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The main objective of all eye movements is to keep the image of the object of interest focused. Head motion makes this objective more complex. However, the vestibular system is responsible for eye movement that compensate head motion. Simulating and analysing eye movement in coordination with head and neck movements is useful for assessing visual system contribution to discomfort in different tasks especially related to motion such as simulation sickness. In this paper, we present an ocular biomechanic model integrated into a head and neck model and used to simulate and analyse eye-head coordination movement during smooth pursuit. The proposed model is based on the physiological and the kinematics properties of the human eye provided from clinical trials performed by Robinson and Collins and also magnetic resonance imaging studies. The model incorporates six extraocular muscles (EOMs) and their connective tissues, known as pulleys. The pulleys are modelled as moving points on the muscle path according to the Active Pulley Hypothesis (APH) provided by Kono et al. Dynamic simulations of smooth pursuit with head movement is presented. The model achieved root mean square error (RMSE) of 0.77°, 0.29°and 0.14°for the horizontal, vertical and torsional rotation angles. It can be further used to simulate and analyse the vestibulo-ocular reflex of the eye.

We report the case of a woman who developed right third nerve dysfunction with synkinesis and ocular neuromyotonia secondary to a compressive arterial aneurysm. Surprisingly, our examination showed a downward drift of the right eye in sustained up-gaze resulting in transient hypotropia, suggesting either fatigability of the superior rectus or contraction of the inferior rectus. We believe this ocular motility pattern is secondary to a co-contraction of the inferior rectus in up-gaze caused by synkinesis (explaining the downward drift), followed by failure of the inferior rectus to relax upon return to primary position caused by ocular neuromyotonia (explaining the hypotropia).

Brown syndrome is characterised by impaired supraduction worse in adduction due to a restricted superior oblique tendon passing through the trochlea. A few reports have previously described Brown syndrome after upper eyelid surgery, including blepharoplasty and ptosis repair. The authors describe two additional cases of Brown syndrome following ptosis repair. The first case is a 65-year-old woman with new-onset vertical binocular diplopia following bilateral levator advancement surgery. Ocular motility examination demonstrated moderate impairment of elevation in adduction. The second case is a 35-year-old woman who presented with new-onset intermittent binocular diplopia following right upper lid ptosis repair. Examination revealed large vertical fusional amplitudes and a large left intermittent hyperphoria in an alignment pattern consistent with Brown syndrome. Despite presenting after surgery, these cases differ in mechanism. The first case likely occurred due to intraoperative impairment of the superior oblique tendon sheath or trochlea, whereas the second case represented an unmasking of a long-standing, previous vertical strabismus that was consistent with a Brown syndrome pattern.

Aim To profile the full range of visual disorders from a large prospective observation study of stroke survivors referred by stroke multidisciplinary teams to orthoptic services with suspected visual problems. Methods Multicenter prospective study undertaken in 20 acute Trust hospitals. Standardized screening/referral forms and investigation forms documented data on referral signs and symptoms plus type and extent of visual impairment. Results Of 1,345 patients referred with suspected visual impairment, 915 were recruited (59% men; mean age at stroke onset 69 years [SD 14]). Initial visual assessment was at median 22 days post stroke onset. Eight percent had normal visual assessment. Of 92% with confirmed visual impairment, 24% had reduced central visual acuity

I experienced periorbital entrapment in a minimally displaced medial wall fracture. An 18-year male was hit in the left eye by a fist. He had decreased horizontal ocular motility with pain. Exophthalmometry of both eyes were same. Computed tomography (CT) demonstrated a minimally displaced medial wall fracture with herniation of orbital fat. Decreased horizontal ocular motility and pain persisted until the fifth post-trauma day. On exploration, entrapped soft tissue was found and dissected from the fractured site, but the bony displacement was minimal. After release, the forced duction test became normal and postoperative CT demonstrated reduced herniated orbital fat. In cases of a minimally displaced medial orbital wall fracture, if the patient feels pain while gazing horizontally, precise inspection of the CT scan is needed. If the pain persists for several days, despite the absence of diplopia, periorbital entrapment should be suspected and exploration can be considered.

Purpose: The purpose is to identify the various causes of ocular disease and surgical interventions undertaken in children (0–18 years of age) seen during an annual ophthalmic surgical trip to Belize. Methods: A retrospective, cross-sectional review of records from seven annual surgical trips conducted by the World Pediatric Project providing pediatric ophthalmologic clinical and surgical care to Belize from 2013 to 2019 was performed. Results: The charts of 313 patients who received care during the surgical mission trips were examined. From these 313 patients, there were 545 independent clinical encounters, yielding 405 diagnoses. Patients aged 6–10 years were most commonly seen (32.1%) followed by those 2–5 years old (28.1%). The most common pathophysiology seen was strabismus/ocular motility disorder (151 diagnoses; 37.4%), followed by refractive issues (69 diagnoses; 17.1%), eyelids and/or lacrimal system disorders (53 diagnoses; 13.1%), disorders of the retina/vitreous (30 diagnoses; 7.4%), lens abnormalities/cataract (28 diagnoses; 6.9%), amblyopia (23 diagnoses; 5.7%), disorders of the cornea/conjunctiva (23 diagnoses; 5.7%), trauma (13 cases; 3.2%), conditions affecting the globe/orbit (7 diagnoses; 1.7%), other (6 diagnoses; 1.5%), and glaucoma (1 diagnoses, 0.2%). Conclusion: This study identified the most frequently diagnosed ocular conditions encountered during annual surgical mission trips to Belize. The most prevalent pathophysiology encountered was strabismus/ocular motility disorders, followed by refractive issues. The most common refractive issues encountered were myopia and astigmatism. This is the first study detailing pediatric ocular disease in Belize.

Purpose Competently performing the ocular examination is an essential skill of every graduating medical student. Assessment of competence in performing the ocular examination is equally essential. Unfortunately, there is a paucity of tools useful in assessing clinical competence in ophthalmology. The Objective Structured Clinical Examination (OSCE) format has been shown to be a useful tool to assess clinical competence in other academic settings. It is hypothesized that the OSCE format can be used to assess clinical competence in performing the ocular examination. This study presents the novel use of the OSCE format for assessing competence in obtaining a history of headache and performing the ocular examination by third and fourth year medical students. Methods Observational design was used to assess the competence of third and fourth year medical students in taking a brief history on the chief complaint of headache and performing the ocular examination. The ophthalmology OSCE was used after a one-week ophthalmology clerkship at the University of Wisconsin-Madison School of Medicine and Public Health. Standardized patients were trained by ophthalmology staff prior to the OSCE. The standardized patients were not dilated for the direct ophthalmoscope portion of the examination. Results Students were graded on their performance in obtaining a history of headache and performing the ocular examination. The ocular examination included assessment of ocular motility, pupils, using confrontation to find a visual field defect, and using the direct ophthalmoscope to match a standardized patient's optic nerve to one of four photos in the room. A check box system was used to assess the student's competence. This was reported as pass, marginal, or fail. Failing students were remediated by an ophthalmologist. A total of 384 students took the exam from 2008 to 2012. Overall, 84% received a passing score, 11% received a marginal score, and 5% received a failing score. Conclusion Establishment of competence and assessment of competence continue to be a major focus of medical student education. The OSCE format provides a standardized testing platform to assess competence with performing the ocular examination. Use of standardized patients provides a more natural format than paper-based or other methods of assessment.

Gunshot wounds of the orbit represent about 6% of injuries in this area. We described the case of the removal of a shot from the left orbit of a 16-year-old girl, accidentally shot by a gun – a toy. The injury did not cause any loss of vision or ocular motility, as foreign body stuck in the orbital cone medially to the optic nerve and annular ring. Endoscopic surgery was performed to remove the ball through the sphenoid sinus using intraoperative navigation. In the postoperative period were observed the disorders of abduction of the left eyeball, which resolved completely after two months. The vision of the left eye remains at the same level as before the injury. Endoscopic removal of foreign body was an effective and safe treatment without loss of vision after injury.

BACKGROUND: Uncorrected refractive errors are a major cause of low vision and even blindness. The refractive errors can be easily diagnosed and corrected by effective screening programmes. The uncorrected refractive errors in children have a definite impact in adversely affecting the learning capacity and scholastic performance. MATERIAL & METHODS: This Cross sectional was conducted from July to December 2013 among 1412 children aged 5-16 years residing in Chandragiri rural area, Chittoor District, Andhra Pradesh. Visual acuity was assessed using Snellen's chart under standard illumination while detailed eye examination among the suspected cases was done by an ophthalmologist including detailed anterior segment evaluation, ocular motility, radioscopy and auto refraction under 2% homatropine cycloplegic refraction. RESULTS: The prevalence of refractive errors was found to be 7.4% among the study children (out of which 6.1% undiagnosed). Simple myopia was found in 2.4% children while astigmatism (both simple and compound combined) was found in around 2.7% children. It was found that the proportion of myopia increased with age being lowest in 5-7 years (0.0%) and highest in 14-16 age group (4.0%). The proportion of astigmatism also was found to be lowest in 5-7 age group (0.0%) and higher in 11-13 age group and 14-16 age group (4.0% each) However, the differences were not statistically significant (P=0.32; NS). The prevalence of myopia was found to be slightly higher in males (2.7%) than in females (2.1%) while that of astigmatism was found to be higher in females (3.1%) than in males (2.3%). However the differences were not statistically significant (P=0.43; NS). A similar prevalence of refractive errors was found in Bangalore and New Delhi while lower and higher prevalence was reported elsewhere. Myopia and astigmatism are the common disorders in several Indian studies including the present study while African studies found myopia to be less common compared to astigmatism and hypermetropia. Many studies including the present study reported an increase in the prevalence of refractive errors with age of the subjects. CONCLUSIONS: A large proportion of refractive errors in children remain undiagnosed. Thus there is tremendous scope for

Purpose: To analyze the cosmetic and functional results of a large series of patients with unilateral congenital ptosis without spontaneous compensatory ipsilateral frontalis hyperaction who underwent supramaximal levator resection (SMLPSr). Methods: A multicenter retrospective review of 35 children (14 girls and 21 boys) of mean age 5.5 ± 3.6 SD years with unilateral congenital ptosis who underwent surgery in 3 different countries: Italy, n = 8; Argentina, n = 11; and Brazil, n = 16. Preoperative evaluation included measurements of upper eyelid margin reflex distance (MRD 1 ) and levator palpebrae superioris muscle excursion, assessment of frontalis hyperaction, and ocular motility examination. At least 6 months postoperatively, photographs were used to measure the upper eyelid contour of OU. The spontaneous blinking amplitude and downward eyelid saccades of OU were quantified in a subset of 14 patients. Quantitative comparison among the 3 centers was performed with nonparametric 1-way analysis of variance (Kruskal–Wallis). Paired t tests were used to compare the pre- and postoperative measurements, and p value < 0.05 was statistically significant. Results: The mean preoperative MRD 1 of the operated eyes increased from 0.5 ± 1.1 SD mm to 3.4 ± 0.84 SD mm (t = 15.9; p < 0.000001), consequently the eyelid positional asymmetry decreased from 3.1 ± 1.21 mm to 0.1 ± 0.86 SD mm (t = 16.5; p ≤ 0.000001). Twenty-nine percent of eyelids had mild contour abnormalities and 31.4% showed some degree of lash ptosis. Spontaneous blinks were abnormal in 93% of the cases (eyelids). The amplitude of the abnormal blinks ranged from 12.9% to 65.4% (mean = 37.1%) of the contralateral eyelids. Downward eyelid saccades were reduced in 79% of the eyelids. The amplitudes the saccades ranged from 2.2% to 84.6% (mean = 54.8%). Conclusions: In unilateral congenital ptosis, SMLPSr effectively reduces the positional asymmetry between eyelids. Mild contour abnormalities and lash ptosis are the main complications of the surgery. Postoperatively, spontaneous blinks and downward saccades were reduced in most eyelids. The reduced postoperative eyelid kinetics indicates that only patients with normal upward Bell signs are good candidates for this procedure.

The quantification of ocular rotation in clinical practice is important, with a number of methods of assessment. However, there is little consensus on which method is most reliable and a lack of comparative data for these methods. The aim of this study was to directly compare the modified Goldmann and Aimark methods in subjects with full ocular motility.This was a prospective cross sectional study to compare the extent of uniocular fields of rotation measured by the Aimark and the modified Goldmann perimeters. The inclusion criteria were full ocular motility and unaided logMAR visions of 0.2 or better in each eye. The results for the four cardinal positions of gaze (right, left, up and down gaze) were analysed and comparisons made with Bland Altman analysis.108 subjects were recruited. The mean ocular rotations for abduction, elevation, adduction and depression were 69.9°±12.8°; 57.8°±12.6°; 61.6°±10.1° and 68.6°±10.5° respectively for the Aimark and 54.4°±8.6°; 47.3°±8.3°; 53.3°±8.6° and 59.5°±9.1° respectively for the modified Goldmann. The Aimark recorded higher ocular rotations for all positions of gaze in comparison to the modified Goldmann. The Aimark method tested twelve axes per eye and the modified Goldmann tested 8 axes per eye. However the Aimark was quicker per axis (RE: 11.7±4.9 seconds; LE: 11.5±5 seconds) in comparison to the modified Goldmann (RE: 13.4±10.6 seconds; LE: 13.1±10.6 seconds).The results between the two tests are not interchangeable. The Aimark method measures greater ocular rotations with a supra-threshold compared to the Goldmann measures with a foveal threshold fixation target.

The congenital cranial dysinnervation disorders (CCDDs) encompass most congenital, static restrictions of ocular motility, often associated with ptosis, and retraction of the globe.[1][1] The CCDDs can be monogenic or chromosomal in origin. Although chromosomal copy number variations (CNVs) has been

Orbital complications of functional endoscopic sinus surgery (FESS) may cause irreversible damage to the orbital structures, including optic nerve, extraocular muscles, and lacrimal drainage system. The clinical diagnosis and management of these patients may be extremely difficult because of the complexity and severity of the injuries. We describe a patient with ocular motility disturbances, anisocoria, and optic neuropathy in the right eye secondary to FESS. Early medical and surgical intervention resulted in symptom resolution.

Intraorbital foreign bodies are one of the commonly encountered orbital problems. They may be sight threatening due to the severity of injury or its complications and even life threatening if not managed appropriately. We present a case of a 24-year old female with history of fall injury from a tree with an impacted intraorbital wooden foreign body. The patient was treated with prophylactic intravenous antibiotics and prompt removal of the foreign body was done under general anesthesia in the operation theatre. The post operative visual recovery was excellent with significant improvement of ocular motility and limited improvement of ptosis. Hence even organic foreign bodies can have good prognosis with timely intervention.DOI: http://dx.doi.org/10.3126/jkmc.v3i3.12248Journal of Kathmandu Medical CollegeVol. 3, No. 3, Issue 9, Jul.-Sep., 2014, Page: 119-121

Purpose of review We review the congenital and genetic diagnoses that are currently included in the congenital cranial dysinnervation disorders (CCDDs). Recent findings Recent literature contains new genotypic and phenotypic descriptions of Duane retraction syndrome, Moebius syndrome, and other CCDDs. New genes which when mutated can result in CCDD have been identified, permitting a better understanding of associated phenotypes. More information is available regarding neurodevelopmental and clinical effects of various gene mutations associated with individual CCDDs. For certain CCDDs, the phenotype of a particular individual may not completely predict the genotype, and conversely, the genotype may not always predict the phenotype. Summary The CCDD concept has focused attention on specific congenital disturbances of human ocular motility and on the fact that these disorders are typically neurogenic in origin. The past decade has seen rapid evolution within this field with the last 2 years yielding additional information about existing diagnoses, genes, and phenotypes that may result in better classification of these disorders and new genotype-phenotype correlations in the future.

International audience; Developmental dyslexia affects almost 10% of school-aged children and represents a significant public health problem. Its etiology is unknown. The consistent presence of phonological difficulties combined with an inability to manipulate language sounds and the grapheme-phoneme conversion is widely acknowledged. Numerous scientific studies have also documented the presence of eye movement anomalies and deficits of perception of low contrast, low spatial frequency, and high frequency temporal visual information in dyslexics. Anomalies of visual attention with short visual attention spans have also been demonstrated in a large number of cases. Spatial orientation is also affected in dyslexics who manifest a preference for spatial attention to the right. This asymmetry may be so pronounced that it leads to a veritable neglect of space on the left side. The evaluation of treatments proposed to dyslexics whether speech or oriented towards the visual anomalies remains fragmentary. The advent of new explanatory theories, notably cerebellar, magnocellular, or proprioceptive, is an incentive for ophthalmologists to enter the world of multimodal cognition given the importance of the eye's visual input.

Introduction The recommended urgent surgical management of ocular motility restriction due to orbital muscle entrapment or impingement associated with orbital wall fracture needs to be elucidated. Aim To evaluate the importance of the time from injury to surgery for the outcome in ocular motility and diplopia, the time lapse of ocular motility, diplopia and hypesthesia recovery. Material and methods Patients with entrapment or impingement of orbital contents due to orbital wall fracture were followed up prospectively over 1 year regarding ocular motility, diplopia, hypesthesia and cosmetic deformity. Results 21 patients (10 entrapments and 11 impingements) were included and treated surgically. The median time from injury to surgery was 36 (8–413) h for the entrapment group and 168 (48–326) h for the impingement group. The median time from study inclusion to surgery was 0 (0–1) days for the entrapment group and 1.0 (0.2–4.8) days for the impingement group. All the patients had ocular motility limitation and diplopia at the inclusion. Ocular motility improved gradually and was normal at final visit. Diplopia resolved gradually in all patients except in two with non-disturbing diplopia, at the final visit. Forced duction test was positive in 90% of the patients in the entrapment group and 70% in impingement group. At final visit, hypesthesia was found in none of the patients in the entrapment group but in 4 patients in the impingement group. Conclusions In this, the first prospective long term follow up of orbital wall fractures with ocular motility restriction, we did not find any significant correlation between the time from injury to surgery and the outcomes in ocular motility and diplopia. An entrapment requires surgery as soon as possible; however, the surgical reduction is at least as important as surgical timing. Surgery should be delayed until it can be performed by an experienced surgeon. Ocular motility restriction causing diplopia due to impingement is not an ophthalmologic emergency and surgery is recommended if the diplopia and ocular motility has not improved over time. Clinical examination of ocular motility and not CT scan findings is crucial to determine whether a limitation of ocular motility exists or not.

Purpose. Extraocular muscle (EOM) pulleys are important in eye movement physiology and may play a role in the outcome of strabismus surgery. Few studies have evaluated "normal" position of EOM pulleys. We sought to assess intraoperatively medial rectus (MR) pulley location and variations in a prospective observational case series. Methods. A total of 194 consecutive patients with all types of strabismus aged 2 to 64 years had primary surgery on MR. We conducted 357 measures of the distance between scleral insertion of MR and anterior part of the pulley. We compared results to preoperative angle of deviation, age, refraction, and position of eyes under anesthesia. Results. Median location of the anterior part of the MR's pulley is 12.03 mm from scleral insertion, varying from 8 to 15 mm. There is a strong relation with refraction (p=0.005) and with preoperative angle of deviation (p=0.00002) and deviation under anesthesia (p=0.0001). The MR's pulley tends to be more anterior in hyperopic cases and esotropias, and posterior in myopias and exotropias. Conclusions. Our study shows physiologic variations of MR's pulley position with evidence of an adaptation to biometric parameters of the globe, represented by refraction state of the eyes in our study. Elsewhere, strabismus leads to an independent variation of MR's pulley location evaluated relatively to muscle's scleral insertion, but probably not if evaluated relatively to the orbit. We discuss consequences on ocular motility and surgery of these variations. They may explain some unexpected effects of strabismus surgery. Further studies are needed to ascertain their real impact.

Importance of thorough history-taking, meticulous examination and tailored investigations cannot be underestimated in any branch in medicine, and the same goes for neuro-ophthalmology too. In patients presenting with visual loss, ocular motility disturbances, or simply headache, the ophthalmologist may be the first one to diagnose life-threatening conditions. Thus, before referring the patient to other services, it is essential to arrive systematically and rationally at a conclusive, problem-oriented diagnosis. This article gives a stepwise approach to work up patients with a potential neuro-ophthalmic condition. It gives a brief and helpful overview about history-taking in these patients and clears most ambiguities regarding examination techniques and the choice and timing of investigations. It may especially prove to be very useful and of special interest for training ophthalmologists.

INTRODUCTION AND PURPOSE To investigate the level of agreement between orthoptists and medical practitioners in the comprehensive eye examination of children seen in an orthoptist-led triage clinic. PATIENTS AND METHODS Patient records over a 6-month period were retrospectively reviewed. Those with a presenting complaint related to vision or ocular motility were triaged into the orthoptist-led clinic and included in the study. Patients who did not meet the triage protocol and those who were not assessed by a medical practitioner at a subsequent appointment were excluded from analysis. The clinical findings from the orthoptist and medical practitioner were collected and compared. RESULTS In total, sixty-three patients were reviewed during the 6-month period and met the inclusion criteria. After the initial comprehensive eye examination with an orthoptist, thirty-two were discharged from hospital and thirty-one were asked to return for a review appointment with a medical practitioner. Agreement between the orthoptists and medical practitioners for the diagnosis of strabismus and/or amblyopia was 84.6% (κ = 0.649, P < 0.001). There was strong agreement between orthoptists and medical practitioners for refractive error of the right eye [τ (19) = 0.352, P = 0.729] and left eye [τ (19) = 1.785, P = 0.090]. Fundus examination comparisons between the orthoptists and medical practitioners showed very high agreement (95.7%). CONCLUSIONS Orthoptists have the skills necessary to provide comprehensive care of children referred for ocular motility and/or vision related disorders. There was close agreement between orthoptists and medical practitioners when performing comprehensive eye examinations.

Background Cyclic strabismus is a very rare condition of ocular motility characterized by alternating strabismus and orthotropia. We report a patient with a 48-h cycle of vertical deviation associated with dysthyroid ophthalmopathy that spontaneously resolved. Case presentation A 40-year-old woman experienced sudden onset vertical double vision. She had already been diagnosed with hyperthyroidism. Asymmetric enlargement of the inferior and medial rectus muscles was demonstrated in her left eye on computed tomography, and was compatible with dysthyroid ophthalmopathy. She clearly described the “every-other-day” pattern of diplopia that spontaneously switched around 8 o’clock every night. She exhibited left hypotropia of 35 prism diopters on a bad day, and 7 prism diopters on a good day. Conclusions This case illustrates that cyclic vertical deviation may spontaneously resolve along with the course of the underlying diseases that initiated the cyclic deviation, especially in patients with conditions involving motor component changes such as dysthyroid ophthalmopathy.

Isolated bilateral absence of the inferior rectus muscle is a rare congenital anomaly. The usual presentation of this disorder involves apparent ocular deviations and abnormal head posture from an early age. A 45-year-old woman presented with a bilateral ptosis and lower scleral show. She had a limitation of infraduction in both eyes but was orthophoric in the primary position and had a normal head posture. Ocular motility testing and imaging confirmed a diagnosis of bilateral absence of the inferior rectus muscle; the ptosis was assumed to be a pseudoptosis. The inferior half of the horizontal rectus muscles was transposed inferiorly in both eyes. Postoperatively there was marked improvement of the bilateral ptosis and lower scleral show.

Progressive external ophthalmoplegia (PEO), marked by progressive bilateral ptosis and diffuse reduction in ocular motility, represents a finding of mitochondrial myopathy rather than a true diagnosis. PEO often occurs with other systemic features of mitochondrial dysfunction that can cause significant morbidity and mortality. Accurate and early recognition of PEO is paramount for the optimal care of these patients. We present an evidence-based review of the presenting neuro-ophthalmic features, differential diagnosis, diagnostic tools, systemic implications, and treatment options for isolated PEO and other PEO-associated mitochondrial syndromes.

The purpose of the study was to evaluate the frequency of ophthalmologic abnormalities in a cohort of myotonic dystrophy type 1 (DM1) patients and to correlate them with motor function. We reviewed the pathophysiology of cataract and low intraocular pressure (IOP). Method Patients were included after clinical and laboratory diagnosis and after signed informed consent. They were evaluated by Motor Function Measure scale, Portuguese version (MFM-P) and ophthalmic protocol. Results We evaluated 42 patients aged 17 to 64 years (mean 40.7 ± 12.5), 22 of which were men. IOP (n = 41) was reduced in all but one. We found cataract or positivity for surgery in 38 (90.48%) and ptosis in 23 (54.76%). These signs but not IOP were significantly correlated with severity of motor dysfunction. Abnormalities in ocular motility and stereopsis were observed. Conclusion Cataract and ptosis are frequent in DM1 and associated to motor dysfunction. Reduced IOP is also common, but appears not to be related with motor impairment. RESUMO O objetivo do estudo foi avaliar a frequência das anormalidades oftalmológicas em uma coorte de pacientes com distrofia miotônica tipo 1 (DM1) correlacionando-as à função motora. Revisamos a fisiopatogenia da catarata e baixa pressão intraocular (PIO). Método Os pacientes foram incluídos após diagnóstico clínico-laboratorial de DM1. Aqueles que assinaram o termo de participação foram avaliados pela escala medida da função motora, versão em português (MFM-P) e protocolo oftalmológico. Resultados Avaliamos 42 pacientes de 17 a 64 anos (média 40,7 ± 12,5), 22 do sexo masculino. Encontramos catarata ou positividade de cirurgia em 38 (90,48%) e blefaroptose em 23 (54,76%) e esses sinais foram correlacionados significativamente à maior gravidade da disfunção motora. Baixa PIO também foi comum e não correlacionada à gravidade motora. Alterações da motilidade ocular e de estereopsia ocorreram. Conclusão Catarata e ptose palpebral são frequentes na DM1 e associadas à gravidade motora. Baixa PIO é comum e parece ser independente da evolução motora.

Background Anomalous head posture (AHP) or torticollis is a relatively common condition in children. Torticollis is not a diagnosis, but it is a sign of underlying disease. Grisel’s syndrome (GS) is a rare condition of uncertain etiology characterized by a nontraumatic atlanto-axial subluxation (AAS), secondary to an infection in the head and neck region. It has not been considered, in ophthalmological papers, as a possible cause of AHP. Case presentation A case of AAS secondary to an otitis media is studied. The children showed neck pain, head tilt, and reduction in neck mobility. The patient had complete remission with antibiotic and anti-inflammatory therapy and muscle relaxants. Signs of GS should always be taken into account during ophthalmological examination (recent history of upper airway infections and/or head and neck surgeries associated to a new onset of sudden, painful AHP with normal ocular exam). In such cases it is necessary to require quick execution of radiological examinations (computer tomography and/or nuclear magnetic resonance), which are essential to confirm the diagnosis. Conclusion GS is a multidisciplinary disease. We underline the importance of an accurate orthoptic and ophthalmological examination. Indeed, early detection and diagnosis are fundamental to achieve proper management, avoid neurological complications and lead to a good prognosis.

Ocular neuromyotonia is a rare ocular motility disorder characterized by involuntary contraction of extraocular muscles resulting in paroxysmal diplopia. Although ocular neuromyotonia is reported as a rare complication after radiation therapy, there are a few cases of ocular neuromyotonia in the absence of irradiation. In the reported cases the possibility of vascular compression has been suggested on radiological imaging. The authors report a case of ocular neuromyotonia treated by microvascular decompression of the third cranial nerve, supporting the hypothesis that neurovascular compression may play a role in its pathogenesis. The usefulness of preoperative 3D imaging for microvascular decompression is also discussed.

Advances in biotechnology continue to introduce new materials for reconstruction of orbital floor fractures. Which material is best fit for orbital floor reconstruction has been a controversial topic. Individual surgeon preferences have been supported by inconsistent inconclusive data. The purpose of this study was to assess and analyze published evidence supporting various materials used for orbital floor reconstruction and to develop a decision-making algorithm for clinical application. A systematic literature review was performed from which 48 studies were selected after primary and secondary screening based on set inclusion and exclusion criteria. This cumulatively included 3475 separate orbital floor reconstructions. Results revealed risk and benefit profiles for all materials. Autologous calvarial bone grafts, porous polyethylene, and polydioxanone (PDS) were most widely used for orbital floor reconstruction. Increased infection rates were reported with polyglactin 910/PDS composites and silastic rubber. Ocular motility was reduced most with lyophilized dura and PDS. Preoperative and postoperative rates for diplopia and enophthalmos varied among the materials. In conclusion, our results revealed continued inadequate evidence to exclusively support the use of any one biomaterial/implant for orbital floor reconstruction. Results have served to create a decision-making algorithm for clinical application. Our authors propose certain parameters for future studies seeking to demonstrate a comparison between 2 or more materials for orbital floor reconstruction.

Evaluation of a patient with orbital disease needs a multidisciplinary approach. Clinical examination should seek to glean information regarding pathophysiologic effect and location and to evaluate consequences of this disease on cosmetic, vision and ocular motility. Procedures of imaging are based on the implied complementary exams that should be done according to the suspected clinical location and characters help to characterize the underlying process. Imaging can define the location, size, limits and relationship of the disease to other tissues and especially to the vascular system. It may be completed by blood test. The final diagnosis is based on several arguments and can appeal for a diagnostic biopsy in the most difficult cases.

Resume L’examen d’un trouble oculomoteur doit permettre de le definir, de localiser sa cause et d’enumerer des hypotheses concernant son mecanisme et son etiologie afin de guider les examens complementaires necessaires au diagnostic. Nous detaillons ici les differentes etapes de l’examen : l’interrogatoire, l’examen de la motilite proprement dit et les tests a realiser dans le meme temps, en insistant sur les elements semiologiques importants pour arriver au diagnostic.

Aim: The uniocular field of fixation (UFOF) may be assessed using the Goldmann perimeter subjectively and objectively. Haggerty et al. in 2005 proposed a technique examining six axes corresponding to the primary field of action of each extraocular muscle (EOM). Comparative evidence on subjective and objective assessment and the effect of target size is unclear. The purpose of this study was to determine the effect of subjective and objective assessment and target size upon the mean total EOM excursions and individual muscle excursions using the Haggerty technique in normal subjects. Methods: Volunteers were recruited with right visual acuity of 0.10 logMAR or better, no manifest strabismus, full ocular motility, and no ocular pathology. Subjective and objective UFOF using two fixation targets (1Ie and 1IIe) were plotted for the right eye by one examiner using the Haggerty technique on the Goldmann perimeter. Results: Twenty-four participants (22 females, 2 males) with a mean age of 20.3 ±1.6 years were included. The mean total EOM excursions performed objectively using target 1Ie and 1IIe were 288.2 ± 4.7° and 288.5 ± 5.7° , and subjectively were 290.7 ± 4.8° and 299.4 ± 7.2°. The mean total excursion comparing objective and subjective assessment was not affected by target size. Increasing the target size produced a significant enlargement in total EOM excursions when assessed subjectively but not objectively. As regards individual muscle excursions, the inferior rectus excursion showed the greatest difference when comparing subjective and objective assessment ( p < 0.0001). A significant difference was also found for the inferior oblique using target 1Ie. Only the inferior oblique was affected by increasing target size when assessed subjectively ( p ¼ 0.007). Bland-Altman analysis showed large variation comparing objective and subjective assessments and for increased target size. Conclusion: The degree of excursion obtained performing objective and subjective assessment can vary for individual EOMs. Target size may also influence the mean total EOM excursion. Standardised method of assessment is vital when assessing the UFOF to avoid misinterpretation of change caused by a different methodology.

We report a case of craniosynostosis showing spontaneous improvement in presumed superior oblique palsy and V-pattern exotropia in long-term follow-up. A 3-year-old girl who presented with head-face anomaly, V-pattern exotropia and abnormal head posture was admitted to our clinic. The diagnosis of Crouzon syndrome was established, and bilateral coronal suture excision and decompression were made by neurosurgeons. After the cranial operation, the patient was followed up for 6 years without further cranial or strabismic operation. At the end of this period, we observed that corrected visual acuity was 20/20 in both eyes and her ocular deviation disappeared in all gaze positions. Strabismus in craniosynostosis may be related to anatomical malposition of the rectus muscles. Spontaneous improvement in ocular deviation may occur, therefore, this possibility must be considered in the planning of surgical intervention. (Turk J Oph thal mol 2012; 42: 306-9)

Purpose: Ocular motility disturbances are common in a number of neuropaediatric and neurometabolic disorders. Assessment of ocular motor function can be a source of information for diagnosis and follow-up of these patients. Aim: To evaluate a new clinical ocular motor function test: ocular motor score (OMS) and provide reference values in children and young adults without known ocular or neurological disorders. Material and Methods: A total of 233 children and young adults, 103 males and 130 females between the ages of 6 months and 19 years, were assessed according to a specific OMS protocol. They were divided into four different age groups: 0.5–3, 4–6, 7–10 and 11–19 years. The OMS protocol consists of 15 different subtests evaluating ocular motor function, and a total score of minimum 0 up to max 15 can be obtained: the minimum score, 0, is considered normal while 1 represents an abnormal function. Results: The median OMS in the whole reference group was 0.3 (range 0–4.8). The median OMS in the different age groups, starting with the youngest, was: 0.9 (range 0.3–4.8), 0.3 (range 0–3.4), 0.3 (range 0–2.3) and 0 (range 0–3.5), respectively. The youngest subjects, aged 0.5–3, showed a significantly higher total OMS compared with the other age groups (p

Ocular motility abnormalities may be a marker of neuro-degeneration beyond motor neurons in amyotrophic lateral sclerosis (ALS). We formally compared clinical neuro-ophthalmic abnormalities in ALS patients and a control population.Patients attending a multidisciplinary ALS clinic (n=63, age 60.8+/-16.4 years) and their caregivers serving as controls (n=37, ages 55.0+/-12.7 years) participated in this cross-sectional study. Visual acuity was assessed. Video recordings of a standardized ocular motility exam including gaze fixation, voluntary saccades, reflex saccades, smooth pursuit, eyelid opening and Bell's phenomenon were rated by two senior neuro-ophthalmologists who were masked to subject group.Visual acuity was lower in ALS patients versus control subjects (OR 0.81 (0.71-0.93), p=0.003, logistic regression). Inter- and intra-rater reliability for ocular motility examination ratings were good (Cohen's Kappa0.6). Findings observed only in ALS subjects included gaze impersistence (14%, p=0.01), moderately or severely restricted voluntary upgaze (13%, p=0.01), and moderate or severe eyelid opening apraxia (27%, p=0.0002). Accounting for age, moderately or severely saccadic horizontal smooth pursuits distinguished ALS from control subjects (OR 3.6 (1.2-10.9), p=0.02, logistic regression).Clinical findings of decreased visual acuity, gaze impersistence, voluntary upgaze restriction, eyelid opening apraxia, and saccadic horizontal smooth pursuits are more frequent in patients with ALS than in similar-aged controls. These findings are potential clinical markers of neurodegeneration beyond upper and lower motor neuron disease in ALS. Further study is warranted regarding their application to disease categorization and outcomes assessment.

Purpose To determine the accuracy of orthoptist referrals from a preschool-based vision screening program for children 3-4 years of age and to report the outcomes of referred children. Methods This was a retrospective review of records of participants in the preschool vision screening program in the Walsall, United Kingdom, area for the 2006-2007 school year. Screening examinations were performed by orthoptists and included assessment of visual acuity, ocular alignment, ocular motility, and stereoacuity. Results For the 2006-2007 school year, 2,830 of 3,623 children (78%) were screened, Of these, 413 were referred to the Hospital Eye Service. Comparison of the screening results and the Hospital Eye Service examination revealed that recorded visual acuities were similar in 81% of subjects and ocular alignment in 94%. Visual acuity was 6/9 or better at the hospital examination in 87% of referred children, with 46% requiring spectacle use only; 17% of referrals were diagnosed with amblyopia. Conclusions Although the Walsall vision screening program diverged from UK national guidelines by testing at an earlier age, there was no evidence that earlier screening led to a large number of incorrect referrals, and early screening may allow for better outcomes. Sensitivity of screening was not tested, and orthoptist screening in the United Kingdom is likely to be more accurate in this age group than nonspecialist or lay screening that is performed in many other areas.

The adult neuro-ophthalmologist may see patients presenting for the first time with symptoms and signs classically associated with paediatric conditions. Therefore a literature review combined with case descriptions from the author’s clinic is presented here, divided into problems of the optic nerve, ocular motility or visual function. Though such a review cannot be comprehensive nor cover every paediatric condition that has ever presented to an adult clinic, the authors hope that it will provide some useful insights and interesting clinical vignettes to assist clinicians in their own practice.

Purpose: To elucidate the aetiology of congenital Brown syndrome. Methods: Four consecutive patients diagnosed with unilateral congenital Brown syndrome had a comprehensive standardized ocular motility examination. Any compensatory head posture was measured. Brain magnetic resonance imaging (MRI) with regard for the IV cranial nerve (CN) was performed in all patients. Orbital MRI was performed in 2/4 patients, with images acquired in eight directions of gaze and superior oblique (SO) muscle areas compared. Results: CN IV could not be identified bilaterally in two patients, but was absent only on the side of the Brown syndrome in the two other patients. On the normal side, orbital MRI revealed a smaller SO muscle area in upgaze than in downgaze, demonstrating normal actions of this muscle. On the side of the Brown syndrome, the SO area remained the same in upgaze and in downgaze and approximately symmetric to the area of SO in downgaze on the normal side. Conclusions: These cases add further anatomical support to the theory of paradoxical innervation in congenital Brown syndrome. CN IV was absent in two patients on the side of the Brown syndrome, but without muscle hypoplasia. SO muscle size did not vary in up- and downgaze, which we interpreted as a sign of constant innervation through branches of CN III.

Purpose: To determine the frequency and clinical features of the extrinsic ocular motility changes in patients with multiple sclerosis living in the state of Sao Paulo (Brazil), consecutive cases series from 1996 to 2011. Methods: Eighty-three consecutive multiple sclerosis subjects were enrolled, aged from 17 to 59 years. All patients had a history taking and a comprehensive ocular exam. Results: Extrinsic ocular motility changes was detected in 17 (20,48%) out of 83 individuals. Diplopia as the first symptom of the disease occurred in 11 (13,25%) individuals. Conclusions: Frequency of diplopia as first symptom of multiple sclerosis is relevant. According to this statement, crucial importance should be given concerning spreading of knowledge and skills to internal medicine and general ophthalmology practicing physicians about early diagnosis of multiple sclerosis, which would reduce a delay in diagnosis of the disease and would help patients in the prognosis of the disease which they endure.

Cysticercosis is the most common parasitic disease of the central nervous system. Although seizure is the most common presenting feature, the presentation depends upon the location of the cysts. The other sites of involvement of cysticerci are soft tissue and eye. Unusual location of the cysts may result in uncommon manifestations. Ocular cysticercosis can involve both the intraocular and extra ocular muscle. Extra ocular muscle cysticercosis is rare. Cysticercosis rarely presents as proptosis. Orbital cysticercosis presents with limitations of ocular motility in 75% of patients. We report a case of disseminated cysticercosis presenting as bilateral proptosis.

The study investigated the effects of choline combined with Bangerter filter in the treatment of amblyopia. All amblyopic subjects used a Bangerter filter on the corrective spectacle lens (1d over the left eye, 1d over the right eye). Choline was then administered orally to 39 patients once daily, five days per week for the entire study period. Subjects treated with the Bangerter filter showed a mean visual acuity of 0.27 logMAR; at 12mo of treatment, the mean visual acuity reached 0.09 logMAR. Patients treated with the Bangerter filter and citicoline showed a mean visual acuity of 0.35 logMAR; at 12mo of treatment, the mean visual acuity reached 0.01 logMAR. No significant changes in the angle of deviation were observed in both groups. Subjects in both forms of amblyopia therapies demonstrated an increase in visual acuity. However, these effects were markedly enhanced when coupled with the administration of choline. Findings suggest that the effects are particularly relevant in the more severe amblyopic cases.

Acquired palsy of the lateral rectus presents with horizontal diplopia and has a broad differential. Herpes zoster ophthalmicus- (HZO) related cranial nerve palsy is a transient and self-limiting condition. Systemic antiviral treatment is administered in order to prevent sight-threatening complications. In suspected cases, zosteriform rash should be questioned. One should keep in mind that acquired esotropia in the elderly may sometimes present following HZO.

The swinging eyelid procedure is a versatile technique to approach orbital and periorbital surgical fields with less visible scar. Although mainly used in orbital surgeries, this procedure can also be used to expose the zygomatic arch and periorbital areas. The swinging eyelid procedure, therefore, enables appropriate reduction of zygomaticomalar fracture under direct visualization. We used this technique for a 27 years old man with a displaced zygomaticomalar fracture that pushed on the lateral rectus muscle. Good functional and cosmetic results were obtained postoperatively without ocular motility impairment.