Abraham Spierer

Treatment of children with amblyopia by perceptual learning

Recent studies have shown that perceptual learning has the potential to treat amblyopia. In this study we tested whether a recent perceptual learning technique that improved visual functions in adults can be applied to improve the vision of children after the conventional treatment of patching has failed. A prospective clinical pilot study was carried out in children who were non-compliant with patching or in whom patching had failed despite good compliance. Each child underwent a complete eye examination before and after treatment. The treatment was based on a perceptual learning technique that was similar to the adult study [Polat, U., Ma-Naim, T., Belkin, M., & Sagi, D. (2004). Improving vision in adult amblyopia by perceptual learning. Proceedings of the National Academy of Sciences of the United States of America, 101(17), 6692-6697]. Between blocks, children played a computer game to engage and maintain their attention in order to increase compliance. Each child received two treatment sessions a week, with a total of not more than 40 sessions. Each session lasted for about 1h and included a total practice time of about 30min. The age of the children (n=5) was between 7 and 8years (mean 7.3years). For the whole group, the average improvement in visual acuity was 1.5 Snellen lines or 2.12 ETDRS lines. The training improved the contrast sensitivity, which reached the normal range after treatment. Thus, the perceptual learning technique can be successfully used to treat children with amblyopia even after the conventional treatment of patching fails.

Superior oblique muscle paresis aftersub-Tenon's anesthesia for cataract surgery

A 68-year-old man developed strabismus after having sub-Tenons anesthesia for cataract extraction and intraocular lens implantation. An ipsilateral hypertropia with superior oblique muscle paresis developed in the operated eye. The hypertropia appeared 1 day after surgery and resolved 1 month later. Although sub-Tenons anesthesia is considered safer than other methods of local anesthesia, strabismus may occur.

The Role of Increased Intraocular Pressure on Upgaze in the Assessment of Graves Ophthalmopathy

The significance of the increase in intraocular pressure (IOP) on upgaze in the diagnosis of Graves ophthalmopathy and its normal range are controversial. The authors measured the increase in IOP on upgaze in 69 hyperthyroid patients with Graves disease, diagnosed at 1 month to 15 years previously, to assess their clinical, laboratory, and ophthalmic state. Ninety-seven healthy subjects served as controls. The distribution of increase in IOP on upgaze values in 46 patients with noninfiltrative ophthalmopathy (classes 0 to 1) was the same as in the control group. The 23 patients with infiltrative ophthalmopathy (classes 2 to 4) had increased frequency of higher increases in IOP on upgaze values compared with the other two groups. However, because of considerable overlap, increase in IOP on upgaze was not discriminatory between the groups. Increase in IOP on upgaze correlated positively with the severity of exophthalmos. There was no correlation among age, sex, time since diagnosis, thyroid functional state, and drug therapy. The authors conclude that an increase in IOP on upgaze is a normal finding augmented by Graves infiltrative ophthalmopathy. It has no diagnostic advantage over the simple clinical signs of ophthalmopathy.

Strabismus surgery in children with Möbius syndrome

Möbius syndrome is a congenital disorder of facial diplegia associated with lateral gaze paralysis. Although palsy of the sixth and seventh cranial nerves is the minimum diagnostic finding for Möbius syndrome, neuropathologic evidence indicates that this is a more complex syndrome.(1) Clinically, it is characterized by a total absence of facial expression and severe esotropia. Other anomalies may be associated with this syndrome, especially other cranial nerve palsies and Poland syndrome. The etiology of this syndrome has not been clearly established. Brain stem necrosis resulting from a vascular deficiency has been offered as a possible pathogenetic explanation.(2) The strabismus in Möbius syndrome is congenital esotropia with bilateral limitation in abduction. Even though many reports have described the various features of Möbius syndrome, only a few articles have reported the results of strabismus surgery in children, including bimedial rectus muscle recession. (3-5) Some authors report that bilateral medial rectus muscle recession alone has been disappointing; therefore, a combination of a medial rectus muscle recession and a lateral rectus muscle resection was recommended for satisfactory results. (5-7) In more severe cases, muscle transposition was needed to ensure straight position of the eyes in primary gaze. (8-9)

An increase in superoxide dismutase ameliorates oxygen-induced retinopathy in transgenic mice

AbstractPurposeOxygen therapy is a well-recognized risk factor for retinopathy of prematurity. We examined whether an increase in the naturally occurring enzyme copper–zinc superoxide dismutase (CuZnSOD), which controls oxygen, can reduce the severity of oxygen-induced retinopathy in a mouse model.MethodsSeven transgenic mice overexpressing CuZnSOD and six wild-type mice were exposed to 75% oxygen from postnatal day 7 to 12. Seven transgenic mice and five mice of the wild type were kept in room air and served as controls.Fluorescein-conjugated dextran angiography of retinal vasculature was performed and flat-mounted preparations were evaluated by scoring blood vessel growth, blood vessel tuft formation, extraretinal neovascularization, degree of central constriction, and tortuosity of vessels. In addition, quantification of the number of blood vessel tufts was performed in a masked fashion with haematoxylin and eosin staining of paraffin-embedded eye sections.ResultsThe mean retinal score±SD obtained by the wild-type mice was 9.4±2.0, whereas the transgenic mice overexpressing CuZnSOD obtained a value of 2.4±1.6 (P=0). The two control groups (wild type and transgenic) that were kept in room air, each obtained a score of 0. Significantly fewer extraretinal vascular tufts were seen in the transgenic mice (0.26±0.34) than in the wild-type mice (4.27±1.6) after both groups were exposed to oxygen (P<0.001).ConclusionsThe results suggest that high SOD activity protects neonatal mice against oxygen-induced retinopathy, and support the assumption that oxygen radicals are a major causative factor in oxygen-induced retinopathy.

Refractive Status in Children After LongTerm Follow up of Cataract Surgery With Intraocular Lens Implantation

PURPOSE To evaluate the resultant refractive status in children 5 to 11 years after cataract surgery with a high power intraocular lens (IOL) implantation. METHODS Charts of eight patients (10 eyes) who underwent cataract surgery with IOL implantation by the same technique were reviewed. Age at surgery was 2 months to 3 years. High-power IOL of 27.0 to 30.0 diopters (D) was implanted in seven eyes and lower IOL (between 19.0 D to 23.0 D) in three eyes. Follow-up period was between 5 and 11 years. RESULTS In children who received a high-power IOL, the resultant refraction after 5 to 7 years was found to be between -5.50 and -12.00 D. In the group that had a lower power IOL implanted, the refraction was between -2.50 and +9.00 after 6 to 11 years. The results were plotted on a graph of refraction vs. IOL power and showed that the IOL power that may result in emmetropia in an older child is 23.2D. CONCLUSIONS The implantation of a high-power IOL (27 D to 30 D) in eight young children resulted in refractive status within 3 D of emmetropia during the first year or two of life and in high myopia at age 5 to 12 years.

Unilateral and Bilateral Lateral Rectus Recession in Exotropia

BACKGROUND AND OBJECTIVE To evaluate the surgical results obtained by unilateral and bilateral lateral rectus recession for the correction of exotropia. PATIENTS AND METHODS The charts of all patients with exotropia who were operated on at the Goldschleger Eye Institute at Sheba Medical Center during an 11-year period were retrospectively reviewed. Study participants all underwent a complete orthoptic and ocular examination. Twenty-five patients with moderate-angle exotropia underwent unilateral lateral rectus recession (group 1) and 38 patients with large-angle exotropia underwent bilateral lateral rectus recession (group 2). The angle of exotropia was measured by the prism and cover test. Moderate exotropia was defined as 25 prism diopters (PD) and large-angle exotropia as greater than 25 PD. RESULTS The mean age at the time of the surgery was 10.0+/-5.2 years in group 1 and 8.5+/-8.0 years in group 2. The mean preoperative exotropia was 16.1+/-5.7 PD in group 1 and 29.6+/-14.4 PD in group 2. A mean postoperative exodeviation of 4.2+/-5.4 PD was found in group 1 and 5.8+/-13.6 PD in group 2. The success rate (deviation of < 10 PD) was 84% in group 1 and 74% in group 2. There was no incomitance in group 1. CONCLUSION Unilateral lateral rectus recession is an effective surgical method for correcting moderate-angle exotropia with results similar to bilateral lateral rectus recession for larger exotropia angles.

Congenital ptosis repair-surgical, cosmetic, and functional outcome: a report of 162 cases.

OBJECTIVE To evaluate the surgical and functional outcome of congenital ptosis repair and the anisometropic changes after surgical repair of ptosis to determine the potential contribution of anisometropia to the development of refractive amblyopia. METHODS The clinical records of 162 children with congenital ptosis that had been surgically repaired between 1995 and 2006 at the Goldschleger Eye Institute were reviewed and analyzed for functional and cosmetic outcome, visual acuity status, and presence of amblyopia. RESULTS A total of 162 patients (mean age, 10 months) underwent surgical ptosis repair, of whom 120 (74%) had unilateral and 42 (26%) had bilateral ptosis. The surgeries were levator resection (47.5%), frontalis suspension (46.3%), and Fasanella-Servat (7.4%). Good functional and cosmetic outcomes were achieved in 130 (80.2%) patients, with unilateral cases showing more postoperative asymmetry. The reoperation rate was 10.4% (8/77) for levator resection, 29.3% (22/75) for frontalis suspension, and 20% (2/10) for Fasanella-Servat. There were no significant differences in visual acuity, spherical equivalent, or mean cylinder at 90° between the ptotic eyes before and after surgery (P = 0.33, P = 0.83, and P = 0.65, respectively), and compared with the sound eyes (P = 0.66, P = 0.78, and P = 0.08, respectively). The mean astigmatism correction by vector analysis after ptosis surgery was 1.1±0.68 D. CONCLUSIONS Congenital ptosis repair yields good functional and cosmetic outcome, although the reoperation rate is relatively high (19.8%). Congenital unilateral ptosis was not associated with any differences in anisometropia or astigmatism between the ptotic and sound eye.

Adjustment of sutures 8 hours vs 24 hours after strabismus surgery.

PURPOSE To compare the postoperative results of adjustable-suture strabismus surgery when suture adjustment was performed 8 hours (group 1) and 24 hours (group 2) after surgery. METHODS A retrospective clinical study was conducted in two hospitals. Strabismus surgery and muscle adjustment were performed in 90 patients. All patients had horizontal strabismus (40 patients had esotropia and 50 patients had exotropia), and they underwent either primary surgery or reoperation. Mean age of the patients was 29.9 +/- 14.1 (range, 14 to 74) years. The angle of deviation was measured in all patients before surgery, after surgery both before and after adjustment, and at the final follow-up examination. The follow-up period was 6 to 40 months (mean, 19.6 months). RESULTS Preoperative data were similar in the two groups. The mean angle of deviation immediately after muscle adjustment was 0.6 +/- 6. 1 prism diopters in group 1 and 0.4 +/- 6.3 prism diopters in group 2. This similar deviation in the two groups (P =.9) changed during the follow-up period, and at the final examination the measured angles in groups 1 and 2 were -1.0 +/- 7.9 and -2.5 +/- 10.3 prism diopters, respectively (P =.48). The most considerable outcome measure was the calculated drift values. At the last follow-up these values were -1.6 +/- 5.8 for group 1 and -2.9 +/- 11 prism diopters for group 2 (P =.5). Subdividing the patients on the basis of their deviation before surgery, a postoperative drift toward exotropia was found in most patients of group 1. In group 2, however, a greater tendency toward exotropia was shown only by those patients who had displayed exotropia preoperatively, whereas patients with preoperative esotropia showed a greater tendency toward esotropia after surgery. CONCLUSION In patients undergoing horizontal extraocular muscle surgery with adjustable sutures, suture adjustment 8 hours or 24 hours after surgery did not produce significantly different results.

Vision screening of preverbal children with Teller acuity cards.

OBJECTIVE To evaluate the modified Teller visual acuity test as a mass screening tool for testing visual acuity in infants and preverbal children. DESIGN Prospective case series. PARTICIPANTS A total of 1126 healthy children undergoing mandatory examination at the Mother and Child Health Center. INTERVENTION Visual acuity was tested by the modified Teller visual acuity test. MAIN OUTCOME MEASURES Visual acuity was measured in all children. Clinical evaluation was performed in children who failed the Teller acuity test and in a control group. RESULTS Visual acuity was below the normal range in 5% of the children. In the study group referred for complete eye examination, there were 9% false-negative and 44% false-positive results. In the age range of 12 to 17 months, false-negative and false-positive results were obtained in 5.6% and 50% of the children, respectively. CONCLUSIONS The Teller acuity card procedure can be used for vision screening in preverbal children. Testing was associated with a high rate of false-positive results.