Visual rehabilitation indicating neuroplasticity in an esotropic adult patient with diplopia after sudden visual acuity loss in the non-amblyopic eye: A case report

BACKGROUND

The aim of this case report is to present the successful management of both diplopia and amblyopia in a specific clinical situation, demonstrating neuroplasticity of the visual system in an adult patient. Causes of diplopia include eye pathologies in monocular diplopia and ischemic ocular motor nerve palsies, sudden life-threatening and chronic conditions in central nervous system in binocular diplopia. Strabismic amblyopia and nonarteritic anterior ischemic optic neuropathy are quite often ophthalmic conditions, first one is caused by suppression during developmental period and the latter one by ischemia of the optic nerve in adults. Coexistence of aforementioned conditions may cause unusual clinical situation in which ability of nervous system to functional reorganization could be demonstrated.

CASE PRESENTATION

In our adult patient, diplopia was incited by the loss of suppression of the strabismic amblyopic eye, which was the consequence of a sudden decrease of the visual acuity in the previously better eye in the course of nonarteritic anterior ischemic optic neuropathy. This led to impairment in daily activities.

RESULTS

Visual training rehabilitation improved distance and near visual acuity in the amblyopic eye over three months, and prescribing two pairs of glasses with prisms enabled the patient to return to daily activities.

CONCLUSION

The discussed patient lost the suppression of the strabismic amblyopic eye. Management of amblyopia is usually undertaken in children, however considering neuroplasticity we successfully attempted to improve visual functioning of our patient, despite lower intensity of neuroplasticity functions in an adult brain.

Outpatient assessment of neurovisual functions in children with Cerebral Palsy

This study examined the feasibility of the Atkinson Battery for Child Development for Examining Functional Vision (Atkinson, Anker, Rae, et al., 2002) to evaluate neurovisual functions of children with neurodevelopmental disorders in outpatient setting. A total of 90 patients underwent a comprehensive evaluation. Among these, a group of 33 children with Cerebral Palsy (CP), mean age 6 years, with different types of CP (26% diplegic, 37% hemiplegic and 37% tetraplegic) were selected to constitute the cohort of the study. Visual sensory measures as well as higher level visual functions were considered. Overall, 73% patients had impairments at the assessment protocol, the majority of which presenting difficulties on both visuoperceptual and visuospatial tasks (79%). Subgroups of participants presented similar profiles of impairments with spared basic visuocognitive abilities and limitations in visuoperceptual and visuospatial domains. The Atkinson's battery proved to be valuable for evaluation in outpatient setting and follow-up testing. Some limitations emerged. For the definition of personalized and detailed rehabilitation programs a breakdown of the different components of vision and subsequent in-depth evaluation are needed.

[Influence of prism overcorrection on residual postoperative strabismus]

BACKGROUND

Prism overcorrection is a complementary procedure to reduce the residual postoperative esotropia caused by anomalous retinal correspondence (ARC) after surgery for esotropia. We have investigated the results of this treatment.

PATIENTS AND METHODS

For Group 1, the files of 63 patients treated with postoperative prism overcorrection in the Department of Ophthalmology, University of Giessen, were evaluated regarding the pre-and postoperative squint angles (SPCT, simultaneous and APCT, alternate prism and cover test) and the angle of ARC, determined by the red filter test and by the increase of esotropia after neutralisation of the squint angle (APCT). Postoperatively, squint angles had been measured immediately (APCT) after removal of the eye patch and 10 minutes to 2 hours later (SPCT and APCT). Subsequently, prism overcorrection was performed with a Fresnel prism foil (40 PD basis temporally) in front of the fellow eye for a maximum of 3 months. After 3 months, SPCT and APCT were performed. For Group 2, the files of 28 patients with a preoperative angle of ARC of 5 degrees or more, treated in the Department of Ophthalmology, University of Heidelberg, were evaluated. These patients had not been treated with prism overcorrection. The squint angles had been measured (SPCT and APCT) on the preoperative day, on the first postoperative day, a few hours after removing the eye patch, and after three months.

RESULTS

For Group 1, at surgery, the patients were 4 to 12 years old (median: 6.2 years). The preoperative squint angle ranged from + 5 degrees to + 27 degrees (median: + 12 degrees) in the SPCT and from + 7 degrees to + 27 degrees (median: + 14 degrees) in the APCT. The angle of ARC was between + 4 degrees and + 15 degrees (median: + 7 degrees). Both combined recess and resect surgery (with or without additional oblique muscle surgery) or bilateral retroequatorial medial rectus myopexy, in part depending on the squint angle pattern with medial rectus recession, were performed. Immediately after removing the patch, the squint angle (APCT) was between - 10 degrees and + 5 degrees (median: + 1 degrees). Ten minutes to 2 hours later, the manifest squint angle ranged from 0 to + 12 degrees (median: + 7 degrees). The angle had decreased significantly to - 6 to + 12 degrees (median: + 5 degrees) after 3 months. For Group 2, the patients' ages were between 5 and 12 years (median: 6.5 years). The squint angles ranged from + 11.5 degrees to + 35 degrees (median: + 20 degrees) in the SPCT and APCT. The angle of ARC was between + 5 degrees and + 17 degrees (median: + 8 degrees). Combined recess and resect surgery or bilateral recession of the medial rectus (with or without oblique muscle surgery both) were performed. The SPCT several hours after removal of the patch showed angles of - 4 degrees to + 14 degrees (median: + 4.25 degrees). Three months later the manifest squint angles ranged from - 5 degrees to + 14 degrees (median: + 3 degrees).

DISCUSSION

After prism overcorrection (Group 1), there was a significant reduction of the residual esotropia. Without this additional treatment (Group 2), there was no significant change in the postoperative squint angle. However, neither the positive outcome in Group 1 nor the difference to Group 2 do unequivocally prove that there is a beneficial effect of prism overcorrection, since preoperative conditions were different and the sample size in Group 2 was small, especially after matching for equal preoperative conditions. A spontaneous reduction of the postoperative esotropia cannot be excluded. Further studies are necessary in order to investigate the specific effect of prism overcorrection.

Was bringt der Refraktionsausgleich bei Strabismus divergens intermittens und dekompensierender Exophorie?

BACKGROUND

The aim of this study was to investigate the effect of full correction of the retinoscopic measurements done in cycloplegia in two groups of patients with intermittent exotropia (IE) and decompensating exophoria (DE), respectively.

PATIENTS AND METHODS

58 patients (n = 29 each of IE and DE) fulfilled the inclusion criteria: retinoscopy in cycloplegia, follow-up of at least 6 weeks, age more than 2.5 years and reliable visual acuity. Exclusion criteria were all forms of secondary and constant exotropia, A-V incomitance of high amount and eyes with amblyopia (visual acuity in far distance < 0.5). The age median of refractometry was not higher in patients with IE compared to those with DE: 7.4 (3.10; 47.8) vs. 7.3 (3.8; 40.11) years, p = 0.33. Glasses were prescribed in any case of myopia and astigmatism as well as in hyperopia of > + 0.5 dpt.

RESULTS

Mean refraction of both eyes (mean value of spherical equivalent of both eyes) was higher for IE compared to DE: 0.7 +/- 1.8 (- 5.13; + 4.75) vs. 0.1 +/- 1.7 (- 5.25; + 2.5) dpt, p = 0.9. Visual acuity improved in both groups significantly: median of visual acuity in IE: 0.9 (0.3; 1.25) vs. 1.1 (0.5; 1.25), p = 0.02; in DE: 1.0 (0.4: 1.25) vs. 1.0 (0.6; 1.25), p = 0.03. Considering only patients aged over 7 years the difference stayed significant only in the group of DE: IE: median 1.0 (0.5; 1.25) to 1.0 (0.5; 1.25), p = 0.2; DE: median 1.0 (0.8; 1.25 to 1.0 (0.8; 1.25): visual acuity was nearly always 1.0 and better, p = 0.009. In hyperopic patients a significant improvement of visual acuity could be seen: in IE from median 0.9 (0.3; 1.25) to 1.1 (0.5; 1.25), p = 0.02 , in DE visual acuity: median 1.0 (0.4; 1.25) to 1.1 (0.6: 1.25), p = 0.02, as well as stereoacuity improved significantly: median 60 (30; 240)'' vs. 60 (15; 240)'', p = 0.03. In patients aged over 7 years the improvement was no longer significant in IE: p = 0.7, but stayed significant in DE: p = 0.03. There was no significant change of the angle deviation in both groups.

CONCLUSIONS

According to the results of this study, full correction of refractive errors in IE and DE leads to an improvement of the visual acuity mainly due to correction of myopia and astigmatism, but not to a better compensation of the angle deviation.

Erworbenes Innenschielen im Alter

BACKGROUND

Patients, most of whom are in their 8th decade of life, can suffer from a minimal acquired esotropia. They complain of blurred vision instead of diplopia due to their confusion. This is accompanied with the risk that the investigation covers only monocular disturbances.

PATIENTS AND METHODS

Of 39 such patients, 22 underwent surgery while 10 were fitted with prisms. Another 3 recovered spontaneously and became, therefore, classified as VIth nerve palsies although no limitation of the abduction could be stated. Four patients refused any therapy, and 2 of them recovered in the course of many years.

RESULTS

After 2 to 7 years, the individuals corrected with prisms were still compensated while within the operated cohort 3 had a recurrence after years.

CONCLUSIONS

In almost all cases the prescription of separate glasses for distance with about 3 Delta base out on either side compensates the deviation for several years. In surgical units one finds a summation of chronically decompensated patients with obvious diplopia who need a bimedial recession. Lateral rectus resections are not appropriate as they lead to actual overabduction and final recurrence as well.

Weaning children with accommodative esotropia out of spectacles: a pilot study

BACKGROUND/AIM

Many children with accommodative esotropia must continue spectacle use throughout life. This study was undertaken to determine which factors are predictive of successfully weaning children with accommodative esotropia out of spectacles.

METHODS

A retrospective review of 10 children with accommodative esotropia, who were gradually weaned from their hyperopic correction, and three age matched controls was performed. The main outcome measure was resolution or non-resolution of esotropia following weaning and eventual discontinuation of spectacles. Secondary outcome measures were final refractive error and the final esotropic or esophoric angle without correction.

RESULTS

Six patients were successfully weaned from spectacles. At the completion of the weaning period one child was orthophoric and the other five children had well controlled esophorias. The other four patients remained spectacle dependent because of persistent esotropia or decreased vision without spectacles. The baseline and final refractive errors were significantly lower in the children successfully weaned from spectacles (p = 0.014). While the children who were successfully weaned from spectacles were older when initially diagnosed with accommodative esotropia (4.6 v 2.5 years), this difference was not statistically significant (p = 0.09).

CONCLUSION

Some children with accommodative esotropia may be weaned out of spectacles during the grade school years with resolution of their esotropia. It is likely that gradual reduction of the hyperopic correction increases divergence amplitudes, but it is unclear whether this facilitates emmetropisation.

Promoting generalized social interactions using puppets and script training in an integrated preschool. A single-case study using multiple baseline design

Puppet script training was used to teach the social skills of greeting, responding to conversations, and initiating conversations to a preschool child with visual impairments. Susie and four peers without disabilities were taught social skills utilizing puppets enacting sociodramatic scripts within group training sessions. Training sessions were immediately followed by free-play activities among peers without disabilities to assess skill generalization. A single-case study using a multiple-baseline design demonstrated that the intervention increased performance of social skills during recess with peers. Results demonstrated that Susie learned the target behaviors and generalized their use to free-play activities with her peers.

The efficacy of vision therapy for convergence excess

BACKGROUND

Convergence excess is a commonly encountered non-strabismic ocular motility disorder. There are, however, very few research data that evaluate the effect of vision therapy for this condition in a clinical population.

METHODS

The records of 83 consecutive patients with convergence excess who were treated with vision therapy were reviewed to assess the impact of treatment on clinical findings and patient symptoms.

RESULTS

Statistically and clinically significant changes in direct and indirect measures of negative fusional vergence were seen, with 84% of patients reporting a total elimination of initial symptoms. Larger increases in negative fusional vergence were found than those previously reported. This may be a result of the more extensive and better controlled in-office treatment used in this study.

CONCLUSIONS

Vision therapy was successful in enhancing negative fusional vergence and eliminating symptoms in the vast majority of patients with convergence excess and should be considered an effective treatment for this condition.

[Non-surgical treatment of convergent strabismus with a localization method]

The results of non-operative treatment of 100 cases of convergent strabismus, 75 with macular and 25 with eccentric fixation are presented. Two kinds of prismatic correction were applied: hyper-correction with alternative obturation and correction, exactly compensating the squint angle. The aim of the former one was to decrease the squint angle and help the eyes to be in prismatic orthotropy. The latter prisms enabled permanent symmetrical stimulation of the retina which lead to the development of normal binocular vision. The duration of the treatment was 3-10 years. In all patients, parallel position of the eyes, normal binocular vision and improvement of visual acuity were achieved.