The anesthetic management of the pediatric strabismus patient.

Postoperative nausea and vomiting continues to be a common perioperative complication for pediatric strabismus patients. Postoperative pain management and the choice of general anesthetic can increase the incidence of perioperative nausea. Current techniques for induction of general anesthesia and selection of agents, prevention and treatment of postoperative pain, and options for antiemetic therapy will be reviewed.     

The management of strabismus in adults--II. Patient and provider perspectives on the severity of adult strabismus and on outcome contributors.

PURPOSE: As part of a larger study intended to evaluate the management of strabismus in adults, we documented and compared patient and provider perspectives on the various factors that may contribute to treatment outcome and value of strabismus care. METHODS: By completing a questionnaire, 170 patients with strabismus (ages 19 to 87 years) and 11 strabismus specialists who performed surgery on these patients each indicated the relative weight of several disease- and treatment-related contributors to the outcome and value of care. In addition, each respondent rated the severity of the strabismus before and after surgery. RESULTS: Overall severity ratings improved as a result of surgery. The improvement perceived by the physicians was 5.1 +/- 1.7 on a 10-point scale and was larger than the 2.6 +/- 3.6 points improvement perceived by the patients ( P < 0.001). Patients and physicians expressed different views on the relative contributions to outcome and value (overall P < 0.001). Both groups indicated "the condition," "the physician," and "the procedures" as the largest contributors, but "condition" was perceived as more important by the physicians than by the patients ( P < 0.001), and "physician" was more important to the patients than to the physicians ( P < 0.001). CONCLUSION: Although in approximate agreement on the main contributors to outcome and value, discrepancies exist between perspectives of patients and physicians on the relative weights of those contributors. Public information, education, and counseling may bring these perspectives better in line and ultimately improve both quality and patient satisfaction.     

The management of strabismus in adults--I. Clinical characteristics and treatment.

INTRODUCTION: This is the first in a series of articles intended to evaluate the management of strabismus in adults, including clinical outcomes and the quality, cost, and value of treatment from the perspectives of patients and health care providers. Here we present clinical characteristics, complexity of surgery, treatment success, and resolved complaints in a group of adult patients who underwent strabismus surgery. METHODS: This is a multicenter retrospective study analyzing the type and amount of ocular misalignment before and after surgery in adult patients with strabismus onset before (BVM, or age < 9 years) or after (AVM, or age >/= 9 years) visual maturation. Success was evaluated in terms of alignment, motility, and the presence of diplopia; subjective success was measured in terms of resolved complaints. The complexity of surgery was determined using the Intensity/Complexity Index and compared with success rates. RESULTS: Data are reported on 299 patients (90 BVM and 145 AVM) whose eyes were successfully aligned in 63% of the BVM cases and 81% of the AVM cases. Subjective complaints resolved at similar rates in the BVM and AVM subgroups. Successful alignment was not correlated with complexity of surgery, but motility and sensory success rates were correlated with complexity of surgery. CONCLUSION: Within each of the BVM and AVM subgroups, this study of adult strabismus showed similar surgical success rates compared with published data. This qualifies these patient groups as clinically typical of adults undergoing strabismus surgery. Additional studies will expand on health value analyses.     

开眶术后斜视的手术治疗

目的 分析开眶术后斜视的临床特点及手术治疗效果.方法 回顾性病例研究.回顾分析中山大学中山眼科中心自1998年3月至2003年7月期间住院行开眶术后斜视的诊治病例9例.其中男性5例,女性4例;年龄12～柏岁,平均26.4岁;右眼4例,左眼5例.全部病例随访1～3年(平均1.4年).常规行远、近标准E视力表检查.眼前后节行裂隙灯显微镜和眼底镜检查.眼位检查包括角膜映光法、同视机检查法和视野弧检查法等.结果 开眶术后发生的斜视需手术矫正者共9例.大部分为瘢痕粘连引起的限制性斜视,占66.7%.9例患者均采用手术治疗,术式包括受累肌瘢痕松解术、后徙术+缩短术、Jensen术等.术后眼位完全矫正6例,轻度欠矫2例,明显欠矫1例.4例术前有复视者,术后2例自觉复视消失,2例仅向某个方位有轻微复视,可耐受.所有患者眼球运动均较术前明显好转.结论 眼眶术后发生的斜视需手术治疗者多为瘢痕粘连引起的限制性斜视,松解并后退粘连的眼外肌联合对抗肌缩短术或直肌联结术或肌移位术,术终用固定缝线将眼位固定于过矫位可获得理想的矫正效果.     

The effects of short-term experimental strabismus on the visual system in Macaca mulatta.

Experimental esotropia was produced surgically in infant rhesus monkeys (Macaca mulatta) for brief periods of time. Electrophysiological studies of the visual cortex showed that esotropia of only 2 weeks duration in an infant monkey is sufficient to cause a marked shift of dominance in favor of the fixating eye and to virtually extinguish cortical neuronal responses from the esotropic eye. In the lateral geniculate nucleus cell (LGN), shrinkage of 6% to 8% occurred in the parvocellular layers connected with the esotropic eye, the magnocellular layers showing no changes. After the fixating eye had been sutured for 3 weeks, a complete reversal of the cortical physiology in favor of the esotropic eye occurred, whereas no recovery in cell size was observed in the LGN. Surgical realignment of an esotropic eye caused recovery of cortical neuronal responses from the formerly esotropic eye, but the number of binocularly responsive cells remained reduced.     

旋转斜视的临床特征及处理

目的 探讨旋转斜视临床特征及不同处理方法。方法 12例主述旋转复视患者根据眼球运动、同视机、双马氏杆和眼底照相等不同检查结果2例行下斜肌减弱术，10例行上斜肌矢状移位术。结果 所有患者未再述旋转复视，视自然物体清晰。结论 上斜肌矢状移位术适用于前下方明显的外旋转斜视，是治疗旋转斜视的主要方法，而上半视野旋转斜视明显时应采取下斜肌减弱术。     

斜视对心理的影响

斜视不但影响患者的视功能、容貌,对患者的心理影响也是明显的.主要表现在斜视患者普遍存在抑郁、低自尊、社交焦虑和就业方面.另外,斜视患儿父母也因其孩子的影响而存在抑郁、紧张、焦虑.对年幼患儿斜视手术可以有效地改变他们的视功能,提高其适应社会的能力.对青少年和成年人斜视手术可改善其容貌,提高自尊水平,减少受到的社会歧视,减轻社交焦虑,更好的获得就业.     

斜视对双眼视觉功能的影响及术后康复

人类立体视功能的产生有诸多必要条件,双眼平行的视觉方向是其中之一。斜视后双眼的视觉方向不再平行,从而导致双眼视觉功能破坏;同时双眼视觉功能的丧失也意味着中枢对眼位的控制能力变差,进而促进斜视的发展。斜视的主要治疗方法是手术,术后患者可以达到双眼正位,但很多患者的双眼视觉功能并未恢复,一些患者还会由于双眼视觉功能的异常导致短期内斜视复发。因此,斜视的治疗不仅是手术达到双眼正位,术后双眼视觉的康复也同样重要。术后康复训练方法主要包括同视机双眼视觉康复训练、融合能力训练、电脑软件训练、视感知觉训练法等。人类大脑终身具有可塑性,如在术后双眼正位的情况下及时加以适当训练,帮助患者更好地恢复双眼视觉功能,加强大脑对双眼眼位的控制力,更好地保持术后双眼正位。（国际眼科纵览, 2018,  42:   179-183）     

儿童斜视手术治疗与临床分析

目的：评价儿童各种斜视手术的疗效。方法：对102例患者施行手术,随访1－2年,手术方法包括双侧外直肌缩短术,双侧内直肌徒后术;单眼内直肌徒后和外直肌缩短术,双眼内直肌徒后并附着点下移,或行双眼外直肌缩短并附着点上移,或单眼内直肌徒后并附着点下移加外直股缩短附着点上移,双眼外直肌徒后并附着点上移,或行单眼外直股起诉一并附着点上移加内直股缩短并附着点下移,如伴有下斜肌功能亢进者,则行下斜肌徒后术。结果：术后95例斜视均明显改善,随访1－2年的102例斜视患者占,78例（76．47％）,斜视得到治愈,17例（16．675）斜视得到美容治愈,7例（6．86％）手术失败。结论：各种类型斜视通过各种手术方法后,均能得到良好的矫正而无严重并发症。     

小儿斜视矫正术后伤口的管理

目的 观察小儿斜视矫正后术眼伤口被敷料遮盖或无遮盖的行为反应.方法 3～7岁斜视患儿120例,体重15～34 kg.随机分为4组(n=30),全身麻醉.A组单眼无敷料遮盖;B组双眼无遮盖;C组单眼敷料遮盖绷带包扎;D组双眼敷料遮盖绷带包扎.观察苏醒阶段患儿评分等级:安静1分、擦眼2分、哭闹3分、抓敷料与哭闹4分,以及苏醒前后的心率变化.结果 年龄、性别、体重各组之间无差异;手术时间B、D组(21.45±4.79,20.09±4.88)min长于A、C组(15.34±4.85、16.22±4.80) min,差异有统计学意义.C、D组评分值2.90±1.12、3.0±0.90,苏醒期心率(124±28、132±35)均明显高于A、B两组(1.33±0.75,1.60±0.96;94±18,98±20).结论 斜视患儿矫正术后擦眼、哭闹、抓敷料发生率无敷料遮盖组明显低于遮盖组,可平稳渡过苏醒期.     

斜视社会心理影响的研究进展

人们对斜视患者的偏见存在于社会生活的诸多方面。斜视会引起一系列的社会心理问题,且与精神障碍关系较为密切。斜视专用生存质量评估量表是评价斜视、斜视手术以及其他治疗方法对患者社会心理影响的有效工具。研究显示,斜视矫正手术能够改善斜视患者以及儿童父母的社会心理状态。本文对斜视社会心理影响的研究进展作一综述,希冀为了解、发现和处理斜视患者的社会心理问题提供帮助。     

The reliability of adjustment in strabismus surgery.

It has been recommended that the position of the operated muscles be adjusted shortly after strabismus surgery to achieve better alignment on the first postoperative day and thereby ensure satisfactory later alignment. We compared prism cover test measurements on the first postoperative day with measurements within the first few months after surgery to determine whether day 1 measurements remained stable or whether they changed significantly, providing an inaccurate basis for adjustment. Our study found a fairly large variability in the deviation between the first and last day of the study. Eighteen percent of patients varied by 5 to 9D, and 49% differed by > 10D or more. Equally important was the finding that, had an adjustment been made, it would have made the final result worse than without adjustment. Both of these factors would seem to indicate a degree of variability that controverts the predictability of the adjustment procedure.     

Amniotic membrane in the management of strabismus reoperations

Purpose

To reduce postoperative scar formation and to improve duction using amniotic membrane (AM) in strabismus reoperations.

Methods

A prospective study of interventional case series comprised of 14 patients with restrictive strabismus. Objective clinical findings (visual acuity, angle of deviations and degree of duction deficits) were recorded in both the pre- and post-operative periods. Strabismus surgery included the excision of adhesions and scar tissue, repositioning of extraocular muscles (according to the degree of deviations) and placement of two sheets, one between muscle and tenon and the other between muscle and sclera. Conjunctival recession with covering of the bare sclera using AM was also performed.

Results

The mean preoperative deviation of the patients was 34.3 prism diopters (PD) and mean post-operative deviation was 4.6 PD. The mean pre-operative duction deficit of the patients was 1.7; mean post-operative duction deficit was 0.2. Postoperatively all patients improved in relation to deviation and duction. Less than 8 PD deviations with no duction deficits were achieved in 12 (86 %) of the patients.

Conclusions

Amniotic membrane placement around the extraocular muscle improves the duction and decreases the residual angle of deviations by inhibiting postoperative scar formation.     

The effect of strabismus surgery on retrobulbar hemodynamics.

PURPOSE: To investigate the potential alterations of ocular hemodynamics after strabismus surgery using color Doppler ultrasonography. MATERIALS AND METHODS: Twenty eyes of 18 patients and the left eyes of 20 healthy age- and sex-matched volunteers were evaluated. Patients were divided into two groups according to the number of operated muscles. Group 1 included seven patients with surgery on one rectus muscle; group 2 included 13 patients with surgery on two rectus muscles. Nine patients underwent adjustable suture eye muscle surgery. The ophthalmic artery, central retinal artery, short posterior ciliary artery, long posterior ciliary artery, and central retinal veins of both groups were examined. With spectral analysis, peak systolic velocity, end-diastolic velocity, resistivity, and pulsatility indices were calculated. RESULTS: There was no difference in the Doppler ultrasonography parameters between the group with surgery on one-horizontal rectus muscle and the group with surgery on two-horizontal rectus muscles. The adjustable suture procedure did not affect retrobulbar hemodynamics. There was no difference between the preoperative and postoperative Doppler examinations. CONCLUSIONS: In contrast with some recent studies, our results suggest that the strabismus surgery involving one- or two-horizontal rectus muscles does not have a measurable effect on retrobulbar blood flow.     

Current concepts in the management of strabismus in children with cerebral palsy.

Few guidelines have been advanced for the management of brain damaged children with strabismus. Conservative therapy with lenses, prisms, occlusion, atropine and late surgery has been suggested but without specific methods or ages being advocated. The authors undertook the treatment of these children utilizing the standard principles of strabismus therapy as applied to neurologically normal children. A further consideration is a satisfactory cosmetic appearance which wins greater self, peer and parental acceptance in these handicapped children. The results of therapy of this series of patients with cerebral palsy indicates that satisfactory alignment can be achieved in the majority even in the presence of severe motor involvement and/or mental retardation. Ninety percent of those patients with treated accomodative esotropia achieved a satisfactory alignment. Those patients with non accommodative esotropia had a satisfactory alignment in 77% of the patients operated upon and those with exotropia achieved this result in 86% of the patients operated upon. Only five (2%) patients spontaneously reduced their angles to cosmetically acceptable ranges. Overcorrections occurred in 10 (11%) patients in the surgically treated nonaccommodative esotropes and 4 (3%) of these patients required further corrective surgery. Only one exotropic patient was rendered esotropic postoperatively. The average age of initial surgery in the esotropic patients was 3.9 years and 5.7 years in the exotropic patients. The older ages for surgical intervention reflects the more conservative approach to these neurologically abnormal children and allow an increased time interval for the development of a stable preoperative oculomotor alignment.