眼科国际新进展

1、ADVANCES IN CLINICAL AND BASIC RESEARCH OF OCULAR MOTILITYYang, Dongsheng 杨杨 东东 生生 Department of OphthalmologyUPMC Eye CenterChildrens Hospital of Pittsburgh University of PittsburghVisual sensory systemVisual systemOcular motor system INTRODUCTIONTroxler effectAreas to be covered 1. Normal oculomot

2、or responsesA. Introduce some basic concepts/phenomenaB. Methodology/equipmentC. Binocular control of oculomotor responses2. Abnormal oculomotor responses/oculomotor disorders A. types of oculomotor disordersB. Nystagmus syndromes:Infantile nystagmus syndrome Fusion maldevelopment nystagmus syndrome

3、Acquired nystagmusspasmus nutans syndrome3. Strabismus Discussion on some hot issues Types of normal oculomotor responses1. Smooth pursuit eye movement2. OptoKinetic Nystagmus (OKN)3. Saccadic eye movement4. Vergence eye movement5. Fixational eye movement6. Vestibular-Ocular Response (VOR) Smooth pu

4、rsuit responses Slow Eye Movement Keeps Moving Object on Fovea Stimulus Motion of image across fovea Proprioceptive Asymmetrical RespSmooth PursuitOptokinetic nystagmus (OKN) Combination of Fast Phase: Saccade Slow Phase: Pursuit Holds images of the world steady during sustained movement Asymmetrica

5、l OKNOptokinetic Nystagmus (OKN) Slow eye movement Holds images of the world steady during brief movement and rotations Stimulus Semicircular CanalsVestibularSaccadeFast Eye Movements Brings Object of Interest onto Fovea Voluntary “Look Over Here” Involuntary Response to Stimulus Peripheral Visual A

6、uditorySaccadesVergence eye movements Disconjugate slow eye movments Moves the eyes in opposite directions so that images of a single object are placed on the fovea StrabismusVergenceVergence eye movements1oFixational eye movements: tremors, drifts & microsaccadesRoles of eye movements Align the

7、 lines of the sight to a visual targetStabilize images on the retinaRefresh the retinasMethodologyMagnetic coil systemSampling Rate: 500 - 1000 HzAccurate: 0.15 average accuracyMeasurement range: Horizontal, Vertical and Version. 30 deg.Input/out put connections: I/O.Software settings: data analysis

8、 tools/softwareMethodologyRoutine Tests:Diagnosis of ocular motor disordersHead free eye movement recordingTime (second)Eye velocity (deg/s)Eye position (deg)Velocity Increasing waveformsNystagmus WaveformsDiagnosis of ocular motor disordersTime (second)Eye position (deg)Eye velocity (deg/s)Velocity

9、 Decreasing Waveforms Diagnosis of ocular motor disorders(From DellOsso)DJRADJREFDJRLDiagnosis of ocular motor disorders(From DellOsso)DJRADJREFDJRLDiagnosis of ocular motor disordersNull zonetimerightDiagnosis of ocular motor disorders(A)Periodical Alternative Nystagmus, APAN2.5 sec5 degJerk LeftJe

10、rk RightDiagnosis of ocular motor disordersPeriodical Alternative Nystagmus, PANConvergence dampingTime (second)Eye position (deg)FarNearFarNearODOSDiagnosis of ocular motor disordersNystagmus acuity function：00.8-100-50050BNQ3.LAB (rh0_2s) : Vel. points within 1 by 4/sec windowEy

11、e Velocity (/sec)00.8-10123BNQ3.LAB (rh0_2s) : Pos. points within 1 by 4/sec windowTime (sec)Eye Position ()Diagnosis of ocular motor disordersInfantile Nystagmus Syndrome (INS) (Old Congenital Nystagmus)Diagnosis criteria: Infantile onset, ocular motor recordings show diagnostic

12、(accelerating) slow phasesGeneral comments:Waveforms may change in early infancy, head posture usually evident by 4 years of age. Vision prognosis dependent on integrity of sensory system.Common associated findings:Conjugate, horizontal-torsional, increases with fixation attempt, progression from pe

13、ndular to jerk, family history often positive, with or without associated sensory system deficits (e.g., albinism), associated strabismus or refractive error, decreases with convergence, null zone present, associated head posture or head shaking, may exhibit a ”latent” component, (a)periodicity. Fus

14、ion Maldevelopment Nystagmus Syndrome (FMNS) Old Latent/Manifest Latent NystagmusInfantile onset, associated strabismus, ocular motor recordings show two types of slow phases (linear and decelerating), jerk in direction of fixing eye.Diagnostic CriteriaCommon Associated FindingsConjugate, horizontal

15、, uniplanar, Usually no associated sensory system deficits, may change with exaggerated convergence (“blockage”), head posture associated with fixing eye in aDDuction, no head shaking, no (a)periodicity. Dissociated strabismus may be present. Decreases with increased fusion (binocular function).Inte

16、nsity decreases with age.General CommentsSpasmus Nutans Syndrome (SNS)Diagnostic Criteria:Infantile onset, variable conjugacy, abnormal head posture and head oscillation, improves (“disappears”) during childhood, Normal MRI/CT Scan of visual pathways. High frequency oscillation (10 Hz), asymmetric,

17、pendular waveforms.General Comments: Usually spontaneously remits in 2-8 years (?).Common Associated Findings:Dysconjugate, asymmetric, multiplanar, family history of strabismus, may be greater in one (aBDucting) eye, constant, head posture/oscillation, usually no associated sensory system deficits,

18、 may associated strabismus and amblyopia, may increase with convergence, head bobbing, head posture may be compensatory. Normal fundus, Decreases with increased fusion. Saccadic OscillationsFlutterFlutter Dysmetria0TTTT0000Saccadic pulseSquare wave jerkDouble saccadic pulseMacro Saccadic Oscillation

19、sTT = TargetDysmetriaTypes of Oculomotor Disorders Infantile Nystagmus Syndrome (INS)Fusion Maldevelopment Nystagmus Syndrome (FMNS)Spasmus Nutans SyndromeAcquired Nystagmus Saccadic Intrusions and OscillationsStrabismusNon-Surgical treatmentMedicationsVisual TrainingAcupuncture BiofeedbackVibratory

20、 StimulationPrisms, Telescopes, Contact LensesBotoxTreatment of ocular motor disordersNYSTAGMUS TYPETREATMENTInfantile Nystagmus SyndromeFresnell Prisms, Orthoptics, Gabapentin, Baclofen, Biofeedback, AcupunctureAcquired Pendular NystagmusFresnell Prisms, Orthoptics, Gabapentin, Baclofen, Clonazepam

21、, Cannibis, Alcohol, Carbamazipine, 5-Hydroxytryptophan, Scopolamine, Memantine. BotoxPeripheral VestibularPositional Excercises, Betahistine, Cinnarizine, Acetazolamide.Downbeat3,4 Diaminopyridine, Clonazepam, GabapentinUpbeatBaclofen, Clonazepam, GabapentinPeriodic AlternatingBaclofen, BotoxSee-Sa

22、wBaclofenSaccadic Intrusions/OscillationsBaclofen, Propanolol, ClonazepamSuperior Oblique MyokymiaCarbamazapine, Propanolol, Timolol,OpsoclonusCorticosteroids, Propanolol, Clonazepam, BaclofenOcular Motor NeuromyotoniaCarbamazpineVoluntary Ocular FlutterPrism, OrthopticsChronic Internuclear Ophthalm

23、oplegiaPrism, OrthopticsSURGICAL TREATMENTSOPERATION 1 INDUCED CONVERGENCE (ARTIFICIAL DIVERGENCE) OPERATION 2 HORIZONTAL NULL POSITION OPERATION 3 CYCLOVERTICAL VERTICAL - MULITPLANAR NULL OPERATION 4 HEAD POSITION WITH STRABISMUS OPERATION 5 4 MUSCLE TENOTOMY c REATTACHMENT OR RECESSION Beneficial

24、 Effects of EOM Surgery Central Visual Acuity Head Posture Null Zone Position and Width Foveation Waveform Type APAN Cycle Gaze Dependent Visual Acuity Visual Recognition Time Visual “Well Being”Roger DavisRoger DavisPre Surgery NullRoger DavisRoger DavisRoger DavisExpectedPost Surgery NullActualPos

25、t Surgery Null01-1-2-3321 secondRight EyeLeft EyeDegrees Binocular control of fixational eye movementsEffect of suppression with binocular fixationPercent020406080100RELE Binocular control of fixational eye movementsPercent0102030405060708090100RELEEffect of suppression with monocular (RE) fixation

26、Binocular control of fixational eye movementsThe indirect suppressionvisual part: visual suppressionnon-visual part: ocular proprioceptionHerrings law?Links to other ocular motor disorders?Strabismus?Nystagmus? Binocular control of fixational eye movements MR increased or decreased amplitudes in fel

27、low eyes.Decreasing amplitude in fellow eye when the restricted eyes amplitude is mechanically restrictedIncreasing amplitude in fellow eye when the restricted eyes amplitude is mechanically restrictedInfantile NystagmusPrevalence of functional state in 358 operated esotropic patients after multiple

28、 surgeries. SBV: subnormal binocular vision; ET: residual esotropia, XT: residual exotropia (Re-dram from Noorden GK von 1988)STRABISMUS TREATMENTLong-term follow-up of congenital esotropia in a population-based cohort.Louwagie CR, Diehl NN, Greenberg AE, Mohney BG.Department of Ophthalmology, Mayo

29、Clinic and Mayo Foundation, Rochester, Minnesota, USA.PURPOSE: To report the long-term outcomes of a population-based cohort of children diagnosed with congenital esotropia during a 30-year period. METHODS: The medical records of all patients diagnosed with congenital esotropia as residents of Olmst

30、ed County, MN, from January 1, 1965, through December 31, 1994, were retrospectively reviewed. RESULTS: A total of 130 children were diagnosed during the 30-year period at a median age of 7.4 months with a mean deviation of 30. During a median follow-up of 11.9 years, 126 patients underwent a mean o

31、f 1.8 strabismus surgeries. The risk for undergoing a second surgery was significantly greater in patients with a larger presenting angle (p = 0.017) and a younger age at first surgery (p = 0.006). The Kaplan-Meier rate of having a second surgery was 51% at 10 years and 66% at 20 years. For those wi

32、th 6 weeks or more of follow-up from the final surgery, last examined at a mean age of 15.1 years, 42 of 94 (45%) were within 8 of orthotropia and 30 of 98 had some level of stereopsis (/=3000 arcsec). CONCLUSIONS: In this population-based study of children with congenital esotropia, a second surger

33、y was necessary in half the patients after 10 years and was more likely in those patients with a larger presenting angle and a younger age at first surgery. Approximately half of the patients were within 8 orthotropia and one-third had measurable stereopsis after a mean of 10.9 years of follow-up.J

34、AAPOS. 2009 Feb;13(1):8-12. High-grade stereo acuity after early surgery for congenital esotropia.Wright KW, Edelman PM, McVey JH, Terry AP, Lin M.Department of Ophthalmology, University of Southern California, Los Angeles.OBJECTIVE: To evaluate the effectiveness of very early surgery for establishi

35、ng straight eyes and sensory fusion in patients with congenital esotropia. DESIGN: A review of consecutive patients with congenital esotropia who underwent surgery between 13 and 19 weeks of age. SETTING: A childrens hospital with a teaching affiliation. PATIENTS: Seven patients who had surgery betw

36、een 13 and 19 weeks of age. INTERVENTION: A bilateral medial rectus recession through a fornix incision with recessions ranging from 5.75 to 6.5 mm in infants younger than 6 months of age. MAIN OUTCOME MEASURES: Sensory fusion as measured by stereo acuity and Worth four-dot testing and motor alignme

37、nt within 8 prism diopters. RESULTS: Five of the seven patients achieved essentially straight eyes with tropias of less than 8 prism diopters after one horizontal surgery. Five patients cooperated with sensory testing, and all showed stereo acuities that ranged from 400 to 40 seconds of arc. Three c

38、hildren had evidence of high-grade stereo acuity by showing stereopsis on random dot stereograms (Randot, Stereo Optical Co, Chicago, Ill) and by fusing the Worth four-dot test at distance and near range. Two of the patients with high-grade stereo acuity achieved a stereo acuity of 40 seconds of arc

39、 by Titmus testing; however, one had a late reduction of stereo acuity to 70 seconds of arc. CONCLUSION: Very early surgery can result in excellent motor alignment and high-grade stereo acuity in some patients with congenital esotropia. Arch Ophthalmol. 1994 Jul;112(7):913-9.Project Number: 3R01EY00

40、5236-24S1 Principal InvestigatorBIRCH, EILEEN ELIZABETHTitle:DEVELOPMENT AND MAINTENANCE OF BINOCULAR VISION Organization:RETINA FOUNDATION OF THE SOUTHWESTDESCRIPTION (provided by applicant): Congenital and early onset binocular imbalance affect the visual maturation of 3-4% of U.S. infants. Even w

41、hen treatment is successful in restoring clear media and good alignment, less than 1% of patients achieve normal stereoacuity and many develop amblyopia. During the previous grant period we established that minimizing the duration of misalignment in esotropic infants enhances binocular sensory outco

42、mes. We will build on this work by assessing whether better binocular sensory outcomes are achieved with alignment before 6 months of age, if binocular sensory outcome is associated with long-term alignment and/or risk for amblyopia, if binocular sensory status at the onset of esotropia is predictiv

43、e of long-term response to treatment, and whether surgical alignment of infantile esotropia places the infant at risk for accommodative esotropia. Our recent work with on nasal-temporal asymmetries in the motion VEP of patients with infantile esotropia has identified a close link between asymmetry a

44、nd monofixation but the relationship with other asymmetries in eye movements and motion perception remain unclear. We will investigate relationships among asymmetries in motion VEP responses, OKN, motion perception, fusion, and stereopsis during normal maturation and in infantile and accommodative e

45、sotropia. These studies also will allow us to determine whether asymmetries precede or co-develop with tropia or whether they occur as a response to prolonged abnormal visual experience. The identification of the mVEP as an objective measure of monofixation during the previous grant period has set t

46、he stage for a series of studies that will address whether suppression is present at the earliest stages of esotropia, whether amblyopia develops in response to unequal suppression, and how suppression changes in response to treatment. The addition of a new paradigm, VEP dichoptic masking, will enha

47、nce the scope of these studies. Studies of the maturation of positional acuity in normal infants and pediatric patients with amblyopia will employ a broader range of positional tasks will be used to investigate the relationship between short-range and long-range deficits, the relationship between su

48、ch deficits and recognition acuity deficits by which amblyopia is defined. In addition, we will continue working to build a battery of sensory tests for clinical trial outcome measures and for individual clinical assessment. These studies will help to define the necessary and sufficient conditions f

49、or the development of normal binocular vision and enhance treatment outcomes of pediatric patients. STRABISMUS TREATMENTThe residual strabismus of 8-10 PDA standard of cure. No more surgery due to risk of over/under correction.Obstacle of high grade stereopsis.Cause to amplyopiaTD100.00.2

50、5-3036Position (degree)Time (second)00.00.25-1000100200Velocity (deg/sec)00.00.25-1000 100200Backward MotionA3 msdivergence velocityvergence positionversion positionversion velocityZhu, Hertle, & Yang. J. Vision. 2008Relationships between the quick phases of vertical versio

51、n and quick phases of horizontal vergenceVisually induced version-vergence nystagmus00.00.25-6-303Position (degree)Time (second)00.00.25-200-1000100Velocity (deg/sec)00.00.25-200-1000 100 Forward MotionB26 ms7 msvergence velocityvergence positionversion velocityversi

52、on positionTD2TD3Relationships between the quick phases of vertical version and quick phases of horizontal vergenceVisually induced version-vergence nystagmusZhu, Hertle, & Yang. J. Vision. 2008Time difference (ms)Zhu, Hertle, & Yang. J. Vision. 2008Relationships between the quick phases of

53、vertical version and quick phases of horizontal vergenceVisually induced version-vergence nystagmusTemporal dissociation between the vertical quick-phases and horizontal vergence quick-phasesLarge temporal dissociation of vertical saccadic and horizontal vergence components is demonstrated from smal

54、l involuntary nystagmus. This result is in line with the recent finding of temporal dissociation of saccadic and vergence component (Kumar et al 2005). Visually induced version-vergence nystagmusZhu, Hertle, & Yang. J. Vision. 2008Relationships between vergence peak velocity and version peak vel

55、ocity. Representative data from subject KG. Relationships between V versional and H vergence peak velocity 00.00.25-3036Position (degree)Time (second)00.00.25-1000100200Velocity (deg/sec)00.00.25-1000 100200Backward MotionA3 msdivergence velocityvergence positionvers

56、ion positionversion velocity00.00.25-6-303Position (degree)Time (second)00.00.25-200-1000100Velocity (deg/sec)00.00.25-200-1000 100 Forward MotionB26 ms7 msvergence velocityvergence positionversion velocityversion positionA: divergence and upward saccade from backwar

57、d motion. B: divergence and downward saccade from forward motion. C: convergence and downward saccade from forward motion. Positive correlations were demonstrated for divergence and upward-saccades from backward motion, and for convergence and downward-saccades from forward motion (p0.001). This is consistent with Busettini and Mays model, which suggest that increased vergence velocity is due to current vergence motor error signal being multiplied by the saccadic burst neurons (2005b). Relationships betw