W. Rüssmann

Counterrotation of the globe in macular translocation

Abstract Background: Macular translocation is a new treatment option in age-related maculopathy. The aim of this study was to report experience with the handling of the sensory problems concerning subjective cyclorotation and binocularity that arise with this technique. Methods: The data of 33 patients who had undergone macular translocation and counterrotation of the globe by muscle surgery in a first operation, followed by silicone oil removal and sometimes revision of the eye muscles in a second operation, were evaluated. The counterrotation consisted of a partial transposition of the rectus muscles and extensive surgery on the anterior margins of the oblique eye muscles. Subjective monocular cyclorota- tion, motility and binocularity were tested. Results: In 5 patients after the two operations binocular single vision was proved; in one of these cases there was even stereoscopic function. Seventeen patients excluded one eye: 13 excluded the operated eye, 4 the fellow eye. Eleven patients experienced double vision or tilted images under binocular viewing conditions and thus required further surgery or occlusion of one eye. Conclusion: The majority of patients were not hindered by subjective cyclorotation. Nevertheless, in a large proportion of patients binocularity could not be reestablished because of still reduced visual acuity or cyclotropia. The data show that the aim of restoring binocularity can be achieved but in practice is often not attained.

Modified transposition procedure of the vertical recti in sixth nerve palsy

PURPOSE To report a modified transposition procedure of the vertical recti for severely limited abduction of the globe caused by sixth nerve palsy and to compare this with the Hummelsheim transposition procedure. METHODS Retrospective study of 13 eyes of 12 patients that had Hummelsheim transposition procedure and 19 eyes of 17 patients that had modified transposition procedure of the vertical recti for severely limited abduction of the globe caused by sixth nerve palsy. The modified transposition procedure joins lateral strips of the vertical recti and sutures this junction to the lateral rectus muscle. Functional results of the Hummelsheim procedure are compared with functional results of the modified transposition procedure. RESULTS Abductive capacity improved by 4.19 +/- 1.67 mm in the Hummelsheim group and 4.08 +/- 1.7 mm in the modification. The angle of squint changed from +22.33 +/- 6.74 degrees to -0.20 +/- 2.61 degrees in the Hummelsheim group and from +25.54 +/- 5.66 degrees to +0.95 +/- 5.26 degrees in the modification group. The functional results as to abductive capacity and postoperative angle of squint showed no significant difference between the two methods (P >.05, t test). The modification was less time consuming. CONCLUSIONS A modification of the transposition techniques of eye muscles in sixth nerve palsy is introduced. Its functional results are comparable to the classic technique of Hummelsheim. Operative risk and trauma are reduced, because the technique avoids scleral stitches and was found to be less time consuming than the Hummelsheim procedure.

A cost-effectiveness model of screening strategies for amblyopia and risk factors and its application in a german setting.

Purpose. To develop a general setting–independent decision-analytical model that determines the costs, effectiveness, and cost-effectiveness of four screening strategies to detect amblyopia or amblyogenic factors in pre-school children and to apply the model in a German setting. Methods. The general setting–independent decision–analytical model was developed from the perspective of society and the statutory health insurance was developed. Outcomes were the total number of newly detected true positive cases of amblyopia and the costs per newly detected true positive case of amblyopia. Strategies were screening of high-risk children up to the age of 1 year (ophthalmologists), screening of all children up to the age of 1 year (ophthalmologists), screening of all children aged 3 to 4 years (pediatricians or general practitioners), and screening of children aged 3 to 4 years visiting kindergarten (orthoptists). For the application example in a German setting, data from the published medical literature were used. Results. In the base-case analysis of the application example, screening high-risk children by opthalmologists had the lowest average cost per case detected but became dominated (less effective and more costly than an alternative) if a low (5.3%) probability of familial clustering of strabismus was assumed. Considering the various assumptions tested in the sensitivity analysis, screening of all children up to the age of 1 year by opthalmologists was the only strategy not dominated by others. Detection rates, including cases detected before screening, were between 72% and 78% for the strategies that screen for all children. Conclusions. The model suggests that in Germany, both from a cost-effectiveness and a pure effectiveness point of view, screening all children up to the age of 1 year by opthalmologists is the preferred strategy to detect amblyopia or amblyogenic factors. All strategies left a significant portion of children undetected.

The cost-effectiveness of screening strategies for amblyopia: a preliminary report.

Five screening strategies for amblyopia in different age groups were compared according to a decision-analytical model from the perspective of the health insurance funds. Our findings indicate that the costs per detected case of amblyopia range from about 1200 DM to 3000 DM (613 Euro to 1534 Euro). The two most cost-effective screening strategies were to screen high-risk children up to the age of one by ophthalmologists and to screen all children up to the age of one by ophthalmologists. The screening of high-risk children identifies only about a third of all affected children in this age group, when compared with the number of cases detected by screening all children up to the age of one. However, the average cost per detected case of amblyopia among high-risk children is lower than the cost of screening all children in this age range.

Basisuntersuchungen der Strabismologie

ZusammenfassungBesprochen werden Basisuntersuchungen für das manifeste und latente Begleitschielen und für das Lähmungsschielen. In der Regel liefert die Anamnese erste Hinweise auf die Schielform. Die Untersuchung beginnt mit der Beurteilung der Kopfhaltung.Der objektive Winkel wird aus den Hornhautreflexbildern und den Einstellbewegungen (Abdecktest) geschätzt.Ab- und Aufdecktest gestatten es, manifestes und latentes Schielen zu unterscheiden.Lang-Test, Lichtschweiftest nach Bagolini und Hellrotglas geben Aufschluss über die Qualität des Binokularsehens (anomale oder normale Sehrichtungsgemeinschaft). Die Abschätzung von Schielwinkeländerungen in den diagnostischen Blickrichtungen nach Hornhautreflexbildern und Abdecktest, der Limbustest nach Kestenbaum,wird ergänzt mit der Prüfung der Sehschärfe und der Fixation.Ohne Fixationsprüfung können weder Abdecktest noch Binokulartests korrekt ausgewertet werden.AbstractBasic examination techniques for manifest and latent strabismus as well as for paralytic strabismus are discussed.Usually the medical history gives the first clues for the form of strabismus. The examination starts with an evaluation of the head posture.The objective angle is estimated through corneal reflections and the corrective saccade (cover test).Uncover and cover testing allows the differentiation between manifest and latent strabismus.The Lang test, Bagolinis test and the light red glass test provide information regarding quality of binocularity (abnormal and normal retinal correspondence).Estimation of changes in the angle of strabismus in the diagnostic gaze positions by corneal reflections, cover test and the limbus test of Kestenbaum is complemented by testing of the visual acuity and fixation.Without evaluation of fixation neither the cover test nor tests for binocularity can be interpreted adequately.

Kindliche Sehstörungen Screeningprogramme im internationalen Vergleich

Worldwide in a number of countries, screening programs aimed at detecting visual disorders in children are established. Repeatedly, proposals are brought forward to optimize already existing programs. Countries without such a program are interested in learning about current models as a guide for planning their own program. This study was performed to take stock of the screening programs for visual dysfunction in children in existence in the years 1999-2000 worldwide. The aspects considered were the childs age at examination, examiners qualification, type of examinations performed, cost-bearing entity, and cost-efficacy analysis. The health ministries of 190 sovereign countries were asked via a questionnaire for information about possibly existing screening programs. The results of the survey were analyzed quantitatively regarding geographic, political, and socioeconomic aspects, yielding data for the exchange of experience in optimizing existing programs and developing new programs.ZusammenfassungScreeningprogramme zu kindlichen Sehstörungen sind weltweit in vielen Ländern etabliert. Die vorliegende Arbeit verfolgt das Ziel einer Bestandsaufnahme der im Zeitraum 1999–2000 weltweit existierenden Screeningprogramme unter den Aspekten Untersuchungsalter der Kinder, Untersucherqualifikation, Untersuchungsort, Kostenträgerschaft, Kosten- und Effizienzanalysen und Art der durchgeführten Teiluntersuchungen. In einer Fragebogenumfrage wurden die Gesundheitsbehörden von 190 souveränen Staaten kontaktiert und zur Existenz eines Screeningprogrammes, zur Art der Durchführung und zu eventuellen Analysen des Programmes befragt. Die Ergebnisse der Umfrage wurden quantitativ und unter Berücksichtigung geographischer, politischer und sozioökonomischer Rahmenbedingungen ausgewertet und stellen somit Datenmaterial für einen Erfahrungsaustausch bei der Optimierung bestehender Programme oder bei der Etablierung neuer Programme dar.AbstractWorldwide in a number of countries, screening programs aimed at detecting visual disorders in children are established. Repeatedly, proposals are brought forward to optimize already existing programs. Countries without such a program are interested in learning about current models as a guide for planning their own program. This study was performed to take stock of the screening programs for visual dysfunction in children in existence in the years 1999–2000 worldwide. The aspects considered were the childs age at examination, examiners qualification, type of examinations performed, cost-bearing entity, and cost-efficacy analysis. The health ministries of 190 sovereign countries were asked via a questionnaire for information about possibly existing scree-ning programs. The results of the survey were analyzed quantitatively regarding geographic, political, and socioeconomic aspects, yielding data for the exchange of experience in optimizing existing programs and developing new programs.

Vertical and cyclotorsional deviations following peribulbar anesthesia

Abstract · Background: Motility disorders may occur consecutive to peribulbar anesthesia. The underlying pathology is still debated. The aim of the study was to contribute to the discussion by a meticulous orthoptic examination of a series of patients. · Methods: In a series of 16 patients with diplopia after peribulbar anesthesia, measurements of the angle of squint in the nine directions of gaze, Bielschowsky’s head-tilt test and motility analysis were performed. The findings were discussed with regard to the possible types of muscular lesions. · Results: Hypotropia and deorsoadduction accompanied by relatively small cyclotropia were found in all cases. Bielschowsky’s head-tilt test mostly revealed neutral findings. · Conclusion: The findings were discussed under the hypothesis of a fibrotic muscular change in the superior oblique and inferior rectus muscle. This hypothesis turned out to be concordant with the orthoptic measurements, implying that treatment of the disorder should consist in low-dosage recession of the fibrotic muscles, which in our experience was rewarding.

Qualität des Sehscreenings der Kinderärzte

Kinderärzte und praktische Ärzte haben im Rahmen des Vorsorgeprogramms der Krankenkassen u.a. die Aufgabe, bei Kindern im Alter von 3½ bis 4 Jahren die Sehschärfe zu testen. Sie tun dies mit geringer Effektivität, die Rückmeldequote des Vorsorgeprogramms [5] stagniert seit Jahren.Nur 10% der Kinder mit Sehfehlern wie Strabismus und Refraktionsfehlern werden durch das Screening erkannt, d.h. 90% der visuell auffälligen Kinder werden nicht oder zu spät erkannt und therapiert. Damit wird der Therapievorteil in der latenten reversiblen Vorphase der Entwicklung des visuellen Systems viel zu selten ausgeschöpft.In einer Studie wurden die Ergebnisse der 3 für die Vorsorgeuntersuchungen empfohlenen Sehtests mit den Ergebnissen eines kompletten ophthalmologischen Befundes einer Augenklinik verglichen. Resultat: nur einer der Sehtests kann empfohlen werden.

Vergleich subjektiver und objektiver Parameter nach Augenmuskeloperation

Fragestellung: Studien zur Qualität der Schieloperation beziehen sich meist auf die Einschätzung durch den Untersuchenden.Material und Methode: Um den Patienten in der Beurteilung des operativen Ergebnisses mit einzubeziehen, wurde mittels Fragebogen an 175 Patienten ein Vergleich von subjektiven Angaben und objektiv meßbaren Parametern vorgenommen. Das funktionelle und kosmetische Ergebnis wurde 1 und 6 Wochen nach Schieloperation erfaßt. Parallel hierzu wurden objektive Parameter, wie Schielwinkelreduktion und Qualität der Stereoopsis, dokumentiert.Ergebnisse: Eine Woche nach Schieloperation waren insgesamt 94,2% der Patienten mit Esotropie (n = 52) mit dem postoperativen kosmetischen Ergebnis zufrieden, 5,6% nicht. In der Gruppe der Exotropien (n = 36) lag die Zufriedenheit mit dem postoperativen kosmetischen Ergebnis bei 91,7%; weniger zufrieden waren 8,3% der Patienten. Änderungen in der Qualität der Stereoopsis wurden, sowohl im Kollektiv der Eso- als auch Exotropien, von einigen Patienten nicht wahrgenommen oder konnten nicht mitgeteilt werden.Schlußfolgerung: Insgesamt bestand eine hohe Kongruenz zwischen objektiven und subjektiven Ergebnissen 1 Woche nach Augenmuskeloperation.Background: In regard to quality-control studies concerning strabismus surgery we were interested in a comparison of subjective and objective parameters after squint surgery.Materials and methods: In a questionnaire 175 patients were asked for their evaluation of the functional and cosmetic results 1 week and 6 weeks after squint surgery. Parallel, objective parameters like reduction of the squint angle and quality of stereoopsis were documented.Results: Overall 94.2% of patients with esotropia (n = 52) were satisfied cosmetically and 5.8% were not 1 week after squint surgery was performed. In the group of patients with exotropia (n = 36), 91.7% of the patients were satisfied cosmetically and 8.3% were not. Even in cases of esotropia or exotropia no changes in the quality of stereoopsis were noted by some patients or they could not be mentioned in the questionnaire. Some patients did not appreciate the improvement of binocular function found in our examination.Conclusions: Good congruence between objective and subjective results 1 week after squint surery was found.

Im Abseits? Bemerkungen zur Asthenopie

Die Vielfalt der Möglichkeiten lässt sich nicht allein mit Messverfahren differenzieren. Dazu sind vielmehr eine genaue Anamnese und ergänzende Diagnostik notwendig, die sehr weitreichend sein kann. Ebenso wie für die Diagnostik gibt es auch für die Therapie der Asthenopie keine Patentlösung. Zur Messund Korrektionsmethodik nach H.-J. Haase (MKH) hat Kommerells Freiburger Arbeitsgruppe Daten veröffentlicht; sie lassen die mit der MKH ermittelten Werte als Produkt der Messtechnik erscheinen. Eine kürzlich veröffentlichte niederländische Studie hat gezeigt, dass bei der Heterophorie mit Beschwerden – auch Pathophorie genannt – positive Ergebnisse sowohl mit nach üblichen orthoptischen Verfahren ermittelten Prismenbrillen erreicht werden können als auch mit solchen, die nach der MKH bestimmt wurden. Betrachtet man diese Befunde zusammen mit den Freiburger Daten, so kann man sich des Eindrucks nicht erwehren, dass die menschliche Interaktion zwischen Asthenopiker und Brillenbestimmer für den Erfolg von Prismenbrillen ein wesentlicher Faktor ist. Man könnte den Schluss ziehen, der Therapeut möge unter den verschiedenen Messverfahren nach Erfahrung und Neigung auswählen, weil zuletzt doch nur zähle, ob die Beschwerden des