Carmel Noonan

Intervention for intermittent distance exotropia with overcorrecting minus lenses

AimThere are numerous treatment options for intermittent distance exotropia. The aim of this study is to evaluate the use of overcorrecting minus lenses as a primary treatment option for intermittent distance exotropia (IDEX) and determine ocular alignment status after 5 years from commencement of the study.MethodsProspective nonrandomised longitudinal cohort study in which 21 patients were recruited with a diagnosis of IDEX. Treatment was instigated with the minimum minus lens required to achieve control of the manifest deviation. The strength of lenses was reduced over time while monitoring the results of orthoptic measurements. The results were evaluated by nonparametric (Wilcoxon) and parametric (paired t-test) analysis.ResultsThirteen female and eight male patients were recruited with a mean age of 5 years at the start of treatment. There was a significant reduction in angle of deviation after treatment. Overcorrecting lenses did not appear to induce myopia. Twenty-four per cent of the patients had a successful outcome, 28% had a good outcome, and 33% required surgery at a later date.ConclusionsFifty-two per cent of the patients achieved a successful or good outcome with overcorrecting minus lenses alone, and this was maintained for at least 1 year follow-up. Those requiring surgery had been unable to wean out of lenses but had a successful outcome after one procedure. We recommend overcorrecting minus lenses as a primary treatment option for IDEX with the knowledge that surgery, if subsequently required, is safely delayed to an older age without prior loss of binocular vision.

Complications of Botulinum Toxin A and Their Adverse Effects

Aim: To evaluate the prevalence of complications after low doses (< 3 units) of botulinum toxin (BT) injection to horizontal extraocular muscles for diagnostic and therapeutic purposes. Methods: A case record review was undertaken of patients treated with BT (Dysport™) since 2000. Data were extracted for gender, age, diagnosis, number of BT injections, dose, recorded complications, and time to recovery. Results: Two hundred eleven (211) cases were reviewed, 48.5% children, 51.5% adults (45.5% male, 54.5% female). Diagnoses included constant and intermittent esotropia and exotropia, decompensating esophoria, exophoria and microtropia, accommodative spasm, mechanical restrictions, and cranial nerve palsy. One hundred sixty-three (163) patients had one injection; 38 had two; 7 had three; 2 had four; 1 had six; for a total of 274 injections. BT dose was 1 unit in four cases; 2.5 units in two; 3 units in seven; and 2 units in the remainder. At 2 weeks follow-up, six cases had induced vertical deviation; three had subconjunctival haemorrhage. At 2 weeks, 23 cases had ptosis, but a further 10 cases had ptosis that had resolved by 2 weeks follow-up. All complications had resolved by 6 weeks follow-up. Conclusions: A low incidence of complications per injection (12.4%) was found particularly for induced vertical deviations (2%) and hemorrhages (1%). Incidence for ptosis was the highest (8.4%). Notably, 10 additional cases of ptosis had resolved before follow-up. Two children were given occlusion therapy to prevent the possibility of stimulus deprivation occlusion until ptosis resolution.

Post-stroke visual impairment: a systematic literature review of types and recovery of visual conditions

Aim: The aim of this literature review was to determine the reported incidence and prevalence of visual impairment due to stroke for all visual conditions including central vision loss, visual field loss, eye movement problems and visual perception problems. A further aim was to document the reported rate and extent of recovery of visual conditions post stroke. Methods: A systematic review of the literature was conducted including all languages and translations obtained. The review covered adult participants (aged 18 years or over) diagnosed with a visual impairment as a direct cause of a stroke. Studies which included mixed populations were included if over 50% of the participants had a diagnosis of stroke. We searched scholarly online resources and hand searched journals and registers of published, unpublished and ongoing trials. Search terms included a variety of MESH terms and alternatives in relation to stroke and visual conditions. The quality of the evidence was assessed using key reporting guidelines, e.g. STROBE, CONSORT. Results: Sixty-one studies (n=25,672) were included in the review. Overall prevalence of visual impairment early after stroke was estimated at 65%, ranging from 19% to 92%. Visual field loss reports ranged from 5.5% to 57%, ocular motility problems from 22% to 54%, visual inattention from 14% to 82% and reduced central vision reported in up to 70%. Recovery of visual field loss varied between 0% and 72%, with ocular motility between 7% and 92% and visual inattention between 29% and 78%. Conclusion: The current literature provides a range of estimates for prevalence of visual impairment after stroke. Visual impairment post stroke is a common problem and has significant relevance to the assessment and care these patients receive. Prospective figures regarding incidence remain unknown.

Modified Lundie loops improve apraxia of eyelid opening.

Background: Current treatments are unsatisfactory for improving apraxia of eyelid opening, defined as a delay or inability to open closed eyelids voluntarily in the presence of intact motor pathways. Methods: Improvement in functional health was assessed using the Blepharospasm Disability Scale (BDS) in five consecutive patients with apraxia of eyelid opening treated with wire loops affixed behind ordinary spectacles (Lundie loops) and modified to provide pressure on the brow as a stimulus to keep the eyelids elevated. Results: All five patients showed improvement in BDS scores. The mean percentage of normal activity of the study population improved from 25% to 37.6%. Outdoor activities were not significantly altered with the use of the device. Conclusions: Modified Lundie loops appear to be helpful in improving the functional health of patients with eyelid apraxia. These results will need to be verified in larger trials.

A randomised controlled trial to compare the clinical and cost-effectiveness of prism glasses, visual search training and standard care in patients with hemianopia following stroke: a protocol

Introduction Homonymous hemianopia is a common and disabling visual problem after stroke. Currently, prism glasses and visual scanning training are proposed to improve it. The aim of this trial is to determine the effectiveness of these interventions compared to standard care. Methods and analysis The trial will be a multicentre three arm individually randomised controlled trial with independent assessment at 6 week, 12 week and 26 week post-randomisation. Recruitment will occur in hospital, outpatient and primary care settings in UK hospital trusts. A total of 105 patients with homonymous hemianopia and without ocular motility impairment, visual inattention or pre-existent visual field impairment will be randomised to one of three balanced groups. Randomisation lists will be stratified by site and hemianopia level (partial or complete) and created using simple block randomisation by an independent statistician. Allocations will be disclosed to patients by the treating clinician, maintaining blinding for outcome assessment. The primary outcome will be change in visual field assessment from baseline to 26 weeks. Secondary measures will include the Rivermead Mobility Index, Visual Function Questionnaire 25/10, Nottingham Extended Activities of Daily Living, Euro Qual-5D and Short Form-12 questionnaires. Analysis will be by intention to treat. Ethics and dissemination This study has been developed and supported by the UK Stroke Research Network Clinical Studies Group working with service users. Multicentre ethical approval was obtained through the North West 6 Research ethics committee (Reference 10/H1003/119). The trial is funded by the UK Stroke Association. Trial Registration: Current Controlled Trials ISRCTN05956042. Dissemination will consider usual scholarly options of conference presentation and journal publication in addition to patient and public dissemination with lay summaries and articles. Trial Registration Current Controlled Trials ISRCTN05956042.

Comparison of Octopus Semi-Automated Kinetic Perimetry and Humphrey Peripheral Static Perimetry in Neuro-Ophthalmic Cases

Aim. To compare semikinetic perimetry (SKP) on Octopus 900 perimetry to a peripheral static programme with Humphrey automated perimetry. Methods. Prospective cross-section study comparing Humphrey full field (FF) 120 two zone programme to a screening protocol for SKP on Octopus perimetry. Results were independently graded for presence/absence of field defect plus type and location of defect. Results. 64 patients (113 eyes) underwent dual perimetry assessment. Mean duration of assessment for SKP was 4.54 minutes ±0.18 and 6.17 ± 0.12 for FF120 (P = 0.0001). 80% of results were correctly matched for normal or abnormal visual fields using the I4e target versus FF120, and 73.5% were correctly matched using the I2e target versus FF120. When comparing Octopus results with combined I4e and I2e isopters to the FF120 result, a match for normal or abnormal fields was recorded in 87%. Conclusions. Humphrey perimetry test duration was generally longer than Octopus SKP. In the absence of kinetic perimetry, peripheral static suprathreshold programme options such as FF120 may be useful for detection of visual field defects. However, statokinetic dissociation may occur. Octopus SKP utilising both I4e and I2e targets provides detailed information of both the defect depth and size and may provide a more representative view of the actual visual field defect.

A pilot randomized controlled trial comparing effectiveness of prism glasses, visual search training and standard care in hemianopia

Pilot trial to compare prism therapy and visual search training, for homonymous hemianopia, to standard care (information only).

Delivery of high quality stroke and vision care: experiences of UK services

Abstract Purpose: We sought to identify exemplars of high quality care provision from established stroke vision services. Methods: We identified areas of high quality services across the UK, judged as having integrated stroke/vision care provision for stroke survivors. Healthcare professionals were selected to participate in 1:1 interviews or focus groups. A strengths–weaknesses–opportunities–threats (SWOT) framework was used to lead the discussion in a semi-structured format. Thematic analysis was undertaken. Results: Interviewees (n = 24) from 14 NHS Trusts included eye clinic managers, nurses, orthoptists, occupational therapists and physiotherapists. Identified strengths of their services included established communication, training provision for stroke team staff, “open access” for referrals, use of standardised screening/referral forms, provision of lay summaries and information sheets, patients assessed on the stroke unit with continued follow-up and initial visual assessments made within 1 week of stroke onset. Weaknesses included lack of funding, insufficient orthoptic cover, and time consuming retraining of stroke staff because of staff rotation and changes. Opportunities included increasing the number (or length) of orthoptic sessions and training of stroke staff. Perceived threats related to funding and increased appointment waiting times. Conclusions: Practical elements for improved stroke and vision care provision are highlighted which can be implemented with relatively little financial inputs. Implications for Rehabilitation Integrated vision services within stroke units can improve the detection of visual problems in stroke survivors leading to earlier visual rehabilitation. Orthoptists within core stroke teams are beneficial to the delivery of a high quality service. This study illustrates clear practical elements to support the provision of high quality integrated stroke and vision services. Relatively little financial inputs are required to fund such services but with larger potential to improve patient care.

Ketamine and Botulinum: A Safe Combinationfor the Management of Childhood Strabismus

Aims: To determine the prevalence of ketamine side effects in children receiving botulinum toxin injections for strabismus under ketamine anesthesia and to establish the prevalence, severity, and duration of ptosis in these children. Methods: Children who had undergone ketamine anesthesia for botulinum toxin injections (1999 to 2006) to correct strabismus were identified in a retrospective review. A questionnaire to establish occurrence of nightmares, sleepless nights, hallucinations (ketamine side effects), or ptosis (botulinum toxin side effect), was sent to parents or guardians. Details of side effects were obtained by telephone and the patients’ medical records were analyzed. Results: Questionnaires were sent to 113 patients (total of 130 injections). Ninety-seven (114 injections) completed questionnaires were returned. Emergence reactions were experienced by 12 patients (12.4%). Two children experienced sleepless nights, nightmares, and hallucinations. The remaining 10 experienced one side effect only. Eighteen children had ptosis at their 2-week follow-up appointment, most which resolved within 6 weeks. There were no life-threatening or sight-threatening adverse events. Conclusions: Botulinum toxin injection under intravenous ketamine anesthesia can safely be used for children. Ketamine anesthesia may be associated with side effects, namely hallucinations and sleep disturbances.

Detection of Visual Field Loss in Pituitary Disease: Peripheral Kinetic Versus Central Static

Abstract Visual field assessment is an important clinical evaluation for eye disease and neurological injury. We evaluated Octopus semi-automated kinetic peripheral perimetry (SKP) and Humphrey static automated central perimetry for detection of neurological visual field loss in patients with pituitary disease. We carried out a prospective cross-sectional diagnostic accuracy study comparing Humphrey central 30-2 SITA threshold programme with a screening protocol for SKP on Octopus perimetry. Humphrey 24-2 data were extracted from 30-2 results. Results were independently graded for presence/absence of field defect plus severity of defect. Fifty patients (100 eyes) were recruited (25 males and 25 females), with mean age of 52.4 years (SD = 15.7). Order of perimeter assessment (Humphrey/Octopus first) and order of eye tested (right/left first) were randomised. The 30-2 programme detected visual field loss in 85%, the 24-2 programme in 80%, and the Octopus combined kinetic/static strategy in 100% of eyes. Peripheral visual field loss was missed by central threshold assessment. Qualitative comparison of type of visual field defect demonstrated a match between Humphrey and Octopus results in 58%, with a match for severity of defect in 50%. Tests duration was 9.34 minutes (SD = 2.02) for Humphrey 30-2 versus 10.79 minutes (SD = 4.06) for Octopus perimetry. Octopus semi-automated kinetic perimetry was found to be superior to central static testing for detection of pituitary disease-related visual field loss. Where reliant on Humphrey central static perimetry, the 30-2 programme is recommended over the 24-2 programme. Where kinetic perimetry is available, this is preferable to central static programmes for increased detection of peripheral visual field loss.