Strabismus and binocular function in children with Down syndrome. A population-based, longitudinal study

PURPOSE: We have performed a population-based, longitudinal study on strabismus in children with Down syndrome. The aims of the study were to examine the frequency and type of strabismus, the age at onset, and the binocular potential. METHODS: An unselected population of 60 children with Down syndrome born 1988-1999 was followed with repeated examinations. Mean follow-up time was 55+/-23 months (range 24--115). The alignment of the eyes was examined using Hirschberg corneal reflex test and cover test for near fixation. To evaluate binocular function, Titmus House Fly Test and Lang's stereo test were used. RESULTS: Twenty-five patients (42%) had strabismus (21 esotropias, two exodeviations and two vertical deviations). Only one case of infantile esotropia was found, the other esotropias were acquired forms. The mean age at "onset" (e.g. when strabismus was first noticed) was 54+/-35 months. In the acquired esotropia group (n=20), 15 (75%) were associated with hypermetropia (mean spherical equivalent +4.3+/-1.7 D). Seventeen of the strabismic patients had an accommodation weakness. Eleven of the strabismus patients gave a clearly positive response to one or both stereotests. CONCLUSIONS: The majority of the Down syndrome children with strabismus have an acquired esotropia and hence a potential for binocularity. Hypermetropia and accommodation weakness are probably important factors in esotropia in Down syndrome patients.     

Unexplained head tilt following surgical treatment of congenital esotropia: a postural manifestation of dissociated vertical divergence

BACKGROUND: Strabismus surgery for congenital esotropia can be complicated by the development of a postoperative head tilt. PURPOSE: To determine the pathophysiology of acquired head tilting following horizontal realignment of the eyes in children with congenital esotropia. MATERIALS AND METHODS: Retrospective analysis of nine children with congenital esotropia who developed unexplained head tilts following horizontal realignment of the eyes. RESULTS: Shortly after strabismus surgery, each child developed a head tilt in association with asymmetrical dissociated vertical divergence (DVD). Five children maintained a head tilt toward the side of the fixing eye (group 1), which did not serve to control the DVD. Four children maintained a head tilt toward the side of the hyperdeviating eye, which served to control the DVD (group 2). Children in group 2 had earlier horizontal muscle surgery and developed better stereopsis than those in group 1, suggesting that the higher degree of single binocular vision and stereopsis in these children may have led to a compensatory torticollis to control an asymmetrical DVD. CONCLUSIONS: The onset of an unexpected head tilt after congenital esotropia surgery is usually a postural manifestation of asymmetrical DVD. In this setting, a head tilt toward the side of the fixing eye corresponds with a postural manifestation of the underlying central vestibular imbalance that produces DVD, while a head tilt toward the side of the hyperdeviating eye serves to counteract the hyperdeviation and stabilise binocular vision.     

Accommodative Esotropia Long Range Follow-up

Thirty-nine adult patients treated for typical (refractive) accommodative esotropia in childhood continue to have problems because they have not outgrown their hypermetropia, and the majority have not developed stable binocular vision. Their hypermetropia became maximal (median 5.7 diopters) by age 6, decreased in adolescence, and then stabilized (median 4 diopters). Thirty-eight of the 39 adults wear correcting lenses full-time. Nearly all depend on relaxed accommodation to maintain alignment when they remove their glasses. Ten patients, all of whom received treatment before a constant esotropia developed are essentially orthophoric with glasses and have normal binocular vision. The remainder have small-angle deviations with glasses, 14 with varying degrees of amblyopia and peripheral fusion and 15 with anomalous correspondence and suppression. As adults, only one patient with normal binocular function has required surgery whereas 13 of the patients lacking normal fusion have had surgery for increasing esotropia, postoperative exotropia, or consecutive exotropia.     

Update on accommodative esotropia

PURPOSE: The aim of this study was to present an update on accommodative esotropia. METHODS: The diagnosis, clinical features, etiology, treatment, prognosis, and clinical course for the 3 types of accommodative esotropia are presented. RESULTS: Accommodative esotropia is the most common pediatric strabismus and must be differentiated from other pediatric esotropias. Although its average age of onset is 2.5 years, it can begin during the first year of life and is seen rarely in older children and teenagers. Refractive accommodative esotropia and nonrefractive accommodative esotropia have a better prognosis for achieving normal binocular vision and high-grade stereopsis with appropriate and timely treatment than partly accommodative esotropia. Children with successfully treated accommodative esotropia need to be followed up with to prevent possible deterioration and development of a superimposed nonaccommodative esotropia, which in some cases may require extraocular muscle surgery. Emmetropization and spontaneous resolution of the esotropia occur rarely and may take many years. CONCLUSION: Approximately 50% of all pediatric esotropias are either entirely or partly accommodative. Proper care is long term and includes monitoring the refractive error and binocular vision status over the years.     

Binocular visual function in congenital esotropia after bilateral medial rectus recession with loop suture

PURPOSE Our aim was to evaluate the binocular visual function in congenital esotropia after bimedial rectus recession with loop suture and to address the factors that could take part in the attainment of binocular function. SUBJECTS AND METHODS Forty children with congenital esotropia who were operated on between 12 and 48 months of age were included in the study group. Postoperative follow-up ranged from 2 to 10 years. In order to determine the factors affecting the sensory results in congenital esotropia, we classified our patients into two groups according to their fusion status. We compared the preoperative and postoperative characteristics of patients in these two groups. RESULTS Twenty-one of 40 patients (52.5%) fused the Worth four-dot at near (Group 1), 19 patients (47.5%) did not (Group 2) at the final examination. No patient showed evidence of stereopsis. We found significant differences between these two groups in respect to the final angle of vertical deviation, the age at surgery, the presence of postoperative inferior oblique overaction, dissociated vertical deviation and abnormal head position. Correlation analysis revealed that early alignment of the eyes and the absence of postoperative vertical deviation were associated with increased incidence of achieving some degree of binocular vision. CONCLUSION In congenital esotropia, not all infants may have the potential for normal binocular function owing to yet unknown constitutional factors. We determined that achieving some degree of binocular function may be related to early alignment of the eyes. Additionally, close follow-up and precise treatment of the accompanying vertical deviation, especially inferior oblique overaction and dissociated vertical deviation,in a timely manner may enhance the attainment of binocular sensory function.     

283例手术治疗共同性内斜视临床特点分析

目的探讨共同性内斜视各类型分布、不同类型及手术年龄对双眼单视功能的影响。方法回顾分析手术治疗的共同性内斜视283例,统计各类型内斜视的分布。重点分析婴儿内斜视、非调节性内斜视和部分调节性内斜视三种类型及其手术年龄对双眼单视功能的影响。结果 283例共同性内斜视患者中,婴儿内斜视136例(48.57%)、非调节性内斜视77例(27.21%)、部分调节性内斜视44例(15.55%)、残余性内斜视18例(6.36%)、知觉性内斜视4例(1.41%)、连续性内斜视4例(1.41%)。部分调节性内斜视存在融合功能和远近立体视的比率均高于婴儿内斜视和非调节性内斜视,P<0.05;而婴儿内斜视和非调节性内斜视远近立体视差别不大,P>0.05;<2岁患儿融合及近立体视存在率高于2～9岁和>9岁患儿,P<0.05。结论在手术治疗的共同性内斜视中,婴儿内斜视占首位。部分调节性内斜视对双眼单视功能影响最小。手术年龄小有助于双眼单视功能的改善。     

周期性内斜视手术前后双眼视觉及手术时机的探讨

目的 观察和分析周期性内斜视手术前、后双眼视觉及其手术时机的选择.方法 将30例4～21岁符合标准的内斜视分为2组:周期性内斜视者14例;恒定性内斜视(初诊时为周期性内斜视)16例.同视机测定远双眼视觉级别,颜少明<立体视觉检查图>测定近立体视锐度.观察术前、术后的远双眼视觉,近立体视锐度变化.结果 14例周期性内斜视患者术前正位日及术后远双眼视觉及近立体视锐度与正常人群相比无显著性差异.16例恒定性内斜视(初诊时为周期性内斜视)术前12例(75%)无双眼视觉,术后16例(100%)具有同时知觉能力,16例(100%)可获得融合力,但融合范围低于正常人群.10例(62.5%)获远立体视,8例(50%)获得不同程度近立体视.结论 周期性内斜视应尽量在周期性期间手术,有利于双眼单视功能的恢复,达到功能治愈的目的 .     

先天性内斜视手术治疗的远期效果观察

目的观察先天性内斜视手术治疗后眼位和双眼单视功能的变化。方法追踪观察60例先天性内斜视手术治疗后眼位和双眼单视功能的变化，并进行分析。结果先天性内斜视手术治疗后远期眼正位率明显低于术后近期正位率，4岁前手术组患者术后双眼单视功能明显优于4岁后手术组。结论先天性内斜视患者手术时机以在4岁前为宜，术后随访观察眼位变化并进行相应处理。     

Some principles in surgical treatment of strabismus

Taking into consideration the age of the patient, the strabismus surgery targets different things. Thus, for infants, the goal of the surgical intervention for congenital esotropia, is to prevent the occurrence of amblyopia and binocular vision dysfunctions (ARC, suppression). In preschool children, we operate aiming the recovery of the binocular vision, while in children over ten years old, the surgery is done only for esthetic reasons. On the other hand, in adults, the strabismus surgery has two aspects: for esthetic reasons in monocular strabismus with amblyopia, or for diplopia treatment in strabismus of traumatic or neurological cause. To get the best results, the surgical intervention has to respect several rules, which differ with patient's age. This presentation will discuss several surgical procedures: for congenital esotropia (including its advantages and drawbacks), for preschool children strabismus and also for strabismus in adults. We will also review the surgical treatment for Duane syndrome, Ciancia syndrome and superior oblique muscle palsy.     

后天性共同性内斜视手术治愈后的双眼视觉

目的：探讨后天性共同性内斜视手术治愈后双眼视觉的恢复规律。方法：对40例后天性共同性内斜视经手术治愈后患者的临床资料进行分析。结果：40例后天性共同性内斜视患者术前36例(90％)无双眼视觉。术后40例(100％)具有同时知觉能力，40例(100％)可获得融合功能，但融合范围低于正常人群，26例(65％)获得远立体视，18例(45％)获得不同程度的近立体视。结论：后天性共同性内斜视患者黄斑中心凹立体视损害最严重，对于后天性共同性内斜视的临床处理应更加积极，树立婴幼儿期的持续性内斜应急诊处理的观念，使更多患儿获得良好的立体视觉。     

Is there a need for binocular vision evaluation in low vision?

The purpose of this study was to determine the need for a binocular vision evaluation in the management of low vision patients. Thirty subjects were selected with visual acuities of at least 6/60 in each eye. Twenty-three had age-related macular degeneration as the primary ocular pathology and seven had various other ocular conditions. The binocular vision evaluation comprised: detailed history and symptoms with an emphasis on the occurrence of near vision problems; modified binocular vision assessment which included cover test at near, ocular movements, convergence, Bagolini glasses, horizontal vergence reserves and prismatic measurement of any observed anomaly. History and symptoms revealed horizontal and vertical diplopia, jumbling of print, asthenopia, intermittent blurring and print being too small. Binocular vision assessment revealed exophoria at near, manifest horizontal deviations, convergence insufficiency, and vertical muscle imbalance. These anomalies occurred either singly or in combination. The results indicate that there is a need for binocular vision evaluation in low vision in order to reveal near vision disorders that may be partly attributable to binocular vision anomaly and not solely due to ocular pathology. This information should facilitate the implementation of the appropriate course of optometric management for these patients.     

共同性斜视患儿手术前后三级视功能的临床观察

目的观察共同性斜视患者手术前后双眼视觉功能的变化,探讨手术矫正在共同性斜视患者双眼视觉功能重建中的重要性。方法收集了37例共同性斜视患者,手术前后分别进行眼部常规检查,屈光检查和三棱镜加交替遮盖法测定远、近斜视度;同时视、融合功能采用同视机检测,立体视功能采用颜少明编绘的《立体视觉检查图》检测。有屈光不正的患者须戴眼镜矫正后进行检测。记录术前、术后1、3、6个月各项检查数据,并对数据资料进行统计分析。结果术前所有患者中,有同时视功能者8例,占21.6%,有融合功能者7例,占18.9%,平均融合范围1.90°±4.15°,有立体视功能者0例;术后1个月同时视功能较术前有明显恢复（P〈0.05）,融合功能及融合范围、立体视无明显恢复（P〉0.05）;术后3、6个月同时视、融合功能及融合范围、立体视均较术前有明显改善（P〈0.05）。结论 （1）共同性斜视患者视觉三级功能都受到了严重损害。（2）术后视觉三级功能较术前均有明显提高,手术矫正眼位是双眼视觉功能恢复和重建的前提因素。（3）我国斜视患者手术年龄偏大,病程较长,应加强科普宣传,加大全国斜弱视的普查,尽可能做到早发现、早诊断、早治疗。     

儿童部分调节性内斜视的治疗及调整缝线在手术中的应用

目的 探讨儿童部分调节性内斜视的术前治疗、手术时机与手术量以及调整缝线在治疗中的应用。设计 回顾性病例系列。研究对象 北京儿童医院眼科接受手术治疗的部分调节性内斜视患者30例。方法 对手术治疗的部分调节性内斜视患者的临床资料进行回顾性分析。患儿术前矫正屈光异常,观察斜视度稳定,并予适当弱视治疗,在双眼视力相当的情况下进行手术,按照裸眼和戴镜斜视度的平均值设计手术量。术中常规使用调整缝线技术,术后早期依据眼位情况决定是否需要调整。术后随访6~15个月。观察眼位及双眼视功能。主要指标 术后眼位、双眼视功能、眼位调整情况。结果 有3例患儿进行了眼位调整,均为过矫,避免了二次手术。末次随访时30例患者中26例（87%）眼位在正位~+8△之间,4例（13%）眼位+10△~+15△。术前能合作行双眼视功能检查者19例,有双眼视功能者2例（11%）。末次随访时能合作双眼视功能检查者21例,有双眼视功能者15例（71%）。结论  内斜视伴有调节因素时应及时全矫配镜,在残余斜视度稳定、双眼矫正视力基本相当后应尽早手术。手术设计根据戴镜与裸眼视近的平均斜视度,调整缝线有助于保证术后早期的眼位满意,降低了二次手术的风险。（眼科, 2013,22: 121-123）     

Etiology and surgical management of horizontal pontine gaze palsy with ipsilateral esotropia.

INTRODUCTION: An esotropia ipsilateral to a horizontal pontine gaze palsy has been infrequently reported. We discuss the etiology and review the surgical management of this ocular motility defect. METHODS: Four patients with radiographically documented dorsal pontine lesions and persistent horizontal gaze palsy with esotropia ipsilateral to the gaze palsy were treated. In each patient, the esotropia was present in attempted primary gaze, producing symptomatic diplopia. An anomalous face turn was required to attain single binocular vision. RESULTS: All 4 patients underwent surgical correction to alleviate the anomalous head position and diplopia. Bilateral, asymmetric surgery was required to achieve a long-term successful result. Single binocular vision in the primary position with elimination or marked improvement of the compensatory head posture was initially achieved in all 4 patients. One patient, who had not undergone asymmetric strabismus surgery to reconcile incomitance produced by the esotropia, rapidly developed a residual esotropia. CONCLUSIONS: Ophthalmologists should recognize that concurrent esotropia may occur in patients with horizontal pontine gaze palsy. Single binocular vision in the primary position, an expanded binocular visual field, and alleviation of a compensatory head position are achievable with strabismus surgery.     

手术治疗先天性内斜视临床探讨

目的：探讨先天性内斜视的临床特点、手术时机、手术方法及疗效。方法回顾分析43例施行手术的先天性内斜视病例的治疗结果。结果正位36例,正位率83.72%,欠矫5例,占11.63%,过矫2例,占4.65%,随访2~4年,部分病例经过二次手术,术后进行弱视治疗及双眼单视功能训练,最终获得正位率41例,占93.02%,弱视治愈率92.11%,23.26%病人恢复双眼单视功能。结论先天性内斜视的患者应早期手术治疗,术后弱视治疗及双眼单视功能训练,对远期眼位正位,弱视的治愈及双眼单视功能的重建非常重要。     

影响屈光性调节性内斜视立体视锐度发育因素分析

目的分析影响屈光性调节性内斜视患者立体视锐度发育的因素。方法对100例屈光性调节性内斜视按斜、弱视常规戴镜的原则进行治疗;采用同视机测量斜视度数;用颜少明的立体视觉检查图测量近立体视锐度。结果屈光性调节性内斜视患者发病年龄越小、戴镜前斜视度越大、两眼视力差距越大,立体视锐度的发育越差。结论屈光性调节性内斜视患者的立体视锐度发育与发病年龄、戴镜前斜视度、两眼视力有关。     

67例V型斜视的手术探讨

目的 探讨V型斜视的临床特征及不同手术方法及效果.方法 回顾性分析了67例V型斜视的手术治疗.其中外斜V征46例,内斜V征21例,依据是否伴有下斜肌功能亢进及亢进程度,行下斜肌减弱术或水平直肌垂直移位术,所有患者按原在位水平偏斜度常规矫正水平斜视.观察手术前后的眼位、斜肌功能和双眼视觉.结果 67例手术中,49例行下斜肌后徙术或后徙转位术,术后43例上、中、下均正位,V征消失;术前无下斜肌功能亢进或下斜肌功能亢进"+"者13例,行水平直肌垂直移位术后11例正位,V征消失.67例患者术后19例恢复双眼视.结论 下斜肌后徙,后徙转位术适用于下斜肌功能亢进(++)-(+++)的V征,水平直肌垂直移位术适用于无下斜肌功能亢进或下斜肌功能亢进+的V征,应根据下斜肌功能亢进程度选择手术方式.     

儿童内斜视矫正术后双眼单视的建立及影响因素

目的 观察和分析内斜视儿童眼位矫正术后双眼单视功能的建立情况及其影响因素.方法 回顾性系列病例研究.收集2008年11月至2011年9月间在山东大学附属省立医院眼科中心行共同性内斜视矫正手术并且术后随访眼位正位(≤±8△)的连续性病例111例.采用手电筒式Worth四点灯评估患儿的中心融合和周边融合;采用Titmus立体视图测定患儿的立体视锐度.采用x2检验比较不同内斜视类型之间周边融合建立的差异;采用Logistic回归分析内斜视类型、弱视治疗时间、手术年龄、两眼屈光参差差值、术后斜视度对周边融合建立的影响,并采用优势比(OR)进行比较.结果 111例内斜视儿童中,术后获得周边融合者68例(61.3％),其中获得中心融合者6例(5.4％);56例(50.5％)建立了不同程度的立体视.手术年龄(b=-0.842,P＜0.01)、弱视治疗时间(b=-0.135,P＜0.05)、最终随访的斜视度(b=-1.305,P＜0.05)与术后周边融合的建立呈负相关;两眼屈光参差差值与术后周边融合的建立不相关(b=-19.670,P＞0.05).4种内斜视类型之间术后周边融合建立的差异有统计学意义(x2=-15.977,P＜0.01),周边融合建立的困难程度依次为先天性内斜视(OR=1.0)、非调节性内斜视(OR=3.008)、部分调节性内斜视(OR=4.475)、高AC/A型内斜视(0R=82.217).结论 内斜视儿童手术年龄愈早、术前弱视治疗时间愈短、术后斜视度愈小,术后愈易建立周边融合;4种内斜视类型中,建立周边融合的难易顺序依次为先天性内斜视、非调节性内斜视、部分调节性内斜视、高AC/A型内斜视.     

Congenital esotropia with a bifixation result report of a case

Surgical alignment of the eyes in congenital esotropia within the first two years of age can result in the development of binocular vision. With one exception, reported here, the binocular vision has been extramacular and never macular. In this one case the patient was proven to be a bifixator. This is such an unusual outcome that the diagnosis of congenital esotropia must be questioned. Moreover, dissociated double hypertropia was not found in this case.     

The blindspot syndrome

Constant esotropia, with its accompanying sensorial anomalies, generally presents a poor prognosis for functional recovery of binocular vision. The blindspot syndrome presents an exception to this. The present paper suggests methods for the diagnosis and an approach to the management of this condition.