To reach a better understanding of the suspension of the eye in the orbit, an orbital mechanics model based upon finite-element analysis (FEA) has been developed. The FEA model developed contains few prior assumptions or constraints (e.g., the position of the eye in the orbit), allowing modeling of complex three-dimensional tissue interactions; unlike most current models of eye motility. Active eye movements and forced ductions were simulated and showed that the supporting action of the orbital fat plays an important role in the suspension of the eye in the orbit and in stabilization of rectus muscle paths.
Elastic and viscous shear moduli of orbital fat are low. Little energy is dissipated in the fat. The required deformation of the fat during eye rotation is limited because the eye slides, to some extent, within the Tenon capsule.
Manual FiO(2) adjustments varied widely in frequency and step size. Deep desaturations and large FiO(2) adjustments were associated with medical or nursing procedures. When large adjustments are really necessary, it will be challenging to implement them in an automatic adjustment device.
Background Reoperations are frequently necessary in strabismus surgery. The goal of this study was to analyze human-error related factors that introduce variability in the results of strabismus surgery in a systematic fashion. Methods We identified the primary factors that influence the outcome of strabismus surgery. For each of the human-error related factors we quantified variation with clinical assessments: measurement of the angle of strabismus, surgical strategy and surgical accuracy. Firstly, six patients were examined by six orthoptists, and accuracy of prism cover tests was assessed. Secondly, a questionnaire with sample cases (10°, 15°and 20°of infantile esotropia) was put to orthoptists, to determine variation in current surgical strategy. Finally, photographs made during surgery were analyzed to assess surgical accuracy. The influence of human-error related factors was related to the influence of inter-patient differences with a mechanical model. The relative contribution of all factors was assessed with a sensitivity analysis, and results were compared to clinical studies. Results The surgical trajectory of strabismus surgery could be modeled mathematically. Measurement of angle of strabismus, surgical technique, anatomy and physiology were considered. Variations in the human-error related factors were: (1) the latent angle at distant fixation was measured with a 90% confidence interval of 5°, and comprised 20% of the total variance of the postoperative angle, (2) orthoptists decided for bilateral recessions of, respectively, 7.3±1.7 mm (total amount of two recessions), 9.1±1.2 mm and 10.3±1.3 mm, which comprised 15% of the total variance, and (3) surgical accuracy was estimated at ±0.5 mm, which comprised 20% of the total variance. Conclusion The human error in strabismus surgery could be quantified with a sensitivity analysis. Approximately half of the reoperations in strabismus surgery are caused by inaccuracy in the measurement of the angle of strabismus, variability in surgical strategy and imprecise surgery.
The leash-like mechanical behavior of the pulley bands seems unsuited for stabilization of the muscle bellies. The patient with Crouzon's syndrome had relatively good eye motility and stable rectus muscle paths despite the lack of functional pulley bands.
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