2003 Abstracts
British Orthoptic Journal 2003
Editorial
Sixty yet still active!
Alison Y. Firth
Supranuclear and internuclear control of eye movements: a review
Fiona Rowe
Abstract:
Aim: To review conjugate and disjugate eye movement systems
Methods: A literature review was undertaken to review saccadic, smooth pursuit and vergence eye movements in particular but also the integration of vestibulo-ocular and opto-kinetic responses
Results: The type of movement generated, the mechanism of reaction to produce the eye movement, supranuclear pathways and internuclear pathways plus neural integration of the eye movement are described.The neural substrate for horizontal and vertical gaze control is addressed and the clinical disorders of eye movement that may be encountered are disucssed.
Conclusion: Knowledge of neuro anatomy is pertinent to the understanding of eye movement pathways and the subsequent disorders that occur due to pathology affecting these structures
Key words: Eye movement, Internuclear, Opto-kinetic response, Saccades, Smooth pursuit, Supranuclear, Vergence, Vestibulo-ocular response.
Stroke re-visited: visual problems following stroke and heir effect on rehabilitation
Claire MacIntosh
Abstract:
Aims: To review vision problems following stroke, their effect and how they can be managed. To identify the orthoptist's role as part of the multi-disciplinary stroke rehabilitation team.
Methods: A literature review was undertaken and analysis made of an audit of 76 patients on a stroke rehabilitation ward.
Results: Around 60% of patients suffering a stroke can have a vision problem. The problems include reduced vision, which can be a result of uncorrected refractive error;visual field loss; visual inatention and other cognitive deficits; and oculr motility disorders, following brainstem stroke.
Conclusions: Stroke is common and its incidence is rising in an ageing population. A significant proportion of stroke patients have vision problems, which often go unrecognised, and can have an impact on the patient and their rehabilitation. Visual inattention is given much coverage in the literature; visual field loss is well recognised; reduced vision and ocular motility disorders receive little attention. The orthoptist has the skill and knowledge base to identify, manage and advise on many of these vision problems, and can provide the interface between the patient, multi-disciplinary team and the relatives or carers with regard to visula status.
Key words: Stroke, Vision, Visual inattention/neglect, Visual fields
Variability in automated visual fields: a literature review.
Ian Cunningham and Paul Knox
Abstract:
Aim: To present a review of literature examining variability, current and new mwthods of analysis of visual field progression using the Humphrey Automated Perimeter
Methods: An examination of the literature was carried out on different types of variability, including intra-test and inter-test difference, ageing effects and anisotropic changes within the visual field in normal subjects and patients with glaucoma.
Results: Determining progression of visual field defects is difficult due to variation between examinations. New data on the causes of this variability and new methods for analysing series of fields against baseline data may allow for more accurate detection of deteriorating visual fields.
Conclusions: A degree of variation should be expected between examinations. Current analytical software may help clinicians determine the accuracy and progession of visual field loss.
Key words: Ageing, Anisotropy, Automated visual fields, Test-retest variability.
Attention deficit hyperactivity disorder: Do we know what we are dealing with?
Susan C. Rome
Abstract:
Aims: To review the condition of attention deficit hyperactivity disorder (ADHD) in children, with particular regard to any link with abnormal visual conditions and the implications for orthoptists dealing with these children.
Methods: A literature review was undertaken to explore the current thinking on diagnosis and management of ADHD and to establish whether any link with visual disorders could be found.
Results: Research shows that children with ADHD may suffer from subtle visual differences compared with children without the condition. The question whether medication with Ritalin plays a prt in this remains to be answered.
Conclusion: Some children with ADHD do have visual problems. In caring for these children, a multidisciplinary, muliagency approach to assessment and management is important and visual function testing plays an important part in this.
Key words: ADHD, Attention deficit hyperactivity disorder, Ritalin, Visual system dysfunction.
The orthoptic 'slant' on patients undergoing macular translocation
Jignasa V. Mehta, David Wong, Judith Wylie, and B. Jane Young.
Abstract:
Aim: To highlight the involvement of an orthoptist and the typical orthoptic assessment of patients undergoing macular translocation for the treatment of age-related macular degeneration (ARMD).
Methods: Some background information regarding ARMD and the current treatments is discussed. Typical orthoptic assessment with expected responses before and after macular translocation and after counter-rotation surgery is presented.
Results: Due to the nature of the condition and the treatment for ARMD the primary aim of the orthoptic investigation is to assess the amount of 'tilt' experienced by the patient after macular translocation and after counter-rotation surgery. Recognition must also be given to the assessment of retinal misalignment.
Conclusions: The development of new treatment regimes requires the evolution of the orthoptic role and the need to adapt an orthoptic assessment with the introduction of additional terminology to describe different observations in patients treated with macular translocation.
Key words: Age-related macular degeneration, Counter-rotation, Macular translocation, Retinal misalignment, Tilt
The effect of aging on the range of ocular movements and convergence
Jillian H. Davidson and Paul C. Knox
Abstract:
Aims: To investigate the range of visually useful ocular movements under both binocular and monocular conditions and the near point of convergence in an elderly and in a young group of subjects.
Methods: The range of visually useful ocular movements and the near point of binocular convergence were assessed in 12 old (mean age 72.73 +/- 6.1 years) and 10 young subjects (20.2 +/- 1.7 years).
Results: The range of visually useful ocular movements appeared to decrease for all positions in the older group. Under binocular conditions the difference reached statistical significance only in elevation. However 7 of 12 older subjects achieved the maximum measurable elevation. Under monocular conditions, there was a statistically significant reduction of supraduction in either eye and left abduction in the older group. Within the older group there was a statistically significant positive correlation between age and the near point of convergence and it was statistically significantly greater in the older group.
Conclusions: These results suggest a significant decrease in binocular elevation and a reduction in left abduction in healthy older individuals. Ageing does affect the near point of convergence, but only relatively slowly.
Key words: Ageing, Convergence, Range of visually useful ocular movements.
Blur point versus indistinguishable point inassessment of accommodation: objective and subjective findings in early presbyopes
Emma Goodall and Alison Y. Firth
Abstract:
Aim: To measure the distance form the eye and the refraction of the eye at the point at which print blurs and the point at which it becomes unreadable.
Methods: Subjective accommodation in 7 early presbyopic subjects (mean age 45 years), with no additional near correction, was tested using 6/12 reduced Snellen and 6/12 Lea symbols. The point at which blur was first noticed and the point at which the print became indistinguishable were noted in centimetres. Objective measures of refraction were taken at each of these points.
Results: Subjective and objective results for reduced Snellen and reduced Lea symbols were similar (p=0.91; p=0.81) as were the points where the print was no longer distinguishable (p=0,23; p=0.72). The difference between the blurr point and the indistinguishable point measured in centimetres for both the reduced Snellen text and Lea symbols were statistically significant. (p=0.005; p=0.0001). The objective measures for these points, however, were not statistically different (p=0.32 and p= 0.63, respectively).
Conclusion: A clinically significant difference exists in the distance from the eyes between the point at which the print blurs and the point at which it becomes indistinguishable. No significant change occurs in accommodation when measured objectively after the blur point. It is recommended that the end point of this test is the point at which print starts to blur.
Key words: Clinical testing, objective accommodation, Presbyopia, Refraction, Subjective accommodation.
Evaluation of the Sbisa bar for the measurement of sensory fusion.
Emma J. Knowles and Helen J. Griffiths
Abstract:
Aims: To determine the effect of Bagolini striated glasses used in conjunction with the Sbisa bar (Bagolini filter bar) to measure sensory fusion in a normal population. Also to determine whether placing the Sbisa bar over the dominant or non-dominant eye affects the results.
Methods: The strength of sensory fusion of 24 adult subjects with normal binocular single vision was measured with the Sbisa bar with and without Bagolini striated glasses. Both methods were tested with the Sbisa bar placed over the dominant and non-dominant eye.
Results: Using the Sbisa bar with Bagolini striated glasses, the mean strength of the filters required to disrupt sensory fusion was 13.91 (+/-2.13) when fixing with the non-dominant eye and 14.46 (+/-1.11) fixing with the dominant eye. Without the Bagolini glasses the mean strength of the filters required to disrupt sensory fusion was 13.7 (+/-1.97) when fixing with the non-dominant eye and 14.32 (+/-1.22) fixing with the dominant eye. No significant difference in the strength of sensory fusion occured when measured with or without Bagolini striated glasses (p>0.05) nor between the dominant and non-dominant eye when measured with the combined use of the striated glasses (p>0.05). Using the Sbisa bar alone, sensory fusion fixing with the dominant eye was significantly greater than when fixing with the non dominant eye (p<0.02).
Conclusions: Combining the Sbisa bar with Bagolini striated glasses was found to make the interpretation and understanding of the test procedure much easier for the participants without significantly affecting the strength of sensory fusion measured. This method is therefore advocated for clinical use. as ocular dominance may influence the strength of sensory fusion measured it is recommended that the methodology and recording of results are standardised.
Key words: Bagolini striated glasses, Ocular dominance, Sbisa bar, Sensory fusion.
Transient inferior rectus, inferior oblique and superior oblique palsy following arterial ligation for epistaxis.
Mary Forkin and David Parker.
Abstract:
Aims: To present a case of ocular motility problems following arterial ligation for epistaxis together with a discussion of the possible processes involved.
Method: The case of a 75-year-old man who presented with vertical and horizontal diplopia is described.
Result: Examination revealed inferior rectus, inferior oblique and superior oblique palsies. A significant improvement in ocular movements was documented over a 3 month period with the patient regaining binocular single vision.
Conclusions: Since superior oblique palsy in isolation is a recognised complication following arterial ligation for esistaxis and since this patient has demonstrated a tendency towards multiple palsies after previous surgical ligation, some outside the range of surgical dissection, it seems reasonable to speculate that the inferior rectus and inferior oblique wee affected in a similar way in this instance.
Key words: Anterior ethmoidal artery, diplopia, Epistaxis, Inferior oblique palsy, Inferior rectus palsy, Posterior ethmoidal artery, Superior oblique palsy.
A case report of the use of prism glasses to alleviate the effects of Meniere's disease.
Tracy Crowley
Abstract:
Aims: To review the literature on the alleviation of symptoms in Meniere's disease and to present a case report of an adult successfully treated using base in prisms.
Methods: A 66-year-old man who presented with acute attacks of Meniere's disease was assessed for base in Fresnel prisms using the Utermohlen test.
Results: A 2 dioptre base in Fresnel prism applied to the right lens successfully alleviated the acute attack. The patient has remained symptom-free with no further attacks over the past 20 months.
Conclusions: Further research, with a larger study group, is required to determine whether a placebo effect is the cause of the improved symptoms. However in this reported case prisms appear to have been a useful conservative treatment option.
Key words: Meniere's disease, Prisms, Tinnitus, Utermohlen test.
Primary levator synkinesis associated with downgaze
Carole A. Jackson and Vanessa Salisbury
Abstract:
Aims: To present an unusual case of congenital levator synkinesis and discuss the clinical features and importance of correct diagnosis..
Methods: A case is documented. History, orthoptic assessment and photographic illustrations are presented.
Results: Retraction of the upper eyelid on downgaze was present and was not asociated with any type of jaw movement or other stimulus which has previously been associated with levator synkinesis.
Conclusions: primary levator synkinesis associated with eye movements may be more common than previously reported. it can occur as a benign clinical entity.
Keywords: Jaw winking, Lid retraction, Marcus Gunn syndrome, primary levator synkinesis.
Macular translocation for a patient with age-related macular degeneration.
Judith M. Wylie, B. Jane Young, Jignasa Mehta, David Wong.
Abstract:
Aim: To present the orthoptic assessment and results of a patient undergoing macular translocation surgery for exudative age-related macular degeneration (ARMD).
Method: A case is presented of a patient with exudative ARMD. The orthoptic involvement in this new technique is described.
Results: The patient demonstrated a stable satisfactory vision and gross binocularity. The use and interpretation of certain orthoptic tests differs from the usual orthoptic investigation of an ocular motility patient.
Conclusion: Macular translocation is a new treatment for ARMD. the case presented demonstrates the expansion of the role of the orthoptist into new areas of diagnosis and assessment.
Keywords: Age-related macular degeneration, Counter-rotational muscle surgery, Macular translocation, Monocular tilting.
Macular translocation: two case reports of counter-rotation of the globe for monocular torsion.
Alison J. Price
Abstract:
Aims: To document how macular translocation (rotation of the macula to a new retinal position) results in neurosensory changes, producing a subjective appreciation of environmental tilt, or apparent monocular torsion; and to describe the management of such cases.
Methods: Two patients are reported who, following macular translocation surgery, had apparent incyclo-deviation measuring 55 degrees and 60 degrees.
Results: Both subjects required extraocular motility surgery to counter-rotate the globe. A reduction in the monocular torsion was achieved in both cases using transposition techniques. Residual monocular torsion of 10 degrees and 22 degrees was measured using the Maddox rod but neither had a subjective appreciation of the tilt.
Conclusions: Macular translocation is a new treatment for age-related macular degeneration. The resultant torsion may be treated by extraocular muscle surgery.
Keywords: Environmental tilt, Incyclotorsion, macular translocation, Monocular torsion.
The use of blue tint glasses in patients with multiple sclerosis, and others with motion disturbance
Claire MacIntosh
Abstract:
Aims: To raise awareness amongst orthoptists that blue tinted glasses can give symptomatic relief to patients suffering a 'disturbance of motion' which may occur in patients with multiple sclerosis (MS).
Methods: three cases are presented: two with a diagnosis of MS and one with neurological signs but as yet undiagnosed. Orthoptic findings and previous treatment are documented.
Results: The presented cases have different ocular motility findings but similar symptoms, which relate to a difficulty with the perception of motion. these patients found a dramatic improvement in these symptoms when wearing blue tinted lenses.
Conclusion: More research is required in this area. There is no documentation in current literature of the use of blue tinted glasses in patients with motion disturbance. there are no definitive explanations for these findings, but clues may be found in studies of the magncellular and parvocellular pathways.
Keywords: Blue tint lenses, Motion perception, Multiple sclerosis and ocular manifestations.