursuing additional drug strategies to improve the effect and duration of these agents. If successful, these agents may provide new alternatives to surgery for the treatment of strabismus.

Strabisme chez l'enfant

Strabismus is a highly plural and many-sided pathology. The classification of such diseases is very difficult due to the intricacy of clinical signs and pathophysiological mechanisms. The prognosis of strabismus is correlated to the age of onset, due to the influence of visual experience on the development of vision. Examination by an ophthalmologist is mandatory in case of strabismus evidence or strabismus suspicion. Strabismus may reveal an organic ocular disease, such as in the rare but fearsome case of retinoblastoma. By impairing vision, any strabismus can lead to an amblyopia, which can itself be responsible for strabismus in some cases. In early strabismus, monocular amblyopia can be cured, but binocular vision remains impaired; in late strabismus, the treatment must restore both monocular vision of each eye and binocular vision. Priorities must be defined in the treatment of strabismus; satisfactory visual function must be restored first. Optical correction is always essential, and in case of amblyopia, occlusion and optical or pharmacological penalizations may be considered. Most of the time, surgery for ocular deviation is considered only secondarily, after restoration of satisfactory sensorial status. Specialized management as early as possible is necessary in all cases, to improve functional results of the treatment.

A single-blinded, placebo-controlled clinical trial evaluating the safety and efficacy of topical anesthesia with dichlorotetrafluoroethane prior to botulinum toxin type a injections for palmar hyperhidrosis

Botulinum toxin type A is FDA-approved for treatment of strabismus, blepharospasm, cervical dystonia, and glabellar rhytides. This medication has also been used off-label for the treatment of localized hyperhidrosis. However, pain on injection, especially in the palmar area, may limit the use of this therapy. The use of dichlorotetrafluoroethane spray is easy and safe, and may significantly reduce injection pain. The primary objectives of this study are to evaluate the safety and efficacy of dichlorotetrafluoroethane spray when used as a topical anesthetic prior to Botulinum toxin type A injections and determine if its use affects the efficacy of Botulinum toxin type A in the treatment of palmar hyperhidrosis.Ten right-handed participants with clinically diagnosed palmar hyperhidrosis will be enrolled in this study. Participants will be asked to discontinue use of all treatments during a 2 week washout period. On Day 0, participants will receive injections on the palms and digits with 100U of Botulinum toxin type A per hand. Each hand will be randomized; immediately before each injection, one hand will be sprayed with dichlorotetrafluoroethane spray and the other hand will be sprayed with a pressurized air can (placebo). Pain will be measured using a Visual Analog Scale (VAS) 1 minute and 30 minutes after injection. A phone visit will be conducted at Day 7 for assessment of adverse events and quality of life. Study evaluations take place on Day 30, Day 60, Day 90, Day 120, and at 30-day intervals until participants return to baseline sweating levels. At each of these visits, dynamometer (grip strength) and gravimetric (sweat levels) measurements will be taken, an iodine starch test will be performed, photographs will be taken, and participants will complete quality of life and hyperhidrosis severity assessments. Participants will be contacted via telephone 30 and 90 days after their exit visit in order to assess quality of life at these time points. At the end of the study, an independent dermatologist will review the photographs to evaluate changes in the iodine starch test.The study is ongoing and final results and conclusions will be presented. Botulinum toxin type A is FDA-approved for treatment of strabismus, blepharospasm, cervical dystonia, and glabellar rhytides. This medication has also been used off-label for the treatment of localized hyperhidrosis. However, pain on injection, especially in the palmar area, may limit the use of this therapy. The use of dichlorotetrafluoroethane spray is easy and safe, and may significantly reduce injection pain. The primary objectives of this study are to evaluate the safety and efficacy of dichlorotetrafluoroethane spray when used as a topical anesthetic prior to Botulinum toxin type A injections and determine if its use affects the efficacy of Botulinum toxin type A in the treatment of palmar hyperhidrosis. Ten right-handed participants with clinically diagnosed palmar hyperhidrosis will be enrolled in this study. Participants will be asked to discontinue use of all treatments during a 2 week washout period. On Day 0, participants will receive injections on the palms and digits with 100U of Botulinum toxin type A per hand. Each hand will be randomized; immediately before each injection, one hand will be sprayed with dichlorotetrafluoroethane spray and the other hand will be sprayed with a pressurized air can (placebo). Pain will be measured using a Visual Analog Scale (VAS) 1 minute and 30 minutes after injection. A phone visit will be conducted at Day 7 for assessment of adverse events and quality of life. Study evaluations take place on Day 30, Day 60, Day 90, Day 120, and at 30-day intervals until participants return to baseline sweating levels. At each of these visits, dynamometer (grip strength) and gravimetric (sweat levels) measurements will be taken, an iodine starch test will be performed, photographs will be taken, and participants will complete quality of life and hyperhidrosis severity assessments. Participants will be contacted via telephone 30 and 90 days after their exit visit in order to assess quality of life at these time points. At the end of the study, an independent dermatologist will review the photographs to evaluate changes in the iodine starch test. The study is ongoing and final results and conclusions will be presented.

Anterior transposition compared to graded recession of the inferior oblique muscle for V-pattern strabismus

objective To compare the efficacy of anterior transposition (AT) and graded recession (GR) in the treatment of V- pattern strabismus caused by overaction of the inferior oblique muscle. methods The charts of surgically treated cases of V-pattern strabismus were analyzed retrospectively and the patients classified as AT or GR. Age, initial horizontal deviation, initial V-pattern and the amount of V-pattern correction were compared between the two groups. results There was no significant difference in age (p = 0.066), initial horizontal deviation (p = 0.59), initial V-pattern (p = 0.15) or the amount of V-pattern correction (p = 0.78) between the two groups. conclusion AT is at least as effective as GR in the treatment of V-pattern strabismus caused by overaction of the inferior oblique muscle.

Botox: beyond wrinkles

First used and approved over a decade ago for the treatment of strabismus (or misaligned eyes), botulinum toxin (BTX) has demonstrated efficacy in blepharospasm, hemifacial spasm, spastic lower eyelid entropion, and a number of other disorders seen in the traditional medical environment that are characterized by abnormal muscle contraction. Moreover, other conditions—notably some pain and gastrointestinal disorders—have responded to BTX injections.

Botox: beyond wrinkles

First used and approved over a decade ago for the treatment of strabismus (or misaligned eyes), botulinum toxin (BTX) has demonstrated efficacy in blepharospasm, hemifacial spasm, spastic lower eyelid entropion, and a number of other disorders seen in the traditional medical environment that are characterized by abnormal muscle contraction. Moreover, other conditions—notably some pain and gastrointestinal disorders—have responded to BTX injections.