Monographs in Ophthalmology – serie

Thirty years ago, our attention was drawn to the alphabetical incom­ itances in strabismus. As an elevation in adduction is the most frequent incomitance, we decided to start treating these incomitances. A weak­ ening procedure of the inferior oblique muscle seemed indicated. How­ ever, since we wanted to prevent a torsional overcorrection with a head tilt, we displaced the scleral insertion of the oblique muscle towards the equator of the globe. This way, the torsional action of the muscles is saved. A weakening of the horizontal rectus muscles was systematically added, making it a simultaneous horizontal and cyclovertical surgery. Our way to deal with strabismus developed into a coherent entity and the interest of colleagues encouraged us to write it down.We decided to publish a textbook with a theoretical and an extensive practical part. Our approach is based on thirty years of exclusive strabological work, half-time academic and half-time private practice. More than 6500 re­ sults were analysed and the majority have been published. The con­ cerned publications are referred to at the end of the first chapter. Private practice allowed to benefit from the fact that patients were operated on by the same surgeon and remained in personal contact during follow-up.

The authors of this book are busy practical men with no particular barrow to push. The text of the book includes a comprehensive review of all aspects of intraocular lens surgery including details of the design, optics chem­ istry and sterilization of intraocular lenses. Its value is enhanced by excellent illustrations and extensive tabulated references to the litera­ ture. Accounts of patient acceptability are balanced against candid discus­ sion of complications and their management. The historical introduction recalls that in the early stages of develop­ ment of the art, over a period of 10 years, two dozen different lens designs were proposed, most claiming elimination of problems which had arisen with their predecessors. Eventually nearly all disappeared from the scene. In an age where every cataract surgeon has to determine a personal position on intraocular lens implantation the author's reflections on these matters are timely. Intraocular lenses are neither a miracle nor a menace, provided that personal decisions and preferences are carefully thought through and put into practice upon the basis of known facts and not upon the basis of fickle fashion and fad. This book provides a background upon which the reader can eva­ luate in his own mind the validity of information provided by the manufacturers of various lens designs.

Dominant exudative vitreoretinopathy (DEVR) is an eye disease which has only recently received wider attention. In 1969 Criswick and Schepens used the designation "familial exudative vitreoretinopathy" to describe a syndrome they observed in six patients belonging to two families. The condition was characterized by several symptoms involving the vitreous and retina, e. g. "posterior vitreous detachment, organized vitreous membranes, heterotopia of the macula, retinal neovascularizations, subretinal and intraretinal exudates, and localized retinal detachment". The clinical features impressed the authors as strongly reminiscent of retrolental fibroplasia, but none of the patients had a record of premature birth or postnatal oxygen administration. In 1971 Cow and Oliver described the same syndrome in several members of one family. They considered their findings to be compatible with auto- somal dominant transmission. Canny and Oliver (I976) were the first to de- monstrate the fluorescein-angiographic changes of DEVR in four members of the abovementioned family. The most striking finding was "abrupt cessation of the capillary network in a scaloped edge near the equator".Fluorescein was seen to leak from the retinal vessels localized in this marginal zone, and in some eyes from massive fibrovascular lesions as well. Similar fluorescein- angiographic changes have been described in recent years in other reports on families with DEVR (Nijhuis et aI. , 1979; Slusher and Hutton, 1979; Dudgeon, 1979; Ober et a1. , 1980; Laqua, 1980). In 1979 I commenced a clinical study of this still little-known condition at the Nijmegen University Institute of Ophthalmology (The Netherlands).

When the Board of Directors of the Belgian Ophthalmological Soci­ ety, in its session of November 26th 1978, asked me to prepare a report on strabismus to be presented at the joint meeting of the Dutch and Belgian Ophthalmological Societies to be held on June 13th 1981, I felt greatly honored but still more overwhelmed by the immensity of the task. I took advantage of the complete liberty given to me by the Board of Directors, first to limit the work to one particular form of strabismus, i.e. the convergent comitant form; second, to seek the help of what I thought to be the best strabologists in the Low Countries; third, to aim not at an encyclopedic treatise but at a practical volume destined to the general ophthalmologist. This volume is thus limited to the various aspects of convergent strabismus, more accurately of comitant convergent strabismus. The omission of the word" comitant" is purposely made to avoid the dif­ fic'ulties accompanying the explanation of this term and all the acroba­ tics needed to explain that most comitant strabismus are not complete­ ly comitant. The choice of this particular form of strabismus seems logical. First of all, it is the most common form of strabismus. On the other hand, most principles concerning examination and treatment can with some modifications be applied to other forms of strabismus.

In its long series of annual reports, the Belgian Society of Ophthal- mology has a tradition of bringing into focus the recent advances in ophthalmology. But it seems surprising that one has to go back to 1940 to find a major report on the corneal diseases, when R. Rub- brecht wrote an "Aperr;u de la pathologie et de la therapeutique generale des maladies de la cornee". However, this omission is only apparent. In fact, many reports, since then, have contributed to our knowledge of the advances in corneal research. The corneal dimensions were documented in "La biometrie ocu- laire clinique (Y. Delmarcelle et aI., 1976)", the fine structure of the cornea in "L'ultrastructure de tissues oculaires (L. Missotten, 1964)", and many aspects of its metabolism in "Les verres de contact (P. Cochet et ai, 1967)" and "Les complications oculaires des erreurs congenitales du metabolism (J.P. Groux et O. Kallay, 1971)" . Bacterial keratitis was a main topic in "La therapeutique par les antibiotiques autres que la Penicillamine en Ophtalmologie (1. Michiels, 1952). Fungal corneal infections were described in detail in "Les mycoses oculaires" (J . Fran90is et M.Elewaut-Rysselaere, 1968)" and the toxic effects of drugs were dealt with in "Les effets nocifs des medications generales sur I'appareil visuel (J. Michiels et coil. 1972)".

Glaucoma simplex or open angle glaucoma is a slow, progressive illness with an insidious course which can lead to blindness. According to our con­ temporary state of knowledge, the illness begins with a decreased outflow of aqueous humor. This leads, sometimes after a period of decreased aqueous humor production due to a feedback mechanism, to an increase in intra­ ocular pressure (lOP). An elevated lOP can eventually lead to optic nerve damage, which manifests itself morphologically as glaucomatous papillary excavation and functionally in the development of a visual field defect. The classic triad of elevated lOP, papillary excavation and visual field defect, on which the diagnosis of glaucoma was also based in earlier times, is then pre­ sent. To this can now only be added that tonography usually shows a de­ crease in aqueous humor outflow and that gonioscopy must reveal an open angle. On the basis of statistical findings, Goldmann has calculated that there may be an interval of as long as 18 years between the initial increase in lOP and the development of visual field defects. This point of view (which has been confirmed in practice) that the onset of the illness can be demon­ strated by measurement of the lOP has introduced a new element into the discussion around glaucoma, namely, the concept of ocular hypertension. This implies simply that there is an (statistically) elevated intraocular pres­ sure, even though the optic nerve may not (yet) be damaged.

The need to study the corneal complications of measles was not very obvious. Everyone knew of the (kerato) conjunctivitis of measles and considered it to be an innocuous feature of the disease. Every medical worker in developing countries knew that measles in under- or malnourished children runs a very serious course leading to, e. g. , corneal The latter are seen frequently that medical workers in complications. developing countries are in the habit of speaking of post-measles blind­ ness. The aspect of the cornea in post-measles blindness is reminiscent of the keratomalacia in vitamine A deficiency and kwashiorkor. It was suggested that in measles the last reserves of vitamine A are exhausted, thereby precipitating the keratomalacia. The virological origin of measles keratitis has been more or less neglected in literature up till now. This study provides clinical and laboratory data concerning the kerato­ conjunctivitis of measles, gathered from a number of hospitalized children in a rural area of Kenya. The merits of this monograph is that it gives a careful description of the clinical course of measles keratoconjunctivitis and that it emphasizes the role of the virus-infection in addition to protein deficiency and vitamine A-deficiency in the etiology of post-measles blind­ ness. The possible roles of exposure in semi-comatose patients and of the application of traditional autochthone medicine are mentioned. Measles is no longer seen in developed countries but will still be encountered in the developing countries.

Thirty years ago, our attention was drawn to the alphabetical incom­ itances in strabismus. As an elevation in adduction is the most frequent incomitance, we decided to start treating these incomitances. A weak­ ening procedure of the inferior oblique muscle seemed indicated. How­ ever, since we wanted to prevent a torsional overcorrection with a head tilt, we displaced the scleral insertion of the oblique muscle towards the equator of the globe. This way, the torsional action of the muscles is saved. A weakening of the horizontal rectus muscles was systematically added, making it a simultaneous horizontal and cyclovertical surgery. Our way to deal with strabismus developed into a coherent entity and the interest of colleagues encouraged us to write it down.We decided to publish a textbook with a theoretical and an extensive practical part. Our approach is based on thirty years of exclusive strabological work, half-time academic and half-time private practice. More than 6500 re­ sults were analysed and the majority have been published. The con­ cerned publications are referred to at the end of the first chapter. Private practice allowed to benefit from the fact that patients were operated on by the same surgeon and remained in personal contact during follow-up.

This atlas is the fruit of a many years' ex- eet atlas est Ie fruit d'une longue experience Dieser Atlas ist das Ergebnis langjlihriger Er- perience in the application of anatomico-clini- de la methode anatomo-clinique appliquee a fahrung mit der auf die ophthalmologische cal methods to ophthalmological oncology. I' oncologie ophtalmologique. Onkologie angewandten anatomisch-klini- schen Methode. In the field of ophthalmology, as in other En Ophtalmologie comme dans les autres dis- medical areas, oncology has progressively in- ciplines medicales, I' allongement progress if Wie auch in anderen Disziplinen gewinnt die creased in importance with the gradual de l'esperance de vie donne davantage Onkologie in der Ophthalmologie mit der lengthening of life expectation. Apart from d'importance a l'oncologie. En effet, mises a steigenden Lebenserwartung immer mehr an rare tumours and certain malformations in part les rares tumeurs de I' enfant et certaines Bedeutung. Von den wenigen Tumoren des children, neoformations in ophthalmology are malformations, les neoformations en Kindes und gewissen MiBbildungen largely confined to ageing patients.Any of the Ophtalmologie sont l'apanage preferentiel du abgesehen sind Neubildungen in der Ophthal- intraocular tissues may be affected: those of sujet age. Elles peuvent toucher tous les tis sus mologie in erster Linie dem lilteren Menschen the iris, the ciliary body, the choroid or the intra-oculaires: iris, corps ciliaire, choroYde, vorbehalten. Sie konnen an slimtlichen in- retina, as well as of the orbit and the eyelid.

This report for the Belgian Ophthalmological Society concerns a number of fundus diseases, which most ophthalmologists only rarely encounter. Still it is of importance that they should be able to recognize them, not only because most of these eye diseases are treatable when they are diagnosed early enough, but also because they are sometimes associated with major visceral and neurological problems. The ophthalmologist may be the first practitioner to suspect a von Hippel-Lindau's disease or a neurofibromatosis. He should realize at that moment that his role is not only to treat the eyes but also to advise his patient, refer him to other specialists and consider the genetical implications of his diagnosis. Clinicopathologic correlations are of great importance and we felt that it was necessary to emphasize the histopathological aspect of these diseases. A report has to overview the literature on a specific topic. The literature on vascular tumors of the fundus is extremely vast and even if we tried to be as complete as possible, we must confess that we did not cite every author who published on such cases. A third aspect, which was considered as important, was to provide sufficient clinical and histopathologic examples of the various disease, which are reviewed. We are indebted to a large number of friends who kindly authorized the publication of their material. In particular we wish thank Prof. A. Brini (Strasbourg), Dr. D. de Wolff-Rouendaal (Leiden), Prof. P.

The chapters in this book were compiled by a trio of experts in the field of eye movements and contain discussions of anatomy and physiology of the ocular motor system, techniques of examination of patients with diplopia, and pathophysiology of specific disorders of ocular motility.

It is fascinating to read how his concepts for the treatment of complicated retinal detachments evolved from the intra­ ocular use of silicone oil to a combination of vitreous surgery with silicone oil tamponade.