今日の臨床サポート

斜視

著者: 木村亜紀子 兵庫医科大学眼科学教室

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2021/09/01
患者向け説明資料

概要・推奨   

  1. 生直後より内斜視の症例のなかには確かに自然治癒するケースがあるが、大斜視角の場合は自然治癒する可能性は低い。乳児内斜視では良好な両眼視機能の獲得はきわめて難しいといわれており、生後6カ月の超早期手術や生後1年の早期手術が推奨されている(推奨度2)
  1. 調節性内斜視(部分調節性内斜視)では調節麻痺薬を用いた完全屈折矯正眼鏡を作成し、常用させる。内斜視が残存している場合は早急に保存的治療で眼位を正位に保つことで良好な両眼視機能の獲得が期待できる(推奨度2)
  1. 先天上斜筋麻痺では大きく首を左右に傾ける頭部傾斜を認める。右の上斜筋麻痺では左に、左の上斜筋麻痺では右に頭部傾斜を認める。主訴は頭位異常である。片眼遮閉で頭位異常が消失すれば首からくる頚性斜頚との鑑別ができる(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
木村亜紀子 : 特に申告事項無し[2021年]
監修:沖波聡 : 特に申告事項無し[2021年]

改訂のポイント
  1. 定期レビューを行い、日眼用語集に沿って用語を改めた。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 斜視とは、両眼が同じ方向を向いていない状態のことをいい、先天性と後天性がある。
  1. 先天性のものでは複視の自覚はなく、特に小児では、斜視眼に抑制がかかり正常な立体視が育たない危険性がある。治療の目的は良好な両眼視機能の獲得にあり、最も頻度が高い間欠性外斜視では手術時期は就学前後が多く、乳児内斜視(<図表>)では、できれば生後1年以内の早期手術、遅くとも2歳までの手術が望ましいとされている[1]。頭をどちらかに傾ける頭位異常(頭部傾斜)は、先天上斜筋麻痺が原因のことが多い。
  1. 後天性のものでは、複視の自覚がある。
  1. 後天斜視では、原因により自然寛解率が異なり、微小循環障害が原因の麻痺性斜視では約8割は自然に改善するが、外傷が原因の場合には自然寛解率は低い。白内障術後の複視は、滑車神経麻痺のことが多い[2]。また、脳腫瘍、甲状腺眼症、重症筋無力症が原因のこともあり、原因検索をまず行い、特定できない場合は専門の施設へ送る必要がある。
  1. 半年を経過して斜視が残存した場合には、斜視手術の適応である。
 
  1. 後天滑車神経麻痺には滑車神経麻痺だけでなく代償不全性上斜筋麻痺も含まれる。前者では回旋斜視を自覚し、後者では上下斜視を自覚していることが多い。斜視角では前者は軽度の上下偏位と高度な回旋偏位を認め、後者では高度な上下偏位を認める(推奨度2R)
  1. まとめ:後天滑車神経麻痺では交通事故後、外傷後、白内障術後に認められることが多い。特に両眼性は意識消失発作を伴う場合に多い。外観上斜視にみえないが、複視を訴える場合は滑車神経麻痺を疑うことが大切である。一方、代償不全性上斜筋麻痺では幼少時から軽度の頭部傾斜を認め、患者本人に斜視である自覚のあることが多い。
  1. 代表事例:代償不全性は先天性、後天滑車神経麻痺の原因が頭蓋内腫瘍のことはまれで、さらに動脈瘤であることはほとんどない[3][2]
  1. 結論:外傷後に生じた滑車神経麻痺の自然治癒率は低い。
問診・診察のポイント  
  1. 小児の問診では、診察室に入ってくる頭位をまず確認する。頭位異常―顔回し、頭部傾斜、顎上げなど―の確認を行う。出生児の状況(未熟児であったかなど)と、斜視が顕性化してきた時期も確認する。幼少時からの写真を持参してもらって確認するとよい。
  1. 診察では、前眼部・中間透光体・眼底検査は必ず行い、交代遮閉試験で眼位を確認する。眼球運動は左右・上下で確認し、側方視時の下斜筋過動症の有無にも注意を払う。その後、調節麻痺薬下での屈折値検査を必ず施行する。その際、散瞳するので眼底検査も同時に施行する。幼少のため施行できない場合は、セデーションをかけて行う。屈折異常を認めれば必ず矯正する。弱視合併の有無も確認する。

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文献 

著者: Christina Gerth, Giuseppe Mirabella, Xiaoqing Li, Thomas Wright, Carol Westall, Linda Colpa, Agnes M F Wong
雑誌名: Invest Ophthalmol Vis Sci. 2008 Aug;49(8):3432-7. doi: 10.1167/iovs.08-1836. Epub 2008 Apr 25.
Abstract/Text PURPOSE: Infantile esotropia is associated with maldevelopment of cortical visual motion processing, manifested as directional asymmetry of motion visual evoked potentials (mVEPs). The purpose of this study was to determine whether early surgery at or before age 11 months could promote the development of cortical visual motion processing in human infants, compared with standard surgery at age 11 to 18 months.
METHODS: Sixteen children with a constant, infantile esotropia >or=30 prism diopters and onset before age 6 months were recruited prospectively. Eight of them underwent early surgery at RESULTS: The mean asymmetry index and interocular phase difference in the early surgery group were comparable to that in age-matched control subjects, and they were significantly lower than those in the standard surgery group.
CONCLUSIONS: Early surgery for infantile esotropia promotes the development of cortical visual motion processing, whereas standard surgery is associated with abnormal mVEPs. The results provide additional evidence that early strabismus repair is beneficial for cortical development in human infants.

PMID 18441299  Invest Ophthalmol Vis Sci. 2008 Aug;49(8):3432-7. doi: ・・・
著者: Tadamichi Akagi, Kazuaki Miyamoto, Satoshi Kashii, Nagahisa Yoshimura
雑誌名: Jpn J Ophthalmol. 2008 Jan-Feb;52(1):32-5. doi: 10.1007/s10384-007-0489-3. Epub 2008 Mar 28.
Abstract/Text PURPOSE: To determine the cause and prognosis of neurologically isolated third, fourth, or sixth cranial nerve dysfunction in cases of oculomotor palsy, and to determine the best imaging methods to make a correct diagnosis.
METHODS: The medical records of 221 consecutive patients with oculomotor palsy caused by neurologically isolated cranial nerve dysfunction were reviewed. There were 63 cases of third, 41 of fourth, and 117 of sixth cranial nerve dysfunction. The patients were examined at the Neuro-ophthalmology Clinic of Kyoto University Hospital between 1993 and 2001.
RESULTS: Vascular disorders accounted for 34.9% of the third nerve dysfunction, and 90% of these recovered completely in 6 months. Ninety percent of the patients with an isolated third nerve dysfunction that was caused by an aneurysm also had anisocoria, and 68% of the patients with a third nerve dysfunction caused by a vascular disorder had anisocoria. In all of the vascular cases with anisocoria, the difference in the pupillary diameter was <1.0 mm. The presence of ptosis did not play an important role in making a diagnosis of third nerve dysfunction. Ninety percent of the patients with fourth nerve dysfunction and 60% of the patients with sixth nerve dysfunction recovered within 9 months.
CONCLUSIONS: The age of the patient, signs of an improvement, and associated alterations are important diagnostic markers to determine the best type of imaging methods for evaluating neurologically isolated third, fourth, and sixth cranial nerve dysfunction.

PMID 18369697  Jpn J Ophthalmol. 2008 Jan-Feb;52(1):32-5. doi: 10.1007・・・
著者: B W Richards, F R Jones, B R Younge
雑誌名: Am J Ophthalmol. 1992 May 15;113(5):489-96.
Abstract/Text We collected data from a large series of patients with ocular palsies and compared them with data in previous series from the Mayo Clinic. The largest group of patients among 4,278 cases was that in which the cause was undetermined for a long period of follow-up. The abducens nerve was most commonly affected. The probability of establishing a diagnosis was higher in patients younger than 50 years and among those with associated neurologic findings or multiple ocular palsies. The prognosis for recovery was best in the vascular group but was better than 50% for all groups except those with tumors. Investigation may be tailored to each patient according to clinical findings and probabilities of finding a cause, and judicious clinical judgement should be exercised.

PMID 1575221  Am J Ophthalmol. 1992 May 15;113(5):489-96.
著者: Veit Sturm, Marcel N Menke, Pascal B Knecht, Corinna Schöffler
雑誌名: J AAPOS. 2011 Aug;15(4):317-20. doi: 10.1016/j.jaapos.2011.03.018.
Abstract/Text PURPOSE: To study the clinical features and surgical outcome of type 2 (Burian-Franceschetti) acute acquired concomitant esotropia (AACE).
METHODS: Retrospective analysis of children with AACE type 2. All patients underwent strabismus surgery to restore ocular alignment. All children underwent a complete assessment including medical history and pre- and postoperative ophthalmological and orthoptic examinations. Postoperative follow-up was at least 12 months in all cases.
RESULTS: A total of 25 consecutive patients were included. All but 2 patients (92%) were aligned within 8(∆) or less of orthotropia. Of the 25, 15 (60%) regained normal stereovision. In 6 additional cases (24%) some level of binocular vision (Titmus test, 200'' to 3000'') was demonstrated. All of the patients who finally achieved normal stereopsis had lower levels of binocularity on the first postoperative day. The mean interval between surgery and first occurrence of full stereovision was 18 months (range, 2 to 58 months).
CONCLUSIONS: General features of AACE type 2 are concomitance of strabismus, absence of an accommodative component even in the presence of hyperopic refractive errors, and no neurological pathology. The potential for normal binocular vision plays a key role in defining this entity. The reemergence of full stereopsis may take several years.

Copyright © 2011 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.
PMID 21907110  J AAPOS. 2011 Aug;15(4):317-20. doi: 10.1016/j.jaapos.2・・・
著者: Jong-Min Lee, Sin-Hoo Kim, Jeong-Il Lee, Ji-Yong Ryou, Sook-Young Kim
雑誌名: Korean J Ophthalmol. 2009 Sep;23(3):228-31. doi: 10.3341/kjo.2009.23.3.228. Epub 2009 Sep 9.
Abstract/Text We report a case of acute comitant esotropia in a child with a cerebellar tumor. A 3-year-old boy was referred for management of a 9 month history of acute acquired comitant esotropia. On first presentation, the patient's angle of esodeviation was 50 prism-diopters (PD) at distance and near fixation without any lateral incomitance. The cycloplegic refraction revealed +0.75 diopters in both eyes. Very mild bilateral papilledema was found on the fundus examination, but the neurological examination did not reveal any other pathological findings. Brain MRI showed a 5 cm mass located in the midline of the cerebellum as well as hydrocephalus. The mass was completely excised and histological examination confirmed the diagnosis of pilocytic astrocytoma. Despite neurosurgery, the patient's strabismus remained unresolved. One year after neurosurgery, both medial rectus muscles were surgically recessed by 6 mm, resulting in esotropia of 8PD at distant and near fixation without restoration of bifoveal fusion at follow-up 2 years after the eye muscle surgery. Therefore, acute onset comitant esotropia in a child can be the first sign of a cerebellar tumor, even without any other neurological signs and symptoms.

PMID 19794955  Korean J Ophthalmol. 2009 Sep;23(3):228-31. doi: 10.334・・・
著者: Tracey L Shipman
雑誌名: J Pediatr Ophthalmol Strabismus. 2009 Jul-Aug;46(4):235-7. doi: 10.3928/01913913-20090706-12. Epub 2009 Mar 20.
Abstract/Text A case of acute esotropia with bilateral inferior oblique muscle overaction in a 4-year-old boy with a posterior fossa pilocytic astrocytoma is reported. After tumor excision, the esotropia and oblique dysfunction resolved. Acute esotropia with bilateral inferior oblique muscle overaction without abducens palsy is an unusual sign of brain stem mass.

Copyright 2009, SLACK Incorporated.
PMID 19645405  J Pediatr Ophthalmol Strabismus. 2009 Jul-Aug;46(4):235・・・
著者: F Rowe, VIS group UK
雑誌名: Eye (Lond). 2011 Jul;25(7):881-7. doi: 10.1038/eye.2011.78. Epub 2011 Apr 8.
Abstract/Text AIM: Occurrence of ocular motor cranial nerve palsies (OMCNP), following stroke, has not been reported in relation to the type of OMCNP seen and in relation to brain area affected by stroke. The aim of this study was to identify all patients referred with suspected visual impairment to establish the presence and type of OMCNP.
METHODS: Prospective, observation study with standardised referral and assessment forms across 20 sites. Visual assessment included visual acuity measurement, visual field assessment, ocular alignment, and movement and visual inattention assessment. Multicentre ethics approval and informed patient consent was obtained.
RESULTS: In total, 915 patients were recruited with mean age of 69.18 years (SD 14.19). Altogether, 498 patients (54%) were diagnosed with ocular motility abnormalities. Of these, 89 patients (18%) had OMCNP. Unilateral third nerve palsy was present in 23 patients (26%), fourth nerve palsy in 14 patients (16%), and sixth nerve palsy in 52 patients (58%). Out of these, 44 patients had isolated OMCNP and 45 had OMCNP combined with other ocular motility abnormalities. Location of stroke was reported mainly in cerebellum, brain stem, thalamus, and internal and external capsules. Treatment was provided for each case including prisms, occlusion, typoscope, scanning exercises, and refraction.
CONCLUSIONS: OMCNP account for 18% of eye movement abnormalities in this stroke sub-population. Sixth CNP was most common, followed by third and fourth CNP. Half were isolated and half combined with other eye movement abnormality. Most were treated with prisms or occlusion. The reported brain area affected by stroke was typically the cerebellum, brain stem, and diencephalic structures.

PMID 21475314  Eye (Lond). 2011 Jul;25(7):881-7. doi: 10.1038/eye.2011・・・
著者: K W Wright, P M Edelman, J H McVey, A P Terry, M Lin
雑誌名: Arch Ophthalmol. 1994 Jul;112(7):913-9.
Abstract/Text OBJECTIVE: To evaluate the effectiveness of very early surgery for establishing 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 children's hospital with a teaching affiliation.
PATIENTS: Seven patients who had surgery between 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 alignment 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 children 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 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.

PMID 8031270  Arch Ophthalmol. 1994 Jul;112(7):913-9.
著者: E M Helveston, D F Neely, D B Stidham, D K Wallace, D A Plager, D T Sprunger
雑誌名: Ophthalmology. 1999 Sep;106(9):1716-26. doi: 10.1016/S0161-6420(99)90337-8.
Abstract/Text OBJECTIVE: To determine the long-term motor and sensory results after early surgical correction of patients with congenital esotropia.
DESIGN: Noncomparative interventional case series.
PARTICIPANTS: Ten infants with congenital esotropia.
INTERVENTION: Patients had bimedial rectus recession between 83 and 159 days of age; were re-examined in a regular follow-up program; and were retreated when required for strabismus, amblyopia, and refractive errors.
MAIN OUTCOME MEASURES: Final alignment, stereo acuity, variations in vision, alignment, refraction, and number and types of retreatments required during the period of observation.
RESULTS: All patients were aligned initially with bimedial rectus recession of 8.0 to 10.0 mm measured from the limbus. A total of 11 additional surgical procedures were performed on 7 patients to maintain alignment. Four patients required hyperopic spectacle correction to maintain alignment, and two patients required short periods of patching. Visual acuity was 20/40 or better in 19 eyes at the most recent examination, which was between 8.3 and 11.8 years after initial surgery. All patients had final alignment to within 10 prism diopters (PD) of orthotropia at either distance or near. Nine of ten patients had dissociated vertical deviation (DVD), and four of ten patients had latent nystagmus. Four patients had measurable stereo acuity at their last visit, with two achieving a stereo acuity of 3000 seconds (the Titmus fly), one 400 seconds, and one 140 seconds.
CONCLUSION: Surgical alignment of congenital esotropia can be achieved in the 4-month-old with bimedial rectus recession, but this does not ensure continued alignment. At least one additional surgical procedure is required on average to maintain alignment in the first 10 years after initial successful surgery. These patients can also be expected to have one or more of the following: DVD, latent nystagmus, refractive component, or latent strabismus. Regardless of outcome, patients with congenital esotropia have optokinetic asymmetry. Attainment of stereo acuity, including high-grade stereo acuity, may be enhanced by attainment of orthotropia or small-angle esotropia but is likely to be ultimately dependent on constitutional factors rather than age of alignment.

PMID 10485540  Ophthalmology. 1999 Sep;106(9):1716-26. doi: 10.1016/S0・・・
著者: M R Ing
雑誌名: Ophthalmology. 1983 Feb;90(2):132-5.
Abstract/Text To provide sufficient numbers of patients varying in age of initial adequate surgical alignment for congenital esotropia, 162 patients managed by seven ophthalmologists in three countries were personally examined by the author and the results compiled for a clinical study. From this population group, 106 patients were chosen who had reliable answers, satisfactory alignment, and an ophthalmologist's confirmation examination of the congenital nature of the problem by at least 1 year of age. The results of sensory testing showed that those adequately aligned by the age of 6 months vs 12 months vs 24 months were not statistically different, but those patients aligned after 24 months of age demonstrated a significantly lower percentage with evidence for binocularity (P less than 0.001). Surgical alignment in the congenital esotropic patient should be accomplished by 2 years of age to attain the highest yield of binocular function.

PMID 6856250  Ophthalmology. 1983 Feb;90(2):132-5.
著者: Sühan Tomaç
雑誌名: J Pediatr Ophthalmol Strabismus. 2002 Jul-Aug;39(4):226-30.
Abstract/Text PURPOSE: To investigate whether restoration of normal stereo acuity is possible in refractive accommodative esotropia.
METHODS: Twenty patients with refractive accommodative esotropia were included in the study. The cycloplegic refraction and the best corrected visual acuity of each patient were recorded. The patients were evaluated by the 4-prism-diopter test, Bagolini striated glasses, the Worth 4-dot test, the TNO stereo test, and the stereo fly plate of the Titmus test.
RESULTS: Eight patients had orthotropia with normal retinal correspondence and 12 patients had a small deviation with abnormal retinal correspondence. Nine patients (8 patients with orthotropia and 1 patient with microtropia) demonstrated a gross level of stereo acuity, whereas the others demonstrated no stereopsis.
CONCLUSION: In patients with refractive accommodative esotropia, the prognosis is not favorable for restoration of normal stereopsis, even if orthotropia is achieved.

PMID 12148556  J Pediatr Ophthalmol Strabismus. 2002 Jul-Aug;39(4):226・・・
著者: M E Wilson, E C Bluestein, M M Parks
雑誌名: J Pediatr Ophthalmol Strabismus. 1993 Jul-Aug;30(4):233-6.
Abstract/Text One hundred twenty-seven medical records of patients with accommodative esotropia met our inclusion criteria and were analyzed. All included patients were within 10 prism diopters of orthophoria and had stereopsis and other binocular sensory test results recorded at their latest visit. Bifixation, defined as stereopsis of 50 arc seconds or better, was present in 31 patients (24%) with an average follow up of 89 months. Monofixation (peripheral fusion) was present in the remaining 96 patients (76%) with an average follow up of 84 months. Patients with bifixation were less likely to have presented with constant esotropia (19% vs 39% [P = .04]) and were more likely to be aligned within 8 delta of orthophoria in their first glasses (84% vs 21% [P < .0001]). No patient with bifixation had constant esotropia longer than 4 months. In addition, patients with bifixation were less likely to have worn bifocals (39% vs 59% [P = .09]), or undergone esotropia surgery (23% vs 62% [P < .0001]). These data suggest that maintenance of bifixation is possible in accommodative esotropia if the eyes are straightened before or shortly after the esodeviation becomes constant. With this early therapy, amblyopia and deterioration of ocular alignment are also less likely.

PMID 8410574  J Pediatr Ophthalmol Strabismus. 1993 Jul-Aug;30(4):233・・・
著者: A D Abroms, B G Mohney, D P Rush, M M Parks, P Y Tong
雑誌名: Am J Ophthalmol. 2001 Jan;131(1):111-6.
Abstract/Text PURPOSE: To determine whether time of strabismus surgery for patients with acquired intermittent exotropia and constant exotropia influences postoperative sensory outcome.
METHODS: In a retrospective, cross-sectional study, 76 patients with acquired intermittent or constant exotropia and motor realignment were evaluated for postoperative sensory status. Age at surgery, duration of exotropia, and presence of intermittent or constant exotropia were correlated with postoperative sensory status. The 23 male and 53 female patients had an average age of 9.3 years at the time of surgery and a mean follow-up of 5.9 years.
RESULTS: Patients had a significantly greater chance of having postoperative stereoacuity better than 60 seconds of arc (bifixation) if they were surgically aligned before 7 years of age (P <.01) or before 5 years of strabismus duration (P <.05), or with intermittent as compared with constant exotropia (P <.001). Patients with postoperative bifixation had earlier surgical intervention (P <.025) and shorter duration of exotropia (P <.025) than those with postoperative monofixation.
CONCLUSIONS: Patients with intermittent or constant exotropia may achieve superior sensory outcome with motor realignment before age 7, before 5 years of strabismus duration, or while the deviation is intermittent.

PMID 11162985  Am J Ophthalmol. 2001 Jan;131(1):111-6.
著者: Dean R Melmoth, Simon Grant
雑誌名: Exp Brain Res. 2006 May;171(3):371-88. doi: 10.1007/s00221-005-0273-x. Epub 2005 Dec 2.
Abstract/Text Theoretical considerations suggest that binocular information should provide advantages, compared to monocular viewing, for the planning and execution of natural reaching and grasping actions, but empirical support for this is quite equivocal. We have examined these predictions on a simple prehension task in which normal subjects reached, grasped and lifted isolated cylindrical household objects (two sizes, four locations) in a well-lit environment, using binocular vision or with one eye occluded. Various kinematic measures reflecting the programming and on-line control of the movements were quantified, in combination with analyses of different types of error occurring in the velocity, spatial path and grip aperture profiles of each trial. There was little consistent effect of viewing condition on the early phase of the reach, up to and including the peak deceleration, but all other aspects of performance were superior under binocular control. Subjects adopted a cautious approach when binocular information was unavailable: they extended the end phase of the reach and pre-shaped their hand with a wider grip aperture further away from the object. Despite these precautions, initial grip application was poorly coordinated with target contact and was inaccurately scaled to the objects' dimensions, with the subsequent post-contact phase of the grasp significantly more prolonged, error-prone and variable compared to binocular performance. These effects were obtained in two separate experiments in which the participants' performed the task under randomized or more predictable (blocked) viewing conditions. Our data suggest that binocular vision offers particular advantages for controlling the terminal reach and the grasp. We argue that these benefits derive from binocular disparity processing linked to changes in relative hand-target distance, and that this depth information is independently used to regulate the progress of the approaching hand and to guide the digits to the (pre-selected) contact points on the object, thereby ensuring that the grip is securely applied.

PMID 16323004  Exp Brain Res. 2006 May;171(3):371-88. doi: 10.1007/s00・・・
著者: Liesbeth I N Mazyn, Matthieu Lenoir, Gilles Montagne, Geert J P Savelsbergh
雑誌名: Exp Brain Res. 2004 Aug;157(3):383-90. doi: 10.1007/s00221-004-1926-x. Epub 2004 Jun 25.
Abstract/Text Participants with normal (StereoN) and weak (StereoW) stereopsis caught tennis balls under monocular and binocular viewing at three different speed conditions. Monocular or binocular viewing did not affect catching performance in catchers with weak stereopsis, while the StereoN group caught more balls under binocular vision as compared with the monocular condition. These effects were more pronounced with increasing ball speed. Kinematic analysis of the catch partially corroborated these findings. These results indicate that StereoW catchers have not developed a compensatory strategy for information pick-up, and that negative effects of a lack of stereopsis grow larger as temporal constraints become more severe. These findings also support the notion that several monocular and/or binocular information sources can be used in the control of interceptive action.

PMID 15221161  Exp Brain Res. 2004 Aug;157(3):383-90. doi: 10.1007/s00・・・
著者: Stefania Margherita Mojon-Azzi, Andrea Kunz, Daniel Stéphane Mojon
雑誌名: Br J Ophthalmol. 2011 Apr;95(4):473-6. doi: 10.1136/bjo.2010.185793. Epub 2010 Aug 18.
Abstract/Text AIM: To determine the social acceptance of children with strabismus by their peers and to determine the age at which the negative impact of strabismus on psychosocial interactions emerges.
METHODS: Photographs of six children were digitally altered in order to create pictures of identical twins except for the position of the eyes (orthotropic, exotropic and exotropic) and the colour of the shirt. One hundred and eighteen children aged 3-12 years were asked to select, for each of the six twin pairs, one of the twins to invite to their birthday party. The grouping of the pictures and the composition of the twin pairs were determined by Latin squares.
RESULTS: Children younger than 6 years old did not make any significant distinctions between orthotropic children and children with strabismus. Respondents aged 6 years or older invited children with a squint to their birthday parties significantly less often than orthotropic children. The authors found no impact (p>0.1) of gender, of the colour of the shirt or of the type of strabismus, but did find a highly significant impact of age on the number of invited children with strabismus.
CONCLUSIONS: Children aged 6 years or older with a visible squint seem to be less likely to be accepted by their peers. Because this negative attitude towards strabismus appears to emerge at approximately the age of 6 years, corrective surgery for strabismus without prospects for binocular vision should be performed before this age.

PMID 20720253  Br J Ophthalmol. 2011 Apr;95(4):473-6. doi: 10.1136/bjo・・・
著者: Noortje I Regensburg, Wilmar M Wiersinga, Tos T J M Berendschot, Peerooz Saeed, Maarten P Mourits
雑誌名: Thyroid. 2011 Feb;21(2):177-81. doi: 10.1089/thy.2010.0218. Epub 2010 Dec 12.
Abstract/Text BACKGROUND: Smoking adversely affects the course and severity of Graves' orbitopathy (GO). Cigarette smoke enhances adipogenesis in cultured human orbital fibroblasts. The present study tested our hypothesis that smoking is associated with increased orbital fat in GO patients.
METHODS: This was an observational case series study. In 95 consecutive patients with untreated GO, the ratios of fat volume/orbital volume (FV/OV) and muscle volume/OV (MV/OV) were calculated with validated software. The most affected orbit of each patient was chosen for analysis. Patients were divided into two groups based on smoking behavior. One group was current smokers (Sm+) and the other were those who never smoked or those who had not smoked for at least 1 year (Sm-). Patients were grouped in tertiles of FV/OV and MV/OV and contrast in OVs between the Sm+ and Sm- group. The main characteristics of GO were analyzed using Jonckheere-Terpstra trend analysis and Mann-Whitney U-test.
RESULTS: The proportion of current smokers was not different in GO patients when divided in tertiles according to their FV/OV. In contrast, analysis of MV/OV tertiles showed a trend to a higher prevalence of current smokers in patients with larger MVs. Smoking did not influence FV, but the Sm+ group had significantly larger MVs than the Sm- group.
CONCLUSION: Smoking is associated with an increase in extraocular MV in untreated patients with GO and not with an increase in FV.

PMID 21142817  Thyroid. 2011 Feb;21(2):177-81. doi: 10.1089/thy.2010.0・・・
著者: R Rao, G V Morton, B J Kushner
雑誌名: Binocul Vis Strabismus Q. 1999;14(1):27-32.
Abstract/Text OBJECTIVE: Ocular torticollis secondary to congenital superior oblique palsy can be associated with facial asymmetry. The purpose of this study was to determine if other ocular causes of head tilting also carry the same association.
DESIGN: The study design was clinical evaluation of patients.
PARTICIPANTS: Fifteen patients with marked, moderate, or mild head tilts associated with dissociated vertical deviation (DVD), and 3 patients with nystagmus and a torsional null point. A control group was comprised of 3 patients with congenital superior oblique palsy, 3 with traumatic superior oblique palsy, and two normal patients.
INTERVENTION: A masked observer analyzed full-face photographs of the subjects.
MAIN OUTCOME MEASURE: The presence of facial asymmetry.
RESULTS: Facial asymmetry due to bending in/of the sagittal plane of at least two degrees was found in 3 of 4 patients with a marked head tilt from DVD, in 2 of 5 five patients with a moderate head tilt from DVD, in one of 3 patients with a head tilt due to nystagmus, and in one of 3 patients with a head tilt due to congenital superior oblique palsy. None of the patients with a mild head tilt from DVD, traumatic superior oblique palsy, or the normal controls had clinically noticeable facial asymmetry.
CONCLUSION: Facial asymmetry can be associated with abnormal head postures, specifically, large head tilts from DVD or nystagmus.

PMID 10085531  Binocul Vis Strabismus Q. 1999;14(1):27-32.
著者: F G Velez, R A Clark, J L Demer
雑誌名: J AAPOS. 2000 Aug;4(4):233-9. doi: 10.1067/mpa.2000.105277.
Abstract/Text INTRODUCTION: Some observers have considered facial asymmetry as characteristic of congenital superior oblique muscle (SO) palsy. However, recent orbital imaging studies have determined that incomitant vertical strabismus resembling SO palsy can be caused by heterotopic rectus muscle pulleys. This finding suggests that facial asymmetry may predict the presence of abnormal orbital anatomy rather than be secondary to ocular torticollis.
METHODS: Subjects who underwent orbital computed tomography or magnetic resonance imaging were divided into 5 groups based on clinical evaluation and previously established imaging criteria: (1) congenital SO palsy; (2) acquired SO palsy; (3) strabismus with pulley heterotopy; (4) strabismus without SO palsy or pulley heterotopy; and (5) orthotropic subjects. Frontal photographs were digitized and the following 3 facial morphometric features recorded: (1) angle of inclination of each orbit; (2) relative facial size; and (3) facial angle.
RESULTS: The 79 subjects who underwent imaging were divided into the 5 groups as follows: 6 with congenital SO palsy; 7 with acquired SO palsy; 20 with pulley heterotopy; 26 with strabismus without SO palsy or pulley heterotopy; and 20 control subjects. All subjects with either congenital or acquired SO palsy had torticollis. Multivariate analysis demonstrated no significant differences in any of the 3 facial morphometric features among any of the groups.
CONCLUSION: Facial asymmetry as assessed by these 3 morphometric features is not useful in distinguishing between congenital SO palsy or pulley heterotopy and other acquired forms of strabismus. This finding casts doubt on the relationship between ocular torticollis and facial asymmetry.

PMID 10951300  J AAPOS. 2000 Aug;4(4):233-9. doi: 10.1067/mpa.2000.105・・・
著者: T K Chan, J L Demer
雑誌名: J AAPOS. 1999 Jun;3(3):143-50.
Abstract/Text INTRODUCTION: Absence of an extraocular muscle was considered rare when demonstrable only by surgical exploration or necropsy. This study presents advances in orbital imaging to correlate clinical findings with absence of the superior oblique (SO) muscle.
METHODS: We performed high-resolution coronal orbital imaging by magnetic resonance imaging (222 orbits) or computerized radiographic tomography (32 orbits) in 127 patients with strabismus. We reviewed the histories and ocular motility examinations in patients who had absence of 1 or both SO muscles. Findings were compared with patients who were clinically diagnosed with SO palsy but had demonstrable SO muscles on orbital imaging.
RESULTS: SO muscles were absent in 6 patients. All had histories suggesting congenital strabismus. In patients old enough for quantitative testing who had unilateral SO muscle absence, visual acuity was a least 20/25 in all and stereopsis was better than 80 arc/s in one. Three patients were orthotropic in primary position. Five patients with unilateral SO muscle absence had clinical findings variably consistent with SO palsy, whereas a sixth patient with Duane syndrome had clinically unsuspected bilateral SO muscle absence. Versions and patterns of hypertropia in patients with SO muscle absence overlapped findings of 20 patients with SO palsy but demonstrable SO muscles.
CONCLUSIONS: Imaging can frequently demonstrate absence of the SO muscle in patients with SO palsy. Such patients may have good vision and stereopsis and clinical findings indistinguishable from SO palsy without absence of the SO muscle. Orbital imaging should be considered in the evaluation of congenital SO palsy to facilitate planning of effective surgical correction.

PMID 10428587  J AAPOS. 1999 Jun;3(3):143-50.
著者: Hee Kyung Yang, Jae Hyoung Kim, Jeong-Min Hwang
雑誌名: Ophthalmology. 2012 Jan;119(1):170-7. doi: 10.1016/j.ophtha.2011.06.038. Epub 2011 Sep 15.
Abstract/Text OBJECTIVE: To evaluate patients with congenital superior oblique palsy (SOP) by classifying them according to their magnetic resonance imaging (MRI) findings and cross-comparing the clinical characteristics of each group.
DESIGN: Retrospective, observational study.
PARTICIPANTS: Ninety-seven consecutive patients diagnosed with congenital SOP.
METHODS: Medical records of patients who demonstrated typical signs of congenital SOP were reviewed. The presence or absence of the trochlear nerve was visualized with thin-section high-resolution MRI of the cranial nerves.
MAIN OUTCOME MEASURES: Presence of the trochlear nerve and superior oblique (SO) muscle hypoplasia on MRI, age at the onset of symptoms or signs, ocular motility examination results, objective ocular torsion, and surgical outcomes.
RESULTS: Of the 97 patients with congenital SOP, 73% of patients were identified with an ipsilateral absent trochlear nerve and variable degree of SO muscle hypoplasia (absent group), whereas the remaining 27% had a normal trochlear nerve and normal symmetric SO muscle (present group). Patients with an absent trochlear nerve showed more frequent head tilt (P = 0.030) that was manifest at an earlier onset before 1 year of age (P<0.001). Patients with a normal trochlear nerve had a more prominent overelevation in adduction (P = 0.008) and more frequently were associated with dissociated vertical deviation (DVD; P = 0.025).
CONCLUSIONS: Congenital SOP patients without a trochlear nerve had a hypoplastic SO muscle and frequently manifested head tilt at an earlier age, whereas patients with a normal trochlear nerve showed prominent overelevation in adduction and frequent DVD.
FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
PMID 21924501  Ophthalmology. 2012 Jan;119(1):170-7. doi: 10.1016/j.op・・・
著者: K D Sethi, M H Rivner, T R Swift
雑誌名: Neurology. 1987 Aug;37(8):1383-5.
Abstract/Text A common symptom of myasthenia gravis is eyelid ptosis. Often, the edrophonium test is negative, particularly in ocular myasthenia gravis. Myasthenic weakness is often improved by cold. We applied ice packs to the eye in 10 myasthenic patients and 7 disease controls. Eight of 10 patients with myasthenia gravis improved, whereas none of the controls improved. The ice pack test is useful in the diagnosis of myasthenia gravis.

PMID 3614664  Neurology. 1987 Aug;37(8):1383-5.
著者: F D Ellis, C S Hoyt, F J Ellis, A R Jeffery, N Sondhi
雑誌名: J AAPOS. 2000 Oct;4(5):271-81. doi: 10.1067/mpa.2000.106204.
Abstract/Text BACKGROUND: As a result of clinical and laboratory investigations of temperature correlates of myasthenia gravis, orbital cooling (ice test) has been developed as a reliable test for ocular myasthenia diagnosis through blepharoptosis response. The test has not been utilized in a prospective manner for myasthenia diagnosis through extraocular muscle responses.
METHODS: Fifteen patients with acquired motility disorders were studied with the use of orbital cooling and other tests for myasthenia gravis. Orbital cooling was performed in a standard fashion for all patients. In 14 of 15 patients, the diagnosis of myasthenia was not established at the time the ice test was performed. Fifteen non-myasthenic patients with acquired motility disorders were also studied with use of the ice test. Temperatures during orbital cooling were measured in the superior cul-de-sac of one patient and between the lateral rectus muscle and globe in 3 patients.
RESULTS: All patients subsequently proven to have myasthenia gravis by other tests and by response to myasthenia therapy had a positive (diagnostic of myasthenia) response to the ice test. No patient had a false-positive or a paradoxical response to the ice test. No control patient had a positive blepharoptosis or motility response to orbital cooling. Temperature measurements demonstrated significant cooling effects in the superotemporal cul-de-sac and beneath the lateral rectus muscles after orbital cooling for 5 minutes.
CONCLUSIONS: Orbital cooling, within certain parameters, can be a useful clinical test for myasthenia diagnosis through motility response, as well as blepharoptosis response.

PMID 11040476  J AAPOS. 2000 Oct;4(5):271-81. doi: 10.1067/mpa.2000.10・・・
著者: Klio I Chatzistefanou, Tassos Kouris, Evangelos Iliakis, Georgios Piaditis, Georgios Tagaris, Nikolaos Katsikeris, Grigorios Kaltsas, Michael Apostolopoulos
雑誌名: Ophthalmology. 2009 Nov;116(11):2236-43. doi: 10.1016/j.ophtha.2009.04.039. Epub 2009 Sep 10.
Abstract/Text PURPOSE: To investigate the diagnostic value and to establish threshold criteria for the ice pack test as an office preliminary test in the differential diagnosis of myasthenic diplopia in comparison with blepharoptosis.
DESIGN: Prospective, comparative cohort study.
PARTICIPANTS: Eighty-nine patients with a recent onset of diplopia, blepharoptosis, or both were evaluated with orbital cooling in a prospective manner. Forty-eight patients presented with diplopia, 25 patients with both blepharoptosis and ophthalmoplegia and 16 patients with blepharoptosis.
TESTING: All patients had the ice pack applied for 5 minutes on both eyelids at the initial orthoptic evaluation. Increasing the duration of cooling to 10 minutes was investigated in 36 diplopic patients. A complete diagnostic work-up was ordered and patients were followed up for a minimum of 6 months before diagnosis of myasthenia gravis was ascertained.
MAIN OUTCOME MEASURES: Difference in cover test measurements in primary position or marginal reflex distance before and after the application of the ice pack, specific cause for diplopia and blepharoptosis.
RESULTS: Fifteen patients were diagnosed as myasthenic. The optimal cutoff point for a positive response to the ice pack test proved to be a reduction in ocular deviation in primary position by 50% or by 10 prism diopters (PD) or more for presenting deviations larger than 20 PD. By this criterion, sensitivity for the detection of myasthenic diplopia was 76.9% (95% confidence interval [CI], 49.06%-92.50%) for the 5-minute application, compared with 92.3% (95% CI, 63.5%-98.9%) sensitivity demonstrated for blepharoptosis. Increasing the time of application to 10 minutes did not improve the diagnostic value of the test. Specificity was high (98.3%; 95% CI, 90.3%-99.9%) and was demonstrated even in patients with coexisting myasthenic and dysthyroid ophthalmopathy. Patients with oculomotor nerve paresis and Horner syndrome invariably were nonresponsive to the test.
CONCLUSIONS: The ice pack test demonstrated high specificity and an acceptable sensitivity in the differential diagnosis of myasthenic diplopia. Data from this series suggest that a partial rather than a complete response to the ice pack test may be expected for myasthenic diplopia. Standardization of the method of application of the ice pack is critical for the interpretation of its effect.

PMID 19744729  Ophthalmology. 2009 Nov;116(11):2236-43. doi: 10.1016/j・・・

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