The management of strabismus

The original causes of strabismus and the complications that develop from efforts by a child to adjust to the condition may present a complex diagnostic and therapeutic problem. The complications of suppression, amblyopia, contractures and anomalous visual habits may become more difficult to correct than the cause of the strabismus. The longer the duration of strabismus, the more complex the problem, the more difficult the treatment, and the less the probability of functional cure. Treatment should be started early. Correction may be brought about by the use of glasses, eye patches and orthoptic training, or by operation. If anatomic abnormality prevents bringing the eyes into line by conservative means, operation should be carried out after the best results possible by these means have been achieved. Surgical treatment, too, where it is indicated, should be done early, in order that normal binocular cooperation can develop before abnormal visual habits can become established.     

SURGICAL TREATMENT OF CONVERGENT STRABISMUS

In convergent strabismus, glasses, visual training and exercises are often helpful, but operation is usually needed in addition to produce a functional or cosmetic cure.Babies who are born cross-eyed should be examined early and nonsurgical treatment started so that proper visual appreciation will be developed in both eyes.Children in whom strabismus develops some time after birth (usually between 18 months and six years of age) should be examined with atropine, glasses prescribed when indicated and full medical treatment instituted. If those measures fail, operation should be done on one or both eyes, the operation depending on the magnitude of the deviation.     

Ophthalmic issues in hemangiomas of infancy

Hemangiomas are the most common benign tumor of infancy. Although most hemangiomas remain asymptomatic, certain hemangiomas can cause significant morbidity and require treatment. Periocular hemangiomas require close observation and early therapy for those lesions with potential for visual impairment. Hemangiomas typically cause visual morbidity by induction of amblyopia, strabismus, significant refractive error or optic nerve compromise. Diagnosis is typically straightforward but occasionally other entities may cause diagnostic confusion and radiologic evaluation can be helpful. This is particularly important if the hemangioma is one component of the PHACES syndrome. Therapeutic options which may be useful include steroids (oral, intralesional or topical), interferon alpha (usually reserved for life- or sight-threatening lesions due to serious potential side effects), laser, embolization and surgery. Ophthalmic treatment using patching, atropine, glasses and stabismus surgery may be necessary.     

Biofeedback techniques in the treatment of visual and ophthalmologic disorders

The literature on the use of biofeedback techniques in the treatment of visual and opthalmologic disorders is reviewed. Although this consists mainly of case studies, there is mounting evidence that biofeedback may be applicable to the treatment of strabismus, nystagmus, blepharospasm, elevated intraocular pressure, and myopia. Because of the success in applying biofeedback techniques in the treatment of other neuromuscular disorders, it is concluded that the use of these techniques in the treatment of blepharospasm and strabismus shows the most promise.     

NONSURGICAL TREATMENT OF CONVERGENT STRABISMUS

It is generally agreed that surgical treatment of convergent strabismus should be withheld until all other less traumatic approaches have proved ineffectual. There are four categories of nonsurgical treatment.One is psychiatric. Too often psychiatric problems in the causation of convergent strabismus are either overlooked or unrecognized.Another is the proper employment of optical devices. For example, spectacle lenses to eliminate the need for excessive accommodation with its associated convergence excess, and the employment of prisms in the lenses to permit the two eyes to see as a unit even though they may not be properly anatomically oriented.Another kind of treatment is orthoptics, the use of exercises and rather complex optical equipment in a laboratory to train the patient in coordination between the two eyes.Treatment with drugs is based on the fact that certain drugs reduce the effort necessary for accommodation (much as eye-glasses do) and therefore lessen the stimulus toward convergence which may possibly tend toward the development of convergent strabismus.     

COMMON EYE PROBLEMS IN CHILDREN

Most penetrating or lacerating injuries of the eye in children justify examination under anesthesia to avoid further harm to an uncooperative patient. The pediatrician in doubt should merely apply a sterile dressing and have an ophthalmologist examine the injury in hospital. Nonperforating injuries may result in severe bleeding 48 to 72 hours later; this may be averted by bandaging the eyes and maintaining rest for four or five days. Removal of foreign bodies should be followed by application of antibiotic ointment and patching to prevent contamination.Congenital stenosis of the lacrimal duct may clear spontaneously or through application of decongestants and sympathomimetic drops. More severe effects, especially infection, justify probing at six months or earlier. The operation should be done under general anesthesia, preferably in hospital.Acute conjunctivitis is best treated by local application of antibiotics or sulfonamides only. Chronic infections may be better managed with the addition of corticosteroids, which reduce local inflammation and control bacterial reaction. Bacterial study should be done only if empirical antibiotic therapy fails. Bacterial desensitization may be helpful. The same methods are effective in blepharitis, aided by hygienic measures. Corticosteroids are most useful in allergic inflammations.Refractive difference is difficult to test before a child can read, and apparent defects may be due to lack of cooperation. Marked inequality of the eyes may signify organic disorder. Strabismus, on the other hand, can be detected as early as 12 or 15 months and should be treated as early as possible by proper lenses, surgery, or both. Pediatricians and parents should be aware that many children appear to have strabismus because of wide epicanthi and deep-set eyes.     

Design and statistical methods in studies using animal models of development

Experiments involving neonates should follow the same basic principles as most other experiments. They should be unbiased, be powerful, have a good range of applicability, not be excessively complex, and be statistically analyzable to show the range of uncertainty in the conclusions. However, investigation of growth and development in neonatal multiparous animals poses special problems associated with the choice of "experimental unit" and differences between litters: the "litter effect." Two main types of experiments are described, with recommendations regarding their design and statistical analysis: First, the "between litter design" is used when females or whole litters are assigned to a treatment group. In this case the litter, rather than the individuals within a litter, is the experimental unit and should be the unit for the statistical analysis. Measurements made on individual neonatal animals need to be combined within each litter. Counting each neonate as a separate observation may lead to incorrect conclusions. The number of observations for each outcome ("n") is based on the number of treated females or whole litters. Where litter sizes vary, it may be necessary to use a weighted statistical analysis because means based on more observations are more reliable than those based on a few observations. Second, the more powerful "within-litter design" is used when neonates can be individually assigned to treatment groups so that individuals within a litter can have different treatments. In this case, the individual neonate is the experimental unit, and "n" is based on the number of individual pups, not on the number of whole litters. However, variation in litter size means that it may be difficult to perform balanced experiments with equal numbers of animals in each treatment group within each litter. This increases the complexity of the statistical analysis. A numerical example using a general linear model analysis of variance is provided in the Appendix. The use of isogenic strains should be considered in neonatal research. These strains are like immortal clones of genetically identical individuals (i.e., they are uniform, stable, and repeatable), and their use should result in more powerful experiments. Inbred females mated to males of a different inbred strain will produce F1 hybrid offspring that will be uniform, vigorous, and genetically identical. Different strains may develop at different rates and respond differently to experimental treatments.     

斜视矫正手术对双眼视觉功能影响的临床研究

目的:探讨斜视矫正手术对双眼视觉功能的影响。方法:将收集的85例斜视患者根据斜视类型分组,共同性外斜视组51例,占60.00%;共同性内斜视组16例,占18.82%。麻痹性斜视组13例,占15.30%,特殊类型斜视组5例,占5.88%。同视机检查并记录患者术前及术后双眼视功能情况。结果:外斜视手术方式多选用单眼外直肌后徙+内直肌缩短术,内斜视手术主要选用双眼内直肌后徙术,上斜肌麻痹多行患眼下斜肌适量后徙或转位术,麻痹性内斜和外斜手术方式为患眼水平肌后徙联合缩短术,外斜V征手术方式为双眼外直肌后徙联合上移半个肌腱,伴有斜肌亢进者需同时行斜肌减弱术,固定性内斜1例手术方式为患眼内直肌断键+直肌联结术。85例患者术后正位73例(85.89%),双眼视觉功能手术前后比较有显著性差异(P0.05),术后较术前可见明显改善。结论:斜视矫正手术可促进双眼视觉功能的恢复,尤其是对于学龄前儿童效果更明显。     

POSTOPERATIVE ESOPHAGEAL COMPLICATIONS—Prevention and Treatment

Postoperative esophagitis and stricture formation may be more serious than the disease for which operation was done.The best treatment is prevention by avoiding use of a nasogastric tube if possible. If it has to be used, the tube should have a small lumen and be removed as soon as possible.When surgical operation is necessary, the cardioesophageal junction should not be sacrificed unless it is absolutely necessary to do so.Conservative treatment if begun early can minimize or prevent the development of esophagitis and subsequent stricture formation.     

Carcinoma of the cervix

Studies by eminent surgeons to reevaluate the place of radical operations in the treatment of carcinoma of the cervix-now that extensive procedures have become less hazardous-apparently have led to confusion in some minds as to choice between surgical and radiation therapy. Pending outcome of the studies, general employment of surgical treatment is unwarranted. Radiation is the treatment of choice in most cases, particularly if the lesion is in an early stage, although radical operation is indicated in certain rare early cases in which delivery of an effective dose of radiation to involved areas is technically difficult. Elsewise it appears at present that operation should be used only in cases of stages III or IV carcinoma-in which results by either means of treatment are poor.One hundred and seven patients were treated with a combination of x-ray and radium irradiation. X-ray was used first to reduce the hazard of implanting the radium. The "five-year arrest" rates were as follows: For 22 patients with stage I lesion, 70 per cent; for 31 with stage II, 55.7 per cent; 33 with stage III, 39.7 per cent; 21 with stage IV, 0. Eighteen patients with diagnosis of carcinoma of the cervix who had had subtotal hysterectomy were treated. The stage of the disease could not be determined. In this group the five-year arrest rate was 52 per cent.     

The role of primary bone grafting in complex craniomaxillofacial trauma

The role of craniofacial surgical techniques and immediate bone grafting in the management of complex craniofacial trauma has been reviewed. Four hundred and one patients with complex facial injuries have been treated. Two hundred and forty-one primary bone and cartilage grafts have been performed in 66 patients. Complex facial injuries should be managed by direct exposure, reduction, and fixation of all fractures utilizing interfragmentary wiring. Very comminuted or absent bone is replaced by immediate bone grafting, producing a stable skeleton without the need for external fixation devices. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O technique. Results of immediate bone grafting have been excellent, and complications are rare. All deformities should be corrected, whenever possible, during the initial operation. This one-stage reconstruction of even the most complex facial injuries will prevent severe postoperative traumatic deformity and disability that may be extremely difficult or impossible to correct secondarily.     

Endoscopically assisted, intraorally approached corrective rhinoplasty.

In the field of facial surgery, operations that require guesswork can result in unexpected complications. One example of such "blind" facial surgery is the lateral osteotomy procedure in corrective rhinoplasty. In most conventional corrective rhinoplasties, the postoperative results of a lateral osteotomy can be controlled by the surgeon's visual perception or manual dexterity; therefore, an experienced surgeon is indispensable in such elaborate operations. Until now, reports have focused on the endoscopic approach through the nasal dorsum or septum through the nostril. However, because of the difficulty in handling the endoscope with osteotomy instruments, it is considered difficult to perform a precise lateral osteotomy procedure using that approach. The authors think the intraoral endoscopic approach should be considered a viable alternative in corrective rhinoplasty.Through small, bilateral gingivobuccal incisions, both the piriform apertures and nasal bones can be easily exposed, and the exact level of the lateral osteotomy can be confirmed directly under the endoscope. The lateral osteotomy is made simply with a reciprocating saw, and symmetrical cutting can be ascertained during the operation. Sometimes, a particular osteotomy level or the proper repositioning of osteotomed segments can be readily evaluated with assistance from the endoscope during the operation. Eleven cases using this procedure were performed over the past 3 years. These endoscopic repairs for a deviated nose were quite helpful for visual confirmation and accurate correction. No complications occurred when using the endoscope with this procedure.     

NDM-1结构功能及抑制剂的抑制机理

在过去的10年中,以新德里金属β-内酰胺酶-1(NDM-1)为代表的金属β-内酰胺酶在全球范围内广泛传播,对公共卫生安全产生了较大的威胁.尤其是近些年这些酶的突变体的出现使得耐药菌给人类健康造成了更加复杂和困难的挑战.目前,临床上仍然缺乏有效的治疗药物和手段.研发有效广谱的抑制剂成为解决此问题的重点.因此本文将针对ND...     

CARCINOMA OF THE CERVIX

Studies by eminent surgeons to reevaluate the place of radical operations in the treatment of carcinoma of the cervix—now that extensive procedures have become less hazardous—apparently have led to confusion in some minds as to choice between surgical and radiation therapy. Pending outcome of the studies, general employment of surgical treatment is unwarranted. Radiation is the treatment of choice in most cases, particularly if the lesion is in an early stage, although radical operation is indicated in certain rare early cases in which delivery of an effective dose of radiation to involved areas is technically difficult. Elsewise it appears at present that operation should be used only in cases of stages III or IV carcinoma—in which results by either means of treatment are poor.One hundred and seven patients were treated with a combination of x-ray and radium irradiation. X-ray was used first to reduce the hazard of implanting the radium. The “five-year arrest” rates were as follows: For 22 patients with stage I lesion, 70 per cent; for 31 with stage II, 55.7 per cent; 33 with stage III, 39.7 per cent; 21 with stage IV, 0. Eighteen patients with diagnosis of carcinoma of the cervix who had had subtotal hysterectomy were treated. The stage of the disease could not be determined. In this group the five-year arrest rate was 52 per cent.     

Interhemispheric connections of ocular-dominance columns in cats with binocular vision impairment

We have investigated the interhemispheric connections of areas 17 and 18 in cats with impaired binocular vision (monocular deprivation, uni- and bilateral strabismus). Monosynaptic neuronal connections were studied using microionophoretic injections of horseradish peroxidase in the single cortical columns and analsys of spatial distribution of retrogradely labelled callosal cells was performed. In the cases of monocular deprivation and strabismus, the spatial asymmetry and eye-specificity of interhemispheric connections are retained. Quantitative changes of connections are more pronounced in strabismic cats. In cats with binocular vision impairments, as well as in control ones, the width of callosal-recipient zone is larger than of the callosal cells zone. This may indicate that interhemispheric connections are non-reciprocal in the areas of cortex that are more distant from the projection of vertical meridian of visual field. We expect that there should be morpho-functional in the cells that are providing connections in opposite directions.     

Applications of Self-Organizing Maps for Ecomorphological Investigations through Early Ontogeny of Fish

We propose a new graphical approach to the analysis of multi-temporal morphological and ecological data concerning the life history of fish, which can typically serves models in ecomorphological investigations because they often undergo significant ontogenetic changes. These changes can be very complex and difficult to describe, so that visualization, abstraction and interpretation of the underlying relationships are often impeded. Therefore, classic ecomorphological analyses of covariation between morphology and ecology, performed by means of multivariate techniques, may result in non-exhaustive models. The Self Organizing map (SOM) is a new, effective approach for pursuing this aim. In this paper, lateral outlines of larval stages of gilthead sea bream (Sparus aurata) and dusky grouper (Epinephelus marginatus) were recorded and broken down using by means of Elliptic Fourier Analysis (EFA). Gut contents of the same specimens were also collected and analyzed. Then, shape and trophic habits data were examined by SOM, which allows both a powerful visualization of shape changes and an easy comparison with trophic habit data, via their superimposition onto the trained SOM. Thus, the SOM provides a direct visual approach for matching morphological and ecological changes during fish ontogenesis. This method could be used as a tool to extract and investigate relationships between shape and other sinecological or environmental variables, which cannot be taken into account simultaneously using conventional statistical methods.     

Iodine 131 in the treatment of large goiters

The treatment of large, complicated goiters with iodine 131 constitutes an interesting alternative to surgery. It is minimally invasive, safe, and effective in most cases, and is particularly valuable in elderly, fragile patients with multiple co-morbidities. Also, it does not preclude the possibility of surgery, should it become a necessary alternative, for whatever reason in the future. The precise pre-treatment evaluation includes thyroid scintigraphy, calculation of thyroid volume and tracheal surface measurement. Patients who are most at risk of acute complications (very small cross sectional tracheal area, underlying respiratory pathology, and hyperthyroidism) should be managed during hospitalization for possible respiratory distress, or rhythm disturbances induced by hormone release. The choice of the iodine 131 activity depends on individual routine practice, either standardized or modulated by thyroid mass. Administration may be repeated depending on the effect obtained and the cumulative dose. Efficacy in terms of volume reduction is practically constant at an early stage. Its effectiveness is difficult to predict, often less in the case of large size goiters. It can be improved by increasing iodine fixation, for example, using synthetic antithyroid drugs. Permanent hypothyroidism is the most frequent and minor complication of the treatment. It involves biological monitoring in order to introduce hormone replacement therapy to avoid thyroid growth stimulation and negate the benefits of radioiodine treatment.     

Ocular fixation with quadriceps tendon allograft

Management of difficult strabismus, such as strabismus fixus and paralytic strabismus, in order to maintain the alignment is complicated. There are many surgical approaches described in the current literature, together with notes on the materials used to stabilize these deformities. We present a new surgical approach using quadriceps tendon allograft for the correction of difficult strabismus such as strabismus fixus and paralytic strabismus. Our idea for using deep frozen quadriceps tendons developed from the fact that this is the most stable and strongest tendon in the whole body. Six patients with strabismus fixus (n = 1), paralytic strabismus secondary to extraocular muscle damage (n = 1) and combined cranial nerve palsy (n = 4) were operated on using a strip of deep frozen quadriceps tendon allograft suturedonto both the globe and the periosteum. The mean age of the patients was 44.33years. (range 17–71 years) All the patients were followed up for six months. The mean preoperative deviation in the six cases was 60 prism diopters(PD) (range 30–123 PD) The mean change in horizontal alignment at 1 month, 3 months and 6 months postoperatively was 54PD, 53 PD and 49.16 PD respectively. We had only one case of under correction. This may possible be due to the remaining function of the antagonist and/or the fact that we had used the distal end of the quadriceps tendon. When the patient (patient No. 5) who had 2 operations was excluded, the mean change in horizontal alignment was 48.6 PD,47.4PD and 43.6 PD. Post-operatively there was no infection or any other complications. According to our study of existing literature, these cases of deep frozen quadriceps tendon allograft application for the indications mentioned above are the first reported cases of its type. We conclude that ocular fixation with quadriceps tendon to the periosteum is a safe and effective option for the management of difficult strabismus. Further research on a larger cohort of patients and longer follow-up time are needed. This revised version was published online in July 2006 with corrections to the Cover Date.     

Grasping molecular structures through publication-integrated 3D models

Although the need for communicating 3D data using simple and intuitive means extends to disciplines as diverse as biology, engineering sciences and the visual arts, none of the currently available molecular-visualization programs depicting potentially highly complex structures are compatible with the portable document format (PDF), the current gold standard of electronic publishing. Therefore, it is highly desirable for authors to be able to provide their readers with a basic 3D display of structures that can be accessed without the need for specialized visualization software. Here, we describe how an interactive 3D model of a molecular complex can be embedded directly into a PDF, thus providing readers with important and educational visual information that would otherwise be more difficult to disseminate.