Purpose:To review the principles and different techniques of minimally invasive procedures in strabismus surgery.Methods:This is a narrative review on minimally invasive procedures in strabismus surgery including general aspects and different new modifications on conventional strabismus surgery. We reviewed 24 articles published between 1993 and 2020.Results:Minimal invasive procedures could be categorized into two subsets: one which minimizes conjunctival opening size and another which minimizes the muscle manipulations. Different conjunctival approaches have been introduced, such as Cul-de-sac and minimally invasive strabismus surgery incisions. Furthermore, there are different techniques for extraocular muscle weakening, strengthening, and transposition, such as mini-tenotomy, plication, mini-plication, Nishida, and modified Nishida procedures. Moreover, there are some techniques for handling strabismus in heavy eyes with high myopia and using adjustable sutures for strabismus correction.Conclusions:Minimally invasive procedures in strabismus surgery consist of surgical procedures that minimize tissue disruption, speed up rehabilitation, and often ultimate better outcomes. These techniques could be replaced traditional methods to reduce conjunctival and lid swelling in the direct postoperative period.

Purpose: To investigate the possibility and consequences of false positive testing for Leber’s hereditary optic neuropathy (LHON) using repeated testing. Methods: In three cases of suspected LHON, initial mutation analysis using restriction fragment length polymorphism (RFLP) and direct sequencing showed rare mtDNA mutations at nt 14482 in two cases and a mutation in nt 14484 in the third case which has been associated with a mild variant of LHON. All three patients consulted a specialized neuro-ophthalmology center for a second opinion. During the examinations the clinical diagnosis of LHON was questioned. Therefore the initial DNA samples were reevaluated again using the same probes. Results: The reevaluation by the testing laboratory of the DNA samples of the three patients revealed misinterpreted initial results and could show that there were no LHON typical mutations in none of the three patients. Conclusion: A high level of suspicion is important when an accumulation of rare mutations occurs. It is only because of the attentiveness of a specialized neuro-ophthalmologist and the testing laboratory that the diagnosis of LHON was averted. Every laboratory testing can produce false positive results. Therefore, we emphasize that a positive test should be confirmed by a second independent laboratory, at least if the clinical findings seem not to be typical for LHON.

Etwa 5 % der Patienten in der ophthalmologischen Praxis leiden an einer nichtorganischen Sehstörung. Bei Kindern können nichtorganische Sehstörungen bereits im Schulalter auftreten. Um diese rasch diagnostizieren zu können, ist das Wissen um die relevanten klinischen Tests ausschlaggebend. Am häufigsten schilden die Patienten eine Sehschärfenminderung mit oder ohne Gesichtsfelddefekt. Meistens werden die Symptome beidseits angegeben. Je nach Symptom stehen verschiedene Tests zu Verfügung, um zwischen einer organischen und einer nichtorganischen Sehstörung unterscheiden zu können. Aus ökonomischen und therapeutischen Gründen sollten nichtorganische Störungen möglichst rasch diagnostiziert werden. Bei Verdacht auf bewusste Simulation sollte der Patient direkt darauf angesprochen werden. Liegt den Symptomen jedoch eine somatoforme Störung zugrunde, sollte behutsamer vorgegangen werden.

Zusammenfassung Etwa 5 % der Patienten in der ophthalmologischen Praxis leiden an einer nichtorganischen Sehstörung. Bei Kindern können nichtorganische Sehstörungen bereits im Schulalter auftreten. Um diese rasch diagnostizieren zu können, ist das Wissen um die relevanten klinischen Tests ausschlaggebend. Am häufigsten schilden die Patienten eine Sehschärfenminderung mit oder ohne Gesichtsfelddefekt. Meistens werden die Symptome beidseits angegeben. Je nach Symptom stehen verschiedene Tests zu Verfügung, um zwischen einer organischen und einer nichtorganischen Sehstörung unterscheiden zu können. Aus ökonomischen und therapeutischen Gründen sollten nichtorganische Störungen möglichst rasch diagnostiziert werden. Bei Verdacht auf bewusste Simulation sollte der Patient direkt darauf angesprochen werden. Liegt den Symptomen jedoch eine somatoforme Störung zugrunde, sollte behutsamer vorgegangen werden.

Zusammenfassung. Eine Schielfrüherkennung ist wichtig um organische Ursachen auszuschliessen, bei Kindern auch um eine allfällig notwendige Amblyopietherapie einzuleiten damit eine bleibende Sehminderung verhindert werden kann und um eine rasche Rehabilitation einzuleiten, da das fehlende binokulare Sehen, bei Innenschielern das verminderte binokulare Gesichtsfeld und eine allfällige Diplopie eine erhöhte Unfallgefahr nach sich zieht. Folgende Therapiemöglichkeiten bestehen: manchmal reicht eine korrekte Verordnung des bestehenden Refraktionsfehelers, definitive prismatische Korrektur bei stabilen, kleinen Schielwinkeln oder vorübergehende prismatische Korrektur mit sogenannten Press-on Folien bei instabilen oder grösseren Schielwinklen und Schieloperationen, die heute auch minimal-invasiv und meist ambulant durchführbar sind, falls der Schielwinkel meist über mindestens 1 Jahr stabil bleibt.

An early diagnosis of strabismus is important in order to rule out treatable organic causes and in children, if indicated, to start as early as possible with an amblyopia treatment. Early detection will also decrease the risk for accidents secondary to diplopia, to the loss of binocular vision and to the restriction of the binocular visual field in case of esodeviations. The following therapeutic options exist: in some cases the prescription of the correct refraction will be sufficient, for small deviations a prismatic correction may allow a longstanding treatment, for larger or incomitant deviations strabismus surgery will be necessary, which nowadays can be performed using minimal-invasive technique on an outpatient base.

PURPOSE:The aim of this study was to evaluate the safety and efficacy of deep sclerokeratodissection (DSKD), a new nonpenetrating technique in glaucoma surgery. MATERIALS AND METHODS:Retrospective comparison between patients treated with DSKS or deep sclerectomy (DS) between 2013 and 2014. In DSKD, the first and only flap is dissected directly into clear cornea with unroofing Schlemm's canal. Beside routine clinical follow-up (visual acuity, intraocular pressure [IOP] readings, slit lamp and fundus examination), postoperative ultrasound biomicroscopy (UBM) investigation and quality of life (QoL) assessment were performed. Statistically significant differences were determined by parametric or nonparametric tests, depending on normality. RESULTS:Twelve (38.7%) DSKDs and 19 (61.3%) conventional DS' were included in this analysis. IOP decreased significantly from 21.5 ± 9.2 mmHg to 6.2 ± 5.4 mmHg on day 1, 13.4 ± 7.7 at 1 month, 12.0 ± 4.1 at 3 months, 12.5 ± 3.1 mmHg at 6 months, and 13.4 ± 4.3 mmHg at 12 months (P < 0.01). No significant difference in the IOP was observed between the two groups at any follow-up (P > 0.1). There was no significant difference in intra- and post-operative complications, the morphology of the surgical site in the UBM as well as in the QoL assessment. CONCLUSION:The results indicate that DSKD is a safe and efficient new variant of nonpenetrating glaucoma surgery. IOP can be lowered as effectively compared to conventional DS, with a similarly low rate of complications. Further reports are necessary to confirm these results.

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The book “Learning Strabismus Surgery: A Case-Based Approach“ targets the novice student as well as the experienced strabismus surgeon by selecting 52 cases covering different levels of difficulty. The cases cover the majority of topics in squint surgery. The authors reproduce the kind of learning that occurs during a 1-year fellowship with strabismus experts. Thus, they suggest studying one case every week. The editors, Dean Cestari and David Hunger from Boston, are bothwell-known excellent strabismus surgeons and teachers. The language is English. Many cases are presented in the following way: history, examination, assessment/plan, surgery including videos, postoperative assessment, follow-up, review/lessons learned and references. A table at the beginning of the book includes for each case the diagnosis, the type of procedures, the clinical features, and which exact surgery has been performed. This allows readers to quickly find a case similar to one of their own patients. The appendix includes strabismus surgery tables and photos of instruments and figures illustrating adjustable suture techniques. Many cases cover topics hardly found in other squint surgery books, such as V-esotropia after LASIK, restrictive strabismus after pterygium surgery, strabismus following ruptured globe, chronic progressive external ophthalmoplegia, and strabismus after bilateral scleral buckle repair. The book and a total of 20 videos with durations from half a minute to 15 min can be accessed with the access code included in each book. The whole book includes goodquality full-colour photographic images, diagrams, and references for each case. The information provided in the book is relevant to ophthalmology residents and general ophthalmologists as well as the experienced strabismus surgeon. The presentation of real clinical cases makes the information easy to digest. In summary, this book can be highly recommended to anyone interested in squint surgery.

This article reviews the principles and different techniques used to perform minimally invasive strabismus surgery (MISS). This term is used for strabismus surgeries minimizing tissue disruption. Muscles are not accessed through one large opening, but using several keyhole openings placed where needed for the surgical steps. If necessary, tunnels are created between cuts, which will allow performing additional surgical steps. To keep the keyhole openings small, transconjunctival suturing techniques are used. The cuts are always placed as far away from the limbus as feasible. This will reduce the risk for postoperative corneal complications and it will ensure that all cuts will be covered by the eyelids, minimizing postoperative visibility of surgery and patient discomfort. Benefits from minimizing anatomical disruption between the muscle and the surrounding tissue are a better preservation of muscle function, less swelling, and pain, and more ease to perform reoperations. MISS openings allow to perform all types of strabismus surgeries, namely rectus muscle recessions, resections, plications, reoperations, retroequatorial myopexias, transpositions, oblique muscle recessions, or plications, and adjustable sutures, even in the presence of restricted motility.

Da die Mitochondrien die Hauptproduzenten von Energie in Form von Adenosin-Triphosphat sind, werden bei Mitochondropathien oft okuläre Gewebe mit hohem Verbrauch an Adenosin-Triphosphat wie der Nervus Optikus, die Retina und das retinale Pigmentepithel betroffen. In diesem Artikel werden die wichtigsten genetisch bedingten okulären mitochondrialen Erkrankungen behandelt. Deren wichtigste ophthalmologische Kennzeichen sind: akuter oder langsam progredienter Visus- und Gesichtsfeldverlust im Rahmen einer meist bilateralen Optikusneuropathie oder einer bilateralen retinalen Pigmentepitheldegeneration, bilateral symmetrisch progressive Augenbewegungseinschränkung und eine bilaterale Oberlidptose. Die folgenden okulären Mitochondropathien werden vorgestellt: Lebersche Hereditäre Optikusneuropathie (LHON); Kearns-Sayre Syndrom (KSS); Chronisch Progressive Externe Ophthalmoplegie (CPEO); Autosomal Recessive Cardiomyopathy, Ophthalmoplegia (ARCO); Mitochondrial Enzephalomyopathy, Lactic Acidosis, Stroke-Like Episodes (MELAS); Neuropathy, Ataxia, Retinitis Pigmentosa (NARP); Mitochondrial Neuropathy, Gastro-Intestinal Encephalomyopathy (MNGIE); Myoclonus Epilepsy, Ragged-Red-Fibers (MERRF); Morbus Wilson; Friedreich Ataxie. Zur Sicherung der klinischen Verdachtsdiagnose erfolgt ein Mutationsscreening, je nach Erkrankung im Blut oder in der Muskelbiopsie. Therapeutisch sind nur symptomatische Maßnahmen wirksam. Gewisse Medikamente, die mit der mitochondrialen Funktion negativ interagieren, sowie ein exzessiver Nikotin- und Alkoholkonsum sollten vermieden werden.

Background: Accidental sharp injuries among the health-care workers are frequent, especially in the surgical disciplines. Because there are only limited data available about accidental sharp injuries in small surgical disciplines, we investigated the occurrence of sharp injuries among ophthalmosurgeons in Switzerland, Methods: An anonymous questionnaire was sent to all 500 members of the Swiss Ophthalmological Association. We asked how often the surgeons or any member of the surgical team suffered injury during an ophthalmic surgery within the last 2 years and which instrument had caused the injury. Using linear regression we analysed the connection between the occurrence of injuries and various factors, e.g., the age or experience of the surgeon, whether any actions in the case of an injury were taken, whether the event was documented and whether actual guidelines were followed. Results: In the 117 analysed questionnaires we counted 193 injuries. 42.7% of the surgeons (n = 50, 95% CI 33.7% - 51.8%) had injured themselves at least once during the past two years and 59.8% of the surgeons (n = 70, 95% CI 50.9% - 68.7%) reported injuries among the rest of the surgical team. On average, surgeons were injured 0.66 times in two years (range 0-4 injuries per person). Most injuries were caused by hollow needles [28.2% of self injuries (95% CI 18,2% - 38.2%)] 24.3% of injuries of team members (95% CI 16.5% - 32.1%). 53.0% of the surgeons (n = 63, 95% CI 44,0% - 62.0%) reported the case whereas 18.8% (n = 22, 95% CI 11.7% - 25.9%) never reported them. Some questionnaires did not contain the answers to those last questions. Using chi-square, we could observe more injuries in the middle-age section and in surgeons with 11-30 years of surgical experience (p < 0.05). The regression did not show any dependence on the rate of injuries on the surgeon's experience and the number of performed surgeries. Conclusions: We conclude that in ophthalmosurgery sharp injuries to surgeons or their surgical team happen frequently and only about 50% of the cases are reported. This study shows that there is room for improvement concerning the documentation and the actions taken after an injury. Thereby potential sources of danger could be better monitored.

Hintergrund: Verletzungen des Medizinalpersonals sind häufig, besonders in chirurgischen Fächern. Da es kaum Daten zu Verletzungen des Personals in kleinen chirurgischen Fächern gibt, widmet sich diese Studie der Ophthalmochirurgie und untersucht das Auftreten von Verletzungen in Operationsteams in der Schweiz. Methode: 500 Fragebogen wurden per Post an alle Mitglieder der Schweizerischen Ophthalmologischen Gesellschaft versendet. Es wurde erfragt, wie oft sich die Ärzte oder Personen aus dem Operationsteam während eines Zeitfensters von 2 Jahren verletzt hatten und wodurch. Wir untersuchten mittels linearer Regression, ob die Anzahl Verletzungen eine Abhängigkeit von verschiedenen Faktoren, beispielsweise Alter oder Erfahrung des Arztes, aufweist, ob im Falle einer Verletzung Maßnahmen ergriffen wurden, ob der Vorfall dokumentiert wurde und ob nach aktuellen Empfehlungen vorgegangen wurde. Ergebnisse: In den 117 analysierten Antwortbogen wurden total 193 Verletzungen angegeben. 42,7 % der Ärzte (n = 50, 95 %-KI 33,7 %–51,7 %) gaben an, dass sie sich während der letzten 2 Jahre mindestens 1-mal selbst verletzt hatten. 59,8 % der Ärzte (n = 70, 95 %-KI 50,9 %–68,7 %) meldeten, dass sich jemand aus dem restlichen Operationsteam verletzt hatte. Der Durchschnittswert der Selbstverletzungen lag bei 0,66 Verletzungen pro Person in 2 Jahren (Spannweite 0–4 Verletzungen pro Person). Hohlnadeln wurden in den meisten Fällen (28,2 % [95 %-KI 18,2 %–38,2 %]) bei Selbstverletzungen, 24,3 % (95 %-KI 16,5 %–32,1 %) bei Teamverletzungen als Verletzungsinstrument angegeben. 53,0 % der operativ tätigen Augenärzte (n = 63, 95 %-KI 44,0 %–62,0 %) gaben an, den Vorfall im Nachhinein dokumentiert zu haben, während 18,8 % (n = 22, 95 %-KI 11,7 %–25,9 %) diese Ereignisse nie dokumentierten. In den restlichen Fällen wurden keine Angaben bezüglich Dokumentation gemacht. In Analysen mittels Chi-Quadrat zeigte sich eine Häufung der Anzahl Verletzungen im mittleren Altersbereich und bei Ärzten, welche seit 11–30 Jahren operativ tätig waren (p < 0,05). Die Regression zeigte keine Abhängigkeit der Verletzungsrate von der Erfahrung der Chirurgen und Anzahl durchgeführter Operationen. Schlussfolgerungen: Verletzungen von Arzt und Operationsteam kommen in der Ophthalmochirurgie häufig vor, werden jedoch nur in rund der Hälfte der Fälle dokumentiert. Diese Studie zeigt, dass ein Verbesserungspotenzial bei der Meldung und den Maßnahmen nach einer Verletzung besteht. Dadurch lassen sich auch die potenziellen Gefahrenquellen besser monitorisieren.

In March 2011 the new Nintendo 3DS went on sale in Switzerland and Germany. The game console features an attractive 3D display without the need of special glasses. By means of a so-called parallax barrier the depth perception can be increased or even turned off. In adults excessive use may cause symptoms such as headaches, dizziness or nausea. In children a visual impairment could be reinforced and an amblyopia could become manifest. Excessive, long hours of use especially in children could have its risks and the possible long-term effects remain unpredictable. On the other hand in the future it is likely that these kinds of 3D screens will be of considerable diagnostic value in orthoptics. The issue is likely to become a more important issue in everyday life in the future. As there is hardly any information available in the medical literature on this subject it is the aim of this article to provide an overview of the technology and physiology with the advantages and disadvantages.

Purpose To present the advantages and disadvantages of minimally invasive strabismus surgery (miSS). Methods Review of available literature and experience from surgeons starting with MISS. Results MISS has the following advantages: less visibility of surgery, decrease of postoperative discomfort and pain, hospital stay and working disability, and preservation of limbal stem cells. Disadvantages of MISS are: long learning curve, need of microscope, difficulties visualizing anatomical variations, and increased risk of globe penetration. Conclusion For skilled surgeons with already experience in microscope assisted strabismus surgery transition to MISS will be easier.

Many patients presenting with photopsia alone will report that something is wrong with one of their eyes. This study aimed to determine if ophthalmologists are aware of the need of a bilateral examination in such patients. Two validated questions were randomly sent to 300 ophthalmologists. The first question investigated if a patient with isolated photopsia in the right eye needs to have dilated fundus examination of his left eye if a dilated fundus examination on the right is normal. The second question explored how probable in such a situation it is that the left eye is affected. A 74.3% of the 300 ophthalmologists responded. They had been practising on average for 20.7 +/- 9.1 years; 31.8% were female. A 14.8% (33 out of 223; 95% confidence interval [CI] 10.7%-20.1%) gave the correct answer to the first question and 6.8% (15 out of 219; 95% CI 4.2%-11.0%) thought that the probability that the left eye might be affected was higher than 50%. A logistic regression revealed that the answers to our first question were not influenced by gender or number of years in practice (p > 0.1 for each). Patients claiming to have photopsia in one eye will be found to have a traction on the nasal retina of the ipsilateral eye or the temporal retina of the contralateral eye and, therefore, not necessarily in the eye they claim the symptoms originate from. The majority of ophthalmologists are not aware of this fact and, thus, are at risk of overlooking potentially treatable conditions.

A 28-year-old woman presented with surprisingly asymptomatic bilateral inferior altitudinal visual field defects. Fundoscopy disclosed superior hypoplastic optic discs which was diagnosed as bilateral superior segmental optic hypoplasia. The patient suffered from maternal diabetes and sacral agenesis syndrome, which is also frequently associated with maternal diabetes.

To evaluate which factors predispose to an intraoperative conversion to the usual limbal approach in minimally invasive strabismus surgery (MISS).