Minimally invasive surgery is rapidly becoming the norm in medicine, as it often leads to better ... more Minimally invasive surgery is rapidly becoming the norm in medicine, as it often leads to better outcomes and earlier rehabilitation. This article reviews the principles and different techniques employed to perform minimally invasive strabismus surgery (MISS). In these techniques, strabismus surgery is performed through keyhole openings, thus reducing the risk of postoperative corneal complications, minimizing postoperative discomfort, and better preserving muscle function. MISS can be used to perform all types of strabismus surgery, namely rectus muscle recessions, resections, plications, reoperations, retroequatorial myopexy, transpositions, oblique muscle recessions, or plications even in the presence of limited motility. Of note, ocular alignment outcomes with MISS versus more traditional techniques have not been compared in randomized trials. Consequently, more controlled evidence is still needed to better delineate the future role and value of MISS in clinical management.
Cerebral visual impairment (CVI) is one of the leading causes of severe visual impairment in chil... more Cerebral visual impairment (CVI) is one of the leading causes of severe visual impairment in childhood. This article was written to highlight any new knowledge related to cerebral visual impairment in childhood.The international literature was searched to describe the type of visual, oculomotor and / or visuo-perceptual disturbances and to discuss the prognosis. CVI children show a wide range of visual disturbances. These could be either visual, oculomotor, perceptual or a combination of all. The severity of CVI depends on the time, location and extend of the brain damage.The visual function seems to improve in CVI children, especially in the cortically damaged, mainly due to brain plasticity. The increased survival rate of very premature infants during the last decades has increased the incidence of CVI in childhood. Better understanding of the pathophysiological mechanisms of CVI, early diagnosis and early intervention could lead to a better quality of life of these children.
Today, millions of children use computers on a daily basis. Extensive viewing of the computer scr... more Today, millions of children use computers on a daily basis. Extensive viewing of the computer screen can lead to eye discomfort, fatigue, blurred vision and headaches, dry eyes and other symptoms of eyestrain. These symptoms may be caused by poor lighting, glare, an improper work station set-up, vision problems of which the person was not previously aware, or a combination of these factors. Children can experience many of the same symptoms related to computer use as adults. However, some unique aspects of how children use computers may make them more susceptible than adults to the development of these problems. In this study, the most common eye symptoms related to computer use in childhood, the possible causes and ways to avoid them are reviewed.
A patient with marked exophthalmos secondary to thyroid eye disease presented for tarsorrhaphy an... more A patient with marked exophthalmos secondary to thyroid eye disease presented for tarsorrhaphy and removal of orbital fat. A single superolateral peribulbar injection was performed. After injection of 3.5 ml of local anaesthetic solution, the globe suddenly dislocated anteriorly. This complication has not been described previously. In patients with exophthalmos, general anaesthesia should be considered as the method of choice for ophthalmic procedures.
Purpose: To investigate whether visual function is related to severity of spastic diplegia (SDCP)... more Purpose: To investigate whether visual function is related to severity of spastic diplegia (SDCP) and brain damage.Methods: 28 SDCP children participated in this study. All of them were classified according to Gross Motor Functional Classification System (GMFCS) and also had a brain MRI and an eye testing (visual resolution evaluation and strabismus assessment), using the VFA-K testResults: The brain MRI showed that: 23 children appeared with mild to moderate periventricular leukomalacia (PVL), 2 with severe PVL, none with cortical atrophy, 3 with combined PVL and cortical atrophy and none with parenchymatic atrophy. According to GMFCS classification, 6 appeared with good motor function, 11 with a mild motor problem, 9 with moderate motor problem, 2 with severe motor disability and none with very severe disability. In visual testing, 7 children appeared with 0.87cpd and 21 children appeared with 1.75cpd; also, 24 children were orthophoric, 4 esotropic (25-60Δ) and none was exotropic...
The purpose of this study was to examine the refractive status, orthoptic status and visual perce... more The purpose of this study was to examine the refractive status, orthoptic status and visual perception in a group of preterm and another of full-term children with cerebral palsy, in order to investigate whether prematurity has an effect on the development of refractive errors and binocular disorders. A hundred school-aged children, 70 preterm and 30 full-term, with congenital cerebral palsy were examined. Differences for hypermetropia, myopia, and emmetropia were not statistically significant between the 2 groups. Astigmatism was significantly increased in the preterm group. The orthoptic status was similar for both groups. Visual perception was markedly reduced in both groups, but the differences were not significant. In conclusion, children with cerebral palsy have impaired visual skills, leading to reading difficulties. The presence of prematurity does not appear to represent an additional risk factor for the development of refractive errors and binocular disorders.
We present the management and postoperative course of a persistent fetal vasculature (PFV) case. ... more We present the management and postoperative course of a persistent fetal vasculature (PFV) case. A four-year-old girl visited the Eye Department of Hippokration, General Hospital of Thessaloniki due to reduced visual acuity of her left eye. She was diagnosed with PFV and underwent surgery (lensectomy, capsulorhexis of the posterior capsule, insertion of an intraocular lens in the posterior chamber, and posterior vitrectomy) in order to dissect the PFV. Along with the postoperative medical care, she underwent intensive treatment for amblyopia. The postoperative course was uncomplicated, and the visual acuity of her left eye improved from hand movement to 20/25 with proper correction. Patients with unilateral PFV and gradually deteriorating visual acuity could be good candidates for a combined surgical procedure, as the one described above, with a good prognosis.
We report on a patient who developed capsular block syndrome (CBS) in the early postoperative per... more We report on a patient who developed capsular block syndrome (CBS) in the early postoperative period with marked myopic shift in absence of anterior dislocation of the posterior-chamber intraocular lens (PC/IOL) and iris diaphragm. Treatment with focal 6-o'-clock Nd: YAG-capsulotomy resulted in complete visual acuity restoration. To the best of our knowledge this is the fist case of early onset CBS with significant myopic shift in absence of anterior PC/IOL dislocation, which was successfully treated with focal 6-o'-clock Nd: YAG-capsulotomy. The possible underlying pathophysiological mechanism is discussed.
Optometry and vision science : official publication of the American Academy of Optometry, 2010
To report an unfortunate case of patient selection for multifocal intraocular lens (MIOL) implant... more To report an unfortunate case of patient selection for multifocal intraocular lens (MIOL) implantation. Interventional case report. A 69-year-old woman with bilateral corticonuclear cataract underwent uneventful phacoemulsification with diffractive MIOL implantation within 1 week. She reported no previous medical history. A few days later she had persisting dizziness and experienced extreme photic phenomena, which progressively deteriorated. After intensive conversation, we discovered that our patient had a medical history of Meniere's disease. Bilateral intraocular lens exchange surgery was performed. One week after monofocal intraocular lens implantation, the patient was satisfied with the final visual outcome and did not report any visual complaints. Retinocortical processing of visual information is impaired in patients with peripheral vestibular disorders such as Meniere's disease. Therefore, these patients are probably not good candidates for MIOL implantation, which r...
To investigate the possible relationship between saccadic performances, gross motor function and ... more To investigate the possible relationship between saccadic performances, gross motor function and brain damage in spastic quadriplegic (SQ) children. Methods: Fifty two cerebral palsied SQ children (2−8 years old) were included in this study. All were classified according to GMFCS system, had a brain MRI and a clinical assessment of saccades. Results: GMFCS classification showed 6 children with good kinetic function (1), 8 with a mild kinetic problem (2), 9 with moderate kinetic problem (3), 13 with severe disability (4) and 16 with very severe disability (5). The brain MRI showed that 4 children had mild periventricular leukomalacia (PVL), 14 moderate PVL, 14 severe PVL, 3 cortical atrophy, 13 combined PVL and cortical atrophy and finally 4 parenchymatic atrophy. 9 children had normal saccades, 26 (50%) were either unable to execute saccades or appeared with chaotic saccades and the rest appeared with affected saccadic performance (using head movements). The statistical analysis (Kruskal-Wallis test) showed a significant correlation between saccades, gross motor function and brain damage severity (p < 0.001). Conclusion: Saccades are highly affected in SQ children and strongly related to gross motor function as well as to severity of brain damage.
To evaluate the safety and efficacy of adalimumab (AD) administration in patients with juvenile i... more To evaluate the safety and efficacy of adalimumab (AD) administration in patients with juvenile idiopathic arthritis (JIA). Twenty-six patients were enrolled from January 2004 to January 2008 in this prospective observational study. Inclusion criteria were either unresponsiveness to disease-modifying anti-rheumatic drugs (DMARDs; n = 17) or to other anti-tumour necrosis factor (anti-TNF) agents (n = 9) or development of uveitis under other anti-TNFs (n = 2 of the 9). Efficacy was estimated using the American College of Rheumatology Pediatric (ACR Pedi) criteria. After 1-5 years of AD exposure, nine different adverse events (AEs) were recorded (12.6 AEs/100 patient-years), mainly mild respiratory tract infections and injection site-related reactions. Serious AEs (SAEs, 2.8/100 patient-years) were the development of abscess at the site of injection (n = 1) and lethal sepsis (n = 1). The ACR Pedi ≥ 30 responses for the first to the fifth year of treatment were 88.5, 57.7, 50.0, 34.6, and 11.5%, respectively. In total, 17 of the 26 (65.4%) patients responded to AD. Five of the 11 patients under steroids discontinued them 6 months post-treatment. Seven patients required weekly AD treatment to maintain remission and four of them benefited from this policy. Recurrent uveitis was hindered in three of the six patients, no new cases were recorded, and radiological regression was observed in two of the four patients with lesions. AD was safe and efficacious during the study period in the majority of patients. However, vigilance is required for the early detection of severe and potentially fatal infections. AD may control recurrent uveitis and radiological progression.
tubers, and a greater TBP than those with a TSC1 mutation, but the ranges overlapped. TBP was inv... more tubers, and a greater TBP than those with a TSC1 mutation, but the ranges overlapped. TBP was inversely related to the age at seizure onset and tended to be inversely related to the cognition index. Further, a younger age at seizure onset or a history of infantile spasms was related to a lower cognition index. In a multivariable analysis the only significant relationship was between age at seizure onset and cognition index. Conclusions: This systematic analysis confirms proposed relationships between genotype, epilepsy, tuber status and cognitive function in patients with TSC, but also indicates that age at seizure onset is the only independent determinant of cognitive function.
Purpose: Selective Dorsal Rhizotomy (SDR) is one of the surgical procedures currently used for tr... more Purpose: Selective Dorsal Rhizotomy (SDR) is one of the surgical procedures currently used for treatment of spasticity. This is a procedure which is applied with the collaboration of paediatric neurosurgery, physiotherapy, and clinical neurophysiology teams. The aim of this presentation is to emphasize the uniqueness of postoperative rehabilitation programme. This was conducted using 110 cases which underwent SDR in Marmara University Paediatric Neurosurgery Division and Acibadem Institute of Neurological Sciences. Materials and Methods: Between 2001 and 2006, 110 cases underwent SDR. In all cases spasticity was observed at a minimum level of 3 and more according to the Ashworth Scale, and thereafter all cases were assessed within a multidisciplinary spasticity gathering. Patients, who were selected for rhizotomy, were given preoperative rehabilitation. Trunk exercises using a Bobath ball and with assisted excersize bands of different directions to both extremities were performed during the preoperative rehabilitation. Main purpose was to strength the affected muscle groups. In postoperative period for the weak muscle groups initially active-assistive lower extremity exercises with Theraband were conducted and then resistive exercises were performed once the patient was capable of undertaking this latter procedure. Results: In all cases a minimum Grade of 1−2 on the Ashworth scale resulted in relaxation occurring following the operation. Patients were given a minimum of 3 months rehabilitation prior to surgery and 2 weeks intensive postoperative rehabilitation within the hospital. Conclusion: SDR is an effective and satisfactory surgical technique for the treatment of spasticity, under the appropriate and correct selection of patients. Postoperative physiotherapy is crucial in order for the patients to benefit from this surgical intervention. This procedure requires special techniques and a different point of view in itself.
Minimally invasive surgery is rapidly becoming the norm in medicine, as it often leads to better ... more Minimally invasive surgery is rapidly becoming the norm in medicine, as it often leads to better outcomes and earlier rehabilitation. This article reviews the principles and different techniques employed to perform minimally invasive strabismus surgery (MISS). In these techniques, strabismus surgery is performed through keyhole openings, thus reducing the risk of postoperative corneal complications, minimizing postoperative discomfort, and better preserving muscle function. MISS can be used to perform all types of strabismus surgery, namely rectus muscle recessions, resections, plications, reoperations, retroequatorial myopexy, transpositions, oblique muscle recessions, or plications even in the presence of limited motility. Of note, ocular alignment outcomes with MISS versus more traditional techniques have not been compared in randomized trials. Consequently, more controlled evidence is still needed to better delineate the future role and value of MISS in clinical management.
Cerebral visual impairment (CVI) is one of the leading causes of severe visual impairment in chil... more Cerebral visual impairment (CVI) is one of the leading causes of severe visual impairment in childhood. This article was written to highlight any new knowledge related to cerebral visual impairment in childhood.The international literature was searched to describe the type of visual, oculomotor and / or visuo-perceptual disturbances and to discuss the prognosis. CVI children show a wide range of visual disturbances. These could be either visual, oculomotor, perceptual or a combination of all. The severity of CVI depends on the time, location and extend of the brain damage.The visual function seems to improve in CVI children, especially in the cortically damaged, mainly due to brain plasticity. The increased survival rate of very premature infants during the last decades has increased the incidence of CVI in childhood. Better understanding of the pathophysiological mechanisms of CVI, early diagnosis and early intervention could lead to a better quality of life of these children.
Today, millions of children use computers on a daily basis. Extensive viewing of the computer scr... more Today, millions of children use computers on a daily basis. Extensive viewing of the computer screen can lead to eye discomfort, fatigue, blurred vision and headaches, dry eyes and other symptoms of eyestrain. These symptoms may be caused by poor lighting, glare, an improper work station set-up, vision problems of which the person was not previously aware, or a combination of these factors. Children can experience many of the same symptoms related to computer use as adults. However, some unique aspects of how children use computers may make them more susceptible than adults to the development of these problems. In this study, the most common eye symptoms related to computer use in childhood, the possible causes and ways to avoid them are reviewed.
A patient with marked exophthalmos secondary to thyroid eye disease presented for tarsorrhaphy an... more A patient with marked exophthalmos secondary to thyroid eye disease presented for tarsorrhaphy and removal of orbital fat. A single superolateral peribulbar injection was performed. After injection of 3.5 ml of local anaesthetic solution, the globe suddenly dislocated anteriorly. This complication has not been described previously. In patients with exophthalmos, general anaesthesia should be considered as the method of choice for ophthalmic procedures.
Purpose: To investigate whether visual function is related to severity of spastic diplegia (SDCP)... more Purpose: To investigate whether visual function is related to severity of spastic diplegia (SDCP) and brain damage.Methods: 28 SDCP children participated in this study. All of them were classified according to Gross Motor Functional Classification System (GMFCS) and also had a brain MRI and an eye testing (visual resolution evaluation and strabismus assessment), using the VFA-K testResults: The brain MRI showed that: 23 children appeared with mild to moderate periventricular leukomalacia (PVL), 2 with severe PVL, none with cortical atrophy, 3 with combined PVL and cortical atrophy and none with parenchymatic atrophy. According to GMFCS classification, 6 appeared with good motor function, 11 with a mild motor problem, 9 with moderate motor problem, 2 with severe motor disability and none with very severe disability. In visual testing, 7 children appeared with 0.87cpd and 21 children appeared with 1.75cpd; also, 24 children were orthophoric, 4 esotropic (25-60Δ) and none was exotropic...
The purpose of this study was to examine the refractive status, orthoptic status and visual perce... more The purpose of this study was to examine the refractive status, orthoptic status and visual perception in a group of preterm and another of full-term children with cerebral palsy, in order to investigate whether prematurity has an effect on the development of refractive errors and binocular disorders. A hundred school-aged children, 70 preterm and 30 full-term, with congenital cerebral palsy were examined. Differences for hypermetropia, myopia, and emmetropia were not statistically significant between the 2 groups. Astigmatism was significantly increased in the preterm group. The orthoptic status was similar for both groups. Visual perception was markedly reduced in both groups, but the differences were not significant. In conclusion, children with cerebral palsy have impaired visual skills, leading to reading difficulties. The presence of prematurity does not appear to represent an additional risk factor for the development of refractive errors and binocular disorders.
We present the management and postoperative course of a persistent fetal vasculature (PFV) case. ... more We present the management and postoperative course of a persistent fetal vasculature (PFV) case. A four-year-old girl visited the Eye Department of Hippokration, General Hospital of Thessaloniki due to reduced visual acuity of her left eye. She was diagnosed with PFV and underwent surgery (lensectomy, capsulorhexis of the posterior capsule, insertion of an intraocular lens in the posterior chamber, and posterior vitrectomy) in order to dissect the PFV. Along with the postoperative medical care, she underwent intensive treatment for amblyopia. The postoperative course was uncomplicated, and the visual acuity of her left eye improved from hand movement to 20/25 with proper correction. Patients with unilateral PFV and gradually deteriorating visual acuity could be good candidates for a combined surgical procedure, as the one described above, with a good prognosis.
We report on a patient who developed capsular block syndrome (CBS) in the early postoperative per... more We report on a patient who developed capsular block syndrome (CBS) in the early postoperative period with marked myopic shift in absence of anterior dislocation of the posterior-chamber intraocular lens (PC/IOL) and iris diaphragm. Treatment with focal 6-o'-clock Nd: YAG-capsulotomy resulted in complete visual acuity restoration. To the best of our knowledge this is the fist case of early onset CBS with significant myopic shift in absence of anterior PC/IOL dislocation, which was successfully treated with focal 6-o'-clock Nd: YAG-capsulotomy. The possible underlying pathophysiological mechanism is discussed.
Optometry and vision science : official publication of the American Academy of Optometry, 2010
To report an unfortunate case of patient selection for multifocal intraocular lens (MIOL) implant... more To report an unfortunate case of patient selection for multifocal intraocular lens (MIOL) implantation. Interventional case report. A 69-year-old woman with bilateral corticonuclear cataract underwent uneventful phacoemulsification with diffractive MIOL implantation within 1 week. She reported no previous medical history. A few days later she had persisting dizziness and experienced extreme photic phenomena, which progressively deteriorated. After intensive conversation, we discovered that our patient had a medical history of Meniere's disease. Bilateral intraocular lens exchange surgery was performed. One week after monofocal intraocular lens implantation, the patient was satisfied with the final visual outcome and did not report any visual complaints. Retinocortical processing of visual information is impaired in patients with peripheral vestibular disorders such as Meniere's disease. Therefore, these patients are probably not good candidates for MIOL implantation, which r...
To investigate the possible relationship between saccadic performances, gross motor function and ... more To investigate the possible relationship between saccadic performances, gross motor function and brain damage in spastic quadriplegic (SQ) children. Methods: Fifty two cerebral palsied SQ children (2−8 years old) were included in this study. All were classified according to GMFCS system, had a brain MRI and a clinical assessment of saccades. Results: GMFCS classification showed 6 children with good kinetic function (1), 8 with a mild kinetic problem (2), 9 with moderate kinetic problem (3), 13 with severe disability (4) and 16 with very severe disability (5). The brain MRI showed that 4 children had mild periventricular leukomalacia (PVL), 14 moderate PVL, 14 severe PVL, 3 cortical atrophy, 13 combined PVL and cortical atrophy and finally 4 parenchymatic atrophy. 9 children had normal saccades, 26 (50%) were either unable to execute saccades or appeared with chaotic saccades and the rest appeared with affected saccadic performance (using head movements). The statistical analysis (Kruskal-Wallis test) showed a significant correlation between saccades, gross motor function and brain damage severity (p < 0.001). Conclusion: Saccades are highly affected in SQ children and strongly related to gross motor function as well as to severity of brain damage.
To evaluate the safety and efficacy of adalimumab (AD) administration in patients with juvenile i... more To evaluate the safety and efficacy of adalimumab (AD) administration in patients with juvenile idiopathic arthritis (JIA). Twenty-six patients were enrolled from January 2004 to January 2008 in this prospective observational study. Inclusion criteria were either unresponsiveness to disease-modifying anti-rheumatic drugs (DMARDs; n = 17) or to other anti-tumour necrosis factor (anti-TNF) agents (n = 9) or development of uveitis under other anti-TNFs (n = 2 of the 9). Efficacy was estimated using the American College of Rheumatology Pediatric (ACR Pedi) criteria. After 1-5 years of AD exposure, nine different adverse events (AEs) were recorded (12.6 AEs/100 patient-years), mainly mild respiratory tract infections and injection site-related reactions. Serious AEs (SAEs, 2.8/100 patient-years) were the development of abscess at the site of injection (n = 1) and lethal sepsis (n = 1). The ACR Pedi ≥ 30 responses for the first to the fifth year of treatment were 88.5, 57.7, 50.0, 34.6, and 11.5%, respectively. In total, 17 of the 26 (65.4%) patients responded to AD. Five of the 11 patients under steroids discontinued them 6 months post-treatment. Seven patients required weekly AD treatment to maintain remission and four of them benefited from this policy. Recurrent uveitis was hindered in three of the six patients, no new cases were recorded, and radiological regression was observed in two of the four patients with lesions. AD was safe and efficacious during the study period in the majority of patients. However, vigilance is required for the early detection of severe and potentially fatal infections. AD may control recurrent uveitis and radiological progression.
tubers, and a greater TBP than those with a TSC1 mutation, but the ranges overlapped. TBP was inv... more tubers, and a greater TBP than those with a TSC1 mutation, but the ranges overlapped. TBP was inversely related to the age at seizure onset and tended to be inversely related to the cognition index. Further, a younger age at seizure onset or a history of infantile spasms was related to a lower cognition index. In a multivariable analysis the only significant relationship was between age at seizure onset and cognition index. Conclusions: This systematic analysis confirms proposed relationships between genotype, epilepsy, tuber status and cognitive function in patients with TSC, but also indicates that age at seizure onset is the only independent determinant of cognitive function.
Purpose: Selective Dorsal Rhizotomy (SDR) is one of the surgical procedures currently used for tr... more Purpose: Selective Dorsal Rhizotomy (SDR) is one of the surgical procedures currently used for treatment of spasticity. This is a procedure which is applied with the collaboration of paediatric neurosurgery, physiotherapy, and clinical neurophysiology teams. The aim of this presentation is to emphasize the uniqueness of postoperative rehabilitation programme. This was conducted using 110 cases which underwent SDR in Marmara University Paediatric Neurosurgery Division and Acibadem Institute of Neurological Sciences. Materials and Methods: Between 2001 and 2006, 110 cases underwent SDR. In all cases spasticity was observed at a minimum level of 3 and more according to the Ashworth Scale, and thereafter all cases were assessed within a multidisciplinary spasticity gathering. Patients, who were selected for rhizotomy, were given preoperative rehabilitation. Trunk exercises using a Bobath ball and with assisted excersize bands of different directions to both extremities were performed during the preoperative rehabilitation. Main purpose was to strength the affected muscle groups. In postoperative period for the weak muscle groups initially active-assistive lower extremity exercises with Theraband were conducted and then resistive exercises were performed once the patient was capable of undertaking this latter procedure. Results: In all cases a minimum Grade of 1−2 on the Ashworth scale resulted in relaxation occurring following the operation. Patients were given a minimum of 3 months rehabilitation prior to surgery and 2 weeks intensive postoperative rehabilitation within the hospital. Conclusion: SDR is an effective and satisfactory surgical technique for the treatment of spasticity, under the appropriate and correct selection of patients. Postoperative physiotherapy is crucial in order for the patients to benefit from this surgical intervention. This procedure requires special techniques and a different point of view in itself.
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Papers by N. Kozeis