8
Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng, Honolulu,Hawaii OulS, rles, The optimum time for surgical alignment in congeni- t L oot opi. has been a subject of controvergy in ophthalmology for many years ' ''.It was n"t t":,q 19: that congenilal esotropia was considered incurable and that ther-e were no successful reeults of treatment other ihan cosmetic.'o''' However, in the past two decades, the concept hae evolved that a degree or graile ofbinocular- ity, oi "cure," was poseible in some cases that received burgical alignment :''^'t o't' etottg tn1 difficulties facing the inve-stigator evalu- esotropia. ; is generally ,agreed that adequate surgical a)ig:r- LI:こ ξ af,7:recursor Of any blnocula五 ty,p and ests fot rcD nts should be oddrcssedto Mdlcolm R Ing, llts p,^"nn, Street. Suile 1110, Honolulu Howoii Introduction it has beeD noted that no prospective studies are available,r However, since the age of initial surgical treatment doea not necessarily correlate with the age of adequate surgical alignment (aome are aligued after the second or third surgery), any prospective etudies based oD age at initial sugery would be of leseer value if alignment is of maximum importance' Therefore, a retiospective cohort study of adequately aligned cases wooltl be the best available data base from which to derive any conclusione. A meaningful stuily would have to ilclude patients from more than one practice to provide adequate numbers for statistical comparison. Prejudicial biae would be minimi.zecl by having all the evaluations performed by the same examiner without any knowl- edge ofthe patient's history until after t'he evaluatiou is colpleted. in atldition, the same criteria for both the iliagnoeis of congenital esotropia and binocularity res;lt€ should be applied throughout the stuily' Ttrie paper reports a etudy desigrted with the above suidelines that corelates t"he motor and sensory results -.ith th" .s" of adequate surgical a-Iignmeut' Subj ects and Methods A multi center study was conductedby the author with subjects selected according to t'he following criteria: (1) a hieLry of eeotropia from the age of six months or vouneer: (2) confumation by ophthalmologist's diagno- "i" b! oo" y"." of age, or through examination by 18 monihs ofageif other featuree companionto congeuital eaotroDia. such a8 diseociated vertical divergence anil low hyperopia were present;2o (3) eurgical alignment achieved to withiu 10 prism iliopters of orthophoria for a minimum of aix months; and (4) suffrcient matulitv io reliably respond to eensory teeting. Patients with neurc- logical abnornalities were excluded' _ 11 ating thJ resuits of heatment has been the controversy as to what srouD of strabiemic infarts constitutes "ongeuital" -esotiopia.'' to and what criteria denote a cut" of th" condition. Different t€sts have been given difrerent relative importance by researchers in previous evaluations, leadin! to further confusion about the reeults.r"" furthermore the results have been reported on relatively small numbers of patients so that even the etatietical evaluatious have been subject to queetioo' Somewhat belatedly, findings in the neurophysiologic tesearch on the development of immature binocular Dathwavs in -"mmals offered eome rationale for ctini"i""" *it" r""oiJ earlv surgical alignment ''-')r 締驚獣揚 t聯 primate model available for the study ofcongeni- RNAL oF pEDrATRIc oPHTHALMoLocY & srRAelsMUs

Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

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Page 1: Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

Early Surgical Alignmentfor Congenital EsotroPia

Malcolm Ro lng,M.D.Honolulu,Hawaii

ンOulS,

・rles,

The optimum time for surgical alignment in congeni-

t L oot opi. has been a subject of controvergy inophthalmology for many years ' ''.It was n"t t":,q

19:that congenilal esotropia was considered incurable and

that ther-e were no successful reeults of treatment other

ihan cosmetic.'o''' However, in the past two decades, theconcept hae evolved that a degree or graile ofbinocular-ity, oi "cure," was poseible in some cases that received

burgical alignment :''^'t o't'

etottg tn1 difficulties facing the inve-stigator evalu-

esotropia.; is generally ,agreed that adequate surgical a)ig:r-

LヽI:ここξaf,7:recursor Of any blnocula五ty,p and

ests fot rcD nts should be oddrcssedto Mdlcolm R Ing,llts p,^"nn, Street. Suile 1110, Honolulu Howoii

Introduction it has beeD noted that no prospective studies are

available,r However, since the age of initial surgicaltreatment doea not necessarily correlate with the age ofadequate surgical alignment (aome are aligued after the

second or third surgery), any prospective etudies based

oD age at initial sugery would be of leseer value ifalignment is of maximum importance' Therefore, aretiospective cohort study of adequately aligned cases

wooltl be the best available data base from which toderive any conclusione.

A meaningful stuily would have to ilclude patients

from more than one practice to provide adequate

numbers for statistical comparison. Prejudicial biae

would be minimi.zecl by having all the evaluationsperformed by the same examiner without any knowl-edge ofthe patient's history until after t'he evaluatiou is

colpleted. in atldition, the same criteria for both the

iliagnoeis of congenital esotropia and binocularityres;lt€ should be applied throughout the stuily'

Ttrie paper reports a etudy desigrted with the above

suidelines that corelates t"he motor and sensory results-.ith th" .s" of adequate surgical a-Iignmeut'

Subj ects and Methods

A multi center study was conductedby the author withsubjects selected according to t'he following criteria: (1) a

hieLry of eeotropia from the age of six months or

vouneer: (2) confumation by ophthalmologist's diagno-

"i" b! oo" y"." of age, or through examination by 18

monihs ofageif other featuree companionto congeuitaleaotroDia. such a8 diseociated vertical divergence anil

low hyperopia were present;2o (3) eurgical alignment

achieved to withiu 10 prism iliopters of orthophoria for a

minimum of aix months; and (4) suffrcient matulitv ioreliably respond to eensory teeting. Patients with neurc-

logical abnornalities were excluded' _

11

ating thJ resuits of heatment has been the controversyas to what srouD of strabiemic infarts constitutes"ongeuital"

-esotiopia.'' to and what criteria denote a

cut" of th" condition. Different t€sts have been given

difrerent relative importance by researchers in previousevaluations, leadin! to further confusion about thereeults.r"" furthermore the results have been reportedon relatively small numbers of patients so that even theetatietical evaluatious have been subject to queetioo'

Somewhat belatedly, findings in the neurophysiologictesearch on the development of immature binocularDathwavs in -"mmals offered eome rationale forctini"i""" *it" r""oiJ earlv surgical alignment ''-')r

‐締驚獣揚 t聯primate model available for the study ofcongeni-

RNAL oF pEDrATRIc oPHTHALMoLocY & srRAelsMUs

Page 2: Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

ESCITROPIA

TABLE 1

AGE OIAGNOSIS CONF}RMED8Y OPHTHALMOLOG'ST,S EXAM LENGTH OF FOLLOW-UP FROM I'I!IT.

lCAL AuCMИ ENT!NITl´

Alignlnent age(months)

M nimum‐ Average(yr:mo)

Alignm((mon

0-

13 -

Alig nmer

(mont,

0-(

7-1

13-`

25‐ ラ

Total

Maximum (yr:mo) Alignrh6ht age(lhonths)

2:3 - 23rO

TABLE 3

LENGTH oF FOLLOW_uP FRoMLAST SURGICAL PROCEDURE

Alignment age Minimum -(months) Maximurn (yr:mo)

Minimuh - AverageMaximum (yr:mo) (yr:mo)

412・ 16:7 8:7

4:1_175 8:8

2iO_23:0 8:4

2:3 ‐21:8 7:9

Average(yr:mo)

O-6

7‐ 12

13-24

25‐ 79

Total

013-o:6

0:3- 1:o

O:5‐ lio

O:5‐ 1:o

O:3‐ 1:o

0‐ 6

7-12

13=24

25-79

0:4

06

0:8

0:8

0:7

8:4

The author performed the examination on all patientsexcept those previously treated bv hi- ;;;::::::uniformly perf'ormed o" .tt p"ti"rit" i"i;ff ":fr:testi ng instruments. Corrected S".U"n

-

;;r;;";;i;was obtained. Cover testing was Derformed Jit-"r-:lr.accommodarion control techniqu"" lir; " #il:"jwearing full refractive correction and fi)(.if .i jo)i6letter targets at digtance ard near. C"""" d;i;";;;;the cover-uncover, simultaneous pri".

";;;;;;,;;the a.lterna0e cover test. The seneory tests were: (1)Bagolini striared glasses with n""til, t*e"t li'r)limeter, (2) Worth 4 lights ai t/B metut *[;id.Jsized as well as the smaller .i".. light", ;;f,tiji;:Po_laroid Titmue vectographic stereotest.

ln tJ'e Bagolini striated glasses teet, the patient wasasked to fixate a small lijht h"ld "t'lit;;;;';tf;:looking through plano glals *i*, tr" "ti"ti""" n?ll'ione eye and 1BE" in ihe other. I" thi" t""t;th;;;;;;";.jgive rise to a etreak that emanates fr"- tfr" fisi;i,li,;ito the striatione. The patient

"""ta tfr""i"ii_jf" i"".".tseeing: (1) a cross with or withrll:1, ll. rhe striations

",i.* ;#X';:r ii".f#?,iJornoculanty) or, (2) rarely, two light€ *ith til;;?:::l^",:f::."tt"tk:, or (3) visualizati"i"

"r """^"iiiilLllf otl l"Y:" both at once (no bino"ut."itvi..lJrir'patrenh wrth binocularitv weri'""u"n ir i"niii;;;;;i.;;" encouraged to switch

.t:""""irir'"-.""1;,;"Til:r#:;i""fi ::lf;:i*:The Worth 4 [ght tests witrier'*',,a-"i"1"-,"i:r'r";;,r-ri!i,l"l::Ji:}:'j{:f :1VB

_ meter. As previousty a""uU"a by 'p;;ili;":#

Taylor, '' the size of the sc.,rp'ti"'t", oi thoi-" ;tt' "#i:ffi"'i";il:*"lTltuaron, car.be obtained by movi''g th" 1..g";;;;;d;;l:srze near Worth 4 lights .*ry i"o_ th;;;il;;;;dor ng geometric calculations. Thi,

""oto*; ir;; "b:;;

shown to average Bo by parks i. hi";;;;;;d;syndrome- patients and l" B? seconds i" 60% ;;;;congenital esotropia caees considered

"*.a f,, _i'_'-tn the present study, a different method .f "o;;;;;;was ueed eince the smaller lights

""bt;; ;;';;il"j;12

0‐ 6

7‐ 12

13‐ 24

25‐ 79

11‐ 12:6

1:3 ‐ 17:6

1:5‐ 23:1

6:6

7iO

フil

1:1‐ 21:lo 7:4

1:1‐ 23:1 7:O

艦=恐

l鍔寧L鳳盤糧::糧盤恵暉器ポ町 鍵七:i漱悪 膚

屁∬よi塁_.The

steroacuity-"."u."il"nts, m.de by the polanTitmus vectograph overlay, wersrecorded in seconds

聾町事:躍1:ξStftill,1:聰

語曇靭疑I挙ご圏極i膏輛奮蕊罷馨錯鵠■蹴 機 器驚淵籠部:1ぺ寧宙』提l:蕊鯨麟ly

d岬ギ押蹴 濡 橘 :

鍮 11畔=鶉:趨等;琴写;出慨蕊面:淵

曇輩ぜF軍」譜躍ЪillittT][:j

course of the strablsmu■77':dJulciV:nleas:」 :ξ

patching,on o

status ofAfter exar

refnement racquired or a

Eliminatedconfrrmingmonthe of alesohopia hasAIeo eliminrunreliable orwhose historla history of r162r patientsexamined arPrevioualy strfor the study,

電機し′oF ιんeκα,2,η ed by ο′1施 sα

“e co■′:

λtsゎ″

。OunNAし OF F」ANUARY/FEBRUARY 1983,VOLuME 20,NUMB

Page 3: Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

ING

T

T Alignment age(months) 3 or4

Average{yr:mo)

8:7

+050■ +450

+05o■ ‐+5.25

0‐ 6

7‐ 12

13‐ 24

+142

+204

|| . o_|‐ ‐11(55%)1 7(35%) 2(10%) 2。

 

467-12 26{57%, 16(34%) 4{996)

8‥8“7‥9日

+025-+425

plano=+375

口ano・ 1525

+178

1 +126

+160

Average

13-24

25‐ 79

Total

13 (54%) 8 (33%) 3 {13%) 24

8 {50%) 5 (31%) 3 (19%) 16

58{55%) 36 (34%) 12 {11%} 106

as patching, glasses, miotics, and prisms; and (8) theimpression of the patient's ophthalmologist regardingthe etatus of binocul arity.

Afler examining the compiled hietories, furtberrefinerreut wa8 attempted to exclude patients withacquirrd or accommodative esohopia.

Eliminated were patients that ilid not have abonfirrdng ophthalmologist'8 examination by 12

a history of never being adequately aligned. A total of162* patients from eight centers in three countries wereeraroined aad 56 were eliminated becauee of thepr€viously stated reasons. Of the 106 patieDts retainedfor the etudy, there were 54 males and 52 females.

of the author's patietuts wete included but wereby one of thz porticipdtir8 stt'bisnologists undet

Results

For the purposes of comparison in the variousparameters iu study, the patients were divided into foursubgroups according to the age of iaitial adequatesurgical alignment (Tablee 1-13). The subgroups are:(1) Aligxred by age 6 Eonthg (Cage8 1 thrOugh")(2) Aligned by age ? to 12 bonths. (Cases 21 thlough 66)(3) Aligned by age 13 to 24 bonths. (Cases 6? thrcugh 90)(4) Aligrted by age 25 to ?9 bonths. (Cases 91 thlouah 106).

All the patiente hail their initial confrmation of theesotropia by an ophthalmologiEt by at leaet 12 monthsof age, but it wae felt to be important to calculate theaverage age of confirmation for the various subgroups.The ages at which the diagnosis for congenital esotropiawas confirmed by direct observation by an ophthalmol:ogist are compared in Table 1, which shows that theaverage age of confirmation was four uonths in theearliest-aligaed group, but was similar for the othersubgroupe and averaged eeven months overall,

Comparison of the length of follow-up from the initialadequate eurgical alignment is showt in Table 2. Theaverage length of follow-up for all the subgtoupe wassimilar and averaged eight years, four nonthe for thegroup as a whole.

The length of follow-up from the laet surgicalprocedure ie compared in Table 3. Ttre averagelength offollow-up time was similar for aII four eubgroups.

To rule out any significant difference in the initialrefractive error for the four subgtoupa, a comparison ofthese data is ehowr in Table 4 (excluding the fewinitially myopic caseli 22,29,53,55and 105). Tbere wagan average oflow hyperopia for all subgroup, and therange and avelage waa gimilar for all eubgroups.

Table 5 compares the initial deviatione using thelargeet measurenent (for either near or dietance). Theaverage initial deviation was sinilar for all subgroupe.

The number of horizontal muscle procedures lrr'fonaed to achieve alignment, at the time of this etudy,was det€rmined for each subgroup. Table 6 shows thesedata along with a comparison of the percentage of casesin that subgroup that had requied that particular

TABLE 5‐ |

lNlTlAL DEVIAT10N(PRISM D10PTERS)

ag9 ■ Miり imЧ ●‐「) . I MaXi市 lm

′erage′

「mo)

6:6

フ:0

フ 1

7:4

フ:o

O‐ 6

7-12

13‐ 24

25-79

40‐ 85 62

20‐ 70 1 54

20-701 54

20‐ 90 52

20‐ 90 ‐ 55

∞・u m

th

le P

tioned

ls

the

hepa$udy,d.icalrhasie

(3)

lnts of,tO

months of age, even though acquired accommodativeegohopia has been found as early ae 4Yz months ofage.2e

鵠鍛潔議ゴ躙g剛誡dttl∬譲:L淵,|。se hLtory suggested acqdred e80trOpia,or who had

teved saile conilition of no preuious hnowledge of thc potient

10URNAL OF PEDIATRIC OPHTHALMOLOGY&STRABISMuS

詢ures

Page 4: Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

N。

に轟

「「――――――‐‐――――      ‘――――,i

l‐

¨

ESOTROPIA

|■|■|Vertical muscle procedures, which included

for the obliques and vertical recti, are shown iDas-well as the perceutage ofcaaes within that Isubgroup that had received vertical muscleApprorimately one third of ali cases receivedmuscle surgery.

Several inveetigatorstr,re,ro have claimed thataliglment is achieved, glaases and./or mioticsneeded to nurture t,Le result in a high percentagecaaea. In general, this was found to be true foi r

patients iD this study. The number of patientspercentage of patients within the four subgroupsrcceived spectacle and/or miotic treatment igTable 8. At least halfto two thirils of all patients insubgroulx required this t1rye of therapy.BydttninJreddual attil,:ila轟「[為rrected

acuity difference of one line or more, the incidenceamblyopia varied irrsigaificantly in the various gr

gross etereopeis.Some investigatorsrr,r' clairr that motor

data is the criterion for any conclusions aboutstrabismus surgery. Using this de{inition of,,cure,"results for the four subgroups are shown in Table 1(

subgroups.*

A:ignmOnt age

(mOnthS) IPatients ‐ cases

0-6

7-12

13-24

25-79

‐■ 8(40%)

14(30%)

lo{4196)

20

46

. 24

116

‐ ,A LE18 ‐

NuMBER OF PATIENTS WHORECEIVED GLASSES OR MIOTiCS

bir憮

of

¨

n′

Alignment age

{monlhs) Pbti6htt

O-6

フ‐12

13‐ 24

25-79

11(55%)

3116フ%,

17171%)

13(ol%)

フ2168%)

20

46

24

16

106

Wi畔

of

∝輌

Шぬ

pb‐

alb‐セ

Total

0(11%)

44(41%) 106

number of eurgical procedures. The numbers of proce-dures performed for each of the subgroups wae remark-ably eimilar, and the data ehow that approximatelyhalfof the patients overall had achieved their motoralignment from a single horizontal muscle procedure,and at least one third received a second horizontalmuscle procedure,

14

a scotoma was found. However, in general, the testn-ot found to be helpful in distinguishing binocularithe patients.

Bagolini striated glasses minimally disturb the roJ the natural environment. The results oftesting,these striated glasses are shown in Table i2.significance is that, in contrast to the patients

・ CLi s9“ αre=7イ′6。 Or freed。″,ぇο`sむ

れIrtcα れ′

」ANUARY/FEBRUARY 1983,VOLuME20,NUMBER

んl朧 撃|||||ま.基‐

Page 5: Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

TABLE 101

tat'ticsotagel for

o‐ 6

7-12

13-24

25‐ 79 1

31フ %).■

0(0%). :

2(13%)

515%)

13{54%〕

11(69%)

64{60%)

Al19nment age

(mOnthS)

Phoria or intermit€nt .

tropia

6(3o%)

17(37%)

11{46%)

3(18%)

37(35%)

nts

upshownrts in

oft

s‐。n

)d

denceous

:esults,ure,"ble l

le(10

D)

)ntage

力。五aach

SO,

horiaach■

lases

rgence

his

lt in

lber

ble ll

o haveon Of

ixatione test

ulality

) theting

bv 6. 12 or 24 months ofagein which nearly all thowed a

ii""*J* *non"", less than half of those aligned after

iii "* "i za --ttts showed a binocular response Most

.i"t.i?i"tJ-ri*"d subgroup alternatinglv eaw onlv

""" "i tf," ff*ftt iteaks aia time' These patiente clearly

-anifesterl no binocularity with this test'*ft" *""f" of the crucial sensory examination with

w"rti q Glttt and stereopsis testing are displayed in

i"ii" ti. s?.t* it was believed that patients with borb

stereOpsls

DiscussiOn

iiiott ""a "t"t"opsis probably had a more secure form

oiliio"ut*;tv tft"" ttrose showing only one oftbese two

"""iid"" JUi""""laritv, the table displavs the number'

;;ffi; iotctio"" noted eeparatelv' Table 13 also

"i"*" irt" ""t"u"r from each subgroup who respouiled

""""ti""f"1" "itttar sensory teat' Ttrese results are also

...-

the

A;;l;rJ in percentases in the Figure Alis:rment

""liul"a1n."".ge through 24 months results in ahigh

n"*"*-"4" "i n"tiente wiih evidence for binocularitv'itt

" i"irt "-ifr*

percentage ofthose aligned after the

"g" oiil -o"th" ehow theee functions' The differences

*;-;; th" frrst three eubgroups compared with the

lat€st-alimed subgroup reach a high level ofstatishcal.i""in"J*.; while ttte difference in results between

"d;i;;;; earlier aligned suberoups did not''t

ftt" "ir" "f

the ecotoma varieil ir the patients who

a.-""Ji.t"a f""i"n with Worth 4lights' OnIv 48 out of8e t"iJ

""-Ue" of p ade nt6 who fueed the larger lights at

1/3 meter could aleo fuse t}re emaller lights at the same

disia;; a; ;elL and these patieuts therefore demon-

.tiut"a "-.U"i "i,"tomas.

Forty-four patients whofusedtl" riai-teiugtt* as well as the larger lishte algo

4.."i.i.-"t"a i,t""eopsis, but 28 of the patients whofailed to fuse the smaller lights did demonsbate Eome

'Difference betueen th'e first thrce subgroups Ds' Latest'

,tii"ii ""iir.ii, "ni squaie = 46.9, probabilitv of etror less

tho.n .001,6" Df freedon.

IDiflerence betueetu each of the first three subgtoupg (6 nto'

ua. |i'mo. ii. 24 mo.), chi squorc = 7 03, 4o of frcedotu, noteignificant.

e12

;.JouRNAL oF pEDrATRtc oPHTHALMoLoGY & STRABISMUS

Page 6: Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

ESOTROPIA

「| :| | IAILE■ 1

NUMBER OF PATIENTS WiTHDISSOCIATED VEBTICAL OIVERGENCE

Alignment age No icases(mOnt16) Patients

0‐ 6

17-12

13124

25‐ 79

Fusion of the Worth 4 lights can be denonstrated inpatients with up to.8_prism diopters ofl"t"rot opi. aidsome investigatore6,r6 have coacluded Eith Co"te;;J;;that 'the_vieualizing of four lights in the p."""""" oibifoveal fixation, or even in the presence of a smallmanifest_ esotropia, suggeats a more stable Ui"o"ut.irelationship than if no fusion could be aemonstratea_fr

46

24一

‐6一

‐6

26

‐5

Ю〓け一

0-6

7‐ 12

i3-24

25-79

Total l l :||‐

0{0%)

0(0%)

1(5%)

9(56%)

10(9%)

between fusion of either standard o" -ic"o Woiiilights and the frnding of stereopsis. So^" p"ti"rJ*i-

Parke felt that these patients obtained periphrealfusidespite-a foveal esodeviation by virtue ofihe abilityPanum's visual space for peripheral binocular visiolencompass a retinal image disparity up to bo ofviation. Parks also pointed out that fusional ve

bi利itll:lll:lin°fIXaiOn are cOmparable tO th」 sE

TVo previous studiee6,r6 have shown that thoseettOyed isiOn ofWOrth 41ights alsO hadfusiOnalwith the major amblyoscope 80 the latter test wasused in this study.

As reported earlier, there was no exact

one function did not demonstratethe otherandthe concept that they are different facets offunction-

even at that late age.

of the monofixation syndrome.Jampolsky' has called the cover t€st the .,

¨卿binぐ輌”呻耐山続叫面

8 pr

Ⅵ tl

disc

Aindi

bin:

stra

coni

oneesot

on l

on13

auga10r

to e'

exat

Sun

Tcage (

esotlogisjthe rExa;tionhistrof e>i

JOUF

“∞nT事よギダ潤ξ撫鯖蹴'精器:1織棚esotrope, but is extremely rare. Only t*Jpatienis-instudy demonstrated this degree of

"*""tLrrc" io "iacuity. Most patients achieved what has bee; ;esnated_as "gross" stereoacuity (200 io 3000 secondlrc). _The- vast majority of patients *ho .h;;;;runchonal cure with stereopsis fell within the confrr

court test" of binocularity, and thjs test was roperl'ormed in this study. Jampolsky had howeverconcludedthattherewas3:竃

Tヱ:l〕:ユ誕よゼ』illF器and pho五 a in his“fusiOnal

FIGURE

淵酬ぜ1路瞬讐」lttED

75

 

 

 

5。    25

(ぎ)ЩOく卜ZШO∝Шα

0-6 7-12 13-24 25=79

AGE:N MONTHSAT TIME OF ALIGNMENT

Fυ S′ 0″ OR sァER[OPs′ sFυ S′0″ 4ArD S,EPEOPs′s

四M

」ANUARY/FEBRUARY 1983,VOLuME 20,NUMBER

Page 7: Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

ING

TABLE 13||1 1. ‐

| ||

RESULTS OF wORTH 4 JGHT ANO STEREOPSIS TES■ NG二

Alignment ageimonths)

Fusion andstereopsis

Fusion ο′ | | |NocasesstereoPsis Neither

0‐ 6

7‐ 12

13-24

25‐ 79

15

38

15

一〇

‐1

‐7

 

5

4

7

3

19

20

46

24

16

106

8 prism diopters ofhetcrotropia can apparently coexist

*i*--p";pft"t.f binocularity in the monofrxation cages

discussed bY Parks 'u--eU"a""a -of a manifest deviation Eay or may not

nail.t" Uin*.tioo, and a more reliable indicator of

lifr:l-;;;t appea.s-to be refined steleoacuity Manv

,irabir-otogi"t. have seen a presumablv well-aligned

.""g""itti ""J"p" slip into an exotropic position and

orre-micht conclude that ai some point these previously

;;;i;;;;;; *".e close to or definitelv "orthophoric"

;;;h;;;;;" exotropia Clearlv' binocularitv could

o"fu U" a"-o"at tted by relying on sensory t€sts 10

augsrent a clinical impression derived from motor teets

croup 106 patients were chosen wbo had reliable

i"-"T"t", "ti"rt"bry alignment and an ophthalmol-

lA"t'. "i.rn "f tne congenital nature of the problem by

at leaet one Year of age.--Th;;"tb. of sensory testing showed that those

ra"qo"t"ty alignecl by the age of 6 monthg versua 12

i-.i*" tltt"E Z+ months were not statisticallv differ'

"nt.-LJ tftot" patients aligned aft€r 24 months of age

l"io*t.*t"a a signifrcartly lower percentage with

evidence for binocularity (p ( '001)'

Acknowledgnents

A modifrcation of a theeis sublaitted t"- pt94ruiirii"ii f"" membership iu the American ophthal-

molosical SocietY, MaY 1981'-1"["o*f"ag-""t is given to Dr' Robert Wort'h'

pt"-i""""t "ii:"tUc

Health, Universitv of Hawaii School

.iiil"-aiJ"", *tt" prepared the statietical analvsis' and

i. ii-"-ioiio*i"g sirabismoloS:istE without whose pa-

ll""i" *ti" "t,tai"ould

not have been accomplished: Dr'

;;;-rfil;, Pittsburgh, PA; Dr' Artbur Jampolskv'

s;;-F;;;;, cA; Di. Joeeph Laug, Zurich' switzer-

i"li, il-. n'r.""rt"u Parks, washington' DC; Dr' John

il*t-tiJ"u"""", v*couver, BC, Canada; Dr' Alan Scott'

irt i+.""i""., Ce; an<I Dr' Daniel Tavlor' New Britain'

CT.

References

1. Robb RM: Comment: When should one opelate for'

"."*i*i """ti"mua? in Brockhuret RJ' Boruchoff SA'

ii'i*li-*i si, t""sell s (eds): corlttoDeryv irL ophthdl-

rriilgr. il "aaprtia, wB Saunders Co' 19?7'vol1pp €1-

z. 61'"t"ol.a"t FD: Clinical course and manage$ent of' ;;;.;i;. ; Allen JH (ed): strubismus ophthatmic

S"i^i["i"^ tt stf^uis, CV Mosbv Co' 1958' vol I pp 325'

353.q i,lt., DM: How earlv ieearly eurgeryin themanagement"

"iitt"li"-u"f e rch Ophthalmol1963; 70:752'?56

0

1‐

hn

n

)r

,0

ly

10

i3

0‐

Df

a

,S

alone.-. '" irr.d"qo""y of relying solely on motor alignment

t" "t.f""t" tt".t-ent is de;onstrated by the results of

;;;;;;;l;;;;Iar who was aligned bv six and ahalf

"".* "i-""-". gf" ophthatmologist ihought him to be

li""""i"t -.ia "bifoveal" although he had noi been

t.ti""t"a t" t"t ""nsory

tesr' Apparently' there was no

;;#;;il;;;;'"t.ble squint but a definit€ small-angle

l".it *"1t i"t"a aurinj this studv and no binocularitv

*in w""irt lngft., ete-reopsie testing' or even Bagolini

tttt"t"i gi"t*! was demonstrated' This case empha-

.U." tft" iJi"ipl" tttat a fair comparison of the results in;;;;;;;i-;;;;'""ia treatment cau onlv be made bv

u-sin;;; "t-" -t".ti"g

deviceg and standards of

eramination.

Summary

To nrovide euffrcient numbers of patients varying in

*;;i;;J.;;"t"te surgical alignment for congerital

'.;;;;;;-;"=;";ts mLaged bv seven ophthal'r'ol-oststs in thrJ countries were personally examined by

d;th.;il ihe re"ul* compiled for a clinical studv

E;";-i;;;; ;;s mininized bv having the examina-tion ne.rformed without prior knowleilge of the clrrucalhi;;';d th" ;ie weie standadized in both method

"f *;'J;;;; .od t""t d"r.i""". From this population

JouRNAL oF PEDIATRIc oPHTHALMoLoGY & STRABISMUS

・e

ly

ia

17

Page 8: Early Surgical Alignment for Congenital EsotroPia · Early Surgical Alignment for Congenital EsotroPia Malcolm Ro lng,M.D. Honolulu,Hawaii ンOulS, ・rles, The optimum time for surgical

ESOTROPIA

4. von Noorden GK: Strabismus eurgery: Early and veryearly, letter to the editor. Atch Ophthalmol 1964;71:159.

5. Costalrbader FD: Strabismus eurgery: Early and veryearly, letter to the edltot. Arch Ophthtlnal 1964t 7l:761,

6. Ing M, Cost€nbader FD, Parks MM, et al: Early surgery fotcongenital esotropie" Arn J Ophtholmol 1966; 61:1419-

1427.7. Fisher NF, Flom MC, Jarnpolskv A: Early surgery for

congenital esotropia - An J Ophthaltuol 1968; 65:439.

8. von Noorden GK,Isaza A, Park ME: Surgical heahnent ofcongenital esotropia. ?rans Am Acad Ophtholnol Oto'I ary ngol l9'l 2; 7 6t1 465'1 47 4,

9. Parks MMi Early operations fotstrabismus, in Fells P (ed):

Proceedings of the Fbst Congress of the InternatiandlStrabismological Aesociatiot - Loddon, Ilenry Kimptod,1914, pp 29-34.

10. Stumpf F: Is early surgery really necessary? in Mein J,Bierlaagh, JJM, Brummelkamp-Dons TEA (ed's)t Orth'optics. Proceedit gs of the Second Intetnational OrthnpticConS?ess. A&aterdam, Excerpta Medica, 197 I, pp 220'223

11. Gale D: The surgical management of egotropia in infancy.Trans Ophthalmol Soc UK 1972;92:67*683.

12. Uemura Y: Surgical correctiou ofinfantile eeotropia. ./pn JO p htha lnol l9'7 3: 17:50-58

13. Folter RS, PaulTO, Jampolgky A: Mangeme[t ofiDfantilegsoltopia. Am J Ophthali@l 19'16:,92t291'299-

14. Doggart JJ: Diseases of Children's Eyes. St Louis, CVMosby Co, 1950, P 1?0.

15. Berke RN: Requisites for postoperative third degree fusion.Trans Am Acad Ophthahnol l9SSl62:3&63.

16. Parko MM: The oonofrxation syndrome. Trans AmOphthalmol Soc r969; 67:60965?.

17. Taylor DM: Is congenital esotropia functionally curable?Trans Arn Ophthalnol Soc 1972;70:529-576.

18. Costenbader FDr Factors in the cure of squint, inAllenJH(ed): Strabisazs Ophthalmologr Sym-posittzr. St Louis,CV Mosby Co, 1950, P 343.

19. Jampolsky A: When should one operat€ for congenitalshabismus? i!! Brockhurst RJ, BoruchoffSA, I{utchinsonBT, Lessell S (eds): Cot trouersv in Ophthalmology.Philadelphia, WB Saunders Co, 1977, vol 1 pp 416-'$3.

20. Parks MM: Operate early for congenital strabismus, inBrockhurst, RJ, Boruchoff SA, Hutchinson BT, L€ssell S(ed,e): Controuersy in Ophthalmolagy Philadelphia, WB

Saundere Co, 1977, vol 1 PP 423-433'

21 Wiesel TN,Hubel DH:Erects of vlsual depnvatlon

器は胤淵:∫攪〕湖慾::∬お3場詫;∫3:よ

22. Wiesel TN, Hubel DH: Comparis6n of the effectsunilateral and bilatetal eye closure ou corhcalrespotrses in kittens. J Neurophysiol 1965; 2811029-1040.

23. Ilubel DH, Wiesel TN: I'he peiod of susceptibi.lity tophyslologlcal erects ofun■ ateral eye closure m httens

ntysぁ′1970,206:419‐ 436 .

24. von Noorden GK: A primate model for amblyopia, i1Relnecke RD(ed):Strα ゎおれ

“Procα a,″gs or`ル

MeetinE of the Internotional Strubienalogicalιおz New York,Grune and Stritton,1978,pp 2329

25 BigOl■nl B: Sensory anomahes in stra'smus BrρP力

αルηο′1974,58:313‐ 318

26. Taylor D, Wybar K: Sensory aspects ofnolmalvision, in Perkins ES, Hill DW (eds): Scientific Founda-tions of Ophthalmology. Chicago, Year Book Me<lical

Publishers Inc, 197'l, PP 223-230.

2?. Raab E: Useful extensioEs of common strabismus tests.

Am Orthoptic J 1972;22:47-5328 Relnecke RD:In dlscusslon,Rawhngs

Dynalluc depth reversal stereogram81979,86:1471‐ 1473

SC,YatesOρん′力α′

“οlogy

29 Pollard ZF:AccommodaiveesotropladuingthenrstyeaIoflre Arcヵ Oρλ′みα′′πο′1976,94:19121913

30. Hiles DA, Watson BA, Biglan AIV: Characteristicsinfantile esohopia follo*.ing early binedial rectus

sion. Arch Ophthalnol 1980i 98t697'70331. Jampolsky .{- A simplified approach to strabismuo

diagnosis, in Burian HM (ed): Strobismus: Proceedinqs of

the New Otkans Acadenr of Ophthaltn rogy. St Louis,

CV Mosby Co, 1971, pP 34'92.32. Patks MM: In discussiou, von Noorden et al: Surgical

heatment of congenital esotropia. ftons Am Acad

Ophthatnol Otolaryngol L972' 761147 4.

33- Costenbader FD: Infantile esottopia. Trans Am Ophthal-nol So c L961; 59t397 -429.

34. Jampolsky A: Managementof omalldegree esodeviations,in Haik GM (ed): Srrobisnrzs: Prcceedi\gs of the NeuO eans Academy of Ophthalmologv. SLLouie, CV MosbvCo, 1962, pp 123-139.

Ac湖鰤

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叩肺血are脚岬肺町 ‐emて鵬襦暉炒爬‰

一rb剛∽ 一‘崚●2一 ,&M

」ANUARY/FEBRUARY 1983,VOLUME 20.NUMBER l