THE STRABISMUS OR THE EYE DEVIATION
- Is an affection in which the position of the eyes is not parallel.
- Is frequently accompanied by amblyopia (lazy eye)
- Strabismus and the amblyopia are two conditions in which the child is deprived of normal binocular sight, using only one eye.
- The aim of the treatment is to make the child use both eyes at the same time, enabling him with the binocular sight and consequently the sight in relief (three dimensional sight).
THE TREATMENT OF THE STRABISMUS AND AMBLYOPIA
- “It’s never too early to treat a strabismus”
- The treatment must be set up as soon as possible so that its efficiency could be better.
- The aim of the treatment:
- Obtaining a normal visual acuity of both eyes
- Aligning the eyes- reducing the strabismus deviation
- Obtaining or improving the binocular sight
When do we begin the treatment?
- The congenital strabismus – appears in the first 6 months of life. It must be approached even from this age, otherwise binocular sight wouldn’t develop normally.
- The consultation must be done even earlier, in the first months. The strabismus can be caused by an organic amblyopia (cataract, congenital glaucoma, tumors) which urgently needs a different type of treatment.
- If the strabismus appears later – the treatment also needs to begin immediately in order to find again the elements of binocular sight and to let them develop themselves.
What does the treatment consist of?
- Correction of faulty refraction (dioptres) – as soon as possible, even under the age of one.
- All the children with strabismus must wear glasses, constantly, all day long. The aim is to obtain a good and equal sight, they allow using prisms (special lenses for the correction of the small deviations), they allow occlusion (the covering of one eye).
- The correct measurement of the dioptres is done after instilling drops with special substances that immobilize the capacity of the eye to adapt (atropine or cyclogyl).
- The treatment of the amblyopia – the covering of the good eye in order to force the weak eye to work.
- The duration of the treatment is according to the depth of the amblyopia and to the age.
- It can be total, if it’s about a deep amblyopia (6-7 days a week) or partial (a few hours a day) in easy and medium amblyopias.
- The results are very good when the treatment is accurately applied and in time.
- Here is the performance of an ex-amblyop eye (20%of the normal view before the treatment) after the application and observance of the cure of the necessary occlusion.
- It is only a step in the treatment of the strabismus.
What does the operation refer to?
- The operational technique consists in strengthening the hypoactive muscles (shortening, advancing) and weakening the hyperactive muscles (retroposition).
- In the simultaneous strabismus both eyes are usually operated.
What is the best age for the operation?
- The best age for the operation depends on the age when the strabismus appears. .
- The congenital strabismus – which appears in the first 6 months of life – must be operated as soon as possible, even under the age of one, otherwise the child won’t develop a normal binocular sight.
- It is a complex affection that touches several pairs of muscles. Usually, two or three operations are necessary for solving all the problems.
- The later appeared strabismus – after using up the other forms of treatment: glasses, occlusion – if the deviation persists – we proceed to the surgical treatment.
Is another operation necessary?
- If the strabismus angle is big, in deep amblyopia, in paretic strabismus – it is necessary after a first operation the correction of the left angle, that means a second operation, performed on other muscles, without considering the first one a failure.
- The operation is done under general anesthesia, in conditions of perfect sterility. After the operation the child goes home even without a dressing, if the operation was performed only on one muscle at one eye.
- The first postoperator examination is done the second day and the postoperator treatment step is taken.
- Even from the first days the series of ortoptic treatment are initiated for strengthening the effect obtained through the operation and sensorial readjustment of the binocular sight.
What risks and complications could appear?
- In any surgical operation there are, theoretically, risks of anesthesia and operation.
- In the case of strabismus the risks are minimum:
- The diplopia (double sight) after the operation is transitory.
- The postoperator infections are prevented through antibiotic instillation, anti-inflammatories and keeping a strict hygiene of the eye and hands. It manifests itself with: swollen eyelid, red eye, muco-purulent secretion and they can develop into cellulitis.
- If signs of post-operator infection still appear, a treatment is begun immediately also on a general way with antibiotics, anti-inflammatories, antiallergical and all these signs disappear.
- The intraoperator incidents are prevented through a correct operator technique.
- Over or under corrections of the strabismus angle.
- The ortoptic readjustment is always preceded by the treatment of amblyopia, and if necessary, by surgery.
The ortoptic exercises are done assisted by synoptofor. They are postoperator efficient, after the deviation was corrected through operation.
- They are also indicated in strabismus that don’t need operation: strabismus with small deviation, insufficiency of convergence (a condition in which the eyes don’t function well at short sight), accommodation trouble, amblyopia treatment.
- The result is the obtaining and training binocular sight, in other words it teaches children to look with both eyes at the same time.
STRABISMUS IN ADULTS
What are the causes of the strabismus at adults?
- In many cases strabismus persists since childhood and it was incompletely or not at all treated.
- There are also strabismus beginning at an adult age. These can be caused by:
- General affections: diabetes, vascular accidents, thyroidian diseases, myasthenia, aneurysm or intracranial tumors, multiple sclerosis.
- Cranial traumatisms with paresis of the cranial nerves III, IV and VI.
- After operations of cataract, glaucoma, retina detachment.
What are the symptoms?
- If strabismus is present from childhood the symptoms are minimum.
- If it appears later, the most frequent symptom is diplopia (double sight). Some people complain about tiredness when reading, headaches, the head is kept turned in a vicious position
- Why does the double sight appear? When eyes are no longer parallel, each eye sees a different separated image.
- Children with strabismus learn to ignore one of the images in order to avoid the double sight.
- The adults with recently appeared strabismus don’t have this capacity. They can avoid diplopia only if they close one eye, cover it or the strabismus is operated.
What is the treatment about?
- There is a wrong idea that the strabismus is difficult or impossible to treat at adults.
- In fact, adults have several treatment options:
- glasses with prism – in small deviations
- ortoptic exercises – insufficiency of convergence
- surgical treatment
What is the operation about?
- The technique of the operation is the same as the one for children and it takes place under general anesthesia.
- The operation is done on the strabic, the fixing eye or on both of them, according to the case.
- If the deviation angle is big, a secondary operation may be necessary.
The aim of the intervention:
- aligning the eyes
- eliminates or improves the diplopia, reduces ocular tiredness
- reduces or eliminates the vicious position of the head
- The adult person with strabismus addresses himself to the ophthalmologist firstly for the unaesthetic aspect of the eyes.
- Every person has the right to look like a human being.
- The psychological impact, after solving the adult strabismus, is extraordinary, both as self-respect, through the improvement of the aesthetic aspect, and in the social environment in
- Cataract means loosing the crystalline lens’s transparence (a lens from within the eye). As a result, the light can’t any longer get into the eye and the sight fails gradually.
- It may appear at any age, even at birth (the congenital cataract).
- The causes of the cataract are:
- congenital (from birth)
- advanced age
- traumatisms (eye or facial traumatisms)
- general diseases (diabetes, myasthenia, etc)
- eye diseases (uveites, glaucoma, eye operations)
- medicines used for a long time (cortisone)
Signs – the fail of the sight (sensation of “dim sight”)
- cannot see well any longer with no kind of glasses
- distance sight fails and close sight improves
- double view
- lower sight at powerful light
- in the advanced forms the pupil becomes white
- There is no pain, tears, redness (only if the eye has also got other diseases)
- The diagnosis is determined by the doctor (there can also be associated diseases).
- in the incipient phases a medicinal treatment of slowing the evolution of the cataract can be done.The only curative treatment is the surgical treatment.
- the operation is urgent for the congenital cataract (at child, especially if it at only one eye; if the intervention is done at older ages, the eye remains “lazy”)
- on adults, the intervention may be done anytime ( when the daily activity is affected)
- there is no waiting “to be ripe” because the mature cataract predisposes to complications (glaucoma, inflammations)
- The glaucoma is an ocular affection characterized by the increase of the intraocular pressure. In time, changes of the optic nerve and of the field of vision appear.
- If it is not treated, it can determine, gradually or suddenly, the loss of sight (blindness).
Types of glaucoma:
- congenital (from birth)
- primitive (without apparent cause)
- secondary (appeared after an eye stroke, burn, local or general treatment with certain substances, after ocular diseases etc.)
- may or may not be any sign
- failing of sight (a sign, unfortunately, belated)
- ocular redness
- seeing some colored circles (“rainbow”)
- temporary sensation of “dim sight”
- watering eyes
- at child – photophobia (the child can’t stand the light)
- the eye of increased dimensions
- unjustified watering
- very bright eyes
The diagnosis is determined by the doctor:
- the type of glaucoma
- the stage of the affection
- the necessary treatment are established
- is, firstly, medicinal
- in some cases, if the pressure is not mentioned at optimum values through medicinal treatment, a laser intervention is done or even a surgical one
- the glaucoma operation doesn’t “give back” the sight, it is done for the eye just not to be damaged more
OBSTRUCTION OF THE LACHRYMAL-NAZAL DUCT
- It is the most frequent congenital anomaly of the tear ways. Usually, the obstruction is situated in the nasal meatus (mucus, membrane, periosteum).
- It appears at 30% of the new- born, in the first 3 weeks of life.
- permanent watering, muco-purulent secretion which accumulates in the internal angle of the eye (it often associates with the purulent conjunctivitis).
- Local antibiotics – drops, eyesalve, massage around the lachrymal bag (at the base of the nose).
- If the obstruction doesn’t disappear in 4-8 weeks, a surgical treatment is applied. The intervention is done under general anesthesia and it’s short.
- The probe of lachrymal ways gets into until the obstacle level and defeats it. Lavages are done with antibiotic solutions.
- At adult, the obstruction of lachrymal ways appears after inflammatory diseases of the eye and nasal mucous membrane.
- The disobstruction can be executed in the same way, even under local anesthesia.
- It is a focal chronic inflammation of a gland from the eyelid. It can appear as a result of a sty.
- It appears as a small prominent, mobile tumor.
- It ca be external- when it is prominent under the skin or internal – prominent under the conjunctiva.
- It evolves to encystation, increasing the inflammation, spontaneous opening (rarely).
- The treatment is done with local antibiotic- eyesalve- in order to treat the infection and prevent its spreading, cold compress at the beginning.
- For many times the incision and the curettage of the content is necessary, followed by the application of the antibiotic eyesalve and a compress for a few hours.
- The recurrent chalazions raise the possibility of a malignant tumor and the histopathologic exam must be performed.
PALPEBRAL PTOSIS (fallen eyelid)
- It is a malposition of the upper eyelid in which the edge of the eyelid is down.
- The congenital ptosis is usually unilateral. The cause is the diminished or absent (congenitally) function of the lifter muscle of the eyelid.
The treatment is surgical:
- when lifter’s function is just diminished – the resection of this muscle is practiced
- when its function is absent – the suspension of the eyelid is done at the frontal muscle (forehead’s muscle) which will take over the function of lifting the eyelid.
- The won ptosis appears later on, during life.
- Senile – it weakens the muscle and the eyelid’s tissues.
- Myogen – appears in general affections: myasthenia, dystrophy.
- Mechanical – eyelid tumors
- The treatment aims the general cause when this exists.
- The surgical treatment is the same to the one for congenital ptosis.
- Represents the wrong position of the eyelid, in which its edge is turned out, with the widening of the palpebral slit.
- It affects, most frequently, the lower eyelid.
- The excessive watering appears frequently – caused by the overturning of the lachrymal point.
- The too big opening of the palpebral slit leads, by exposition, to the affectation of the cornea.
- The congenital ectropion is rare, associated with the blepharofimosis.
- The won ectropion may be:
- Senile – caused by the weakening of the orbicular muscle. The eyelid is limp, its edge lengthens.
Watering appears, the irritation of eyelid’s skin, blepharoconjunctivitis may be associated.
- Spastic – generated by prolonged conjunctivitis or other eye inflammations.
- Paralytic – by injuring the facial nerve. The palpebral slit stays open (lagophthalmus) and the eye uncovered. Sometimes tarsoraphia is necessary (the eyelids are sutured).
- Healing up – after traumatisms, burns, postoperator
- Senile – caused by the weakening of the orbicular muscle. The eyelid is limp, its edge lengthens.
- The treatment is surgical and it consists in shortening the eyelid edge in order to restore the position.
- It represents the wrong position of the eyelid in which its edge is turned to the eyeball.
- It usually affects the lower eyelid. It is extremely unpleasant because the eyelids are turned to the eye and they scratch the cornea.
- The congenital entropion is rare, usually associated to other congenital illness.
- The won entropion may be:
- Senile – given by the tissues atrophy from the eye socket and apparently the eye is pushed back into the socket
- Spastic – through aging, local irritation
- Healing up – after burns, trachoma, Sd. Stevens-Johnson
The treatment is surgical and aims the muscles strengthening that retract the eyelid.
THE TUMORS OF THE EYELID
- The first priority is to determine the diagnosis.
- All the eyelid tumors (excepting chalazion, which is inflammatory) must be investigated through anatomico-pathologic exam. It is the only exam that tells us certainly if the tumor is malignant.
- This is done through biopsy or after removing the tumor.
- The type of tumor shows the treatment.
- The malignant tumor needs larger excision (surgical removing). Some of them benefit from radiotherapy.
THE RETINOPATHY OF PREMATURITY (ROP)
- It is an affection met at premature children who are born with an immature retina, with an incomplete development of the blood vessels from the retina.
- More exposed are children born under the age of 32 weeks and with a weight under 1500 g.
- It usually appears at both eyes, more advanced at one eye.
- Lately, more and more children prematurely born, survive (through a specialized care) and so ROP is more frequent. It is favored by the exposition to oxygen at high pressure.
- The development of retina blood vessels begins from the intrauterine life (16 th week) and it ends at 2-3 months after birth.
- ROP develops in the first 5-15 weeks of life.
- It is characterized by the appearance of abnormal vessels and fibrous tissue on retina, which spread to the anterior side of the eye.
- At most of the children, ROP regresses spontaneously until 15 weeks of life.
- If it evolves – it develops gradually, in stages, until the total retina detachment.
The ophthalmologic consult is obligatory for all the children prematurely born.
- If signs of ROP are observed in the first 4-6 weeks of life, the consult will be repeated at 1-2 weeks, too, then, if it regresses, at one month until the age of one year and once a year until adolescence.
The treatment depends on the stage of evolution.
- Cryotherapy – lies in applying a probe on the external surface of the eye, which freezes and destroys the abnormal vessels from the retina and the progression of the illness is stopped.
- This method of treatment is applied in stage 3 of evolution.
- LASER treatment – has the same aim, less secondary effects.
- Surgical treatment – for stages 4 and 5, with retina detachment.
- A vitrectomia is done to eliminate the traction exercised by the fibrous abnormal tissue and to apply the retina (in normal position).
- In these severe stages, even if the retina is applied, the sight is failed.
- In conclusion, ROP is a serious illness. All premature children must be examined by the ophthalmologist.