[Which cases of strabismus can be cured?]

Fünfzig Jahre Schielbehandlung – Ein Erfahrungsbericht aus Klinik und Praxis

Der Aufbau der orthoptischen Abteilung an der historischen I. Univ.-Augenklinik Wien zwischen 1960 und 1997 und die internationalen Fortschritte werden beschrieben, jedoch auch die besonderen Behandlungsmethoden der Klinik, wie z. B. der Ausgleich des Schielwinkels mit Prismen vor Schieloperationen oder die Prismenbehandlung von kindlichem Strabismus ohne Operation. Bei Entlassung von der Klinik fühlt sich der Patient als subjektiv geheilt. Die Nachhaltigkeit der Therapie zeigt sich erst später in der augenärztlichen Praxis. Die Vielzahl von Amblyopien, konsekutiven Divergenzen, Diplopien oder Horror fusionis nach mehrfachen Schieloperationen lässt unsere Schielbehandlung als fragwürdig erscheinen. Schielen ist nur selten ein anatomisches Problem, vielmehr ein funktionelles. Ohne Fusion ist ein dauerhafter Parallelstand der Augen nicht möglich. Daher ist für die Zukunft ein geändertes Programm zu empfehlen: weniger Operationen in der Kindheit, mehr Fusionstraining mit Prismen und dem jungen Patienten mehr Zeit geben für seine Entwicklung.

Short-Term Motor and Sensory Outcomes in Acquired Nonaccommodative Esotropia of Childhood

Information on the management of acquired nonaccommodative esotropia (ANAET) of childhood is incomplete. Most prior reports combine the results of patients with both accommodative and nonaccommodative esodeviations. The primary objective of this study was to describe the early postoperative motor and sensory results of children with acquired nonaccommodative esotropia. The medical records of 72 consecutive children with ANAET who underwent surgical correction at East Tennessee State University College of Medicine from August 1, 1995 through October 1, 2001 were retrospectively reviewed. The median age at surgery for the 72 study patients was 43.8 months with a median angle of deviation of 30 prism diopters (PD) at both distance and near. Ten patients (13.9%) required a second surgical procedure while one patient (1.4%) required a third. The cumulative probability of a second surgery within two years of the first procedure was 24% (95% CI 4-43%). During a median postoperative follow-up period of 7.1 months, 64 (88.9%) patients were within 8 PD of orthotropia on the last postoperative examination. Normal postoperative stereoacuity was achieved in several children whose deviation began after 30 months of age, as well as in one child who was misaligned for at least two years prior to surgery. Although the postoperative follow-up on these patients with acquired nonaccommodative esotropia managed without prism adaptation is short, the motor results are similar to other studies on patients with acquired esotropia, with sensory outcomes superior to those obtained in children with congenital esotropia.

Which Angle for which Surgical Strategy in Comitant Strabismus?

BACKGROUND

The fusion-free angle measured in the awake state was adopted as the angle of reference and the basis for conventional muscle surgery. The surgical effect is amount dependent. Further analysis: The basic angle does not, however, correspond to the fusion-free angle in all types of comitant strabismus. In infantile esotropia it corresponds to the minimum angle. The difference between the maximum and the minimum angle represents the angle of variability. Weakening-reinforcing techniques (conventional surgery) to correct the minimum angle should therefore be combined with a progressive lessening technique (posterior fixation suture) to reduce the variability. In normosensorial strabismus the prism adaptation test, or prismotherapy, allows accurate determination of the basic angle to be corrected. The imbalance of the passive forces in an antagonistic muscle pair can be assessed during surgery under general anaesthesia in two ways, the eye position and the measurement of muscle extensibility. These two parameters are partially independent from the minimum angle measured in the awake state. The intraoperative data can, therefore, be considered as valuable parameters for adjusting the amount of conventional surgery. Patients, method and results: A series of 80 children with infantile esotropia were operated on between 11 and 100 months of age. The surgical procedure consisted of bilateral posterior fixation sutures and uni- or bilateral medial rectus recessions. The intraoperative data were recorded in all cases. The amount of global recession was calculated on the minimum angle and adjusted if necessary during surgery according to the intraoperative data. The long-term results (follow-up of two years or more) show that the failures arose more often in the cases in which no adjustment was made.

DISCUSSION AND CONCLUSION

An intraoperative adjustment of the amount of surgery is indicated according to the imbalance of passive muscle forces. Our long-term results, as yet uncompleted, suggest that the variance in results can be reduced by this strategy, along with taking into account the different angles of a deviation.