The impact of simultaneous correction of the V pattern on the results of surgical treatment in children with intermittent exotropia

PURPOSE

This study is to investigate the impact of the coexistence of basic intermittent exotropia and vertical incomitance in the form of the V and sub-V pattern on the results of surgical correction of intermittent exotropia.

METHODS

The records of 81 pediatric patients who had surgery for intermittent exotropia and a follow-up of more than 1 year were reviewed retrospectively. They were divided into groups: a concomitant group which underwent only horizontal muscle surgery of bilateral lateral rectus recession and a V pattern group which had additional inferior oblique recession, further separated into two subgroups: ≥ 15 prism diopters (classic V pattern group) and ≥ 10 < 15 prism diopters (sub-V pattern group). The surgical outcome, deviation control, stereoacuity, and postoperative drift were assessed after 3 months and 1 year postoperatively.

RESULTS

Patients with sub-V and classic V pattern intermittent exotropia showed significantly better surgical success rate (p = 0.025) and less postoperative drift (p = 0.042) than patients without vertical incomitance. One year after surgery, successful surgical outcome was achieved in 83.72% of the vertically incomitant group: 80.76% for the classic V pattern and 88.24% for the sub-V pattern group, while only in 60.53% of nonpattern patients.

CONCLUSIONS

Patients operated for intermittent exotropia with a coexistent V pattern have consistently better surgical long-term results than those with only horizontal deviation. Additional inferior oblique recessions in the sub V pattern group provided excellent outcomes with no overcorrections; therefore, surgeons should consider addressing vertical incomitance even when the typical criteria for the V pattern are not met.

Management of simultaneous ocular elevation and depression deficit in patients after reconstruction surgery for orbital floor fracture

Purpose

To present and examine the results of surgical correction of simultaneous ocular elevation and depression deficit in patients who underwent reconstruction surgery for orbital floor fracture.

Methods

A retrospective analysis of medical records of patients who had undergone surgical correction for diplopia associated with orbital fracture which persisted after orbital reconstruction surgery. All patients underwent orthoptic evaluation before surgery and postoperatively with various times of follow-up.

Results

Eight cases of blow-out fracture of the orbital floor were identified. Surgical plan varied from case to case. It included thorough revision of inferior rectus/oblique complex with or without recession of the former or flap tear repair and additional procedures. Postoperatively 4 patients (50%) were diplopia free, 3 (37.5%) presented diplopia in extreme upgaze and 1 (12.5%) in mid-upgaze and adduction. None of the patients reported diplopia in the primary position neither downgaze.

Conclusion

Diplopia persisting after reconstructive surgery of a fractured orbital floor may be corrected surgically. Our results suggest that at least two surgical procedures are necessary to achieve satisfying outcomes. Contralateral inferior rectus recession combined with superior oblique recession and superior rectus posterior fixation appears to be effective procedures for use.

Objective cyclodeviation measurement in normal subjects by means of Cyclocheck® application

PURPOSE

To evaluate the range of cyclodeviation in normal individuals by means of Cyclocheck^® application recently designed by the authors and freely available at www.cyclocheck.com.

METHODS

Healthy subjects with normal muscle balance, best-corrected visual acuity of ⩾0.8, and stereopsis on Randot charts of ⩽100 s of arc were included in the study. Two separate digital fundus photographs were taken of each eye of every patient. The disk-foveal angle was calculated using the Cyclocheck^® application. The average result of the disk-foveal angle measurements were considered for data analysis.

RESULTS

A total of 131 patients met inclusion criteria for the study population. The mean value of the disk-foveal angle in the whole study group (both right and left eye) was 6.39° ± 2.72° with 5.26° ± 2.56° (range from -0.4° to 12.55°) in the right eye and 7.52° ± 2.39° (range from 1.25° to 12.76°) in the left eye. The mean value of the disk-foveal angle of the left eye was greater by 2.26° than that of the right eye.

CONCLUSION

Cyclocheck^® software allows easy assessment of cyclodeviation. Normal individuals present with a positive value of the disk-foveal angle with a certain spread of the results. The analysis of obtained measurements revealed a significant asymmetry between both eyes with the left eye being more excyclodeviated in an otherwise orthotropic population, which remains a subject for further investigations.

Awareness among medical students regarding the binocularity level in the course of future specialty choice

BACKGROUND

Vision standards exist in many occupations with particular reference to medical science. The presence of a sufficient level of binocular vision is especially important in surgical specialty to perform visually demanding procedures. The purpose of this study was to reveal the level of awareness of one's binocular status among medical students, and the significance of having binocular vision in terms of specialty choice.

MATERIAL AND METHODS

self-constructed questionnaire was given to all subjects enrolled in the study. The first group comprised 53 students from the second and third year of the Medical University of Lodz, who then underwent an ophthalmological examination with binocularity assessment. The second group included 57 students of the last years of the Medical Faculty, who did the same survey and outlined how the ophthalmology course improved their knowledge of stereoacuity and vision requirements for the chosen specialty. Statistical analysis was performed using Person's χ² test.

RESULTS

Overall, 32% (N = 17) of the students from the first group and 84% (N = 48) from the second group stated to be familiar with the term "binocularity" and its importance in performing surgical procedures. The awareness of the existing occupational contraindications related to low visual acuity and binocularity was declared by 16% (N = 9) and 54% (N = 31) of the subjects included in each group, respectively. University lectures were indicated as the main source of knowledge by 28% (N = 15) of the individuals from the first group and by 59% (N = 39) from the second group. The ophthalmology course was considered to be sufficiently covering the basics needed for the future doctor by 34 resident physicians (60%).

CONCLUSIONS

The medical students' awareness of their own binocular status appears low. There is a strong need for implementing at least some quality standards for visual assessment to decide if a given student has an adequate eye function to participate in surgical procedures. Med Pr. 2020;71(1):9-16.

The influence of concomitant medial wall fracture on the results of orbital floor reconstruction

INTRODUCTION

Up to 35% of orbital floor fractures extend to the medial wall. This results in restriction of both abduction and adduction, leading to horizontal diplopia. The greater the defect, the more pronounced the enophthalmos.

AIM OF THE STUDY

The aim of the study was to determine the influence of concomitant medial wall defects on enophthalmos and diplopia, and the influence of intraoperative revision on the results of surgical reconstruction in patients with orbital floor fracture.

MATERIAL AND METHODS

78 cases of orbital floor fracture, with or without concomitant medial wall defect, were retrospectively analyzed. Reconstruction surgeries were performed in a similar fashion, but with variation in the alloplastic materials used. Careful investigation of the area was performed during the surgery.

RESULTS

Patients with associated medial wall defects had significantly more pronounced enophthalmos than those with isolated floor fracture, with no such difference after the orbital reconstruction. Postoperative vertical diplopia was more common in patients with an associated medial defect.

CONCLUSIONS

Associated medial wall defect leads to more severe enophthalmos at presentation. However, if the medial aspect of the orbital wall is revised properly, postoperative outcomes are not inferior to those in cases of isolated floor fracture.

Cyclocheck: a new web-based software for the assessment of objective cyclodeviation

PURPOSE

To present a novel, free, web-based software tool (www.cyclocheck.com) for the assessment of objective cyclodeviation, based on measuring the disk-foveal angle (DFA) and to evaluate reproducibility of the results.

METHODS

Digital fundus photographs of both eyes of all study subjects were obtained using DRS CenterVue nonmydriatic fundus camera. Four separate measurements were made for each eye, and the DFA was calculated using Cyclocheck software independently by two observers to determine reproducibility and repeatability of the technique. The results were statistically analyzed using the interclass correlation coefficient (ICC) and the Bland-Altman method.

RESULTS

A total of 32 subjects (mean age, 34.4; range, 12-83) were enrolled: 18 were orthophoric; 14, strabismic. The ICC for the intraobserver repeatability for one observer was 0.979 (95% CI, 0.970-0.985; P < 0.0005) and for the other was 0.988 (95% CI, 0.983-0.991; P < 0.0005). The ICC for the interobserver agreement was 0.994 (95% CI, 0.992-0.996; P < 0.0005), indicating high reproducibility of the measurements.

CONCLUSIONS

Cyclocheck can assess ocular torsion quickly and easily. It provides reliable and reproducible measurements of the DFA and thus objective cyclodeviation in both orthophoric and strabismic subjects.

Phacoemulsification with pupilloplasty in a patient with congenital cataract and iris colohoma - case report

Coloboma is a term used to denote a partial or complete absence of specific ocular tissues. It is a congenital malformation, which results from the improper closure of the optic cup during fetal development. We present a case of a 16-year-old female, who was referred to the Department of Ophthalmology due to iris coloboma and congenital cataract in the left eye. We describe surgical management including phacoemulsification combined with coloboma repair with sutures tied using the slip-knot technique, The presented surgical technique is safe and effective.

[Visual outcomes, binocular vision and subjective accommodation after Crystalens HD accommodating intraocular lens implantation]

OBJECTIVE

To evaluate visual acuity, binocular vision and subjective accommodation in patients after Crystalens HD accommodating intraocular lenses (IOLs) or monofocal IOLs implantation.

MATERIAL AND METHODS

75 consecutive patients (aged 48 to 75 years) after bilateral cataract surgery with acrylic monofocal IOL (n = 36) or single-optic accommodating IOL (Crystalens HD) (n = 19) implantation and healthy presbyopic population (n = 20) were enrolled. Presence of asthenopic symptoms, diplopia and spectacle dependence was assessed. Orthoptic status, prism bar and amblyoscopic motor fusion, Frisby Near Stereotest, TNO and Titmus tests were performed. Convergence and subjective accommodation were evaluated using Krimsky-Prince rule.

RESULTS

Asthenopic symptoms were present respectively in 36.1%, 15.8% and 35.0% of patients and spectacle dependency was reported by 86.1%, 21.1% and 85.0% of patients in subsequent groups. Negative fusional distance vergence means were 9.53 ± 5.53, 8.05 ± 3.66, 6.65 ± 5.33 respectively (p = .039). Negative fusional near vergence means were 26.53 ± 11.39, 28.68 ± 11.70, 20.75 ± 12.60 in subsequent groups (p = .001). Mean subjective right eye/ left eye accommodation was 5.01 ± 1.47/ 4.86 ± 1.72, 6.29 ± 2.33/ 6.02 ± 1.90, 4.13 ± 0.89/ 4.22 ± 1.3 respectively (p = .009). There were no statistically significant differences between groups in positive fusional vergence, stereoacuity and near point of convergence.

CONCLUSIONS

Bilateral accommodating IOL implantation provided full binocular vision in the majority of patients. Spectacle dependence and asthenopic symptoms were less frequent in patients with accommodating IOLs. Accommodating IOLs provided significantly better useful accommodation than monofocal IOLs.

Surgical management of upgaze diplopia in patients after posttraumatic orbital floor reconstruction

OBJECTIVE

The most common complication of otherwise successful reconstructive surgery of a fractured orbital floor is persistent diplopia. For patients with troublesome double vision in upgaze, a reasonable solution is offered by strabismus surgery. The aim of our study is to examine the results of extraocular muscle surgery in cases of diplopia that persisted in upgaze after posttraumatic orbital floor reconstruction.

MATERIAL AND METHODS

In this study we present a retrospective series of 24 patients with troublesome vertical diplopia in upgaze. In all cases, the surgery consisted of a posterior fixation suture placement on the contralateral superior rectus muscle with or without its recession. Full orthoptic examination was conducted before and 3 months after the surgery.

RESULTS

Postoperatively 19 patients (79%) were diplopia free and 6 (21%) had vertical diplopia in extreme upgaze. The field of binocular single vision improved threefold. None of the patients reported diplopia in the primary position or in any position other than upgaze.

CONCLUSION

Vertical incomitant strabismus and diplopia in upgaze persisting after orbital reconstructive surgery may be corrected surgically. Contralateral posterior fixation of the superior rectus muscle, with or without its recession, appears to be an effective procedure for use in these patients.

[Large hang-back recession of superior rectus muscles as effective treatment of patients with dissociated vertical deviation]

PURPOSE

The aim of this study is to report the results of large bilateral superior rectus hang-back recession in patients with dissociated vertical deviation.

MATERIAL AND METHODS

Retrospective analysis of patients with dissociated vertical deviation treated in the Department of Ophthalmology between 2011 and 2013. Our enrolment criteria included vertical strabismus angle over 15Δ and the absence of inferior or superior oblique overaction in patients who underwent bilateral superior rectus recession ranging from 8 mm to 12 mm. The surgical outcomes were evaluated.

RESULTS

Nine patients at the age of 14 to 46 years were included in the study. The mean vertical angle of deviation in the non-dominant eye was 22.8Δ ± 5.3Δ. The mean amount of recession was 9.8 ± 1.4 mm.

CONCLUSIONS

Large bilateral hang-back recession of the superior rectus muscles effectively reduces the vertical angle in patients with dissociated vertical deviation without concomitant oblique muscle overaction. dissociated vertical deviation (OVO), strabismus surgery, large recession of superior rectus muscles.

[The role of orthoptic assessment in outcome prognosis in patients undergoing reconstruction surgery for orbital blow-out fracture]

AIM

The aim of this study is to analyze the results of orthoptic examination in patients with orbital blow-out fractures, who underwent reconstruction surgery and to determine which preoperative factors influence the outcome prognosis.

MATERIAL AND METHODS

113 patients after orbital injury were examined. 78 subjects after reconstruction surgery for orbital floor or floor and medial wall fracture, with or without orbital rim involvement, were included in further analysis. All subjects underwent the orthoptic assessment at baseline and at 3 months after the surgery.

RESULTS

Ordinal regression model was utilized in order to determine which orthoptic parameters significantly affect the surgical outcome of a reconstructive procedure. We have found that the following factors were associated with less favourable treatment outcomes: the large field of binocular single vision, the large angle of deviation in upgaze and downgaze, the positive forced duction test and the concomitant inferior rectus paresis.

CONCLUSIONS

The thorough orthoptic assessment and identifying the potential oculomotor dysfunction prior to reconstructive surgery enables proper outcome prognosis in patients with orbital blow-out fractures.

Signal intensity and T2 time of extraocular muscles in assessment of their physiological status in MR imaging in healthy subjects

Background:

Lack of standardised orbital MR protocols leads to a situation, when each institution/centre may arbitrarily choose sequence parameters. Therefore, the results obtained and published by the authors may not be compared freely, and what is most important may not be considered fully reliable. Signal intensity (IS) and T2 time (T2) are important parameters in estimation of inflammatory processes of extraocular muscles in the clinical practice.

The aim of this study was to determine the reference values (i.e. cut-off values) for absolute signal intensity and T2 relaxation time in healthy subjects, their relativised values to white matter (WM) and temporal muscles (TM) and to evaluate the correlation between those parameters.

Material/Methods:

The orbital examination was performed in healthy volunteers according to the protocol prepared in the Radiology-Imaging Diagnostic Department of the Medical University of Lodz for patients with suspected/diagnosed thyroid orbitopathy. Using two of the standard sequences IS and T2 time were calculated for the muscles and two relativisation tissues in realtion to WM and TM. Subsequently cut-off values for healthy volunteers were calculated.

Results:

The differences between muscles for IS, IS MAX, IS/TM, IS/WM, IS MAX/TM, IS MAX/WM and T2 MAX/WM were not statistically significant. Therefore one cut-off value of these parameters for all the rectus muscles was calculated. T2-relaxation time and T2 relativised to white matter had to be calculated separately for each muscle.

Conclusions:

No statistical correlation was found between IS and T2-time for extraocular muscles in healthy volunteers. We calculated the reference ranges (cut-off values) for absolute IS and T2-time values and relativised parameters. In the clinical practice the objectification of IS and T2-time values should be done to WM, than to IS or T2 of the temporal muscle. The T2 MAX/WM seems to have the highest clinical utility for the assessment of the pathophysiological status of extraocular muscles.

[The influence of sensory deprivation on binocular vision after bilateral cataract extraction with intraocular lens implantation]

PURPOSE

Cataract extraction with intraocular lens implantation is one of the most frequent surgical procedures. However, benefits associated with the surgery may be restricted by binocular vision disorders. The purpose of the study is to evaluate binocular function of vision in patients after bilateral cataract extraction in relation to the length of period between surgeries.

MATERIAL AND METHODS

The study included 50 patients operated twice, due to bilateral cataract. All patients were examined six weeks after the second surgery and divided into three groups according to the operational interval (< 12 months, 12-24 months, > 24 months). Presence of asthenopic symptoms, distance and near squint angle, fusional amplitudes, stereopsis and convergence were evaluated.

RESULTS

Asthenopic symptoms were present respectively in 8% (n = 1), 42% (n = 8), 37% (n = 7) of patients in groups 1, 2 and 3. Exophoria was found in 16.6% (n = 2) of cases in the first group, 17.5% (n = 3) in the second group and 31.6% (n = 6) in the third group. There was no significant difference in average prismatic fusional vergence range between groups and a negative correlation between amblyoscopic fusional convergence and the period between surgeries was found. Mean stereopsis was 76.7 +/- 62.1; 89.5 +/- 66,2; 76.8 +/- 66.7 seconds of arc in subsequent groups. Average convergence was: 6.8 < or = 6.9 cm in the first group, 7.1 +/- 3.9 cm in the second group and 7.5 +/- 5.0 cm in the third group.

CONCLUSIONS

There are significant differences in binocular vision parameters in patients after bilateral cataract extraction in relation to the period between surgeries. The prolongation of this time was connected with increased number of patients complaining to asthenopic symptoms, with exophoria and reduced amblyoscopic fusional convergence.

[Diplopia as a factor influencing occupational and social activities of people after orbital trauma]

BACKGROUND

Eye injuries are one of the most common sequelae of facial trauma. On the other hand extraocular muscle involvement entails the ocular motility disorders and double vision. The aim of this study was to assess the impact of orbital trauma on the social and professional activities of patients.

MATERIALS AND METHODS

The material consisted of 44 patients after orbital trauma. The objective assessment of the ocular apparatus, especially eye alignment and subjective complaints was performed. All patients were interviewed with a questionnaire in order to assess the impact of visual disorders on daily, and socio-professional activities.

RESULTS

The patients were mostly manual workers, living in urban areas, in whom assaults were the main cause of injury. Most of them showed good visual acuity, but 59% exhibited double vision. The ability to perform the former occupation was retained in 45.5% and 20.5% of workers could not perform the former job. Total or partial inability to work was certified in 23% of subjects. Orbital trauma also affected the functional vision of patients and decreased their quality of life; 30% of patients felt significant limitations in social function and 12% remained dependent on others for their daily activities.

CONCLUSIONS

Orbital trauma and resulting double vision is an important factor influencing the professional activity. Double vision limits the ability to return to work, despite the lack of damage to the eyeballs and preserved good visual acuity. Orbital trauma causing diplopia does not significantly affect the social activities of the patients or their ability to drive.

The use of modern imaging techniques in the diagnosis and treatment planning of patients with orbital floor fractures

BACKGROUND

Ocular motility impairment associated with orbital trauma may have several causes and manifest with various clinical symptoms. In some cases orbital reconstructive surgery can be very challenging and the results are often unsatisfactory. The use of modern imaging techniques aids proper diagnosis and surgical planning.

CASE REPORT

The authors present the case of a 29-year-old male who sustained trauma to the left orbit. Orthoptic examination revealed limited supra- and infraduction of the left eye. The patient reported diplopia in upgaze and downgaze with primary position spared. Dynamic magnetic resonance imaging (dMRI) was performed, which revealed restriction of the left inferior rectus muscle in its central section. A patient-specific anatomical model was prepared on the basis of 3-dimensional computed tomography (CT) study of the intact orbit, which was used to prepare a custom pre-bent titanium mesh implant. The patient underwent reconstructive surgery of the orbital floor.

CONCLUSIONS

Modern imaging techniques such as dMRI and 3-dimensional CT reconstruction allow us to better understand the pathophysiology of orbital floor fractures and to precisely plan surgical treatment.

Results of coaxial phacoemulsification through a 1.8-mm microincision in hard cataracts

BACKGROUND AND OBJECTIVE

To assess the results of coaxial phacoemulsification through 1.8-mm coaxial microincision cataract surgery (C-MICS) phacoemulsification with foldable intraocular lens implantation in eyes with hard cataracts in comparison to eyes with soft cataracts.

PATIENTS AND METHODS

Group 1 consisted of 40 eyes of 40 patients with hard cataracts (grade ≥ 4, Lens Opacities Classification System III scale) and group 2 consisted of 45 eyes of 45 patients with non-mature cataracts (grade ≤ 2, Lens Opacities Classification System III scale). All surgeries were performed by two experienced surgeons under topical and intracameral anesthesia. Examinations were performed preoperatively and 1 month after the surgery. Examined parameters included distance-corrected visual acuity (DCVA), autorefractometry, keratometry, tonometry, endothelial cell counts, and biomicroscopy of the anterior and posterior segment. Surgically induced astigmatism was calculated with vector analysis.

RESULTS

Mean DCVA was 0.16 ± 0.16 preoperatively and 0.92 ± 0.21 postoperatively in group 1 (P < .05) and 0.62 ± 0.18 preoperatively and 0.97 ± 0.08 postoperatively in group 2 (P < .05). Mean surgically induced astigmatism was 0.48 ± 0.44 in group 1 and 0.53 ± 0.38 in group 2 (P > .05). Mean endothelial cell loss was 11.37% ± 12.87% in group 1 and 2.87% ± 9.66% in group 2 (P < .05).

CONCLUSION

Although density of cataract has an unfavorable influence on early postoperative corneal endothelial cell loss, it did not significantly influence final DCVA and surgically induced astigmatism. C-MICS is a safe and effective method of treatment of cataracts, including cataracts with hard nuclei, and usually leads to good functional outcomes.

The use of dynamic magnetic resonance in the diagnosis of ocular motility disorders

Dynamic Magnetic Resonance (dMRI) of the extraocular muscles is based on performing a number of short sequences, while the patient fixates consecutive points placed in different positions of gaze.

PURPOSE

To check the relation between dMRI findings and the results of clinical examination in patients with various types of strabismus.

MATERIALS AND METHODS

We have selected three patients with lateral rectus palsy, superior rectus palsy and inferior rectus restriction from the group, in which we have performed dMRI. We have taken measures of the affected muscles shape, sectional area and volume. The results were related with the clinical examination.

RESULTS

The measurements obtained with use of dMRI reflect the actual state of the affected muscle as seen on the Hess screen. The limitation of the muscles action is represented by a lack of increase in the sectional area and volume in respective gaze intervals. The restriction of the muscle affects its shape by pulling it towards the place of entrapment.

CONCLUSIONS

Data acquired by means of dMRI correspond to the clinical findings and allow a quantitative analysis of the degree of muscle weakness. Defining the extent of the morphological changes in extraocular muscles, related with long-lasting paralysis, let us make an informed decision regarding further treatment.

Evaluation of surgically induced astigmatism after coaxial phacoemulsification through 1.8 mm microincision and standard phacoemulsification through 2.75 mm incision

Improvements in technology connected with cataract surgery have made it possible to decrease significantly the size of corneal incision created during phacoemulsification. Recently, coaxial phacoemulsification through a 1.8 mm microincision (C-MICS) has been introduced. This technique is perceived as the next step in development of phacoemulsification.

PURPOSE

To compare surgically induced astigmatism (SIA) after coaxial 1.8 mm microincision cataract surgery (C-MICS) and standard phacoemulsification through 2.75 mm incision, calculated with three mathematical methods.

MATERIAL AND METHODS

A consecutive, prospective series of 55 eyes of 55 patients who underwent uneventful C-MICS with foldable IOL implantation using 1.8 mm temporal clear corneal incision were included in group 1. Reference group (group 2) included 55 eyes of 55 patients who underwent uneventful phacoemulsification through 2.75 mm temporal clear corneal incision with a foldable IOL implantation. SIA was calculated using three methods.

RESULTS

All patients had uneventful surgery and were examined before the surgery and one month postoperatively. There was a significant postoperative increase in corrected distance visual acuity in both groups (p < 0.01), and the visual outcomes in both groups were similar (p > 0.05). In vector analysis, mean SIA was 0.42 +/- 0.30 in group 1 and 0.77 +/- 0.55 in group 2. In vector decomposition, the mean SIA (C90) in group 1 was 0.24 +/- 0.29 and 0.49 +/- 0.54 in group 2 (p < 0.05). In Naeser's polar values method, deltaKP-0 was -0.06 +/- 0.43 in group 1 and -0.21 +/- 0.84 in group 2 (p > 0.05).

CONCLUSIONS

1.8 mm coaxial MICS induces a significantly smaller value of SIA than standard 2.75 mm phacoemulsification.

[Refractive laser eye surgery and binocular vision disorders--case report]

Laser refractive surgery is a lively developing branch of ophthalmology. There are a numbers of contraindications for this type of surgery, but many of them are difficult to define, for example binocular vision impairment. Accurate analysis of orthoptic examination before refractive surgery, has forced us to dissuade our patient from refractive surgery, despite the fact that there were no other contraindications.

CASE STUDY

A 33 years old woman referred for refractive surgery because of bilateral myopia (right eye: -5.25 Dsph -0.75 Dcyl ax. 170; left eye: -5.0 Dsph). There was no strabismus or other binocular vision disorders in her history. Orthoptic examination revealed exophoria, slight hyperphoria and considerable bilateral convergence insufficiency, which would have contributed to future strabismic complications.

[In what age should we operate on children with primary exotropia? Indications based on own therapeutic results]

PURPOSE

The aim of the study was to evaluate the results of surgical treatment of children with primary exotropia, operated on before 14 years of age.

MATERIAL AND METHODS

The study included 62 children with primary, constant and intermittent exotropia operated on before 14 years of age. The patients were divided into two age groups. The first one consisted of children 2 to 6 years old (mean 4.75 +/- 1.12)--12 girls and 8 boys, the second group consisted of children 7 to 14 years old (mean 9.3 +/- 2.1)--30 girls and 12 boys. Follow-up period was 3.5 years in group I and 4.5 years in group II. History, visual acuity and refraction were obtained in all cases. Horizontal and vertical angles for distance and near, before and after the surgery was measured as well. The postoperative horizontal angle drift was estimated in both groups and function of binocular vision assessed, before and after the surgery.

RESULTS

In both age groups we found no statistical difference between mean angle values before and few weeks after the surgery. However in long-term results, angle for distance was lower in younger children, especially in those with intermittent strabismus. The postoperative angle drift was lower in younger group with intermittent strabismus comparing to the older group, so they achieved a better final surgical outcome. The functional results in both age groups did not differ significantly.

CONCLUSIONS

Early surgery on divergent strabismus makes the prognosis better, especially in intermittent strabismus. Children that are operated on early, seem to have smaller postoperative angle drift.

[Difficulties in diagnosis and treatment of dissociated vertical deviation (DVD). Part II--own experiences]

Oblique muscles motility disorders may influence the magnitude of dissociated vertical deviation (DVD), resulting in greater vertical deviation in abduction and smaller in adduction. The diagnosis of this pattern of dissociation is essential for the selection of appropriate surgical management.

PURPOSE

The aim of this study was to assess optimal diagnostic and treatment procedures in patients with incomitant dissociated vertical deviation, superior oblique overaction and esotropia.

PATIENTS AND METHODS

Five patients with the constellation of esotropia, bilateral superior oblique overaction, A-pattern, and incomitant dissociated vertical deviation are presented. In each case the magnitude of vertical deviation was greater in abduction and minimal or absent in adduction. Four patients underwent asymmetric bilateral superior rectus recessions and partial tenotomy of the posterior and middle fibers of superior oblique tendons. In one case additional surgery of horizontal muscles was performed.

RESULTS

In all cases the A-pattern, DVD was markedly reduced or eliminated, and comitancy was achieved.

CONCLUSION

Recognition of the described pattern is important in selecting appropriate surgical management. Asymmetric bilateral superior rectus recessions and partial tenotomy of the posterior and middle fibers of superior oblique tendons is useful in reducing the A-pattern and incommitancy in DVD.

[Difficulties in diagnosis and treatment of dissociated vertical deviation (DVD). Part I]

Dissociated vertical deviation (DVD) is a poorly understood eye motility disorder of unexplained etiology. It occurs as a common hyperdeviation present in most cases of congenital esotropia, but also appears in patients with normal binocular vision and exotropia. DVD is a bilateral condition, often with distinct asymmetry. Its clinical characteristics includes elevation, extorsion and abduction of the nonfixating eye, with fixating eye incyclotorting concomitantly. Commonly it is associated with a compensatory head tilt. Main problem of DVD diagnostics of DVD is quantification of its magnitude due to large variability of various measurements during one eye examination, and usually one fails trying to obtain reproducible measurements in one patient. Therefore, establishing of a proper treatment plan is often unfeasible. Differential diagnosis is occasionally difficult in individuals with inferior and superior oblique overaction with or without co-existing DVD. Primary goal of DVD management is to improve patients' physical looks so that the upward turning of the eye is hardly noticeable. Both conservative as well as surgical treatment should be considered. Planning and performing the effective surgery is extremely difficult in DVD; and various surgical approaches to DVD are used worldwide.

Manipulations of the features of standard video lottery terminal (VLT) games: effects in pathological and non-pathological gamblers

The present study was conducted to identify game parameters that would reduce the risk of abuse of video lottery terminals (VLTs) by pathological gamblers, while exerting minimal effects on the behavior of non-pathological gamblers. Three manipulations of standard VLT game features were explored. Participants were exposed to: a counter which displayed a running total of money spent; a VLT spinning reels game where participants could no longer "stop" the reels by touching the screen; and sensory feature manipulations. In control conditions, participants were exposed to standard settings for either a spinning reels or a video poker game. Dependent variables were self-ratings of reactions to each set of parameters. A set of 2(3) x 2 x 2 (game manipulation [experimental condition(s) vs. control condition] x game [spinning reels vs. video poker] x gambler status [pathological vs. non-pathological]) repeated measures ANOVAs were conducted on all dependent variables. The findings suggest that the sensory manipulations (i.e., fast speed/sound or slow speed/no sound manipulations) produced the most robust reaction differences. Before advocating harm reduction policies such as lowering sensory features of VLT games to reduce potential harm to pathological gamblers, it is important to replicate findings in a more naturalistic setting, such as a real bar.

The relations of trait anxiety, anxiety sensitivity, and sensation seeking to adolescents' motivations for alcohol, cigarette, and marijuana use

The present study investigated relations of anxiety sensitivity and other theoretically relevant personality factors to Copper's [Psychological Assessment 6 (1994) 117.] four categories of substance use motivations as applied to teens' use of alcohol, cigarettes, and marijuana. A sample of 508 adolescents (238 females, 270 males; mean age = 15.1 years) completed the Trait subscale of the State-Trait Anxiety Inventory for Children, the Childhood Anxiety Sensitivity Index (CASI), and the Intensity and Novelty subscales of the Arnett Inventory of Sensation Seeking. Users of each substance also completed the Drinking Motives Questionnaire-Revised (DMQ-R) and/or author-compiled measures for assessing motives for cigarette smoking and marijuana use, respectively. Multiple regression analyses revealed that, in the case of each drug, the block of personality variables predicted "risky" substance use motives (i.e., coping, enhancement, and/or conformity motives) over-and-above demographics. High intensity seeking and low anxiety sensitivity predicted enhancement motives for alcohol use, high anxiety sensitivity predicted conformity motives for alcohol and marijuana use, and high trait anxiety predicted coping motives for alcohol and cigarette use. Moreover, anxiety sensitivity moderated the relation between trait anxiety and coping motives for alcohol and cigarette use: the trait anxiety-coping motives relation was stronger for high, than for low, anxiety sensitive individuals. Implications of the findings for improving substance abuse prevention efforts for youth will be discussed.