Pediatric Ophthalmology and Strabismus

1091 Pages·2013·248.754 MB·English

by  Kenneth W. Wright, Peter H. Spiegel, T.C. Hengst

The following tables can be used as a guideline in planning Strabismus surgery. These
numbers have been derived from Marshall Parks, with modifications from the surgical
experience of Kenneth W. Wright. The numbers are only a guide and should be modified as
necessary.
BINOCULAR SURGERY
Esotropia
MROU LR OU
ET Recession ET Resection*
1S~ 3.0mm 1S~ 3.Smm
20~ 3.Smm 20~ 4.Smm
2S~ 4.0mm 2S~ S.Smm
30~ 4.Smm 30~ 6.0mm
3S~ S.Omm 3S~ 6.Smm
40~ S.Smm 40~ 7.0mm
so~ 6.0mm so~ 8.0mm
60~ 6.Smm
70~ 7.0mm
* When a lateral rectus resection is clone for residual esotropia after
large medial rectus recession (6.00 mm or larger), these numbers
should be lowered.
Exotropia
LR OU MROU
XT Recession XT Resection
1S~ 4.0mm 1S~ 3.0mm
20~ S.Omm 20~ 4.0mm
2S~ 6.0mm 2S~ S.Omm
30~ 7.0mm 30~ S.Smm
3S~ 7.Smm 3S~ 6.0mm
40~ 8.0mm 40~ 6.Smm
so~ 9.0mm
MONOCULARSURGERY
Esotropia Exotropia
MR LR LR MR
ET Recession Resection XT Resection Resection
1S~ 3.0 mm ............... 3.S mm 1S~ 4.0 mm ................ 3.0 mm
20~ 3.S mm ............... 4.0 mm 20~ S.O mm ................ 4.0 mm
2S~ 4.0 mm ............... S.O mm 2S~ 6.0 mm ................ 4.S mm
30~ 4.S mm ............... S.S mm 30~ 6.S mm ................ S.O mm
3S~ S.O mm ............... 6.0 mm 3S~ 7.0 mm ................ S.S mm
40~ S.S mm ............... 6.S mm 40~ 7.S mm ................ 6.0 mm
so~ 6.0 mm ............... 7.0 mm so~ 8.0 mm ................ 6.S mm
60~ 6.S mm ............... 7.S mm
70~ 7.0 mm ............... 8.0 mm
THREE-MUSCLE SURGERY
For large horizontal deviations, surgery on three musdes may be
planned for the primary operation. The amount of surgery can be
judged from the above tables. This works especially well in adults,
where one musde can be placed on an adjustable suture. The
adjustable suture should be clone on the eye for which two musdes
are being operated.
VERTICAL NUMBERS
A rule of thumb for vertical surgery is 3 prism diopters of vertical
correction for every millimeter of recession. Inferior rectus reces
sions are notorious for late overcorrections; therefore, consider
using nonabsorbable sutures or long-lasting absorbable sutures.
Superior rectus recessions for dissociated vertical deviation (DVD)
must be large, with the minimum recession of approximately 5 mm
and a maximum of 9 mm (fixed-suture technique).
KESTENBAUM PROCEDURE FOR NYSTAGMUS
Face-turn to the RIGHT
To correct the right face-turn (eyes shifted to a left null point), move
the eyes to primary position by moving both eyes to the right.
LEFT EYE RIGHT EYE
Degree of Recess Resect Recess Resect
Face-Turn LR MR MR LR
Classic <20° 7mm 6mm 5mm 8mm
Parks 30° 9mm 8mm 6.5mm 10mm
Classic +40% 45° 10mm 8.5mm 7mm 11 mm
Classic +60% 50° 11 mm 9.5mm 8mm 12.5 mm
Pediatric Ophthalmology and Strabismus
Second Edition
Springer Science+Business Media, LLC
Pediatric Ophthalmology
and Strabismus
Second Edition
Editors
Kenneth W. Wright, MD
Clinical Professor of Ophthalmology,
University of Southern California-Keck School of Meclicine
Director, Pediatric Ophthalmology Research and Education
Cedars-Sinai Medical Center
Los Angeles, California, USA
Peter H. Spiegel, MD
Vision Professionals, Palm Springs, California
Inland Eye Clinic, Hemet, California
Attending Physician, Loma Linda University Medical Center
Loma Linda, California, USA
With 838 IDustrations in 1197 Parts, 694 in Full Color
Illustrators
Timothy C. Hengst, CMI
Susan Gilbert, CMI
Faith Cogswell
Springer
Kenneth W. Wright, MD Peter H. Spiegel, MD
Clinical Professor of Ophthalmology Vision Professionals
University of Southern California Palm Springs, CA
Keck School of Medicine Inland Eye Clinic
Director Hemet, CA
Pediatric Ophthalmology Research and Education Attending Physician
Cedars-Sinai Medical Center Loma Linda University Medical Center
Los Angeles, CA, USA Loma Linda, CA, USA
[email protected] [email protected]
Library of Congress Cataloging-in-Publication Data
Pediatric ophthalmology and strabismus / editor, Kenneth W. Wright, Peter H. SpiegeL-
2nd ed.
p.; cm.
Previous ed. cataloged under: Wright, Kenneth W., (Kenneth Weston), 1950-.
Includes bibliographical references and index.
1. Pediatric ophthalmology. 2. Strabismus. I. Wright, Kenneth W. (Kenneth Weston),
1950-. Pediatric ophthalmology and Strabismus. II. Wright, Kenneth W. (Kenneth
Weston), 1950-. ill. Spiegel, Peter H.
[DNLM: 1. Eye Diseases-Child. 2. Eye Diseases-Infant. 3. Strabismus-Child. 4.
Strabismus-Infant. WW 600 P37141 2002]
RE48.2C5 W747 2002
618.92'0977--dc21 2002020934
ISBN 978-1-4899-0511-6 ISBN 978-0-387-21753-6 (eBook) Printed on acid-free paper
DOI 10.1007/978-0-387-21753-6
© Springer Science+Business Media New York 2003
Originally published by Springer-Verlag New York, Inc. in 2003
Softcover reprint of the bardeover 2nd edition 2003
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To my beautiful wife Donna
and my children
Jamie, Matthew, Lisa, Michael, and Andrew
for their unselfish love that allows me to pursue my passion:
pediatric ophthalmology and Strabismus
and
To my mother, Mary Jo, and my father, Harvey,
for their steadfast support that gave me the opportunity
to fulfill my dream.
Kenneth W. Wright, MD
To my wife, Lori, for her love and support.
Peter H. Spiegel, MD
Foreward
History of Pediatric Ophthalinology
T
he editors of this excellent balanced text of Pe established in almost every metropolitan area of sig
diatric Ophthalmology and Strabismus re nificance. The new social demand for improved med
quested a foreward to the first revised edition ical care for children swept the struggling specialty of
to inform the younger readership about the historical pediatrics into prominence and acceptability. The re
details of pediatric ophthalmology and how strabis sentment of general practitioners gradually disap
mus became joined to pediatric ophthalmology. I ac peared and for good reason. Medicine, sooner or later,
cepted the editors' challenging invitation with the un inevitably smothers any trace of self-interest and
derstanding that the reader should realize that history shortsightedness by invariably asking the question,
is notorious for being recorded according to its author's What is in the best interest of the patient? This atti
memory, research, and point of view. This foreward is tude is the ingredient that makes medicine such a
no exception to that observation. laudable profession. The answer was obvious, because
Ophthalmology was one of the first specialties. time showed that pediatricians had raised the stan
Having evolved from surgery, it was welcomed as a dard of care for infants and children.
specialty because ophthalmology was concerned with We should be proud that ophthalmology fulfilled
other sciences and instrumentation unfamiliar to gen the leadership role in the specialty movement by ini
eral surgeons. Refraction, assessment of the alignment tiating a certification process. Conceived in 1916,
and motility of the eyes, and attempting to compre this was the beginning of the American Board to cer
hend the complex neurology of vision were so far out tify that candidates were adequately trained in their
side the scope of knowledge expected of a general sur specialty and had passed an examination given by
geon that the development of ophthalmology as a peers and superiors that validated competence to
specialty brought a sense of relief to its progenitors. practice that specialty. Before certification, the pub
In retrospect, as pediatric ophthalmologists today re lic was victimized by self-proclaimed specialists in
flect an the evolution of ophthalmology from its be adequately trained and incapable of rendering qual
ginning to the mid-20th century, they perceive the spe ity care. Such a hold new order in the specialty
cialty to have been primarily a geriatric one. Little in movement was met with resistance, not only by
that formative period focused an the recognition and some ophthalmologists but also by the other spe
treatment of visual disorders in children. This per cialties. Approximately 25 years passed before certi
ception is not a criticism; rather, it is an observation fication became accepted by all ophthalmologists and
that the natural evolving process of ophthalmology 35 years before all specialties instituted their own
preceded the evolution of pediatrics. boards. The American Board of Ophthalmology must
In cantrast to ophthalmology, pediatrics evolved have considered itself vindicated by the fact that all
from general practice with only a minimal difference boards of the more than two dozen specialties copied
in the basic knowledge between practitioners of the the model it established.
two fields, except for their experience with different Since the middle of the 20th century, subspecial
age groups. This difference proved to be inadequate to ization has become the second part of the specialties
convince the medical community that pediatrics was movement. Subspecialization was the natural out
needed, so that it was difficult for pediatrics to gain growth of the specialty to cantend with its ever
the status of a specialty. However, the force that even expanding base of knowledge and technology. Al
tually drove the development of pediatrics came from though subspecialization fragments the specialty, it
a social thrust outside the medical profession. By the will never be reversed because subspecialization is in
beginning of the 19th century, children first became the best interest of the patient. All specialty boards
recognized as the irreplaceable and essential treasure must cantend with the current subspecialization cer
of any nation wishing to ensure its success. In both tification problern they now face.
Europe and North America, the new attitude encour As the ophthalmology subspecialties were for
aged excellent education and medical care for all chil mally introduced, pediatric ophthalmology was not
dren. Within a few years, children's hospitals became included. The trend was to specialize by type of
vii
viii FOREWORD: HISTORY OF PEDIATRIC OPTHALMOLOGY
ocular tissue and major pathology, such as cornea, This fact coincided with the pediatric ophthalmolo
retina, strabismus, glaucoma, oculoplastics, neuro gists' realization that Strabismus was the predominant
opththalmology, and ophthalmic pathology. Despite pathology. It became obvious that strabismologists
this impressive list of subspecialties, general ophthal needed to have pediatric skills and pediatric ophthal
mology prevailed as the dominant group delivering eye mologists needed to have Strabismus skills. The nat
care to children. Neither the generalists nor the sub ural outcome was a marriage of the two subspecial
specialties initially welcomed pediatric ophthalmol ties. The unacceptability of pediatric ophthalmology
ogy into the recognized subspecialty group. The often as a bona fide subspecialty within ophthalmology ter
heard comment was "we can do everything a pediatric minated with this marriage.
ophthalmologist does," a repetition of the identical The overriding issue regarding ophthalmology be
comment by the general practitioners one century ear ing originally perceived as a geriatric specialty changed
lier when pediatrics was becoming a specialty. But dur with the acceptance of pediatric ophthalmology as a
ing the 1950s, ophthalmology consistently revealed its subspecialty. This change brought balance to the mis
unawareness of the social policy (not a medical pol sion of ophthalmology. The original mission seemed
icy) established a century earlier that children should to be saving vision from disorders that resulted from
receive special care. The understanding that a special the ravages of aging. It then became obvious that oph
environmentwas needed to render the highest qual thalmology's mission was actually twofold: (1 ) to fos
ity care resulted in the spread of children's hospitals ter the development of vision in the pediatric popula
through the world's developed countfies within just a tion and (2) to preserve and restore vision once it has
few years. This policy decisively established the spe developed, with a primary focus on the adult and ge
cialty of pediatrics and charged it with the responsi riatric population.
bility to control and develop the best care for infants The one outstanding exception in attempting to
and children. For pediatrics to remain in control of the define the limits of pediatric ophthalmology is adult
environment in which children are treated, pediatrics strabismus. It is practical for the entire subspecialty
realized it needed to attract trained personnel from all of strabismus to be within the combined subspecialty
other specialties willing to devote their professional of pediatric ophthalmology and strabismus. As stated
lives to children's care. Almost all specialties re previously, the pediatric ophthalmologist must also be
sponded to this need, and soon there was pediatric sur a trained strabismologist. As the knowledge base and
gery, anesthesiology, cardiology, neurology, urology, the technology involved in investigating and treating
otolaryngology, hematology, oncology, and so on. Oph strabismus are practically the same for pediatric and
thalmology, however, remained unresponsive. This adult patients, the need for an adult strabismus sub
unfortunate attitude left ophthalmology on the losing specialty is lacking, especially in light of the success
side of the issue, because the answer to the inevitable ful marriage of the two subspecialties.
question, "What is in the best interest of the patient?" Pediatric ophthalmology and strabismus is now
was obvious. firmly established as a single subspecialty. The clinical
As subspecialties in ophthalmology were becom society of the American Association of Pediatric Oph
ing recognized, strabismus, like glaucoma, easily fit thalmology and Strabismus is 25 years old and pub
the criteria of acceptance. Almost immediately, stra lishes a journal. The specialty is well served by several
bismologists became the strong proponents for pedi excellent texts available in this field. With a rapidly ex
atric ophthalmology to be accepted as a subspecialty. panding trained personnel base distributed araund the
In the 1950s it became clear that the predominant world, the subspecialty of pediatric ophthalmology and
pathology of strabismus had its onset during infancy strabismus has become an essential component of oph
and early childhood. In addition, strabismologists be thalmology. Its success is attributable to an obvious
came aware that the best results of treatment were fact: it is in the best interest of the patient.
obtained by the most minimal duration allowed
between onset and initial treatment of the disorder. Marshall M. Parks, MD