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BINOCULAR VISION & STRABISMUS QUARTERLY (ISSN 1088-6281), the "loftiest scientific journal in the world" ispublished at an altitude of 9100 feet above sea level, in the shadow of the Continental Divide, in Summit County,Colorado, by BINOCULUS PUBLISHING, PO Box 3727, 740 Piney Acres Circle, Dillon CO 80435-3727 USA; Tel andFAX 970-262-0753. A Medical Scientific E-Periodical. Webmaster: Justin Patnode, Webez.net Internet Services,Dillon, Colorado. Official publication date January 1, 2008.

COPYRIGHT 2008. All rights reserved. No part of this publication may be reproduced or transmitted in any form or byany means, electronic or mechanical, including xerographic copy, photocopy, recording, or an information storage andretrieval system, without permission in writing from the publisher.

EDITORIAL OFFICE / MANUSCRIPTS: Please send to the Editor, Binocular Vision & Strabismus Quarterly, PO Box3727, 740 Piney Acres Circle, Dillon CO 80435-3727 USA. Please see and use "Instructions for Authors", pages6-7, this issue. Letters to the Editor are considered "for publication" unless otherwise indicated and may be editedand condensed as space dictates.

ADVERTISING: Please direct inquiries to BINOCULUS PUBLISHING, PO Box 3727, 740 Piney Acres Circle, DillonCO 80435-3727 USA. Tel & FAX 970-262-0753. Media kit and rates on request.

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Library/Institution:: For 2008, one year subscription $US426, electronic version only. (The reason for this increaseover prior years is that, with our conversion to electronic, there is a marked increase in access facility to the journalfor library users.).........Single electronic issues US$47. Back print issues (1985-2006) $36. Please send orders withcheck or money order payable in US $ funds to Binoculus Publishing, PO Box 3727, 740 Piney Acres Circle, DillonCO 80435-3727 USA. Visa, Mastercard and American Express charges gladly accepted, especially for Internationalorders. Bound Volumes also available to subscribers. To subscribe or order, Call/Fax 970-262-0753. Email: JudyRobinson <[email protected]> Or order on the website at www.binocularvision.net

Disclaimer: The ideas/opinions expressed in Binocular Vision & Strabismus Quarterly do not necessarily reflect thoseof the publisher or editorial staff. BV&Sq makes every effort to maintain accuracy; however, cannot guaranteeaccuracy of contents or claims of advertisers. The reader should consult the maker or manufacturer's instructionsbefore using any product appearing in BV&Sq.

The designation of individual issues is by the quarter, not the season, because seasons are never the same, butopposite, in the Northern and Southern hemispheres. The seasons are however designated on the cover with theNorthern season on the top and, inverted below, the current season in the Southern hemisphere.

Bin ocula r Vis ion & S trab ism us Qu arte rly© EDITORIAL BOARD First Quarter of 2008, Volume 23 (No.1)

Leonard AptRobert W. ArnoldE.S. Avetisov, RussiaJohn D. BakerP. Vital Berard, FranceFrank Billson, AustraliaMichael C. BrodskyJorge A. Caldeira, BrazilAlberto O. Ciancia, ArgentinaKenneth J. CiuffredaDavid K. CoatsJeffrey CooperJan-T H.N. de Faber, NetherlandsJay M. EnochCaleb GonzalezMichael H. Graf, GermanyDavid GuytonEugene M. HelvestonRichard W. HertleCreig S. HoytDavid G. HunterRobert S. JampelEdouard Khawam, LebanonLionel Kowal, Australia

Stephen P. Kraft, CanadaKrystyna Krzystkowa, PolandJoseph Lang, SwitzerlandMalcolm L. MazowHenry S. MetzJoel MillerJames L. Mims IIIScott E. OlitskyGian Paolo Paliaga, ItalyEvelyn A. PaysseZane F. PollardJulio Prieto-Diaz, ArgentinaEdward L. RaabMichael X. RepkaJames D. ReynoldsDavid L. Romero-Apis, MexicoAlan B. ScottKurt SimonsAnnette Spielmann, FranceDavid R. Stager, Sr.Martin J. Steinbach, CanadaDavid S.I. Taylor, EnglandGuillermo Velez, ColombiaBruce C. Wick

M. Edward Wilson, Jr.Kenneth W. Wright

EMERITUS

Shinobu Awaya, JapanHenderson Almeida, BrazilBruno Bagolini, ItalyAlbert W. BiglanWilliam N. Clarke, CanadaJohn S. Crawford†Robert A. Crone, NetherlandsEugene R. Folk†David A. HilesDavid HubelBela JuleszHerbert Kaufmann, GermanyPhilip Knapp†Burton J. KushnerPinhas Nemet, IsraelJ.V. Plenty, United KingdomRobert D. ReineckeWilliam E. ScottR. Lawrence Tychsen

INDEX TO ADVERTISERS, VOLUME 23, NUMBER 1, 2008Fresnel Prism and Lens Co. Page 3

Burton J. Kushner's Grand Rounds Collection Pages 9

Gunter K. von Noorden's History of Strabology Pages 9

Eugene M. Helveston's Surgical Management of Strabismus Pages 9

Australian Orthoptic Journal Page 8

British, Irish and American Orthoptic Journals Page 4

DeW it Aniseikonia Inspector, new version Page 64- back cover

mailto:[email protected]

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“... the belief that one’s view of reality is the only reality is the most dangerous of all delusions ...”

-Watzlawick, 1976

EDITOR ISSN 1088-6281 First Quarter of 2008Paul E. Romano, M.D., M.S.O TABLE OF CONTENTS Volume 23, Number 1

MEDLINE Abbr. Binocul Vis Strabismus Q NLM ID: 9607281

6 Advice and Information for Authors 7 Brian D. Stidham, M.D., Memorial Lectureship13 History of Binocular Vision & Strabismus Quarterly18 Correspondence:

Eye Muscle Surgery for Nystagmus, Z.I Wang and L.F Dell’Osso, Ph.D.Reading e-Periodicals, Burton J. Kushner, M.D.

17 2008 Meeting Calendar21 Editorial: Due to TV? Critiques and Moral Changes in Our Society; e-Publishing,

Binocular Vision Vertical Fusion; Unique Esotropia: Papilledema andCystinosis

*** ORIGINAL SCIENTIFIC ARTICLE ***

23 Response Pattern Asymmetry of Binocular Vision Vertical Fusion Amplitudes ina Normal Population.Janet K. Kim, B.S., Ashley M. Hayden, M.D., Elvio A. Sadun, B.S., Laurie D. Dustin, M.S., J. Sebag, M.D. and Alfredo A. Sadun, M.D., Ph.D.

*** CASE REPORTS ***

31 An Unusual Case of Adult Progressive Esotropia Caused by High MyopiaMasahira Ohba, M.D., Hirokatsu Kawata, M.D., Hiroshi Ohguro, M.D. and NaokoFukushi

37 A Case of Intracanial Hypertension and Papilledema Associated withNephropathic Cystinosis and Ocular InvolvementAaron Parnes, M.D., Steven J. Wassner, M.D. and Joel M. Weinstein, M.D.

41 Abstracts 46 Hyde Park Editorial

64 de Wit’s New Version of the Aniseikonia Inspector

BINOCULAR VISION & Strabismus Quarterly: INSTRUCTIONS FOR AUTHORS

SUBMISSION OF MANUSCRIPTS (TYPESCRIPTS)

Electronic Submission: Send one copy of your Letter oftransmittal, copyright transfer, and permissions for publicationsof photos (see below for details of these), and one copy of yourpaper/manuscript, using a word processing program forMicrosoft/ Office typed in a loose typewriter typeface, anddouble-spaced. Include all Tables and Figures (graphs, linedrawings, and photos) preferably as part of the manuscript ratherthan as attachments. to: [email protected]

Standard Hardcopy Submission: Send four (4) copies, typed ina loose typewriter typeface, and double-spaced with xerographiccopies of all figures (graphs, line drawings, and photos). Alsosend two (2) originals of all computer generated/printed figuresand glossy photo prints of and figure by EITHER US Post Officeor a delivery service TO: EDITOR, BINOCULARVISION

740 PINEY ACRES CIRCLE PO BOX 3727DILLON CO 80435-3727 USA

Please also send a CD or 3.5" diskette copy of your manuscriptmade on an IBM or IBM compatible PC using Word Perfect 10or Microsoft word processing program.EITHER WAY- Send acovering letter of transmittal with name, address, telephone andFAX numbers, email address of corresponding author, i.e.,theauthor to whom letters of receipt and acceptance, galley proofsand reprint request forms are to be sent.Note: To comply with the Copyright Act of 1976, include also thefollowing COPYRIGHT TRANSFER STATEMENT, signed byeach and all authors: "The undersigned author(s) transfers allcopyright ownership of the manuscript entitled (title of article) toBinocular Vision & Strabismus Quarterly/Binoculus Publishingin the event the work is published. The author(s) warrants thatthe article is original, is not under consideration by anotherjournal, and has not been previously published".

References: If "PERSONAL COMMUNICATIONS", majoramounts of text or any Figures from any previously publishedpaper are included in your paper, include also reprintpermissions from prior author and publisher if printed. (see"Sources, Credits, and Permits", below).All manuscripts, including solicited material, is subject to editorialreview and revision. Only manuscripts in English are considered.All Manuscripts submitted become the property of the Journaland may not be published elsewhere without written permissionfrom both this Editor and Publisher. There are no publication or "page" charges to authors except forillustrations or printed length in excess of 12 pages. But nocharges are levied without consent of the corresponding author.

TEXT STYLE AND CONTENTPage Headers Each and every page, including xerographicfigure copies, Legends for Figures, Tables and References,should be arabic numbered consecutively with an abbreviatedtitle but NO authors' names at the page top. The Title page ispage 1, ABSTRACT is page 2.Title Page: Declarative titles are acceptable and encouraged.(Pretend you are writing a newspaper headline.)Précis: Include a one sentence précis (35 words or less)summarizing the main outcome/finding of the study.List in this order: All author(s)full names AND ALL DEGREES asdesired when published, academic and institutional affiliations,sources of support, and other acknowledgements. Restate forpublication the corresponding author's name, address, telephoneand FAX numbers, with e-mail address.ABSTRACT: :Do not restate the title as the title will alwaysappear with the abstract. On a separate page (2) provide anabstract-summary of about 200 words, clearly and conciselystating in paragraphs titled respectively the Background andPurpose (or Problem), Methods of study, the major Results, andprincipal Conclusions. CONSERVATIVE statements as toIMPORTANCE, recommendations, and applications may beappropriate. The abstract should be factual, specific andsufficiently complete to provide the reader a quick andcomprehensive view of the content of the paper. [Avoidgeneralizations (i.e. "are discussed") OR "baiting" the reader byholding back or out on your results or conclusions.] TEXT CONTENT: Manuscript material should be organized into

the following parts in this order: ABSTRACT; INTRODUCTION(BACKGROUND AND PURPOSE OR PROBLEM);MATERIALS, SUBJECTS AND METHODS; RESULTS*;DISCUSSION OF RESULTS; CONCLUSIONS (&recommendations) REFERENCES; TABLES; LEGENDS FORFIGURES; FIGURES. In the "Discussion of Results", do not introduce new referencematerial. Instead, we expect you to integrate YOUR NEWRESULTS into the current body of knowledge. Specifically: yourresults should be compared to results obtained by prior workers:Confirmations and agreements should be pointed out. Butdiscordances also require enumeration, discussion, andexplanation. Unique or unexpected results demandinterpretation. The statistical significance* of results must beconsidered and their application should also be entertained.

REFERENCES: Order these numerically in sequence as theyappear in the text. Indicate a reference number in the text witha full sized Arabic numeral enclosed in parentheses, i.e. (1). Onthe separate Reference page they should be numberedconsecutively and typed double-spaced. Author's names andJournal titles should be abbreviated, without periods, as in IndexMedicus. For journals punctuate in the following order:Author'(s) last name Initials ["et al" acceptable for more than3]:[colon] Article title with sub-title, if any.[period] IM Journalabbreviation [Bolded] year; volume number in Arabic numerals:inclusive pages. Example: 1. Jones AB, Jones CD, Jones EF, et al: Results of LaserSurgery for Strabismus. J Outst Surg l999; 2:301-304. For book references: author, title, volume (if more than one)edition number (if other than the first), publisher, city and year.If the reference is a chapter in a book, the order changes asfollows: the author of the chapter, title of the chapter, "in" booktitle, volume, edition, editors, publisher, city, year, inclusivepages of the chapter. Authors are responsible for accuracy.

TABLES: Always "portrait" (< 7" W), NOT "landscape"configuration which requires undesirable sideways position..FIGURES: PHOTOS, GRAPHICS, DRAWINGS Electronic submission, email or on CD is usually acceptable.Standard Hard copy methods: Photo materials for halftones(photographs, photomicrographs, electron micrographs,roentgenograms) should be submitted cropped and unmounted.On the back of each print, affix a pretyped label with the figurenumber, an arrow and/or "top" indicating the top edge, and thelast name of the first author. Line drawings, charts, and diagramsshould be professionally prepared. For computer generatedgraphics, please submit originals, rather than photographicprints. Typewritten labels and lettering are not acceptable ingraphics. Insure that lettering is large enough to be legible if andwhen reduced for publication. Legends for Figures: typed double-spaced in consecutive orderon a separate page following References. Start each with firstauthor's name in parentheses. Indicate scale when appropriate.State clearly the point which the Figure is illustrating. Use arrowson photos liberally to identify and point out structures. [Assumethe reader is not an expert like you are but rather a student.]

SOURCES, CREDITS, PERMITSQuotations must be accurate and give full credit to the source.Brief properly credited quotes do not require permission of theoriginal author or publisher ("fair use"). For large amounts of textor any figures previously published permission to quote andreproduce must be obtained by the submitting author: originalcopies of the letters from the original author and publishergranting permission to reproduce the work must accompany yourmanuscript. Photo permits: if the subject can be recognized, i.e.,any picture which contains more than just eyes and anunidentifiable bridge of the nose, written permission to publishthe picture must be obtained from any subject over age 8 yearsold (and the parents if a minor under age 18).* Statistical Analysis of Results Mandatory. But give "exact"probability values (i.e., p = .06). Do not use relative p values(i.e.,p >< .05). The term "statistically significant", definedtraditionally as a p #.05, is a totally arbitrary and unscientificterm and should not be used (J Lab Clin Med 1988. 111:501). But do consider whether a result may be "clinically/medicallysignificant". rev 22:(1)-PER

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D. BRIAN STIDHAM MEMORIAL LECTURESHIP

LECTURE to be published annually in Binocular Vision and Strabismus Quarterly

Donations Solicited to Fund LectureshipTo the Editor: The Pediatric Ophthalmology community lost a great doctor last October 6, 2005, with thedeath by murder of D. Brian Stidham. I am attempting to create an endowed lectureship to remember Brian in our community andwithin pediatric ophthalmology, and wonder if I could ask you to consider helping in thisregard. I know that your journal concentrates on strabismus and binocular vision, but could Iinterest you in publishing the "Stidham Lecture in Pediatric Ophthalmology and Strabismus"that will hopefully be given on a yearly basis? I would work with the presenter to make certainthat a manuscript would be produced that would be of acceptable quality. Having a targetjournal for the presentation would be a great carrot to draw top speakers to Tucson on a yearlybasis to give such a talk. We have raised $14,000 towards a target of $50,000 endowment that would ensure that thelecture would be perpetuated. I am committed to continue fundraising until the goal is met. IfBinocular Vision and Strabismus Quarterly would serve as the publisher of the named lecture, I feelcertain we will be able to both attract top speakers and donors to remember Brian in the yearsahead, and to provide a great lectureship in pediatric ophthalmology and strabismus to ourprofessional community which would enjoy greater readership and distribution.

Joseph M. Miller, M.D., MPHHead, Ophthalmology and Vision Science

University of Arizona, Tucson, ArizonaIn reply: We are honored to be asked and will most definitely be pleased to publish this lecture eachyear. We would encourage our readership to donate to this fund: Checks should be made payableto The University of Arizona Foundation with memo of "Stidham Endowment" and sent to Dr.Miller at U AZ, Ophthalmology, 655 N. Alvernon Way, Ste 108, Tucson AZ 85711. - PER

ADVICE for authors submitting papers to Binocular Vision & Strabismus Quarterly©

1. READ & FOLLOW INSTRUCTIONS FOR AUTHORS! Inaddition:2. READ & FOLLOW INSTRUCTIONS FOR AUTHORS! Inaddition:

Reviewing the literature: A proper review of the literature startswith a review of current and appropriate textbooks, especially thelatest edition (currently the Sixth of von Noorden’s BinocularVision and Ocular Motility by Mosby, and Duane’s loose-leaf textClinical Ophthalmology. Anticipating a future requirement, it willonly be to your credit now to specifically state what was includedin your literature search, i.e., the topics or subjects and the sitessearched. For any article submitted here that should include at aminimum, Index Medicus (Medline) from 1966 to the present,Index Bnoculus Primus, 1985 to the present, and the Internet forthe American Orthoptic Journal.

Acceptable TERMINOLOGY not acceptableAHP Abnormal Head Postures:3 face turn head turn chin up/down head up/down Head tiltretroequatorial myopexy Fadenoperationretroequatorial myopexy posterior fixation suturesuspension-recession hang back, hang looseBielschowsky Head Tilt Test three step teststrabolog-y, ist Strabismolog’y, istexact p values “Statistically significant”

Re: “lost to followup” - Avoid this at all costs; First it raises thepossibility that the patient had a (=) bad result or was otherwiseso unhappy with their care that they never came back - or wentelsewhere or went nowhere out of fear or dissatisfaction. If they

are “lost followup” you cannot refute the possiblity that one thosevery unhapy thingsppened! Second it is inexcusable - medico-legally. Third: It reflects poorly on you as both a health careprofessional and as a scientist and Fourth: under the worse ofcircumstances suggests or indicates that you may discriminateagainst those of lower socio-economic status (research findings).

WRITING STYLE IS IMPORTANT TOO:(from Investor’s Business Daily Nov. 26, 1997 by Morey Stettner)“Make Dry Data Come Alive in Your Reports ... tips on makingyour technical writing come alive:1. Remember that less is more. ... simplify your language andprune extra words. Eliminate jargon, and keep your sentencesand paragraphs short. ‘If you write in little bites, you break downlots of information for the readers so that it’s easier to absorb,’said Carolyn Mulford, president of The Writing Coach. ...2. White in the active voice. ... For example, write ‘When youreview the data, you will note these trends’. Avoid saying ‘Thesetrends were noted upon a review of the data.’ Another example:Write ‘We will examine’, not, ‘This has been examined’. ...3. Insert ‘talking subheads’. ... unbroken text can intimidate anyreader, ... organize your writing in sections with each carrying aneasy to understand subhead ... a talking subhead ... alerts thereader of what you’re about to discuss ... for instance, instead ofheading a section with ‘Cost of Scanners’ try ‘Rising Cost of theNext Generation of Scanners’. subheads should average 7 words.4. Run a test. ... ask someone in your audience group to read it.TABLES: Don’t forget the crowding phenomenon. It works inTables too. We prefer spaces to lines to separate the items in aTable. You can also get more material within whatever size limitsyou may have, using spaces instead of lines, especially verticallines. Horizontal lines are less of a sin. -PER 22(4)

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Binocular Vision & BOOK REVIEWS, DESCRIPTIONS First Quarter of 2008

Stra bismus Qu arte rly© Volume 23 (N o.1):A Medical Scientif ic E-Periodical for Binoculus Books advertised on following pages pages 9-10

9 THE HISTORY OF STRABISMOLOGYEdited by Gunter K. Von Noorden, M.D.

THE BOOKThe HISTORY OF STRABISMOLOGY is the first monograph devoted entirely to the development of strabismology

in different regions of the world. Each of the co-authors has been assigned a special chapter in which his or her knowledgeof the material is particularly profound. The origins of strabology go back to the beginning of medicine, thousands of yearsago. The story how th is specialty evolved from quackery and superstition in ancient times to its present state ofsophistication is a fascinating one. It should be of more than passing interest, not only to those specialized in this field butalso to others with an interest in the history of ophthalm ology.

The book consists of approximately 400 pages and is abundantly illustrated with fine reproductions of o lddocuments, engravings, drawings and historic instruments, many of which are from ancient and rare manuscripts. Printedon deluxe art paper THE HISTORY OF STRABISM OLOGY is bound by hand and gold embossed on book plate and spine.THE EDITOR

Gunter K. Von Noorden is a world-renowned author and strabologist. His expertise in the entire field of stabismusis docu-mented in his textbook (now in its 6th edition) and uniquely qualify him to organize and edit a book on the historyof strabology. THE AUTHORS

The authors are prominent strabologists from different parts of the world, internationally known for theircontributions. Indeed many have actually played an active part in shaping the history of strabismology during the secondhalf of the 20th century. They are joined by a comprehensive ophthalmolgist who is also an ophthalmic historian ofinternational reputation and by one of the leaders of the orthoptic profession. The following contributed to this book:Henderson C. Almeida, MC, Shinobu Awaya, MD, Alberto Brown-Limon, MD, W illiam E. Gillies, MD, Eugene M. Hel;veston,MD, Joseph Lang, MD, Emma Limon de Brown, MD, Gunter K von Noorden, MD., Hans Rm eky, MD, Geraldo Ribeiro deBarros, MD, and Gill Roper-Hall, DBOT, CO, COMT

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Binocular Vision & BOOK REVIEWS, DESCRIPTIONS First Quarter of 2008

Stra bismus Qu arte rly© Volume 23 (N o.1):A Medical Scientif ic E-Periodical for Binoculus Books advertised on following pages pages 9-10

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BINOCULAR VISION & STRABISMUS QUARTERLY©The First and Original International Scientific Periodical devoted to

Strabismus and AmblyopiaCited Online in MEDLINE and EMBASE; Cited in INDEX MEDICUS and INDEX BINOCULUS

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Binocular Vision & A H istory of Bin ocular Vis ion Qu arte rly First Quarter of 2008Stra bism us Qu arte rly© Vo lum e 23 (No .1):A Medical Scienti fic e-Periodi ical Pages13-16

A History of this scientific periodical, Binocular Vision & Strabismus Quarterly.

A Celebration of Our 22nd Anniversary

The year was 1984. Parks’ sub-specialty of pediatric

ophthalmology, which had absorbed the previously free

standing, but much less marketable subspecialty of ocular

motility/strabology, in the United States, for sure, was

growing rapidly. This was the era before managed care

intruded. It was the very last of the good years to be a

physician and/or an academician.

Our sole suspecialty periodical was the Journal of

Pediatric Ophthalmology and Strabismus which had been

founded as the Journal of Pediatric Ophthal-mology (only)

by Editor Samuel V. Abraham in 1964 (the very first year

your Editor started his ophthalmology training!). With the

advent of the American Association for Pediatric

Ophthalmology (and [later] strabismus) in the early '70's it

was now fully owned by its New Jersey publisher, Slack.

With the requirement of submission of all papers from the

annual AAPOS meetings, the waiting time in 1984 for

publication of an article in the JPOS was two and a half

years! Even though the journal was subsidized by the

AAPOS, Slack would not enlarge the journal enough or even

at all to handle this demand, in spite of significant profits

from the journal. No solution to this dilemma was apparent

from Slack, or elsewhere.

At that time your founding editor (FE) was running the

Pediatric Ophthalmology and Strabismus Service at the

University of Florida in Gainesville. Another member of the

faculty there, Frank Pollack, who ran the Cornea Service, had

recently started a new journal entitled "Cornea" with the help

of the American, New York, arm of the French publisher,

Masson.

At a departmental party at his home, he proudly showed

us his new computer and office for running his journal.

Realizing that our subspecialty could certainly use some help

with regard to publishing that backlog of 2 ½ years for the

JPOS, we mentioned our problem to Pollack. He said he

would talk to Pierre LaHaye, at Masson in New York, who

was in charge of the eye journals.

Pierre said they were very interested in another eye

subspecialty journal. We agreed on undertaking the job of

assembling an Editorial Board and soliciting articles as the

first Editor. It didn't take long to put together an outstanding,

large, international Editorial Board. Alberto Ciancia and

Joseph Lang were especially helpful. Everyone agreed it was

a good idea. Only my old mentors refused an invitation to

join the Ed Board! (I guess taking a job working for a former

student is not a high priority!) They still thought it was a

good idea. Excellent scientific articles were quickly volun-

teered by many Ed Board members. We started putting the

first issue together with the help of Alvin Fayman who was

to be our production manager at Masson.

Only one person in our professional community objected

to BVQ, because he thought we were already publishing

enough articles about strabismus and he didn't want to read

any more. He wrote to our entire professional community in

an effort to stop our efforts, but no one seconded his singular

sentiments.

We titled the journal "Binocular Vision" because BV is

what the study and treatment of strabismus is really all about.

“BV” is also the first term of the title of our mentor von

Noorden's esteemed textbook "Bible", so it had to be OK.

"BV", we intended, would compliment and fit in with the

"JPOS", both literally and figuratively. It would not sound

like a direct competitive threat - which too many of our

associates were all too ready to assume anyway!

To be sure, we further staked out our strabology area by

adding as a subtitle "eye movements, strabismus, and

amblyopia".

We called it a "quarterly", because that was our intended

publication schedule for starting, and because we think the

name of a periodical, when it takes a common term for a title,

needs to have another word in the title so the periodical is not

confused with, and does not have to be additionally separated

from, the clinical item; (i.e., when you refer to periodicals

like Ophthalmology or Retina or Cornea, don't you often find

yourself adding, "the journal" so your listener knows that you

are referring to a periodical and not to a piece of anatomy or

a science? But "journal" is only French for "daily", so we

called it "Quarterly" which it truly is).

In early 1985 as the first issue was about to go to press, in

April, Masson suddenly decided to close its American branch

and sell all of its scientific periodicals, "lock, stock and

barrel", to Raven Press in New York. (We suddenly felt like

a professional athlete getting "traded" without choice or

input.) The President/owner of Raven Press, Dr. Alan

Edelson, PhD, invited us to journey to their New York

offices to discuss the future of BVQ with him.

On arrival, Edelson first told us that Tom France, then

President of the AAPOS, had just visited him only the day\

before seeking a publisher to replace Slack, who would not

permit the needed expansion of the JPOS.

Edelson suggested that France and the AAPOS and we

could and should combine the two publications into one

Raven publication.

Tom and I presented this idea to both of our Editorial

Boards. But our board members were most enthusiastic about

having a separate journal devoted specifically to strabismus

and binocular vision and only by remaining separate could

we do so. Nor did sharing their journal with us go over very

well with Tom France, the JPOS Editorial staff, or the

AAPOS.


That left Dr. Edelson and Raven with just us, BVQ.

Edelson said that BVQ did not justify his efforts financially.

Since BVQ had not even printed its first issue yet, Edelson

felt no obligation to me, BVQ, or its Editorial Board

members. Therefore, he said, that he would not publish BVQ

but rather would simply abandon/cancel BVQ and just let us

die, evaporate or whatever.

Neither I nor our Editorial Board liked that at all. After

further discussions Dr. Edelson agreed to "give" the

ownership and rights to BVQ to your FE. He said we could

try to publish it ourselves, on our own. We had to

contractually agree to do it all by ourselves and not seek or

use the assistance of, or sell BVQ to, any (other) publishing

house for at least five years.

So we became owner, publisher and Editor.

The first major hurdle was to get the OK of our boss, the

University of Florida Ophthalmology Professor and

Chairman who was himself, with his wife, a medical

publisher (Triad Publishing, Gainesville). Fortunately, our

non compete contract with Raven would not allow him to

require that BVQ be published by his company, Triad.

We found a local printer in town, Ewing Press, who

printed the football programs for the University of Florida

football program, (Go Gators!) and with the help of a free

lance local typesetter we set about publishing the journal.

Your FE did the old cut and paste wax layout routine.[Can

you remember that?!] The first issue was actually completed,

printed and mailed out near the end of 1985. Volume 1 was

initially called "1985" because we still had high hopes of

somehow making that year our first full year of publication.

However, that was not to be and the first full year of the

journal was actually 1986, denoted Vol. 1, "1985-1986".

Within that first year we were also to have the first of

many recurring changes with printers. Ewing Press was

bought out by another local printer, Marsh, and we had to

break in another set of layout, typesetters and press

operators.

Volume 2 was then calendar year 1987. In 1988 (Volume

3), half way through it our printer, Mr. Marsh, passed away

and the firm closed down. We then went to our third local

Gainesville printer in three years, Storter.

In early 1989, after leaving UF, and thanks to computers

we took over in house production of BVQ. Fortunately,

"desktop publishing" on computers had just reached the point

where one did not have to be a computer engineer-whiz to do

it.

So we plunged in full time, purchasing a 286-12! desktop

(for about $1800!) and an HP Laser Printer (for another

$1400!), which, believe it or not, has just been retired after

14 years of service although it has required repair from time

to time. Unbelievably? that printer also had about 100,000

road miles on it as we trucked it back and forth between

Florida and Colorado every 3 months for five years (until we

moved here in 1995). We certainly have seen a number of

computers (?12+) come and go, and almost as many copy

and fax machines as well during this same 14 year period.

But we still use our original word processing software

WordPerfect 5.0 because that is all we needed then and now.

Your FE, because of his ancient artistic bent, (alternate

careers at one point were architecture and industrial or

automotive design) continued as the layout man and became

also the typesetter while his "better half" became chief typist

as well as both the managing editor and the business

manager, which included doing just about everthing else

except the printing. She is in fact really "the publisher."

We learned a lot and fast. In those days, it took two

months of our time, truly full time, both of us, to turn out

each issue. That gave us a few weeks to breath and catch up

on other things in between issues. (We have gotten a lot

quicker at it, but it still takes the better part of a month.)

At the end of 1989, Storter decided they suddenly needed

a lot more of our money just to print the journal since we

were no longer paying them for layout and typesetting. So

we searched for another printer which we finally found down

in Kissimmee, (near Orlando), Cody Publications, who was

at that time all periodicals. They were great, printing 50 or 60

commercial publications

Also that Spring, on recommendation, we traveled to

Washington DC to personally talk to the people at the

National Library of Medicine about getting into Index

Medicus. It was already longer that we thought it should

have been but we were soon to find our expectations not

rapidly fulfilled. Nor did our visit to NIH seem to help at all,

in spite of our attempt to play Washington politics.

Maybe, we thought, a more impressive title would help,

so we became Binocular Vision & Eye Muscle Surgery

thinking that "surgery" in the title might be a key to entry to

the NLM as we could claim to be the only journal devoted to

strabismus SURGERY.

Just a year later, in 1991, Mr. Cody retired and closed his

printing business. One of his salesmen, a Mr. Willis, opened

his own company and tried to service Cody's customers.

However, as good as he was as a salesman, he was not a

good printer's agent and after a couple of difficult issues, we

again sought printing elsewhere.

This time we found it in the F.M.A., the Florida Medical

Association. We turned to their printer in Jacksonville,

Centurion Press. They did a nice job on the monthly Florida

Medical Journal and they did a nice job for us.But once

again, after just a few good years, the Florida Medical

Association, which had created Centurion Press to print their

journal, closed it and turned the printing over to a for-eign

printer. [early out-sourcing!] Some employees at Centurion,

who had been most helpful to us, found themselves new

printing jobs


and us too a new, and our current, printer

in Jacksonville, Economy Printing. We

have been with them ever since even

though we are now retired to Colorado.

Fed Ex and UPS and faxes make it easy.

In 1995, following the introduction of

a European journal entitled simply

Strabismus two years earlier, our Board

felt we should change our name

replacing the "Surgery" in our title to

become what we still are today,

Binocular Vision and Strabismus

Quarterly. We also finally officially

retired from Florida and clinical practice,

to the Rocky Mountains.

The last major chapter in our history

to date, was our admission, finally, after

14 years, to Medline and Index Medicus

in the middle of 1998. This was fol-

lowed almost immediately by admission

to Excerpta Medica and EM Base. This

was at least largely the result of the good

offices of BV&SQ Editorial Board

members Larry Tychsen and David

Guyton.

[For the most complete index,

however, of what has appeared in BVQ

over the past 17 years, including the

dozen before we made the NLM grade

we still compose and publish our own

Index Binoc In cases with lus. We shall

continue to do so because the NLM is

only interested in indexing scientific

articles, and only according to the

relatively general (for us) MESH

keywords. A great deal of the material in

BVQ such as meeting reports, book

reviews, news, and editorial followup

type material is therefore not NLM

indexed. Index Binoculus also indexes

scientific articles with more detailed and specific terms than

MESH, facilitating your retrieval of information.]

Last year in the first issue of 2002, we updated and wrote

here:

"Now in 2002, we enter yet another phase.

A combination of events has contributed:

1. This "mom and pop" operation, successful for 17 years, is

finding it harder and harder to keep up with the latest

advances in the use of computers, (no thanks to Bill [the

fraud] Gates) and the new on line services provided by large

publishers.

2. There have been in the last two years, several exciting

medical problems for your editor, which have left him

unimpaired but which have made him realize that he's not

going to be around forever, and it is time to look for a

permanent home for BV&SQ, while I am still able to do so.

3. The journal has enjoyed cooperative efforts of co-

promotion with Swets & Zeitlinger, the Dutch publisher of

Strabismus. Now they are interested in merging the two

journals in the near future.

Keep being a subscriber, but keep tuned for future events!

(Continued)

Update 2003: Well, it (2002) was an exciting year but it

didn't turn out quite as we had intended or hoped. We have

described some of those happenings already in these pages

[See BV&SQ 17(2):76 and 17(4):278]

1. Long time Charter Editorial Board member and

[former] friend Carlos Souza-Dias, as outgoing Prexy of the

ISA, cleverly blocked our well planned proposal for this

journal to become the permanent ISA journal because he

thought $49 a year for one merged journal which combined

two journals currently costing $84 + $126 = $210 per year

-that this was a not an affordable price for ISA members,

who were already being taxed about $75 per person per year

to pay for fellowships for non ISA members!

2. John Martin, the new head of Publisher Swets and

Zeitlinger had so much trouble managing Huibert Simonsz,

the Editor of his S&Z "Strabismus" Journal, that he changed

his mind and upped (insisted upon) his requirement to total

100% Editorial control of the merged journal, in spite of the

fact that nowhere in the scientific publishing world is this

done by anyone. No M.D. was happy with that.

3. The S&Z Board, in spite of the fact that they would

more than double or triple their profit by buying BV&SQ,

reneged totally on previously discussed offers for BV&SQ.

They limited their offer to initially only one sixth and then

finally to only one third of what they had offered in

preliminary discussions. I had been warned of Dutch

businessmen but this was the biggest fraud that this publisher

has ever been subjected to by anyone. [P.S. except Bill

Gates, of course]

Some unintended consequences of these events were

enumerated in last issue's lead editorial. Chief among these

is Editor Burt Kushner, after 17 years and 68 cases of his

superb strabismus "Grand Rounds", deciding to move on to

other major projects since he too has not yet found the

fountain of youth, and after almost two decades wishes to

move on to other projects. We plan to publish in a book, all

68 of these articles.

Fortunately your Editor in Chief's repaired mitral valve is

doing OK, and his ventricular tachycardia has not returned,

and his retinas remain attached, so we can continue on for

the present as we were. Thanks to a peculiar accommodation

of one of our variable annuity investments, when I do finally

kick the bucket, there will be enough bread available to set

up a foundation to support an independent BV&SQ

permanently.

In the meantime we are refreshing the Editorial Board

with some new and younger faces, whom we hope will help

to see that the foundation does its job, forever.

-PER

Originally published in BV&SQ 2000; 15(1):6-7.

Revised and updated 2003; 18(1):4-6

Update BV&SQ 2005; 20(1): 4-6

Since the last printing of this history two years ago, with

the help of Marcia Youngdahl, owner of our local print shop,

we did get that book of Burt Kushner's 68 editions of his

Grand Rounds published last year .We were all quite happy

with the way it turned out. We did the best we could to copy

the gorgeous cover style of Jean Paul Wayenborgh's History

of Ophthalmology, but in a rich red rather than his royal blue.

Everything else continues unchanged in the lives of your

FE and his publisher-orthoptist-wife. She put out Burt's book

virtually single handed last year. [P.S. But who would have

thought that Slack would continue publishing the JPOS, or

that so many AAPOS members would be so willing to help

them do so considering how poorly they treated the AAPOS

and its membership for all those years? Who would have

thought we could have not just one but FOUR scientific

periodicals servicing our subspecialty — and surviving?]

Amazingly this is our twentieth volume and our twentieth

year of publication. We plan to celebrate the completion of

our twentieth year during the annual AAPOS meeting about

this time next year, which will be held just five miles from

our home and offices, up the road at the Keystone ski resort.

-PER

Update 2007 BV&SQ 22(1)

That 2006 AAPOS meeting next door was most

successful but our 9500 foot altitude was not well tolerated

by too many participants (see Dr. Mims III’s report published

in our pages in the Q2 summer issue page 102) so a repeat is

not likely. There are, however, many good ski resorts

available in the more comfortable 8000 or so foot range like

our neighbor Vail.

At that meeting I found out that our recent myopia

collaborator-contributor Michael Chiang was limiting his

periodical subscriptions to those available on the internet.

That did start us thinking about what you see culminating,

thanks to a host of factors, including many advantages, in

this first issue for 2007 conversion to an electronic internet

version (see Editorial in 22(1), pages 15-16).

-PER

Update 2008 BV&SQ 23(1)

Conversion exceeded our expectations in many

ways: very well received by virtually all subscribers but Bill

Gates requires us to contribute two or three times as much

time to editing, typesetting, proofing of BV&SQ than our old

semi-cut and paste. That includes upgrading our know-how

from 1987 WP 5.0 to MS Office, WP 10.0, Adobe PDFs, etc.

Thank God we are retired so we could work FT for a year+

on it !! -PER, now IT Tech

Binocular Vision & Correspondence First Quarter of 2008

Stra bism us Qu arte rly© Vo lum e 23 (No . 1):A Medical Scienti fic e-Periodical Pages 18-20

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EYE MUSCLE SURGERY FOR

NYSTAGMUS

RE: Outcome Study of Two Standard

and Graduated Augmented Modified

Kestenbaum Surgery Protocols for

Abnormal Head Postures in Infantile

Nystagmus. Binocul Vis Strabismus Q

2007; 22:235-241.

To the Editor:

We read with great interest the paper,“Outcome Study of Two Standard and GraduatedAugmented Modified Kestenbaum SurgeryProtocols for Abnormal Head Postures in InfantileNystagmus” by Chang et al (1). The authors statedthat the results for the correction of abnormal headturns in INS using a modified (6-7-6-7 mm)protocol were equivalent to the Parks’ method.While we agree with the authors’ results, which areconsistent with our observations and predictions,we wish to point out that these positive changeswere not the result of either specific formula but ofthe general broadening effect caused by detachingand reattaching the extraocular muscles (four-muscle tenotomy procedure).

Dell’Osso and Flynn (2) showed in 1979that the Anderson-Kestenbaum procedure had anaccompanying therapeutic effect. The null (i.e., therange of low-nystagmus, high-acuity gaze angles),after this null-moving procedure, was broader thanpre-surgically. The three patients studied had thefollowing nystagmus (±strabismus) surgeries: 1)Kestenbaum procedure on the fixating right eye (5mm medial rectus recession and 6 mm lateral rectusresection); 2) Parks procedure (5-6-7-8) followedby an extra Anderson procedure (2 mm recession ofthe left lateral rectus and 3 mm recession of theright medial rectus) for a total of 7-6-10-8; and 3)Kestenbaum procedure on the fixating left eye (8mm medial rectus recession and 7 mm lateral rectusresection). Note that the binocular patient requiredadditional surgery from the original Parks formulaso the final numbers for each muscle in each casewere merely the total required rotation (in mm) / 2.The muscle recessions and resections were only

responsible for the null movement and it washypothesized that the four-muscle tenotomiesembedded in the Kestenbaum procedure producedthe secondary beneficial broadening effects; thiswas demonstrated in subsequent studies (3-5).

These beneficial effects of tenotomyexplained the historically high success rate of theKestenbaum procedure despite different formulaeused by different surgeons. The broadening effect oftenotomy made their exacting calculations andspecific formulae unimportant. As long as the nullis moved to near primary position, the broadeningeffect will decrease the nystagmus intensity forstraight-ahead viewing and therefore, diminish theneed for an abnormal head position. Therefore, itwas recommended that the amount of total musclemovement (determined by the null position) be splitin equal amounts on the lateral and medial rectusmuscles (2). This ensures that the muscles are at amore homeostatic state post-surgically (i.e., thechanges in innervational levels to both the agonistand antagonist muscles required to bring the eyesback to primary position are equal). The 6-7-6-7procedure advocated by Chang et al (1) adheres tothis finding but should only be used for patientsneeding 13 mm of total eye repositioning; if appliedto patients needing more, a secondary head turn oflesser amount may become necessary and laterevident (giving rise to the myth of the returningnull).

Although theirs was a retrospective study,Chang et al (1) seemed to put forth the premise thatone single formula should be used for all infantilenystagmus patients, and suggested that theirmodified formula was equivalent to Park’s. AsDell’Osso and Flynn (2) demonstrated, the firstassumption is therapeutically problematic, sinceinfantile nystagmus is highly idiosyncratic andoptimal therapy needs tailoring to each individual’snull angle/head turn (±strabismus). Asdemonstrated in Figure 7 of their 1979 paper, thetotal amount of muscle movement should bedetermined by the null position of a patient; thus,there is no “one-size-fits-all” formula for this typeof surgery and although all putative formulae are



-19-

essentially equivalent, none are universallyapplicable.

Recent studies have demonstrated theeffectiveness of the tenotomy procedure and itsmultiple therapeutic benefits (6-9). Neurophysio-ogical evidence has also revealed that ahypothesized proprioceptive feedback loop thatcontrols the steady-state muscle tension enablestenotomy’s effectiveness (10,11). This loop appearsto receive sensory input from the palisadeproprioceptive endings at the distal ends of the slowswitch fibers (these endings are irritated during thetenotomy surgery by sutures and scarring). Thereduced steady-state tension produces the overalldamping of post-tenotomy nystagmus. The post-surgical reduction affects only the nystagmus slow-phase amplitude, not other ocular motility functions(7).

REFERENCES

1. Chang YH, Chang JH, Han SH, Lee JB. Outcomestudy of two standard and graduated augmentedmodified Kestenbaum surgery protocols forabnormal head postures in infantile nystagmus.Binocul Vis Strabismus Q. 2007;22:235-41.2. Dell'Osso LF, Flynn JT. Congenital nystagmussurgery: a quantitative evaluation of the effects.Arch Ophthalmol. 1979;97:462-69.3. Dell'Osso LF, Hertle RW, Williams RW, JacobsJB. A new surgery for congenital nystagmus:effects of tenotomy on an achiasmatic canine andthe role of extraocular proprioception. J AAPOS.1999;3:166-82.4. Hertle RW, Dell'Osso LF, FitzGibbon EJ,Thompson D, Yang D, Mellow SD. Horizontalrectus tenotomy in patients with congenitalnystagmus. Results in 10 adults. Ophthalmology.2003;110:2097-105.5. Hertle RW, Dell'Osso LF, FitzGibbon EJ, YangD, Mellow SD. Horizontal rectus muscle tenotomyin patients with infantile nystagmus syndrome: Apilot study. J AAPOS. 2004;8:539-48.6. Wang Z, Dell'Osso LF, Jacobs JB, Burnstine RA,Tomsak RL. Effects of tenotomy on patients withinfantile nystagmus syndrome: foveationimprovement over a broadened visual field. JAAPOS. 2006;10:552-60.

7. Wang Z, Dell'Osso LF, Zhang Z, Leigh RJ,Jacobs JB. Tenotomy does not affect saccadicvelocities: Support for the "small-signal" gainhypothesis. Vision Res. 2006;46:2259-67.8. Wang ZI, Dell'Osso LF. A review of thetenotomy nystagmus surgery: origin, mechanism,and general efficacy. Neuro-Ophthalmol.2007;31:157-65.9. Wang ZI, Dell'Osso LF, Tomsak RL, Jacobs JB.Combining recessions (nystagmus and strabismus)with tenotomy improved visual function anddecreased oscillopsia and diplopia in acquireddownbeat nystagmus and in horizontal infantilenystagmus syndrome. J AAPOS. 2007;11:135-41.10. Eberhorn AC, Horn AK, Eberhorn N, Fischer P,Boergen KP, Buttner-Ennever JA. Palisade endingsin extraocular eye muscles revealed by SNAP-25immunoreactivity. J Anat. 2005;206:307-15.11. Ugolini G, Klam F, Doldan Dans M, et al.Horizontal eye movement networks in primates asrevealed by retrograde transneuronal transfer ofrabies virus: differences in monosynaptic input to"slow" and "fast" abducens motoneurons. J CompNeurol. 2006;498:762-85.

Z. I. WangL.F. Dell’Osso, PhD

Cleveland, [email protected]

(From the Daroff-Dell’Osso Ocular MotilityLaboratory, the Louis Stokes Cleveland Departmentof Veterans Affairs Medical Center and CASEMedical School; the Department of Neurology andBiomedical Engineering; Case Western ReserveUniversity and University Hospitals Case MedicalCenter. This work was supported in part by theOffice of Research and Development, MedicalResearch Service, Department of Veterans Affairs.)



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Re: Reading new electronic version of BV&SQ

From: Burton KushnerTo: Binocular VisionSubject: Re: Personal subscription "Newsletter":BV &SQ 22- Fourth Digital Issue V.22(4)

Paul and Judy

I am curious what feedback you have gottenon the switch to digital only for BV&SQ. Ipersonally do not find it a very good modality. I donot like to read on screen, and printed loose pages isnot the same for me as a journal.

What have others said?

From: "Paul Romano" <[email protected]>

To: "Burton Kushner"

DEAR BURT: YOU ARE NOT ALONE.

But over 95% of our individual subscribers have or

have had no complaints with the electronic issues. And whileour library subscribers are happy with BV&SQ online - they

are asking for IP access to facilitate distribution. (We'reworking on that.)

Re discomfort reading computer text on screen:

Have you tried a free trial of “Pivot Pro" from Portrait.comand used Adobe full screen to present a full vertical page to

read? Please try that. We have found vertical screens somuch better for almost everything we do (and especially

email and web browsing) that we have converted all ourlaptops to external monitors using the screen image turned

vertically with this software (see also Editorial in BV&SQ22(3) last year).

This portrait presentation has another big

advantage over landscape, even widescreen landscape. Ifyou frequently use “Print Screen” to save quickly just the

page you are looking at, instead of ordering a print of what

often turns out to be an unexpectedly long document (as onebay, for example! ), you will get much more of what you are

looking at as you will print out a full vertical page instead ofthat tiny half page you get in landscape mode.

A really big external monitor can also help

especially if you are presbyopic. My main monitor is a 21"diagonal 4X3 (i.e. NOT widescreen) turned vertically with

Pivot Pro. The screen on this monster is almost 13"horizontally x 17" vertically , magnifying a full 8.5 x 11 page

image and all the text on it by over 50% (=150%) withoutzooming the image at all. I got it on ebay for $150. And the

prices are going lower daily. I am a -2 D myope and I use nospecs at all when I work on it.

If you don't have an external monitor or desktop

monitor that you can easily rotate ninety degrees, you canget a good idea how that pivot software works just by

downloading a 30 day free trial of Pivot Pro and turning yourlaptop on its side to see what a vertical screen looks like. If

you liked it, just leave it cockeyed on its side, replace yourlaptop with a desktop keyboard and mouse at Walmart or

any computer shop for about $10 each and just leave yourlaptop parked vertically on its side!

If the vertical portrait mode monitor/ screen doesn’t

make reading BV&SQ more tolerable and comfortable, youcan also make your own real bound copy of each issue by

copying our download of the issue from your computer on toa CD or flash drive, taking that to Kinko's or your local copy

shop, have them print/copy it on to 11"x17" sheets and thenfold it in half and staple it just like our old hard copy version

or any journal or magazine. Our local copy shop charge isquite reasonable for such. If you can settle for no color

copies, just black and white copying, a full 64 page issueshould cost you not much more than the new postage to

send the eight ounce copy to you.

Actually we are doing this for contributors and acouple of subscribers who, like you, really want a bound

printed version. Our regular charge is $47 per issue for suchhand made hard copies in addition to the cost of the

electronic subscription. Such copies are available only tosubscribers to the electronic version, plus shipping outside

the U.S.A.. Regards, P & J

Binocular Vision & Ed itorial: First Quarter of 2007Stra bismus Qu arte rly© Volume 23 (N o.1):A Medical Scientif ic e-Periodical P. E. Romano, MD, MS Ophthalmology -22

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EDITORIAL: Due to TV? Critiques and Moral Changesin Our Society; e-Publishing; Binocular Vision VerticalFusion; Unique Esotropia; Papilledema and Cystinosis.

In the last issue we published a Letter to

the Editor by Sandra Brown, MD concerning

some scientific colleagues and fellow Editors

taking liberties with semantics and the English

language to exaggerate their accomplishments .

Since then we came across, not in ourscientific journals but in the lay press, a coupleof editorial opinions criticizing our scientificefforts, in even broader terms; like this, fromBusiness Week. The original study waspublished in JAMA so we can still say we

med ical scientistsare still trying to dothe right thing! Aswe are coming torealize today, thanksto lawyers profitings o w e l l f r o mprotecting us fromour fe llow man,human beings every-where are quite fal-lible and educationand degrees do notprevent people frommaking errors - inany profession. Toobad our society hasbecome so competi-tive, so vicious, sofault finding, so armchair general-ing. Iblame the rise of TVmedia and all its talkshows, and their lifeand death need forattracting eye ballsfor lowering our morals and societyfor the worst.

Things havechanged. I can thinkback to my very firstefforts 40 years agoat critiquing some-one else’s work, and

Binocular Vision & Ed itorial: First Quarter of 2007Stra bismus Qu arte rly© Volume 23 (N o.1):A Medical Scientif ic e-Periodical P. E. Romano, MD, MS Ophthalmology Page 21-22

-22-

how fearful I was of alienating the recipient,and maybe lots of collateral damage, and howcarefully we went about it. Today, on TV,there’s no holds barred! And even scientists arenot the gentlemen warriors they used to be.Heck, just go directly for the jugular.

In THIS ISSUE

First if you didn’t already go there, goback and read our correspondence section.There’s an important letter from a recognizedexpert on nystagmus and its surgery regardingan article in the last issue of last year. Also acomplaint from great supporter and ex-GrandRounds Editor B.J.Kushner about e-periodicalslike BV&SQ. Our reply as to how to alleviatethe changes due to the new format should beuseful to all you readers.

Since I finished that reply to Burt, myfirst bargain 21" LCD computer monitor diedbut it has been replaced by a Samsung Sync-master (rotating screen) 213T (= 21.3"diagonal)LCD monitor we won on ebay for $300 - it isworth it!- new, it cost over $1000!

The 2x area magnification over 15"laptop screens has cured my residual (-2Dmyope) presbyopia completely! My ultimatecure for the often microscopic type displayed onany computer screen is software recommendedby WSJ’s computer expert Walter Mossberg,available for a small fee from WebEyes.com,that can enlarge the font size alone per se on anywebsite without magnifying the background(like Bill Gates’ magnification aid does.).Elsewhere in 23(1):

Kim JK, Hayden AM, Sadun EA,Dustin LD, Sebag J, Sadun AA. ResponsePattern Asymmetry of Binocular VisionVertical Fusion Amplitudes in a NormalPopulation. Binocul Vis Strabismus Q 2008;23:23-30. To more quickly grasp this research,one has to escalate your previous ideas aboutmeasurement of fusional amplitudes There’snada in our books about their technique andonly one prior paper in the literature, theirreference 11. They measure two ways instead ofone: once starting with the left eye target higher

and once with the right eye target higher. It is inthe comparison of the responses to these twodifferent measurments that they found,unexpectedly, asymmetry.

Ohba M, Kawata H, Ohguro H,Fukushi N. An Unusual Case of AdultProgressive Esotropia Caused by HighMyopia. Binocul Vis Strabismus Q 2008;23:31-35. This is a unique well illustrated firstcase report of this remarkable patient with anextraordinary surgical result.

Parnes A, Wassner SJ, Weinstein JM.A Case of Intracranial Hypertension andPapilledema Associated with NephrophaticCystinosis and Ocular Involvement. BinoculVis Strabismus Q 2008; 23:37-40. Theimportance of this report lies in theirconsideration and discussion of what isostensibly an idiopathic papilledema in an 11year old child and their proposal and hypothesisof its pathophysiology.

Don’t miss the Abstracts or Hyde Parkeditorial with other interesting news on the eyebusiness. To the discussion of insurance in thatlast feature, we would add a telling semanticclue to the motivations of the health insuranceindustry: They express their profits as their“medical LOSS ratio”, i.e., the ratio betweentheir premiums and the medical care they payfor! In their eyes, what you are doing as adoctor, is creating a LOSS for them, denyingthem further profit by rendering unfree andimplied wrongful or bad medical care!

We are going to miss next month’sAAPOS meeting in Washington, D.C. It shouldbe a great meeting. Hope to have a report of it inour next issue. If you are making apresentation there, PLEASE CONSIDERSUBMITTING IT FOR CONSIDERATIONFOR PUBLICATION HERE IN BV&SQ IFIT IS A POSTER THAT IS NOT MANDA-TORY FOR SUBMISSION TO THE JAAPOS-OR IF A FORMAL PRESENTATION, IF ITIS NOT ACCEPTED ON SUBMISSION TOTHE JAAPOS. WE WILL CONSIDERNON-STRABOLOGY PED. OPHTHAL-MOLOGY PAPERS AS WELL. Thanks-per

Binocular Vision & Response Pattern Asymmetry of Binocular Vision Vertical Fusion Amplitudes in a Normal Population First Quarter of 2008Stra bismus Qu arte rly© J.K . Kim , BS , A.M . Ha yden, M D, E .A. S adun , BS , Volume 23 (N o. 1):A Medical Scientif ic e-Periodical L.D. Dustin, MS, J. Sebag, MD, A.A. Sadun, MD, PhD Pages 23-30

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Original Scientific Article

Response Pattern Asymmetry of Binocular VisionVertical Fusion Amplitudes in a Normal Population

JANET K. KIM, B.S.1, ASHLEY M. HAYDEN, M.D.1,

ELVIO A. SADUN, B.S.3, LAURIE D. DUSTIN, M.S.1,

J. SEBAG, M.D.1,2 and ALFREDO A. SADUN, M.D., Ph.D.1

from the 1Doheny Eye Institute, Keck School of Medicine of the University of SouthernCalifornia, Los Angeles, California, 2Vitreous, Macula & Retina (VMR) Institute, HuntingtonBeach, California and 3Massachusetts Institute of Technology, Boston, Massachusetts.

ABSTRACT: Purpose: To compare the maximum vertical fusion amplitudes in verticaldirections (response pattern by respective higher eye), to investigate for possible asymmetry.

Methods: Vertical fusion amplitude (VFA) was measured in one hundred normal adultswith normal single binocular vision using a computer-based device that produced a gradually increasing,symmetric binocular vertical disparity in units of 0.35 prism diopters for each eye at a convergent nearbut optically distant test distance. Vertical fusion amplitudes in the vertical left-over-right (L/R,elevation of the left eye above the right eye) pattern direction were compared to the vertical fusionamplitudes in the vertical right-over-left direction pattern (R/L).

Results: The mean VFA was 4.08 ± 1.01 prism diopters, with vertical fusion amplitudesof 4.40 ± 1.44 prism diopters in the L/R direction and 3.75 ± 1.19 prism diopters in the R/L direction.There was no association between ocular dominance and the direction of greater VFA. Asymmetry in thevertical fusion response was found, with 77/100 subjects showing greater than a 10% difference betweenthe means of the L/R and R/L measurements. The group with asymmetry had 17% greater mean VFAthan the symmetric group.

Conclusion: Normal adults frequently have asymmetric directional vertical fusionamplitudes. The asymmetry appears to be due to the contribution of the direction with the greater VFA,rather than the result of both alternatives. These results are intriguing and bear further investigation.Possible explanations may be asymmetry of orbital anatomy or functional asymmetry of either muscularor neuronal origin. They do not appear to be due to relative ocular dominance. Inherent VFA asymmetryshould therefore be considered in all forms of vergence testing in the vertical direction.

Received for consideration August 19, 2007; accepted for publication October 23, 2007.

Acknowledgments: This research was supported by funding from the VMR Institute.

Competing interests: Authors AMH, EAS, AAS and JS have proprietary interest in the vertical fusionamplitude measuring device described in the study.

Presented at the Assoc. for Research in Vision and Ophthalmology, Fort Lauderdale, FL, May 2007.

Correspondence/reprint requests to: Dr. Alfredo A. Sadun, Doheny Eye Institute, USC Keck Schoolof Medicine, 1450 San Pablo St, Ste 5802, Los Angeles CA 90033-1026. Fax: 323-442-6407.

Email: [email protected]



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INTRODUCTION

Image fusion in binocular vision is aviewer's percept and response to image disparity,which consists of an oculomotor (vergence)component and a non-motor central component (1).In the presence of retinal image disparity betweenthe right and left eyes, vergence movements arespontaneously initiated to maintain single binocularvision. Through vertical, horizontal, and/orrotational adjustments, the necessary degree ofbinocular alignment is maintained despite internaland external factors that may perturb theoculomotor system.

Previous studies have measured verticalfusion amplitudes (VFA) and vertical vergences innormal adults (1-3). However, there is a paucity ofresearch comparing the relative differences ofvertical fusion amplitudes in each of the twovertical directions possible in the test. Most studiesmeasured VFA in only one direction, or, if bothdirections were measur-ed, only the summed totalfusion VFA was reported.

Clinical observations using vertical prismbars (in increments of 1 or 2 prism diopters) haveshown that not only is there wide variation in VFAsamong subjects, but there is also variability withinan individual when comparing opposite directions,i.e. right-eye-elevated-over-left (R/L) and left-eye-elevated-over-right (L/R). To further investigatethese variations, we systematically measuredvertical fusion responses to disparate stimuli foreach direction.

The purpose of this study was to measureand compare the VFAs in the two verticaldirections, right-over-left and left-over-right, fornormal adult individuals using a simple, clinicallypractical test with a measurement resolution betterthan the one prism diopter increments on prismbars. We also sought to determine whether therewere any differences in VFAs based on age, sex, orsighting ocular dominance.

MATERIALS, SUBJECTS, & METHODS

Subjects

One hundred (100) adults over 18 years ofage were recruited for the study and provided their

informed consent. The study was approved by theUniversity of Southern California InstitutionalReview Board and conducted at the VMR Institutein Huntington Beach. Subjects were office staffmembers or normally-sighted family members andcaretakers of patients. In addition, six subjects wererecruited from the Keck School of Medicine of theUniversity of Southern California. All subjects hadnormal single binocular vision at near and had bestcorrected visual acuity of 20/20 in both eyes.Subjects wore their corrective lenses as needed tosee the target clearly at the testing distance.

Exclusion criteria were central visual fielddefects, prior orthoptic treatment, and anystrabismus.

Sighting ocular dominance was determinedby asking the subjects to extend their arms andposition their two hands together to create a smallaperture. Subjects looked through the opening at adistant object and alternately closed each eyeseparately to determine which eye was fixed on theobject.

There were 53 women and 47 men rangingin age from 24 to 83 years, with a mean age of 51.9years (see Figure 1, overleaf, for age distribution).

Visual display and test software

See Figures A and B, facing page->.Subjects looked through a set of plus 12 diopterlenses (focal distance 8 cm) affixed in a framestanding 8 cm above and from the surface of atabletop computer screen (model 700Y, XenarcTechnologies, Santa Ana, California). The screenitself was a normal LCD display, but with a coupleof modifications to the monitor so that it could beused placed flat on a table surface. Thesemodifications were: 1) stabilizing the backside ofthe monitor so that it would lay flat on the tabletop;and 2) placement of a thin sheet of plastic over theLCD screen so that we could put the stereo viewerdirectly over the images without damaging thescreen The same image was presented binocularlythrough the stereo viewer, allowing the targets to bepresented separately to each eye. The stereo viewerhad circular apertures which allowed viewing ofonly the intended image for each eye, but limitedperipheral vision. This isolated the images, so thateach eye saw only the corresponding image for thatside. The test screen was connected to a laptopcomputer (IBM ThinkPad T30, Pentium 4m) withproprietary software. This generated the screenimage of a thin white bar on a (continued....)


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Figure A (Kim JK et al) ABOVE: Testequipment setup. Note the two images ofthe target on the LCD monitor, positioncontrolled by the computer software(available from the correspondingauthor). These targets are misaligned ina left over right direction.

Figure 2 (Kim JK et al): RIGHT ->Subject performing test. Note her righthand is on the “button” to be pressed torecord the end point of each trial,diplopia, or doubling of the images whenvertical fusion failed.


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Figure 2 (Kim JK et al): Target image. The target

image was originally designed to allow two

possible stimulus heights (top vs. bottom lines).

For this experiment, subjects were instructed to

focus on the top thin line (arrow). This thin bar

subtended one degree of visual angle and had a

length of about 30 degrees at 80 mm distance

from the subject. The actual top thin line was 3-4

pixels tall.

Figure 1 (Kim JK et al): Test subject age and sex distribution. The distribution of test subjects byage is represented by decades. The ages ranged from 24 years to 83 years.

black background (see Figure 2, right->). Takingmagnification into account, the stimulus had aheight of about one degree of visual angle with alength of about 30 degrees at the 8 cm test distancefrom the subject. Horizontal convergence requiredwas approximately 25 prism diopters.

Measuring Vertical Fusion Amplitudes (VFA)

Initially, the bars were aligned at thevertical midline, and the subject perceived a singlebar. The bars were then vertically separated awayfrom mid-line in opposite directions. Each barmoved in equal increments of 0.345 diopters persecond in opposite directions for a rate ofseparation of 0.69 prism diopters per second. Thesubject was provided with a button to press whenfusion was disrupted and a doubled image wasperceived. Appropriate calibra-tion of the testsoftware was confirmed by comparison testingunder the same conditions using a vertical prismbar. The assessment was repeated in successivemeasurements to test if it was reproducible.


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Figure 3 (Kim JK et al): Distribution of vertical fusion amplitudes. Vertical fusion amplitude(VFA) is normally distributed. For each individual, the mean VFA represents the average of 5measurements in the L/R direction and 5 measurements in the R/L direction.

Each subject was tested five times in eachdirection in succession, alternating between left eyeup / right eye down (L/R) and right eye up / left eyedown (R/L) for a total of 10 measurements. Eachmeasure-ment was completed in less than 60seconds. The max-imum VFA was recorded as oneincrement of disparity less than the reportedbreakpoint. For each direction, the fivemeasurements were averaged to obtain mean R/LVFA and mean L/R VFA. Also, to allowcomparison with earlier studies that measured VFAonly in one direction, a mean VFA was determinedfor each individual by averaging all 10measurements.

Statistical methods

Statistical analysis was performed using SASsoftware. Two-sample t-tests were performed todetermine if there was any difference in VFA basedon sex or ocular dominance. Analysis of variancewas done to judge whether there was any differencein amplitude based on age. The test for binomial

proportion was applied to see if the number ofsubjects with greater amplitude on one side wasdisproportionately distributed. A chi-square test wasused to determine whether there was anyassociation of VFA asymmetry with oculardominance. P-values less than 0.05 were consideredto be “statistically significant” per tradition.

RESULTS

At the start of the measurement session, allsubjects confirmed single binocular vision at zerovertical disparity. Based upon 10 measurements (5in each direction, alternating R/L and L/R endpoint:end point subjective diplopia) for each subject theaverage VFA was 4.08 ± 1.01 prism diopters.Mean VFA in the left-over-right direction was 4.40± 1.44 prism diopters and in the right-over-leftdirection, 3.75 ± 1.19 prism diopters. Figure 3below shows the distribution of subject amplitudesincluded in the mean VFA. The findings show anapproximately normal distribution.


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Figure 4 (Kim JK et al): Comparison of L/R VFA to R/L VFA for symmetry. The L/R VFA is plottedagainst the R/L VFA for each subject. The diagonal line (y=x) represents the points at which VFA L/Requals VFA R/L (=symmetry). Notably, only 23% of subjects fell within a 10 % difference.

There was a high level of intrasubjectreproducibility, with average standard deviations of0.58 ± 0.29 prism diopters and 0.52 ± 0.30 prismdiopters, respectively, for individual L/R VFA andR/L VFA. On the other hand, there was considerableintersubject variability with mean VFAs rangingfrom 1.97 and 6.88 prism diopters.

VFA did not vary significantly with age orsex. For age analyses, subjects were divided intoquartiles by age (24 to 39 years, 40 to 53 years, 54to 63 years, and 64 to 83 years). Analysis ofvariance showed no “statistically significant”difference in mean VFA among age quartiles(p=0.85). When examining age as a continuousvariable, there was not a “statistically significant”correlation between mean VFA and age (Pearsoncorrelation coefficient = -0.08, p = 0.45). Theaverage mean VFA for the 53 women and the 47

men were (respectively) 4.09 and 4.07 prismdiopters. There was no “statistically significant”difference between the two sexes in mean VFA(p=0.53), L/R VFA (p=0.59), and R/L VFA(p=0.67).

There was, however, asymmetry in theresults with higher fusion amplitudes in one verticaldirection than in the other direction. The averagepercent difference between the L/R VFA and theR/L VFA was 33.6%. Figure 4 below shows theL/R vertical fusion amplitude plotted against theR/L vertical fusion amplitude for each individual,with the diagonal line representing the points atwhich VFA L/R equals VFA R/L. Using a ±10%difference as the threshold beyond which a subjectwas considered to be asymmetric, only 23% ofsubjects showed symmetry. Of the 77 subjects, -


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...(77%) demonstrating asymmetry, 51 ofthese 77 (66.2%) had greater vertical fusionamplitude in the L/R direction (test for binomialproportions, p=0.001). Accordingly, the mean L/Rvertical fusion amplitude (4.40 prism diopters) wassignificantly larger than the R/L VFA (3.75 prismdiopters; p<0.001 by paired t-test). Interestingly, thegroup of 77 showing asymmetry had 17% greatermean VFA than the group with symmetry (p=0.001,t-test). However, when comparing the weakerdirections for asymmetric individuals to those ofsymmetric individuals, there was no “statisticallysignificant” difference between their amplitudes(p=0.48, t-test).

Among the asymmetric subjects, no“statistically significant” difference was found in theamplitudes of the direction of greater fusion ability,regardless of whether the subject had higher R/L orL/R VFA (p=0.68, t-test). There was no differencein the occurrence or degree of asymmetry related toage or sex. Also, there was no association foundbetween the direction of greater amplitude andsighting ocular dominance (chi-square p-value =0.29).

DISCUSSION

The measured total vertical fusionamplitudes of the present study concur with theresults of previous investigations. Normal maximumVFA has been cited as 3-6 prism diopters (4). Paststudies reported a range of normative values as aresult of variations in testing parameters. Smallerstimulus height (1,5), greater degree of convergence(6,7), and smaller rate of disparity introduction (8)all result in an increased ability to fuse verticalimage disparity.

The present study tested VFA at near, withconvergence of 25 prism diopters and a stimulusheight subtending 1/ of visual angle. Disparity wasintroduced at 0.69 prism diopters per second.Consistent with studies using similar testingparameters, the average total VFA in our study was4.08 ± 1.01, with 4.40 prism diopters in the L/Rdirection and 3.75 prism diopters in the R/Ldirection. Bharadwaj et al. (6) used increments of0.05 prism diopters with 25 prism diopters ofconvergence and found mean VFA to be 4.86.Mottier and Mets (9) found mean VFA to be 4.85±1.25 using a synoptophore. As in the study by

Sharma and Abdul-Rahim (10), there was noassociation of gender or age with VFA magnitude.

Earlier studies provided only limited infor-mation on whether there was a difference betweenthe fusion amplitudes in opposite verticaldirections. Ulyat et al. (11) measured vertical fusionamplitude at four target distances and mentionedthat no significant differences were found betweenthe values obtained during base-up or base-downmeasurements. In a study examining the effect ofhorizontal vergence on vertical fusion, Hara et al.(7) observed that eight out of twelve subjects hadgreater fusion amplitude in the left-over-rightdirection in near viewing. Not much additionaldiscussion of the relative contributions of verticalfusion amplitudes in each direction exists in theliterature, and there has not been a studyspecifically determining the level of symmetry.

The results of the present study show thatthese directional VFAs are frequently asymmetric.The majority (77%) of subjects had greateramplitude of fusion in one direction (L/R or R/L)by at least a 10% difference. On average,asymmetric subjects had a 17% higher averageVFA than symmetric subjects (P = .001). Theamplitudes for the direction of lower ability inasymmetric individuals were not signifi-cantlydifferent from the VFA of symmetric subjects. Thissuggests that any increase in average VFA in theasymmetric group was due to the contribution of thedirection with the greater vertical fusion amplitude.

Vertical prism adaptation is unlikely to haveaffected fusion amplitude as each measurement wascompleted over a short period of time. Ogle andPrangen (12) observed larger binocular VFAs aftervertical prism adaptation, which occurs with longerperiods of exposure to image disparity. In ourexperiment the vertical vergence stimulus wasincreased every second, with each measurementtaking less than 60 seconds, thus providing minimalopportunity for short-term adaptation. Across theserepeated measurements, subjects had low standarddeviations averaging 0.58 and 0.52 for L/R and R/Ldirections respectively. Successive measurements ineither direction showed no increasing trend invertical fusion amplitude.

Though hyperphoria may have accountedfor some of the VFA, it is unlikely that it was theprimary cause of asymmetry. Such hyperphoriamight be secondary to either anatomical

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asymmetries or to imbalances in muscle forces.Statistically, phoria would have been expected to beapproximately evenly distributed among right andleft eyes in all subjects and thus be balanced outupon calculation of the sample's mean directionalVFAs. In our results, the mean L/R fusion amplitudewas significantly higher than the mean R/L fusionamplitude. In addition, a significantly larger numberof subjects had greater L/R fusion amplitude, whichcannot be explained solely by the presence of anidiopathic hyperphoria.

The reason for the significantly largernumber of subjects with greater L/R VFA ratherthan R/L VFA is unclear. This bears furtherinvestigation and exploration of variablesinfluencing VFAs. However, perhaps anasymmetrical laterality of VFA is not so surprising,considering the presence of other functionalasymmetries such as handedness and eyedominance. In support of this idea, there is evidenceof inherent functional asymmetry in vergence eyemovements. Perlmutter and Kertesz (3) showed thatwithin the vertical fusion response, the relativemotor contributions of each eye are not equal. Intheir study, subjects were presented with asymmetrical vertical disparity, yet the eyesresponded at different rates with varying overallcompensations. Perlmutter and Kertesz found in onesubject that the left eye compensated for 144% ofthe disparity presented to it, while the other eyecompensated for only 66% of its disparity. Tested inthe opposite direction, the same subject showed yetagain different levels of compensation that variedfrom the amounts from the first direction. Theseapparently independent contributions of each eye tovergences are consistent with our observations.

The present study also demonstratedthat VFAs can be measured with high precisionusing a portable and inexpensive computer-basedsystem. The computer system allowed automation inincreasing disparity and ease in adjusting variables.In addition, it allowed greater precision thanmeasurement with vertical fusion prism bars, whichare limited to increments of 1-2 prism diopters.Though our increments were a fraction of thestandard, we were limited from achieving evengreater resolution by the pixel pitch of the customscreen. In future studies, greater testing sensitivitymay be possible with use of a higher resolutionscreen. Such measures may be useful for thediagnosis of blowout fracture and a variety of

myopathies, as well as for testing the efficacy oforthoptic treatment.

Based on the findings from this study, futurestudies should take into consideration that themaximum VFA measured in one direction does notnecessarily reflect the ability to go in the otherdirection. The reason is unclear, whether it is aresult of functional asymmetry of either muscular orneuronal origin or due to an asymmetry of orbitalanatomy. Further prospective study is needed toexplore variables affecting the balance of verticalfusion function.

REFERENCES

1. Kertesz AE: Effect of stimulus size on fusion and

vergence. J Opt Soc Am 1981; 71:289-293.2. Berens C, Losey RR, Hardy LH: Routine examination

of the ocular muscles and non-operative treatment. Am JOphthalmol 1927; 10:910-918.

3. Perlmutter AL, Kertesz AE: Measurement ofhuman vertical fusional response. Vision Res 1978;18:219-223.4. Parks MM: Vergences. In Tasman W, andJaeger EA (eds.): Duane’s Clinical Ophthalmology,vol.1, chap.7. Philadelphia, J.B. Lippincott, 2002,p.7.5. Howard IP, Fang X, Allison RS, Zacher JE:Effects of stimulus size and eccentricity onhorizontal and vertical vergence. Exp Brain Res2000; 130:124-132.6. Bharadwaj SR, Hoenig MP, SivaramakrishnanVC, Karthikeyan B, Simonian D, Mau K, Rastani S,Schor CM: Variation of binocular-vertical fusionamplitude with convergence. Invest Ophthalmol VisSci 2007; 48(4):1592-1600.7. Hara, N, Steffen H, Roberts DC, Zee DS: Effectof horizontal vergence on the motor and sensorycomponents of vertical fusion. Invest OphthalmolVis Sci 1998; 39:2268-2276.8. Ellerbrook VJ: Experimental investigation ofvertical fusional movements. Am J Optom Arch AmAcad Optom 1949; 26:237-337.9. Mottier ME, Mets MB: Vertical fus ional vergences inpatients with superior oblique muscle palsies. American

Orthoptic Journal 1990;40:88-93.

10. Sharma K, Abdul-Rahim AS: Vertical fusionamplitude in normal adults. Am J Ophthalmol 1992;114:636-637.11. Ulyat K, Firth AY, Griffiths HJ: Quantifying thevertical fusion range at four distances of f ixation ina normal population. British and Irish OrthopticJournal 2004; 1:43-45.12. Ogle KN, Prangen AD: Observations on verticaldivergences and hyperphorias. Arch Ophthalmol1953; 49:313-334.

Binocular Vision & An Un usua l Ca se of A du lt Pro gressiv e E so trop ia C aused by H igh Myo pia First Quarter of 2008Stra bism us Qu arte rly© M. Ohba, MD, H. Kawata, MD, H. Ohguro, MD, N. Fukushi, MD Volume 23 (No.1): 31-36

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Case Report

An Unusual Case of Adult Progressive Esotropia

Caused by High Myopia

MASAHIRA OHBA, M.D., HIROKATSU, KAWATA, M.D.,

HIROSHI OHGURO, M.D., and NAOKO FUKUSHI

from the Department of Ophthalmology, Sapporo Medical University School ofMedicine, Sapporo, Japan.

ABSTRACT: Background: In progressive esotropia associated with high myopia andaxial elongation, eso-hypodeviation of the eyeball occurs due to ocular dislocation and oftenprogresses to complete fixed esotropia in the terminal stage. We report a rare case of thiscondition in whom manual pushing of the eyeball temporarily moved the ocular dislocationback into the muscle cone. A normal eye position and ocular movement were obtained insubsequent strabismus surgery. To our knowledge, there has been no previous report of sucha case. It is uncertain if medial rectus muscle recession should be performed simultaneouslywith combination of the muscle bellies of the superior and lateral rectus muscles in surgeryfor progressive esotropia caused by high myopia. We discuss this issue in the context of thecurrent case.

Case Report: The patient was a 60 year old woman with a chief complaint ofsevere eso-hypotropia of the left eye, for which she requested treatment. Ophthalmologicfindings included refractive indices of -5.25 D right eye and left eye -22.0 D, respectively.,The left eye position was severely eso-hypotropia and ocular movement was limited in alldirections. However, the left eye became capable of abduction when the medial side of theeye was pushed manually by rubbing during attempted levoversion. During levoversionwhile the patient was pushing the eyeball, the dislocation was reduced on ComputerizedTomography imaging. In surgery, left medial rectus muscle recession and combination of themuscle bellies of the left superior rectus muscle and the left lateral rectus muscle wereperformed. After surgery, the eye position was markedly corrected and the abductionlimitation was improved.

Conclusion: We encountered a case of progressive esotropia caused by highmyopia in which ocular dislocation could be temporarily reversed. In this disease, pushing ofthe eyeball (push test) can be used to determine whether dislocation can be temporarilyreversed. If this is possible, determination of the degree of abduction may be useful forselection of an appropriate surgical procedure.

Received for consideration September 14, 2007; accepted for publication October 17, 2007.

Correspondence/reprint requests to: Professor Masahiro Ohba, Dept Ophthalmology, SapporoMedical University School of Medicine, S-1 W-16 Chuo-ku, Sapporo 060-8543, Japan. Fax: 81-11-530-4585. Email: [email protected]



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Figure 5 (Ohba et al): After surgery, the eye position was markedly corrected and the abduction limitationwas improved.

Figure 1 (Ohba et al): Case Report: Patient’s eye positions in primary and 5 cardinal positions of gaze.

INTRODUCTION

In progressive esotropia associated withhigh myopia and axial elongation, eso-hypodeviation of the eyeball occurs due to oculardislocation and often progresses to complete fixedesotropia in the terminal stage (1). We encountereda patient in whom manual pushing of the eyeballtemporarily moved the ocular dislocation back intothe muscle cone, and a normal eye position andocular movement were obtained in subsequentstrabismus surgery.

To our knowledge, there has been noprevious report of such a case. It is uncertain ifmedial rectus muscle recession should be performedsimultaneously with combination of the musclebellies of the superior and lateral rectus muscles insurgery for progressive esotropia caused by highmyopia. Investigation of the condition followingtemporary reduction of ocular dislocation before

surgery may be useful for selection of theappropriate surgical procedure, and we discuss thisissue in the context of the current case.

CASE REPORT

The patient was a 60 year old woman with achief complaint of severe eso-hypotropia of the lefteye for which she requested treatment. Her pasthistory included eso-hypodeviation of the left eye,which started in her early 50s and slowly progressedwith eventual loss of eye mobility. Ophthalmologicfindings at the initial examination included right andleft visual acuities of 0.25 (1.25x-5.0D) and 0.01(n.c.), respectively, and refractive errors of -5.25 Dand -22.0 D, respectively. The left eye position wasseverely eso-hypotropic and ocular movement waslimited in all directions (Figure 1, above).However, the left eye became capable of abduction(passing the midline) when the medial side of theeye was pushed by rubbing during levoversion,


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Figure 2 (Ohba et al): (a: left column): The patient’s left eye became capable of voluntary abductionwhen the medial side of the left eye was pushed by rubbing during attempted levoversion. (b: rightcolumn): The patient’s left eye returned to the fixed in the eso-hypo position after the medial side of theeye was pushed by rubbing during left eye in primary position.

...although eye duction movement was stillinsufficient (Figure 2-a, above). But, the left eyewas fixed and voluntary ocular movement(abduction) was not possible when the eye waspushed by rubbing during primary position (Figure2-b, above).

The patient reported that for severalyears she had sometimes pushed the eye herself tomove the eye laterally. On funduscopy, staphylomawas present in the posterior pole region of the lefteye. Preoperative MRI (Magnetic ResonanaceImaging) detected a markedly adducted position ofthe left eye in the horizontal section (Figure 3-a,next page), with upper lateral dislocation of theeyeball, nasal shift of the superior rectus muscle,and inferior shift of the lateral rectus muscle in thecoronary section (Figure 3-b, next page). Duringlevoversion while the patient was pushing theeyeball, the axial length of the left eye was 31.6 mmand shifts of the superior and lateral rectus muscleswere reduced on CT, confirming that the

dislocation was reduced (Figure 4, nextpage ).Based on the above findings, we diagnosed atypicalprogressive esotropia caused by high myopia.

In surgery, an 8 mm left medialrectus muscle recession and combination of theadjacent half muscle bellies of the left superiorrectus muscle and the left lateral rectus muscle(temporal half of the superior rectus muscle andupper half of the lateral rectus) were performedunder general anesthesia, with suturing together at asite about 11 mm from the muscle insertions.Elevation and abduction were limited in apreoperative forced duction test. After surgery, theeye position was markedly corrected and theabduction limitation was improved (Figure 5, seeprior page, bottom, for comparison withpreoperative condition). On postoperativeimaging, the shifts of the lateral and superior rectusmuscles and the ocular dislocation were improved(See Figure 6, overleaf).


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Figure 3 (Ohba et al): (a: top frame): PreoperativeMRI of the orbits, axial view. MRI detected amarkedly adducted position of the left eye in thehorizontal section. (b: bottom frame): Preoperative MRI of the orbits,coronal view. MRI detected upper lateraldislocation of the eyeball, a nasal shift of thesuperior rectus muscle, and an inferior shift of thelateral rectus muscle in the coronary section.

Figure 4 (Ohba et al): Preoperative CT of theorbits. During levoversion while the patient waspushing the eyeball, the long axial length of the lefteye (a: top frame )

and shifts of the superior and lateral rectusmuscles were reduced, confirming that the globaldislocation was reduced (b: bottom frame).

DISCUSSION

Convergent strabismus fixus isclassified into congenital (2-5) and acquired (6-8)types. Acquired fixus may occur as the final resultof severe abducens nerve palsy or may progress dueto high myopia. In many cases, progressiveesotropia caused by high myopia has alreadyprogressed to extreme eso-hypotropia at the time ofthe first visit to an ophthalmology department.Imaging diagnosis indicates that ocular dislocationis involved in progressive esotropia, as reported byYokoyama et al (1), and it is of interest that somepatients can reverse the dislocation by themselves,albeit temporarily, as for orthopedic shoulderdislocation.

In our patient, pushing the eyeballtemporarily corrected the dislocation and enabledabduction past the midline. Pushing the eyeball mayhave generated flexion between the eyeball andextraocular muscles, which may have released thesuperior and lateral rectus muscles from shiftedpositions back to normal positions, thereby reducingthe dislocation and enabling some abduction. Inpushing the eyeball by rubbing, pushing so as to turnthe affected eye toward lateral supraduction isimportant for improvement of the nasal shift of thesuperior rectus muscle and inferior shift of the lateralrectus muscle. Subsequent improvements of the eyeposition and abduction cannot be obtained withoutacting on the lateral and superior rectus musclesduring compression of the eyeball (see Figure 2-a,b,

prior page)..


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Figure 6 (Ohba et al): Postoperative CT of theorbit, axial & coronal views. CT detected the shiftsof the lateral and superior rectus muscles and theocular dislocation was improved.

In cases with severe contracture of themedial rectus muscle, reduction of the dislocation isdifficult using this method. It is unclear if themethod for temporary correction of dislocation isgenerally applicable because of the small number ofcases examined, but we have obtained temporaryimprovements in eye position and abduction usingthis method in other patients.

Determination of the degree of abductionwhile temporarily reducing the dislocation bypushing the eyeball may be useful for selection of asurgical procedure. In severe myopia-associatedprogressive esotropia, improvement of abductionafter surgery is generally poor. The currentmainstream surgical procedure for this diseaseinvolves combination of the muscle bellies of thesuperior and lateral rectus muscles, as designed byYokoyama et al (9); however, the postoperativemaximum abduction angle is less than 20° in somecases after this procedure (including medial rectusmuscle recession).

Thus, it remains to be determined ifcombination of the muscle bellies of the superiorand lateral rectus muscles alone is sufficient orwhether medial rectus muscle recession is also

necessary. Combination of the superior and lateralrectus muscles alone may be appropriate in cases inwhich sufficient abduction is obtained when thedislocation is reduced by pushing the eyeball, but incases in which abduction is insufficient, medialrectus muscle recession may also be necessary, as inout patient.

Therefore, in cases of progressive esotropiacaused by high myopia, the “push test” should beused to investigate whether the dislocation can betemporarily reversed, and determination of thedegree of abduction may be useful for selection of asurgical procedure. We plan to investigate thisapproach further in an increased number of cases.

CONCLUSION

We encountered a case of progressiveesotropia caused by high myopia in which oculardislocation could be temporarily reversed. In thisdisease, pushing of the eyeball (push test) can beused to determine whether dislocation can betemporarily reversed. If this is possible,determination of the degree of abduction may beuseful for selection of an appropriate surgicalprocedure.


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REFERENCES

1. Yokoyama T, Tabushi H, Ataka S et al. The mechanism of development in progressive esotropiawith high myopia. In: Trans 26th meeting, European Strabismological Association, Barcelona, Spain,September 2000, de Faber JTHN ed. Swets & Zeitlinger, Lisse 2001; 218-221.

2. Martinez L. A case of fixed stabismus. Am J Ophthalmol 1948; 31:80.3. Villasecca A. Strabismus fixus. Am J Ophthalmol 1959; 48:51.4. Remon L, Palomar T, Bagas MN, Dominguez M. Acquired convergent fixus associated with high

myopia: A case report Binocul Vis Strabisms Q 1996;11:41.5. von Noorden GK. Binocular Vision and Ocular Motility, Mosby, St Louis 2002; 471-473.6. Brown HW. Congenital structural anomalies of the muscles. In: Strabismus Ophthalmic

Symposium 2nd ed. Mosby, St Louis 1958; 402-404.7. Hugonnier R, Hugonnier S. Strabismus, Heterophoria, Ocular Motor Paralysis-Cclinical

Ocular Muscle Imbalance. Mosby, St Louis 1969; 327-328.8. Ohba M, Ogawa K, Osanai H, Ohtsuka K. An unusual case of congenital convergent strabismus

fixus. Binocul Vis Strabismus Q 2005; 20:89-92.9. Yokoyama T, Ataka S, Tabushi H et al. Treatment of progressive esotropia caused by high myopia

- A new surgical procedure based on its pathogenesis. In: Trans 27th Meeting, European StrabismologicalAss, Florence Italy, June 2001. De Faber JTHN ed. Swets & Zeitlinger, London 2002; 145-148.

Binocular Vision & A Case of Intracranial Hypertension and Papilledema First Quarter of 2008Stra bism us Qu arte rly© Associated with Nephropathic Cystinosis and Ocular Involvement Vo lum e 23 (No . 1):A Medical Scienti fic e-Periodical A. Parnes, MD, S.J . W assner, MD and J.M. W einste in , MD Pages 37-40

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Case Report

A Case of Intracranial Hypertension and PapilledemaAssociated with Nephropathic Cystinosis and OcularInvolvement

AARON PARNES, M.D., STEVEN J. WASSNER, M.D.and JOEL M. WEINSTEIN, M.D.

from Penn State University, M.S. Hershey Medical Center, Hershey, Pennsylvania

ABSTRACT: An 11-year-old boy with nephropathic cystinosis developed moderate tosevere bilateral optic disc edema two months after he received a deceased donor renalallograft.

The bilateral optic disc edema was found to be a result of intracranial hypertensiondiagnosed by lumbar puncture. No etiology was found. He was treated with acetazolamideand his optic disc edema resolved over a period of eight months and did not recur afteracetazolamide was discontinued. The mechanism of intracranial hypertension in patients withnephropathic cystinosis is not well understood, but may involve obstruction of cerebrospinalfluid outflow due to deposition of cystine crystals in arachnoid villi.

Received and accepted for publication July 30, 2007.

Reprints/correspondence to: Dr. Weinstein, Penn State University, M.S. Hershey Medical Center, POBox 850, Hershey PA 17033. Fax: 717-531-5475. Email: jweinstein@hmc,psu.edu

INTRODUCTION

Intracranial hypertension (IH) has rarely

been reported in patents with nephropathic

cystinosis (1-4). Patients with nephropathic

cystinosis may have more than one risk factor for

the development of IH, including corticosteroid

treatment, renal failure, and renal transplantation,

making it difficult to determine the precise

pathogenesis in each patient. We present a case of

IH in an 11-year-old boy with nephropathic

cystinosis who developed IH. Review of our case

along with others in the literature strongly suggests

that metabolic derangements due to nephropathic

cystinosis per se may play a primary role in the

development of IH, with or without other

predisposing factors.

CASE REPORT

An 11-year-old boy and his identical twinbrother were diagnosed with nephropathiccystinosis at 4 years of age. Both were followed inthe pediatric ophthalmology clinic for cornealinvolvement with cystine crystals. At six years ofage the index patient was found to have anaccommodative esotropia, presumably unrelated tohis cystinosis. He experienced moderate photo-phobia due to conjunctival and anterior cornealstromal crystals but his optic discs were normal ateach visit. Since the time of his diagnosis, he hadbeen treated with oral cysteamine, phosphate,potassium, and 1,25 dihydroxycholecalciferol. At 6years of age hypothyroidism was diagnosed andtreatment was begun with levothyroxine 0.0375mcg daily. Shortly thereafter he was begun onrecombinant human growth hormone (rHGH)(somatropin) 0.35 mg/kg per week.

mailto:jweinstein@hmc,psu.edu


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The cystinosis was initially well controlledwith multiple daily doses of cysteamine and thepatient’s intracellular white cell cysteineconcentrations averaged < 0.7 nmol ½ cystine/mgprotein. At 10 years of age his creatinine had risento 7.4 mg/dL (estimated glomerular filtration rate =10 mL/minute/1.73 m2 ) and he received apreemptive deceased donor renal transplant. Anti-rejection medications at the time of transplantincluded a single dose of methylprednisolone, twodoses of alemtuzumab as well as tacrolimus andmycophenalate mofetil. The kidney functionedwell and he was discharged on post-op day 7 with aserum creatinine of 1.9 mg/dL. At that time he wasreceiving tacrolimus, mycophenalate mofetil, and aother medications including cysteamine,levothyroxine, sodium/potassium citrate,trimethoprim-sulfamethoxazole, valganciclovir, andoxybutynin. He was not receiving corticosteroids.

Two months post-transplant, at a routineophthalmic follow up exam, he was found to havemoderate to severe bilateral optic disc edema. Aneye exam 6 months previously had shown normaloptic discs. He was asymptomatic and cranialmagnetic resonance imaging (MRI) and magneticresonance venogram (MRV) were normal. Alumbar puncture revealed acellular cerebrospinalfluid with a normal composition. However, theopening pressure was elevated (400mm of H2O).He was diagnosed with intracranial hypertension,presumably due to cystinosis, and treated withacetazolamide 750 mg/day. The papilledemapersisted for eight months then resolved and did notrecur following the discontinuation ofacetazolamide.

The patient’s identical twin brother had beentransplanted approximately 1 year earlier and wasdischarged on essentially the same medications asthe index case, with the addition of prednisone inthe twin brother. Upon repeated ophthalmologicevaluations, that twin has never shown evidence ofintracranial hypertension.

COMMENTS

A number of etiologic conditions mayproduce the clinical picture of intracranialhypertension (IH) in conjunction with normalventricular size and normal cerebrospinal fluid

(CSF) composition, as seen in our patient. Theseconditions include, but are not limited to Addisond i s e a s e , c o r t i c o s t e r o i d w i t h d r a w a l ,hypoparathyroidism, and cerebral venous sinusthrombosis. In addition, several drugs have beenimplicated in the pathogenesis of intracranialhypertension (IH), including lithium, naladixic acid,and human growth hormone, as well as varioustetracycline derivatives.

The nomenclature of "pseudotumor cerebri"and IIH has created some confusion in the literatureon this topic. Based on their review of the literature,Friedman and Jacobson offered this clarification (5)as well as a revised set of diagnostic criteria.:

"The nomenclature for IIH remains controversial.'Benign intracranial hypertension' is no longeraccepted, as significant visual morbidity may occurwith this disorder(3). The term 'pseudotumorcerebri,' a historically popular and all-encompassing term, leaves the impression that IIHis not a real disease. IIH is currently the favoredterm for the primary (idiopathic) disorder. Forthose patients with an identified cause ofintracranial hypertension without structural brainimaging or CSF constituent abnormalities, theappropriate diagnostic term would be 'intracranialhypertension secondary to (…).' "

According to the diagnostic criteriasuggested, and now widely accepted, by Jacobsonand Friedman(5), the term idiopathic intracranialhypertension is now applied only to patients inwhom no known etiology can be found to explainthe increased intracranial pressure. These criteriaalso provide that any signs or symptoms may onlyreflect generalized intracranial hypertension orpapilledema. In addition, there must be a normalCSF composition and no evidence of hydrocephalusor a mass lesion on imaging. As a generalguideline, IIH affects primarily obese women ofchildbearing age. However, IIH may occur in non-obese women as well as in men and children. Thedesignation IIH should not be applied to clinicalsyndromes in which the cause of IH is known, suchas venous sinus thrombosis or IH associated withtetracycline use.

Several authors have reported IH in patientswith nephropathic cystinosis. In some of thesepatients, IH has been associated with normal sizedventricles on neuroimaging. In other reports, IH


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has been associated with ventricular enlargement.These cases were diagnosed as “communicatinghydrocephalus” (2). It is not clear from thesereports why increased ICP in some patients withcystinosis results in ventricular dilatation while inothers it does not. One possible explanation is thatthere is a difference in ventricular compliance inthese patients. If this were the case, however, onewould expect a range of ventricular dilatation,rather than an all or none result. Another possibilityis that there is more than one mechanism for theproduction of intracranial hypertension in patientswith nephropathic cystinosis.

Cystinosis and IIH are both rare disorders.Nephropathic cystinosis is estimated to affect oneof every 100,000 to 200,000 children (6), while IIHhas an annual incidence of 0.9 per 100,000 in thepopulation at large, presumably less in the pediatricpopulation (7). If chance is taken intoconsideration, only one of 10 billion people shouldbe stricken with both cystinosis and IIH (1).However, the finding of many clinical cases with(IH) and cystinosis makes a chance association veryunlikely.

Though our patient had other conditions thatmight have predisposed him to the development ofIH, several lines of evidence suggest that cystinosiswas a major contributing factor. Though theliterature strongly supports an association betweenrenal transplantation and the development of IH, thelink between renal failure per se and IH is tenuousat best (8-11). In addition, IH has been reported inat least three cystinosis patients who were nottransplanted, suggesting that cystinosis, rather thantransplantation, may be the etiologic agentresponsible for IH in our patient. Recombinantgrowth hormone intake has been implicated in thepathogenesis of IH in some patients and we cannotrule it out as a contributory factor in our patient(12,13). However, the reports of IH in patientsreceiving rHGH note that the development of on IHoccurred while rHGH was being administered. Inour patient, rHGH had been stopped at the time oftransplantation. We cannot rule out the possibilitythat IH developed while the patient was on rHGH,though his last eye exam was only 3 months beforerHGH was discontinued. Anemia is anotherpossible contributory factor. However, our patienthad anemia secondary to chronic renal failure as

opposed to iron deficiency anemia, the only type ofanemia conclusively linked to the development ofIH (14).

A number of reports have acknowledgedthat cystinosis may very well be etiologic inintracranial hypertension (1-3) A proposedmechanism by which cystinosis may causeintracranial hypertension involves a decrease incerebrospinal fluid reabsorption. Severalneuropathological reports have documentedinvolvement of the central nervous system incystinosis (2-4). In these cases, cystine depositionwas found in the meninges, including the arachnoidgranulations, choroid plexus, pineal gland, andbrain parenchyma. Cystine deposition in thearachnoid villi may very well cause decreasedcerebrospinal fluid reabsorption leading toincreased CSF pressure. However, the mechanismof resolution of IH in patients with cystinosis isunclear. Though cystine accumulates in theintracellular compartment in these patients, plasmacystine remains normal. Intracellular accumulationof cystine is therefore not improved by ameliorationof renal function. It is possible that other pathwaysfor CSF outflow become more active when thearachnoid villi become dysfunctional. However,the exact mechanism of resolution of IH remainsunknown.

If cystinosis was indeed causing increasedintracranial pressure in our patient, then theappropriate diagnosis would be intracranialhypertension secondary to nephropathic cystinosis,as opposed to a diagnosis of IIH. As noted above,the designation IIH should be reserved for patientsin whom the etiology of IH is unknown and is notrelated to a coexisting systemic disease which hasbeen conclusively associated with IH.

CONCLUSION

Nephropathic cystinosis has been associatedwith IH in several reports. Although patients withrenal failure of varying etiologies may have avariety of metabolic and pharmacologic causes forintracranial hypertension, including use of humangrowth hormone and corticosteroids, as well asrenal transplantation, the preponderance of evidencesuggests that cystinosis per se may be acontributory factor for the development of IH inthese patients.


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REFERENCES

1. Dogulu C, Tsilou E, Rubin B, FitzGibbon E, Kaiser-Kupper M, Rennert O, Gahl W. Idiopathicintracranial hypertension in cystinosis. J Pediatr 2004 Nov;145(5):673-8. Review.

2. Ross DL, Strife CF, Towbin R, Bove KE. Nonabsorptive hydrocephalus associated with nephropathiccystinosis. Neurology 1982 Dec;32(12):1330-4.

3. Ehrich JH, Stoeppler L, Offner G, Brodehl J. Evidence for cerebral involvement in nephropathiccystinosis.. 1979 May;10(2):128-37.

4. Vogel DG, Malekzadeh MH, Cornford ME, Schneider JA, Shields WD, Vinters HV. Central nervoussystem involvement in nephropathic cystinosis. J Neuropathol Exp Neurol 1990 Nov;49(6):591-9.

5. Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002Nov 26;59(10):1492-5. Review.

6. Levy M, Feingold J. Estimating prevalence in single-gene kidney diseases progression to renal failure.Kidney Int 2000; 58:925

7. Friedman, DI. Pseudotumor cerebri. Neurosurg Clin N Am 1999; 10:609.

8. Chang D, Nagamoto G, Smith WE. Benign intracranial hypertension and chronic renal failure. CleveClin J Med. 1992 Jul-Aug;59(4):419-22.

9. Francis PJ, Haywood S, Rigden S, Calver DM, Clark G. Benign intracranial hypertension in childrenfollowing renal transplantation. Pediatr Nephrol 2003 Dec;18(12):1265-9. Epub 2003 Oct 30.

10. Chamberlain CE, Fitzgibbon E, Wassermann EM, Butman JA, Kettl D, Hale D, Kirk AD, Mannon RB.Idiopathic intracranial hypertension following kidney transplantation: a case report and review of theliterature. Pediatr Transplant 2005 Aug;9(4):545-50.

11. Obeid T, Awada A, Huraib S, Quadri K, Abu-Romeh S. Pseudotumor cerebri in renal transplantrecipients: a diagnostic challenge. J Nephrol 1997 Sep-Oct;10(5):258-60.

12. Blethen SL. Complications of growth hormone therapy in children.. Curr Opin Pediatr 1995Aug;7(4):466-71. Review.

13. Malozowski S, Tanner LA, Wysowski DK, Fleming GA, Stadel BV. Benign intracranial hypertension inchildren with growth hormone deficiency treated with growth hormone. J Pediatr 1995Jun;126(6):996-9.

14. Biousse V, Rucker JC, Vignal C, Crassard I, Katz BJ, Newman NJ. Anemia and papilledema. Am JOphthalmol 2003 Apr;135(4):437-46. Review.

Binocular Vision & ABSTRACTS First Quarter of 2008

Stra bism us Qu arte rly© Volume 23 (No. 1)A Medical Scienti fic e-Periodical Pages 41-45

Page -41-

Vision / Visual Acuity / Amblyopia

Letter Case and Text Legibility in Normal and Low Vision.Arditi A, Cho J. Vision Research 2007; 47:2499-2505[Authors Abstract]

It is thought by cognitive scientists and typographersalike, that lower case text is more legible than upper case. Yetlower case letters are, on average, smaller in height and widththan upper case characters, which suggests an upper caseadvantage. Using a single unaltered font and all upper, alllower, and mixed case text, we assessed size thresholds forwords and random strings, and reading speeds for text withnormal and visually impaired participants. Lower casethresholds were roughly 0.l log unit higher than upper. Readingspeeds were higher for upper than for mixed case text at sizestwice acuity size; at larger sizes, the upper case advantagedisappeared. Results suggest that upper case is more legiblethan the other case styles, especially for visually impairedreaders, because small letter sizes can be used than withthe other case styles, with no diminution of legibility. (Dr.Arditi, Arlene R. Gordon Research Inst, LighthouseInternational, 111 East 59th St, New York NY 10022. Fax: 212-751-9667)

Testability of Retinomax Autorefractor and IOLMaster inPreschool Children. The Multi-Ethnic Pediatric EyeDisease Study. Borchert M, Wang Y, Tarczy-Hornoch K etal. Ophthalmology 2008; In press. [Authors Abstract]{furtheredited/reduced for space}

Purpose: To determine this in preschool children.

Design: Population-based study of inner citypreschool children in Los Angeles county.

Participants: 2545 Hispanic and 2178 AfricanAmerican children 6 to 72 months old.

Methods: Subjects were identified by door-to-doorscreening within previously identified contiguous census tracts.Pediatric ophthalmologists or optometrists performedcomprehensive eye examinations of all subjects. Refractiveerror and keratometry measurements were attempted on allsubjects with the Retinomax autorefractor after cycloplegia.Axial length measurements with the IOLMaster partialcoherence interferometer were attempted on those subjectsages 30 to 72 months.

Main Outcome Measures: Ability to obtain highconfidence autorefraction readings or axial lengthmeasurements on both eyes.

Results: Overall, 89% were testable in both eyes withthe Reinomax device, and 91% of the children were testablewith the IOLMaster. Testability rose sharply with age, so thatby age 36 months 98% of the children were testable with theRestinomax device and 90% were testable with IOLMaster.There were no consistent gender or ethnicity relateddifferences in testability overall or when stratified by age foreither device.

Conclusions: Young children can be reliably testedwith the Retinomax and IOLMaster devices. This may impactstrategies for management of cataracts and refractive errors inpreschool children. (Rohit Varma, MD, Doheny Eye Institute,1450 San Pablo St, Room 4900, Los Angeles CA 90033-9224)

Crowding - An Essential Bottleneck for ObjectRecognition: A Mini-Review. Levi DM. Vision Research2008; 48:635-654. [Author Abstract]{further edited/reduced forspace by PER}

Crowding generally defined as the deleteriousinfluence of nearby contours on visual discrimination, isubiquitous in spatial vision. Crowding impairs the ability torecognize objects in clutter. It has been extensively studiedover the last 80 years or so, and much of the renewed interestis the hope that studying crowding may lead to a betterunderstanding of the processes involved in object recognition.Crowding also has important clnical implications for patientswith macular degeneration, amblyopia and dyslexia.

There is no shortage of theories for crowding - fromlow-level receptive field models to high-level attention. Thecurrent picture is that crowding represents an essentialbottleneck for object perception, impairing object perception inperipheral, amblyopic and possibly developing vision. Crowdingis neither masking nor surround suppression. We can localizecrowding to the cortex, perhaps as early as V1; however, thereis a growing consensus for a two-stage model of crowding inwhich the first stage involved the detection of simple features(perhaps in V1), and a second stage is required for theintegration or interpretation of the features as an object beyondV1. There is evidence of top-down effects in crowding, but therole of attention in this process remains unclear. The strongeffect of learning in shrinking the spatial extent of crowdingplaces strong constraints on possible models for crowding andfor object recognition.

(UC Berkely, School of Optometry and The Helen WillsNeuroscience Institute, Berkely, CA 94720. Fax: 510-642-7806)

Crowding Between First and Second Order Letters inAmblyopia. Chung STL. Li RW, Levi DM. Vision Research2008; 48:788-798 [Authors Abstract]

To test whether first and second order stimuli areprocessed independently in amblyopic vision, we measuredthresholds for identifying a target letter flanked by two lettersfor all combinations of first and second order targets andflankers. We found that (1) the magnitude of crowding isgreater for second than for first order letters for target andflankers of the same order type; (2) substantial but asymmetriccross over crowding occurs such that stronger crowding isfound for a second order letter flanked by first order letters thanfor the converse; (3) the spatial extend of crowding isindependent of the order type of the letters. Our findings areconsistent with the hypothesis that crowding results from anabnormal integration of target and flankers beyond the stage offeature detection, which takes place over a large distance inamblyopic vision. (Dr. Chung, College of Optometry & Centerfor Neuro-Engineering and Cognitive Science, University ofHouston, Houston TX. Fax: 713-743-2053)

Optical Treatment of Amblyopia in Astigmatic Children.The Sensitive Period for Successful Treatment. HarveyEM, Dobson V, Clifford-Donaldson CE, Miller JM. Ophthal-mology 2007; 114:2293-2301 [Authors Abstract]

Objective: To compare the effectiveness of eyeglasstreatment of astigmatism-related amblyopia in children youngerthan 8 years (range, 4.75-7.99 years) versus children 8 yearsof age and older (range, 8.00-13.53 years) over short (6 week)and long (1 year) treatment intervals.

Design: Prospective, interventional, comparativecase-control study.

Participants: Four hundred forty-six nonastigmatic(right and left eye, <0.75 diopters [D]) and 310 astigmatic



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(RE,±1.00 D) Native American (Tohono O’odham) children inkindergarten or grades 1 through 6.

Intervention: Eyeglass correction of refractive error,prescribed for full time wear, in astigmatic children.

Main Outcome Measures: Amount of change inmean right-eye best corrected letter visual acuity for treatedastigmatic children versus untreated, age-matchednonastigmatic children after short (6 week) and long (1 year)treatment intervals.

Results: Astigmatic children had significantly reducedmean best corrected visual acuity at baseline compared tononastigmatic children. Astigmats showed significantly greaterimprovement in mean best corrected visual acuity (0.08logarithm of the minimum angle of resolution [logMAR] unit;approximately 1 line)., than the nonastigmatic children (0.01logMAR unit) over the 6 week treatment interval. No additionaltreatment effect was observed between 6 weeks and 1 year.Treatment effectiveness was not dependent on age group (<8years vs $8 years) and was not influenced by previouseyeglass treatment. Despite significant improvement, meanbest corrected visual acuity in astigmatic children remainedsignificantly poorer than in nonastigmatic children after 1 yearof eyeglass treatment, even when analyses were limited toresults from highly compliant children.

Conclusions: Sustained eyeglass correction resultsin significant improvement in best corrected visual acuity inastigmatic children, including those previously believed to bebeyond the sensitive period for successful treatment. (Dr. ErinHarvey, University of Arizona Dept Ophthalmology and VisionScience, 655 N Alvernon Way, Suite 108, Tucson AZ 85711)

Changes in Visual Function Following Optical Treatmentof Astigmatism-Related Amblyopia. Harvey EM, Dobson V,Miller JM, Clifford-Donaldson CE. Vision Research 2008;;48:773-787 [Authors Abstract]

Effects of optical correction on best corrected gratingacuity (vertical (V), horizontal (H), oblique (O)), vernier acuity(VHO), contrast sensitivity (1.5, 6.0 and 18.0 cy/deg spatialfrequency, V and H), and stereoacuity were evaluatedprospectively in 4 to 13 year old astigmats and a non-astigmatic age-matched control group. Measurements made atbaseline (eyeglasses dispenses for astigmats), 6 weeks and 1year showed greater improvement in astigmatic than non-astigmatic children for all measures. Treatment effectsoccurred by 6 weeks, and did not differ by cohort (<8 yrs $8years), but astigmatic children did not attain normal levels ofvisual function. (Dr. Harvey, Dept Ophthalmology/VisionScience, The University of Arizona, 655 N Alvernon Way, Ste108, Tucson AZ 85711-1824, Fax: 520-324-3161)

Necessity of Cycloplegia for Assessing Refractive Error in12 Year Old Children: A Population Based Study. FotedarR, Rochtchina E, Morgan I, Wang JJ, Mitchell P, Rose KA.Am J Ophthalmol 2007; 144:307-309 [Authors Abstract]

Purpose: To compare pre- and postcycloplegicautorefraction in two separate age samples of Australianschool children.

Design: Population based cross sectional study ofrandom cluster samples.

Methods: Autorefraction was performed before andafter cycloplegia, using 1% cyclopentolate, in the right eyes of2233 12 years old and 216 6 year old children.

Results: The mean spherical equivalent (SEQ)difference between these measures was 0.84 diopters (D)

(95% confidence interval [CI] 0.81 to 0.87 D), more hyperopicin post than pre cycloplegic autorefractive assessments in the12 year old children and 1.18 D (95% CI 1.05 to 1.30 D) morehyperopic in the 6 year old children. Precycloplegicautorefraction substantially overestimated the proportion ofchildren with myopia, misclassifying 17.8% aged 12 years and9.5% aged 6 years. Conversely, precycloplegic autorefractiondid not detect moderate to high hyperopia in 2.28% of 12 yearolds and 17.14% of 6 year olds.

Conclusions: Our findings reinforce the importanceof using cycloplegic autorefraction in children up to age 12years. (Dr. Mitchell, Centre for Vision Research, DeptOphthalmology, Univ Sydney, Hawksbury Road, WestmeadNSW 2145 Australia)

Factors Associated with Recurrence of Amblyopia onCessation of Patching. Holmes JM, Melia M, Bradfield YS,Cruz OA, Forbes B, PEDIG. Ophthalmology 2007;114:1427-1432. [Authors Abstract]

Purpose: In a prospective observational study, wepreviously reported that weaning (tapering or graduallyreducing) treatment in children treated with 6 to 8 hours of dailypatching for amblyopia resulted in a 4-fold reduction in odds ofrecurrence. We now report the association of additional factorswith recurrence or regression of amblyopia in this same cohort.

Design: Prospective, nonrandomized, observationalstudy.

Participants: Sixty-nine children aged <8 years withsuccessfully treated anisometropic or strabismic amblyopia(improved $3 logarithm of the minimum angle of resolution[logMAR] lines).

Methods: Patients were enrolled at the time theystopped patching for amblyopia. Patients were classifiedaccording to whether patching was stopped abruptly or weanedbefore cessation. They were followed off treatment for 52weeks to assess recurrence of amblyopia.

Main Outcome Measure: Recurrence of amblyopiadefined as a $2-logMAR level reduction of visual acuity fromenrollment (cessation of patching) confirmed by a secondexamination. Recurrence was also considered to haveoccurred if treatment was restarted with a $2-logMAR levelreduction of visual acuity, even if it was not confirmed by asecond examination.

Results: The risk of recurrence was higher with bettervisual acuity at the time of cessation of treatment (adjusted riskratio [RR], 0.68per line of worse visual acuity; 95% confidenceinterval [C], 0.51-0.90), a greater number of lines improvedduring the previous treatment (adjusted RR, 1.5 per lineincrease; 95% CI, 1.1-2.0), and a history of recurrence(adjusted RR, 2.7, 95% CI, 1.5-4.9). Orthotropia or excellentstereoacuity at the time of patching cessation did not appear tohave a protective effect on the risk of recurrence.

Conclusions: The higher risk of recurrence in themost successfully treated children with amblyopia and absenceof protection from orthotropia and excellent random dotstereoacuity suggests that careful and prolonged followup isneeded for all children who have been previously treatedfor amblyopia. (Dr. Holmes, Ophthalmology E7, Mayo Clinic,Rochester MN 55905)

Visual Deprivation May Help Treat Amblyopia in Adults.Nature Neuroscience, August 12, 2007. As abstracted bythe AAO Academy Express, September 6, 2007.



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Researchers mimicked the presence of a unilateralcataract in rats from birth to adulthood. Prior to removing thecataract, the rats were subjected to complete visualdeprivation. This period of dark exposure restored oculardominance plasticity in the adult rats and produced a rapidrecovery in visual acuity after removal of the occlusion.

Binocular Vision

Interaction Between Binocular Rivalry and Depth in PlaidPatterns. Buckthought A, Wilson HR. Vision Research2007; 47:2543-2556. [Authors Abstract]

Binocular rivalry was studied using plaids which werethe sum of orthogonal diagonal gratings plus identical verticalgratings in the two eyes. The rivalry alternations sped up as thespatial frequency difference between the vertical and diagonalgratings was increased above about one octave, but sloweddown for smaller differences. The interaction between depthand rivalry was studied using similar plaids but with depthintroduced in the vertical components. Depth and rivalrycoexisted when the spatial frequency difference between thevertical and diagonal gratings was greater than about oneoctave, but rivalry slowed down and depth perception wasreduced for smaller differences. Plaids consisting of squarewave gratings were used to compare: (1) added gratings; (2)vertical gratings superimposed on (i.e., occluding) diagonalgratings; (3) diagonal gratings superimposed on verticalgratings. Rivalry alternations were fastest in condition (3),indicating that grouping effects played a role. The finalexperiment indicated that depth and rivalry coexisted within aspatial frequency band if the orientation difference between thevertical and diagonal components was 60 to 70 degrees.These results place constraints on models of stereopsis andrivalry, indicating that depth and rivalry can coexist in differentspatial frequency and orientation bands but that each interfereswith the other in the same band. (Dr. Buckthought, Centre forVision Research, Computer Science Bldg Room B0002E, YorkUniversity, 4700 Keele St, Toronto, Ontario, Canada M3J 1P3.Fax: 416-736-5857)

A Bias for Looming Stimuli to Predominate in BinocularRivalry. Parker A, Alais D. Vision Research 2007. [AuthorsAbstract]

Concentric gratings that expand outwards are seenfor a greater period of time relative to contracting gratingswhen engaged in binocular rivalry. During binocular rivalry(BR), which is a fluctuation in visual awareness betweendifferent images presented separately to each eye, equivalentimages tend to be seen in equal proportion over theobservation period. When one eye’s image is particularlysalient, brighter, or moving, this equality is curtailed, and thestronger image predominates. Here a specific direction ofmotion is found to predominate over another of equal speed.This tendency is consistent with the ability of looming objets toorient attention, coupled with previous accounts of the role ofstimulus driven attention in BR. (Dr. Parker, School ofPsychology, Univ Sydney, Brennan MacCallum Bldg (A18),Sydney NSW 2006, Australia.

Stereopsis

Stereoscopic Depth Perception in Peripheral Field andGlobal Processing of Horizontal Disparity Gradient

Pattern. Devisme C, Drobe B, Monot A, Doulez J. VisionResearch 2008; 48:753-764 [Authors Abstract]

This study investigates how the visual system detectsa surface deviation from planar, induced by, crossed oruncrossed, horizontal disparities continuously increasing witheccentricity. Binocular disparities increased linearly andconcentrically, between two given eccentricities. Thethresholds of deformation detection were gathered using amethod in which observers halted a dynamic stimulus. Thethresholds are substantially higher than those measured by thecontrol experiment using a method of constant stimuli. Results,using the adjustment method, highlight lower discriminationthresholds for uncrossed disparities than for crossesdisparities. For the two directions of disparity, thresholds varysimilarly as a function of eccentricity, however twoobservations can be pointed out: thresholds of peripheral startdepend on disparity gradient and staring eccentricity; fovealstart thresholds do not depend on disparity gradient alone.Data suggests that in peripheral field, the visual system is moresensitive to uncrossed disparities than crossed disparities,relative to the frontoparallel plane. According to a verbal reportfrom observers, the reference used for the perceptive judgmentappears not to be the screen plane but rather the peripheralstimulus. Moreover, in the deformation detection of planarsurfaces, horizontal disparities processing depends on theeccentric location of the disparities. It could be global for theperipheral locations and could be based more on depthcontrast for the central locations. (Dr. Celine Devisme, Collegede France, 11 Place Marcelin Berthelot, 75231 Paris, France.Fax: 33-1-55-96-4702)

Binocular Vision / Binocular Motility

Ocular Dominance Diagnosis and Its Influence inMonovision. Seijas O, Gomez de Liano P, Gomez de LianoR, Roberts , SJ, Piedrahita E, Diaz E. Am J Ophthalmol2007; 144:209-216.e1 [Authors Abstract]

Purpose: To analyze the response of normalemmetropic subjects to different ocular dominance tests and toanalyze the influence of this response in surgically inducedmonovision.

Design: A prospective study of diagnostic accuracywas carried out to analyze the different tests to determineocular dominance, without a gold standard test.

Methods: Nine different tests were carried out in agroup of 51 emmetropic subjects to determine both motor andsensory ocular dominance. For analysis, patients were dividedinto two groups according to age. Normal ophthalmologicexamination results were the inclusion requirement, withnormal binocular vision and good stereoacuity.

Results: A significant percentage of uncertain orambiguous results in all tests performed was found, except inthe hole-in-card and kaleidoscope tests. When the tests werecompared, two by two, the correlation or equivalence foundwas low and as much lower if tests were compared three bythree.

Conclusions: No clear ocular dominance was foundin most studied subjects; instead, there must be a constantalternating balance between both eyes in more emmetropicpersons, but not in those with pathologic features. This factwould explain the great variability both between and withindifferent kinds of tests. Also, it would establish that themonovision technique is well tolerated in most patients, withunsuccessful results only in those patients with strong or clear



Page -44-

dominance. Consequently, it seems appropriate to evaluatepatient’s dominance before monovision surgery toexclude those individuals with clear dominance. (OlgaSeijas, c/o Infanta Maria Teresa, 18-5° A, 28016 Madrid,Spain)

The Role of Binocular Stereopsis in Monoptic DepthPerception. Wilcox LM, Harris JM, McKee SP. VisionResearch 2007; 47:2367-2377. [Authors Abstract]

In this study of depth from monocular elements, Kayereported that monocular stimuli, briefly presented to one eye ina stereoscopic display, generate reliable depth percepts. Herewe replicate and extend Kaye’s findings in an effort to identifythe mechanisms underlying the phenomenon. Our experimentsshow that the perceptions of depth is not a simple result ofmonocular local sigh, for the percept of depth disappears whenone eye is patched. In subsequent experiments we assess thepossibility that the percept results from a very coarsestereoscopic match to either the centroid of the luminancedistribution in the unstimulated eye or a simple match to theline of sight in the unstimulated eye. Our results consistentlysupport the match-to-fovea account, and lead us to concludethat monoptic depth is a stereoscopic phenomenon. (Dr.Wilcox, Dept Psychology, Centre for Vision Research, YorkUniversity, Toronto, Canada M3J 1P3, Canada. Fax: 416-736-5814)

Strabismus Pathophysiology

Concordant Eye Movement and Motion ParallaxAsymmetries in Esotropia. Nawrot M, Frankl M, Joyce L.Vision Research 2008; 48:799-808 {Authors Abstract]

The role of eye movements in the perception of depthfrom motion was investigated in esotropia. Elevated motionparallax thresholds, have been shown in strabismus suggestinga global deficit in depth perception involving both stereopsisand motion. However, this motion parallax deficit in strabismusmight be better explained by the role that eye movements playin motion parallax. Esotropia is associated with asymmetricpursuit and optokinetic response eye movements The firstexperiment demonstrates that the motion parallax deficit inesotropia mirrors the pursuit eye movement asymmetry: in thedirection of normal pursuit, esotropic observers had normaldepth from motion parallax. A second set of experiments,conducted in normal observers, demonstrates that this motionparallax deficit is not a secondary problem due to the retinalslip created by inadequate pursuit. These results underscorethe role of pursuit eye movements in the perception of depthfrom motion parallax. (Dr. Mark Nawrot, Center for VisualNeuroscience, Dept Psychology, North Dakota StateUniversity, 1210 Albrecht Blvd, Fargo ND 58105. Fax: 701-231-8426)

The Effects of Strabismus on Quality of Life in Adults. HattSR, Leske DA, Kirgis PA, Bradley EA, Holmes JM. Am JOphthalmol 2007; 144:643-647. [Authors Abstract]

Purpose: As a first step in the development of ahealth related qualtiy of life (HRQOL) instrument, weconducted in-depth interviews to identify the specific concernsof adults with strabismus.

Design: Prospective cross-sectional study.

Methods: Thirty adults with strabismus, 17 withdiplopia and 13 without, were recruited. Individual interviews,

using 11 open-ended questions, were audiotaped, transcribedand transcripts reviewed independently by three investigators.Phrases regarding how strabismus affected everyday life weregrouped into topic areas and the frequency of each topicanalyzed for subjects with and without diplopia.

Results: A total of 1508 phrases were extracted: 207(14%) of 1508 were excluded because they did not pertain toHRQOL. From the remaining 1301 phrases, 48 topic areaswere apparent. For patients with diplopia, the most frequentlyoccurring topics were: nonspecific negative feeling (15/17;88%) (“really hard”); general disability )15/17 (88%) (“affectseverything”); and driving (14/17; (82%). In those withoutdiplopia, the most frequently mentioned topics wereappearance to others (12/13; 92%)(“people notice my eyes”)followed by problems with eye contact (10/13; 77%) andinterpersonal relationships (10/13; 77%). Of the topics thatwere common to both groups (n=42), two of the most frequentwere driving and nonspecific negative feeling.

Conclusions: Multiple individual interviews revealedmnay topics that negatively affect quality of life in patients withstrabismus. The frequency and type of concerns confirm theimportance of HRQOL assessment as an important aspect ofstrabismus management. (Dr. Holmes, Mayo Clinic,Ophthalmology, 200 First ST SW, Rochester MN 55905.

Common Forms of Childhood Strabismus in an IncidenceCohort. Mohney BG. Am J Ophthalmol 2007; 144:465-467[Author Abstract]

Purpose: To report the prevalent forms of childhoodstrabismus.

Design: Retrospective, population based cohortstudy.

Methods: The medical records of all Olmsted County,Minnesota, residents younger than 19 years diagnosed withesotropia, exotropia, or hypertropia from January 1 1985through December 31, 1994 were reviewed.

Results: Six hundred twenty-seven new cases ofchildhood strabismus were identified during the 10 year studyperiod, including 380 (60.1%) with esotropia, 205 (32.7%) withexotropia, and 42 (6.7%) with hypertropia. The five mostcommon forms of strabismus included accommodativeesotropia (27.9%) intermittent exotropia (16.9%), acquirednonaccommodative esotropia (10.2%), esotropia in childrenwith an abnormal central nervous system (7.0%) andconvergence insufficiency (7.4%).

Conclusions: This study provides population baseddata on the most prevalent forms of childhood strabismus.Accommodative esotropia, intermittent exotropia, and acquirednonaccommodative esotropia were the predominant forms ofstrabismus in this Western population. (Dept Ophthalmology,Mayo Clinic, 200 First Street Southwest, Rochester MN 55905)

Strabismus, Diagnosis

Age at Strabismus Diagnosis in an Incidence Cohort ofChildren. Mohney BG, Greenberg AE, Diehl NN. Am JOphthalmol 2007; 144:467-469. [Authors Abstract]

Purpose: To compare the age at diagnosis ofchildren with esotropia, exotropia and hypertropia.

Design: Retrospective, population-based cohortstudy.

Methods: The medical records of all Olmsted County,Minnesota, residents <19 years diagnosed with esotropia,



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Edited by P.E. Romano, MD, MSO. Italics are editorial comments;bolding within abstract is editorial emphasis. Abstracts areselected on the basis of interest to our readers. To avoidduplication you will find none are from The American OrthopticJournal, The British Orthoptic Journal, The Journal of the AmericanAssociation for Pediatric Ophthalmology and Strabismus, TheJournal of Pediatric Ophthalmology and Strabismus, or Strabismus,as most of our readers already subscribe to and/or read them.Publ i c a t io n h e r e in does no t cons ti t u te endorsement,

r e c o m m e n d a ti o n o r a validation of author’sconclusions.

exotropia or hypertropia from January 1, 1985 throughDecember 31, 1994 were reviewed.

Results: The median age at diagnosis of esotropia(n=380), exotropia (n=205) and hypertropia (n=42) was 3.1years, 7.2 years and 6.1 years respectively (P=.001). In thefirst six years of life, esotropia had the highest incidence andwas more likely to occur than either exotropia or hypertropia;exotropia predominated between age seven and 12 years; andeach form was similarly likely to occur between 13 and 18years of age (P=.001).

Conclusions: The age at diagnosis was significantlydifferent for the various forms of strabismus in this population.Esotropia is the most common form in the first six years of life;beyond this age exotropia predominates until the teenageyears when the three forms have a similar but decreasedincidence. (Dr. Mohney, Mayo Clinic, Ophthalmology 200 FirstSt SW, Rochester MN 55905)

Strabometry

Defining Real Change in Prism-Cover Test Measurements.Holmes JM, Leske DA, Hohberger GG. Am J Ophthalmol2008 In press. [Authors Abstract]

Purpose: To describe the interobserver test-retestvariabiliyty of both simultaneous prism and cover testing(SPCT) and alternate prism and cover testing (APCT) inhorizontal deviations, and to calculate 95% limits of agreementthat might be used to define real change.

Design: Prospective cohort study.

Methods: Twenty-three patients with sixth nervepalsy and three controls were independently examined by twoexperienced strabismus surgeons. SPCT and APCT wereperformed at distance and near fixation. Test-retest variabilityand agreement between tests were evaluated using Bland-Altman plots and 95% limits of agreement were calculated.

Results: For SPCT, the 95% limits of agreement half-widths were 6.3 prism diopters (pd) at distance fixation and 6.9pd at near. For APCT, the 95% limits of agreement half-widthswere 10.2 pd at distance aznd 9.2 pd at near.

Conclusions: Based on 95% limits of agreementhalf-widths between two examiners, a change in strabismusmeasurements of less than 10 pd may be attributable to test-retest variability. Changes of 10 pd or more are likely torepresent real change and might be used as the threshold formanagement decisions. (Dr. Jonathan Holmes, DeptOphthalmology, Mayo Clinic, 200 First St SW, Rochester MN55905)

Strabismus Surgery, Complications

Effect of Prophylactic Brimonidine Instillation on BleedingDuring Strabismus Surgery in Adults. Hong S, Kim CY,Seong GJ, Han S-H. Am J Ophthalmol 2007; 144:469-470.[Authors Abstract]

Purpose: To investigate the effects of preoperativebrimonidine-purite 0.15% instillation on intraoperative bleedingand postoperative subconjunctival hemorrhage duringstrabismus surgery in adult patients.

Design: Randomized comparative interventional caseseries.

Methods: One hundred and eighteen eyes of 90consecutive adult patients were instilled with either a singledrop of brimonidine-purite 0.15% (42 eyes), phenylephrine 1%

(38 eyes), or sodium hyaluronate 0.1% (38 eyes) 15 minutesprior to strabismus surgery. Intraoperative bleeding andpostoperative subconjunctival hemorrhage were graded on ascale of one to three. The scores were compared among thestudy groups.

Results: Scores of the intraoperative bleeding andthe postoperative subconjunctival hemorrhage of the treatmentgroups were significantly less than that of the control group(P<.001). The scores of the brimonidine group were similar tothose of the phenylephrine group (intraoperative bleedingscore, P=.405; subconjunctival hemorrhage score, P=.722).

Conclusions: Topical brimonidine administrationbefore strabismus surgery may reduce intraoperative bleedingand postoperative subconjunctical hemorrhage in adultpatients. (Dr. Sueng-Han Han, Inst Vision Research, DeptOphthalmology, Yongdong Severance Hospital, YonseiUniversity College of Medicine, 146-92 Dogok-dong, Kangnam-gu, Seoul 135-720, Korea.

Myopia

Myopia Linked to Birth Month. Ophthalmology. Asabstracted by the AAO Academy Express, August 29,2007.

An Israeli study appearing in Ophthalmology finds thatbabies born in June and July had a 24 percent greater chanceof becoming severely myopic that those born in December andJanuary. The December and January children had the leastnumber of severely myopic individuals.

This finally and undoubtedly proves that myopiais an environmental disease, not a genetic disease!!!! GoAtropine!-per.

X Miscellaneous

Venipuncture.

Ethyl Chloride as a Cryoanalgestic in Pediatrics forVenipuncture. Pediatr Emerg Care 2007; 23:380-383.Abstracted in International Pediatrics 2007; 22:178

Topical ethyl chloride to reduce venipuncture painwas compared to a topical anesthetic and/or no analgesia -no significant differences were found. PERHAPS THEQUALITY OF THE PHLEBOTOMIST IS PARAMOUNT.

Binocular Vision & First Quarter of 2008Stra bism us Qu arte rly© HYDE PARK E DITORIAL Vo lum e 23 (No .1):A Medical Scienti fic e-Periodical - 63

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HYDE PARK EDITORIAL: The Editor's Soapbox, Sandbox & B'LOG

(Prehistoric) Since 1985

Stereoscopic 3D Stars on Film!!s; Hospital Bills onSteroids; How to Cure Society’s Current Hysteria aboutMedical Care (So-Called “Crisis”); $ 662,000 per year; REPs! U Forget VAIL!.

Stereoscopic 3D Movies are BACK!

Stereoscopic depth perception remainsthe epitome of binocular vision. Its goodto see it is still in vogue, as in this recentnews clipping: 3DTV SOON?

Binocular Vision & First Quarter of 2008Stra bism us Qu arte rly© HYDE PARK E DITORIAL Vo lum e 23 (No .1):A Medical Scienti fic e-Periodical Page 46- 63

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3D Models from computer printers

from The Wall Street Journal December 12,2007 by Robert A. Guth. How 3-D PrintingFigures To Turn Web Worlds Real. “... under$100 ... hikers, resorts and real-estate firms arelikely customers for 3-D maps and models thatshow the topographic contours of ski slopes,golf courses and other landscapes. ... Theexpansion by 3-D printers into manufacturingis happening thanks to a steady drop in theprice of printers, improve-ments in thematerials they can handle and a proliferation inthe amount of 3-D data that can be turned intoobjects. Historically, the printers cost hundredsof thousands of dollars and were made by ahandful of small companies. ... now ...machines priced below $20,000, a change thathas radically expanded sales. DesktopFactory Inc. Has already taken 350 pre-ordersfor a $5000 3-D printer it plans to roll out nextyear. ... to expand to custom toys and jewelry.... The figurines cost about $100 each., Theservice is also being marketed with Dell Inc., aspart of a World of Warcraft-themes high end

notebook PC. Buyers of the PC get a voucherfor a free FigurePrints figurine. ...” [like this:]


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VISION and SEEING

Current Visual Challenges: Instant

Headaches or Eye Strain: Watching movies

on your cell phone mini micro screen!!!!.

from The Wall Street Journal January 2, 2008

by Lee Gomes. The Year in Technology:

Pirates, Flash Memory and Hobbies - My,

My! “... One of the things people are doing with

those movies they are downloading, is watching

them on their mobile phones. Not only will

people, especially younger ones, watch movies

on their PCs, something no one would have

believed just a few years ago, but they will

watch them in a matchbook-size display. ... So

much about food and cooking is online that the

‘mainstream media’ of the food world are

alarmed. ... It’s not only cooking, of course, it’s

just about any other pastime you can think of.

As a result, the Internet may make for a new

golden age in hobbies. ...”

[Do you remember my commenting on a paper

on aniseikonia at an AAPOS meeting in 2000?

Do you remember my remarks regarding the

future of binocular vision and that for emphasis

I modeled headgear which mounted a micro

mini TV directly in front of one eye with optical

correction for such a very near viewing

distance so that the micro screen appeared the

size of a normal TV set? That is the way to


-50-

watch such movies!!! I am amazed that I have

not yet seen such a device marketed as an

accessory for any and all cellphones. And a

teensy weensy screen like that costs next to

nothing as they are now part of the cheapest

cellphones.

The most expensive part will be the lens to

focus the images at that distance- about 50

diopters but only a centimeter in diameter.

Anyone who reads this probably has the know-

how and even the parts and pieces to make their

own such viewer!!

LEDs to OLEDs

from The Wall Street Journal December 27,

2007 by William M. Bulkeley. OLED: The

Next Big Thing for Screens? Organic Light-

Emitting Displays Could Challenge LCDs,

Some Say. New displays could remake TV,

cellphone, lighting markets within five years.

“Even as plasma and LCD television screens

flew off the shelves before Christmas,

manufacturers were starting to roll out a new

technology that they predict will produce the

next generation of mass-market video displays.

After decades of development, organic light-

emitting diode displays, or OLEDs, are finally

emerging in consumer products. Some big

companies predict that within five years they

will remake the television, cellphone, computer

screen and lighting markets. OLEDs are

difficult to make and involve temperamental

chemistry. But they produce bright colors,

consume less electricity, and make screens that

are thinner and lighter than any competing

technology. Currently, they are much more

expensive than LCDs, or liquid crystal displays,

but many people in the industry predict that as

manufacturing efficiency improves, their cost

could fall below LCDs. ... Nokia Corp, is using

Samsung Corp OLEDs for the screens of its

new Prism phones, which went on sale this

year. A growing number of Asian cellphones

use O L E D s c re en s f ro m C hi M e i

Optoelectronics Corp, a Taiwanese display

maker, particularly for the small display on the

outside of flip-phones. A Bellevue, Wash.,

company, eMagin Corp uses tiny OLEDs built

on silicon chips as micro display screens a few

inches from the viewer’s eyeball in its headsets

that are designed for game players and soldiers.

... the key advantage of an OLED is that each

pixel emits light, so OLED screens don’t

require backlighting as LCD screens do. That

cuts energy costs and means that screens can be

far thinner and half the weight of LCD screens.

OLEDs can be seen from a wide viewing angle,

unlike LCDs, whose images are best viewed

from directly n front and are unviewable from a

short distance to the left or right. ... plastic that

produce light using one-sixth the energy of an

incandescent light bulb. The company says the

panel could be almost invisibly stuck to a

window or wall and turnon only when needed.

... an OLED light panel that produces 45

lumens, a measure of brightness, per watt of

energy. That is more efficient than the 15

lumens per watt of incandescent bulbs, but well

below the 90 lumens per watt of the most

efficient fluorescent bulbs. ... OLED technology

will eventually be able to produce 150 lumens

per watt of energy. ...” [sounds perfect for my

mini micro direct view TV/movie screen,

doesn’t it...]

Security from SEEING

from The Wall Street Journal November 19,

2007 from The Boston Globe November 18,

2007. Security. Improving Ability to Spot

Dangers in X-rays Is Crucial. “Improving the

human mind’s difficulty in picking out

dangerous objects in X-rays has become as

urgent to security specialists as improving X-

ray technology itself, writes Christopher Shear

in the Boston Globe. The brain seems to have a

few failings that make the task innately difficult

and and psychologists are hoping to nail down

what they are in the hopes of (continued)


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correcting them. One

theory is that the mind

finds it hard to notice

things that it rarely

comes across, according

to research led by J..

Wolfe, a professor of

o p h t h a l m o l o g y a t

Harvard Medical School.

Not everyone believes

h i s a p p r o a c h w i l l

suff ic i en tly improve

performance. Stephen

Mitross, a professor at

Duke University, and

Mathias Fleck, a Duke

graduate student, are

pursuing other avenues

of research. One study

suggests people are

much better at noticing

uncommon threats in

images if they play a lot

of video games in

w h i c h t h e p la y e r

adopts the point of

view of a shooter.

Another line of their research tries to tackle

peoples’ tendency to stop their search once they

have found something suspicious, even if there

could be other problems”


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That last item is really remarkable. A

contact lens!!! Now there’s an optical

challenge. But anyone who can engineer the

rest of that CL will probably be able to figure

that out. The future is here and now and

customers are waiting! This was in the March 3

issue of Business Week which we received as

usual a week ahead on February 25. They must

be using those OLEDs reported earlier.

Another optics tip: Remembering back to

AAPOS 2000, in those days I was peddling and

promoting a green laser pointer for lecturers

since 10% of males with deficient color vision

have trouble seeing the red laser pointers and

the green lasers are much brighter than red too,

aiding any and all other viewing problems, They

were very expensive back then, in the range of

$3-400. Like computers they too are much

cheaper now and well under $100 from many

sources.

Good Financial Advice:

NEXT: We usually progress in HydePark from binocular vision and stereopsisthrough general ophthalmology to generalmedicine. We found nothing in the last categoryfor this issue but our US presidential electioncampaign is certainly highlighting theinsurance aspects of medical care as Barackand Hillary contest and debate this subjectmore than anything else.

We have always thought of the insurancebusiness as being one of the biggest rip-offs ofall and have avoided buying insurance as muchas we can. After all, no insurance company evercreated any money or any wealth. All their

profits are YOUR money, literally all the excessand overcharges for what they sell you! Andthat’s a lot. Some of the consistently wealthiestpeople in our society are those who sell youinsurance. Insurance companies make goodprofits for their stockholders. A recent ad saystheir first job is to insure their assets, not yours!Recently several insurance company executivesand CEOs have been among the very highestpaid. You have to pay sooner or later for everycost you are insuring yourself against anyway.You are just paying some one else a largeamount of your money to force you to save forthese eventual expenses you must bear. That’swhat you pay to protect yourself from having tooccasionally suffer a loss 50% higher than theaverage loss in that area! Up to that level youwould be ahead if you just paid for everythingyourself...

So for “Elsewhere in Medicine” let’sclip some current opinions which support ourown:

from BusinessWeek October 15, 2007 by

Glen Whitman. Bad Medicine for Health

Care. Laws that require people to buy

insurance only drive up the cost of policies.

“...From Hillary Clinton and John Edwards to

Mitt Romney and Arnold Schwarzenegger,

politicians across the spectrum have tried or

vowed to solve America’s health care woes by

enacting an individual mandate - a law

requiring every adult to purchase health

insurance. Despite its bipartisan support, the

individual mandate is bad policy, a vain attempt

to command a better results while doing nothing

to achieve it. ... supporters typically justify the

policy by citing the problem of uncompensated

care. When uninsured patients receive health

services but don’t pay for them, the rest of us

end up footing the bill one way or another.[This

is unavoidable! The people must ultimately pay

for everything anyway!!!-Ed] So advocates of

insurance mandates contend, plausibly enough,

that we should make the free riders pay.[have

they never heard “you can’t get blood from a

stone !?! -Ed] But how big is the free rider

problem really? ... uncompensated care for the

uninsured constitutes less than 3% of all health


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expenditures. Even if the individual mandate

works exactly as planned, that’s the effective

upper boundary on the mandate’s impact. ...

mandating something is not the same as making

it happen. Some people will not comply: 47

states requires drivers to buy liability auto

insurance, yet the median percentage of

uninsured drivers in those states is 12%. ... if

the real concern is making health insurance and

health care available to those in need, we should

focus on reducing health care prices and

insurance premiums. The individual mandate is,

at best, a distraction from that goal. ...A better

approach to health reform would focus on

removing mandates that drive up insurance

premiums. States ought to repeal some or all of

their mandated benefit laws, allowing firms to

offer lower-priced catastrophic care policies to

their customers. The federal government could

assist by guaranteeing customers the right to

buy insurance offered in any state, not just their

own, enabling patients to patronize companies

in states with fewer costly mandates. Indeed,

removing mandates would do far more to

expand health care coverage than adding

new mandates ever could.” (Glen Whitman,

associate professor of economics at California

States University, Northridge, adapted this

column from his earlier paper in Cato Policy

Report).

Another Bad Solution to the

Other Half of the Problem:

from The Wall Street Journal November29, 2007 by John Carreyrou. Maxed Out. AsMedical Costs Soar, The Insured Face HugeTab. Jim Dawson hit cap after hospitalpadding: The $1.2 million bill. “...As spendingon health care has climbed to almost $2 trilliona year, or 16% of the U.S. economy, thenumber of Americans burdened with massivemedical bills has soared as well. According to a2005 survey by the Commonwealth Fund, anestimated 34% of adults aged 19 to 64 faceproblems with medical bills or have accrued

medical debt. A majority of those people -62% - had health insurance, the survey found.

Million dollar medical bills like Mr.Dawson’s, while still unusual, are becomingmore common as insurance policies oncethought to provide catastrophic coverage proveinadequate when it comes to high cost illnesses.... Health plans have been slow to raise theircaps. ... The Segal Company, an employeebenefits consulting firm, says the average healthplan cap among companies it advises is $1million a person - the same as it was in the1970s, when the purchasing power of $1million was the equivalent of nearly $6

million today. Another issue is the widespreadpractice of bill padding by hospitals and otherhealth providers. While hospitals say billpadding is their only defense against theaggressive cost reduction efforts of insurers andgovernment programs, the end result is thatindividuals can, with little warning, be left stuckwith wildly inflated medical bills. For instance,CPMC charged Mr. Dawson $791 forstockings designed to improve blood circu-lation. The same paid can be purchased onthe Inernet for as little as $12. ... the chargeson Mr. Dawson’s bill are ‘Disneyland numbers’that health insurers and government programslike Medicare and Medicaid never pay. ... ‘I donot deny that our charges look insane’ says ...CPMCs CMO... But all hospitals operate thesame way , he says. ‘It’s the reality of theindustry.’ ...”

In my own sub-catastrophic uninsuredsituation, we (my wife and I) have $$$ufferedhugely . ?”Professio nal C ourtesy” hasdisappeared. Professional Persecution seems tohave replaced it. Uninsured we’re billed themax. Its hard to get out of the ER for less than agrand or the hospital for less than ten grand.Discounts (only for cash) and aggressivecounterattacks on showers of billing errors (byJudy) do work.


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-55-

from The Wall Street Journal January 15,2008 by Vanessa Fhurmans. Insurers StopPaying for Care Linked to Errors. Healthplans say new rules improve safety and cutcosts; Hospitals can’t dun patients. “Healthinsurers are taking a new tack in a bid toimprove patient safety and reduce health carecosts: refusing to pay - or let their patients bebilled - for hospital errors. ... includingoperating on the wrong limb or giving a patientincompatible blood. The companies arefollowing the lead of the federal Medicareprogram, which announced last summer thatstarting this October, it will no longer pay the

extra cost of treating bed sores, falls and sixother preventable injuries and infections thatoccur while a patient is in a hospital. Thefollowing year, it will add to the list hospital-acquired blood infections, blood clots in legsand lungs, and pneumonia contracted from aventilator. ... new strategy could drive upmedical costs in other ways as hospitalsabsorb or pass on the expense of introducingthe safety and screening procedures neededto help avoid mistakes. ...”

And Your Government at Work:

Screwing Up and You AgainBadly

from The Wall Street Journal February26, 2008 by Jennifer Levitz and Kelly Greene.States Draw Fire for Pitching Citizens onPrivate Long Term Care Insurance. “ Thislast year, six million letters bearing Gov.Arnold Schwarzenegger’s name and officialstate seal went out to Californians. Themissives, sent by a direct mail company calledSenior Direct Inc., were pitch letters, urgingmany low and middle income residents to buylong term care insurance to cover any futurenursing home bills. Behind the plug: California,like many other states, is trying to curb the highcosts of long term care paid under Medicaid, thejoint federal-state health insurance program forlow income people. Last year, total Medicaidexpenditures for older adults’ nursing facilityand other long term care bills hit $100 billion.So, more states are encouraging such citizens tobuy private insurance. .. . The sta teendorsements are ‘the single best thing that hashappened to the long term care industry.’ ...Total premiums collected for long term care, orLTC, policies were $10 billion in 2007, up 21%from $8.2 billion in 2004. Critics are soundingalarm bells. They argue that the financialbenefits of LTC insurance for many targetcustomers are negligible to nonexistent.Their income and assets are so low that theywould quickly qualify for free care underMedicaid. ... Of all the insurance types on the


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market, long term care is among the mostcomplex - and expensive- forms of coverage.... ‘These policies are very difficult to use, andthe payouts and benefits are difficult to get.’ ...LTC policies also carry some of the highestcommissions in the insurance business. ...Agents often pocket between 30% and 65%of the first year’s total premium payments,then receive annual commissions between3% and 5% for a set period after that. ...”[often for THEIR LIFE or at least the life oftheir defrauded customer... crime does pay ...and the State of California is a co-conspiratorin this dumb-headed scheme to defraud its owncitizens !!!! they say that “ignorance of the lawis no excuse”. We say stupidity in elected officeis no excuse!]

BTW, do you know how we got into thecurrrent Credit Crunch due to gross abuse ofthe subprime mortgage market, right? Answer:Back in the early years of the first ClintonPresidency, Henry Cisneros, Head of HUD,Hillary and Bill decided that what the US reallyneeded was for everyone to be a homeownerand the best way to do that was to elliminateand destroy all the conventional requirementsfor fiscal assets and responsibility for homeownership such as downpayments and interestpayments on the loan!. And they did! And that iswhy we are so screwed up here today! (You doknow that our government was totally 100%responsible for the ‘29 Stock Market Crash andDepression of the 30's, don’t you? - and thatthey got us into World War II to get us out ofit?)

from BusinessWeek March 3, 2008 byC h a d T e r h u n e . . W ran g l in g O ve r‘Reasonable’ Fees. It’s a no-holds-barredbattle between health insurers and hospitals,with customers caught in the middle. “A newand fearsome player has joined the long-simmering battle between insurers and healthcare providers over how much should be paidfor medical procedures. New York AttorneyGeneral Andrew Cuomo announced on Feb. 13

that a six month investigation by his officefound the nation’s biggest health insurers havesystematically defrauded consumers in the stateby setting their reimbursement rates for out-of-net work care artificially low. He has issuedsubpoenas to 15 insurers and intends to sueindustry giant UnitedHealth Group. ... ‘Wehave price anarchy in health care’. ...Hospitals for ‘deliberately rigging’ prices formedical procedures far beyond their actualcosts. ... insurers’ traditional practice ofcomparing area hospital’s rates to determinewhat’s reasonable is wrong because ‘they allhave consultants showing them how to raiseprices’. Medical Savings says it cuts throughthe bloat by basing its reimbursements on whatMedicare pays providers, plus 25%, and says itis introducing a new policy this month that willreimburse at Medicare plus 30%. ... hospitalsroutinely charge health plans three to fourtimes their costs to offset low governmentpayments and charity care. ... Absent moreguidance from regulators, the courts have beenleft to decide. ... disputed in piecemeal fashion -and lately they’ve been finding in favor ofhospitals. ... sharp discounts it had negotiatedwith other insurance plans didn’t make its fullrates unreasonable. Whatever the outcome,Cuomo’s proof should add more clarity to thisfamously vexing issue. ‘This problem isdifficult to address because it concernsbehaviors that are hidden, complicated, andrecurring.’ ... This is long overdue [BW]. (WithBrian Grow in Atlanta).

from The Wall Street Journal February 23,2008 by John C. Goodman.......... Markets andMedicare. The one-size-fits-all paymentsystem is broken. Here’s how to fix it.“...Under a 2003 law, the Medicare trusteeshave certified that the program’s finances havedeteriorated so much that they ‘trigger’ arequi red presid ential res pon se. Sa dly,Washington’s response is not new. The WhiteHouse proposed across-the-board cuts, in


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payments to doctors and hospitals in thebudget earlier this month. Such measures donot improve care, and have not worked tocontain costs in the past. ... Medicare’sunfunded liability is $74 trillion - five timesthat of Social Security. ...

1. Free the doctors2. Free the Patients.3. Free the Entrepreneurs. ...”(Mr. Goodman in the president of the

National Center for Policy Analysis)[In thishalf full page op-ed, we found not one greatidea].

?What to do? To quote the bard, “Firstlet’s kill all the lawyers!” I’ll bet that wouldcut medical costs a third right there! Cuttingmedical costs per se any further is sinful,irrational, insane, impossible and already hasgone too far. Look at the OUTsourcing ofsurgery to Asia. Look at the INsourcing ofMDs from India and the rest of Asia Improved technology and drugs cost money.Better care and better results are NOT FREE!They are not free even under socialism ordictatorships!. No one is applying to USmedical school anymore. It used to be only thebest and the brightest were to be trusted to beour doctors. Never More? Is there anyquestion why? Society seems to expect anddemand perfect M.D. robots with perfect bed-side manners for free. ? Like It’s A Right?

My Rx: AS I said above first let’s kill allthe lawyers! Then let’s Outlaw less thancatastrophic medical insurance for most ofsociety: eliminating the cost of that third partythat addds 50% to our bills will cut out a thirdof the cost of medical care; patients makingchoices out of your own pocket will cut outanother third of the cost. (Hey we’re up to fourthirds!!! eliminated, even better thanfree!)Yes, for those who are too poor to pay atall, the govt (= us via taxation) will have to footthe bill but with no profit incentive, that has tobe cheaper than private greed driveninsurance.

Is the Canadian system any alternative?

How about this evaluation:

SURGEONS! R U READY 4THIS INTERROGATION by all yourpatients ?

from The Wall Street Journal January 9,2008, “The Informed Patient” by Laura Landro.Learning to Ask Tough Questions of YourSurgeon. “... patients are often too intimidatedto ask how qualified a surgeon is, or what safetyprocedures are in place. But as complicationsand errors dog some surgical procedures,experts say it is increasingly crucial for patientsto vet their surgeons and take an active role inpreventing mistakes. ... new efforts are spurredin part by the sharp rise in surgeries performedin outpatient facilities; including doctor’soffices and surgical centers, where patientsaren’t guaranteed the same access to care as in ahospital should something go wrong. A rash ofrecent news has highlighted the risks, such asthe death of rap mogul Kanye West’s motherafter an office cosmetic procedure by a surgeonwho was facing disciplinary action at the statemedical board and two malpractice suits thatended in significant payouts. ...In a new book tobe published this month, ‘I Need an Operation... Now what? A Patient’s Guide to Safe andSuccessful Outcome’ Dr. Russell providespatients with lists of questions for surgeons:


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including their success rates, howmany operations they perform in a year andwhether they have any health issues of theirown that would interfere with their ability todo the procedure. Avoid those [SURGEONS]who are unresponsive, distracted or rushed. ...[it may seem] offensive to ask whether a doctorhad a good safety record or used recreationaldrugs or alcohol. With a checklist, such as thatdevised by Dr. Russell, ‘You can simply say Ihave this list of questions recommended to meand I’m just going down the list,’ she says. ‘It’snot a personal attack.’ ... the American Board ofMedical specialties, whose 24 member boardscertify about 85% of U.S. physicians, recentlybegan airing a televised public serviceannouncement about the importance of boardcertification ... Its abms.org Web site allowspatients to search by name and specialty toverify a physician’s certification. Consumerscan also use state medical boards’ Web sites tosee whether a surgeon’s license is current andwhether there are any disciplinary actionspending: for a $9 fee, the Federation of StateMedical Boards (www.fsmb.org) will also run asearch. ... wrong site surgeries - term thatincludes the wrong procedure, wrong site orwrong person - continue to bedevil safetyexperts. The Joint Commission in 2004 issued aprotocol for all hospitals that includes a final

safety check and requiresthe marking of th eprocedure site with anindelible marker. But thenumber of reported casesof wrong-site surgeryhave actually increased,at a rate of about five toeight new cases per month- for a total of nearly 550since 1996. ...

:

Chiropractors

from Summit Daily News “Health &Fitness Adverotrials by the Chiropractors ofSum mit Coun ty. [Chiropractic spinalmanipulation now recommended by someMDs] “...The American College of Physicianshas published guidelines for the treatment oflow back pain. The new guidelines nowincluded spinal m anipulation. P reviousdiscussions of low back pain by the medicalcommunity have shied away from spinalmanipulation due to a lack of controlled studies.Chiropractors, osteopaths and their patientshave known clinically that there was benefit inspinal manipulation but getting funding anddesigning studies proved difficult. Thosestudies are now starting to be done. As a resultthe medical community is now includingmanipulation as a treatment in low back pain. ...recommendations [were] printed in the Annalsof Internal Medicine October 2, 2007.Recommendation 7: For patients who do notimprove with self-care options, cliniciansshou ld cons ider the addition of non-pharmacologic therapy with proven benefits -for acute low back pain, spinal manipulation;for chronic or subacute low back pain, intensiveinterdisciplinary rehabili tation, exercisetherapy, acupuncture, massage therapy, spinalmanipulation, yoga, cognitive-behavioraltherapy, or progressive relaxation.

P.S. Here’s a followup on those 3Dmovies reported on the first three pages 46-48of this Hyde Park:

http://www.fsmb.org)


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Careers and MONEY MONEY MONEY


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Alternate Careers - NOT

from The Wall Street Journal December13, 2007 by Sue Shellenbarger. Even LawyersGet the Blues: Opening Up AboutDepression. “... lawyers are among the mostmiserable of men - and women - is well known.Some 19% of lawyers suffer depression at anygiven time, compared with 6.7% of thepopulation as a whole. ... one in five lawyers isa problem drinker, twice the national rate. ...19% of associate attorneys quit law firms everyyear ... Two-thirds of 1500 Oregon attorneyssurveyed by the Oregon Attorney AssistanceProgram said they’d had no exposure beforelaw school to the day-to-day life of a lawyer; ifallowed to start over, 30% said they’d choose adifferent field. ...”

How about another medical specialty?These are the currently popular ones.Ophthalmology didn’t even make the list?


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The foregoing Editorial is from a recentissue of Forbes magazine. Things Change! Seethat (on prior pages) average salary on WallStreet of $ 662,000? No wonder the portion ofHarvard MBAs going into “Financial Serviceshas doubled! The wealthiest MD doctor I knowis that McGuire fellow who made his billionsfrom health insurance. Somehow that seems tome to violate the Hippocratic Oath prettybadly... But while telling a falsehood (is that notthe very most common wrongdoing in the entireworld for its entire history...) is now become aserious federal crime worthy of big fines andhard time, morality otherwise seems bedisintegrating.

Why you feel like you are not gettinganywhere; YOU’RE NOT ! See:


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Above: Stock traders trading stocks! Love thatdisplay. Hope to have something like it in my home officesomeday. See also my reply to BJK on page 20 this issue.

Rest of this page: Below: Excellent strategy for lifein general, especially getting others to agree with yourideas. Gentle REPS! It does work. Nothing works betterbased on my 73 years of mistakes not doing this too often.

below:Someone older than me, and bad example!


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MEMORIES of, on the two year anniversary of the Keystone AAPOS meeting.

We hope you have lots of good memories and none of delays on departure on I-70 as in this cartoon. We did warnyou, remember? Do Drop In Again Anytime. -per

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Website of the Aniseikonia Inspector: http://www.opticaldiagnostics.com/products/ai

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