The trochlear nerve: anatomy by microdissection

This work is based on the microscopic study of 30 trochlear nerve trunks (15 heads). In 17 cases, the trunk arose from two nerve bundles, in 8 cases from one bundle, and for the other 5 nerves, three or four bundles. The mean total length of the trochlear nerve was 86 mm. The nerve may be separated into the 3 following parts: infratentorial, intracavernous, intraorbital. In all 30 cases studied, the first part of the nerve was infratentorial, thus leading us to suggest the term "infratentorial part" for this segment of the nerve. In 27 cases, contact was found with the superior cerebellar artery, in the infratentorial part. In the intracavernous part of ten nerves we found two rami tentorii and in eight cases fibers were exchanged with the ophthalmic nerve. In the orbit, 18 trochlear nerves crossed the posterior ethmoidal artery. 23 trochlear nerves ended on the medial face of the superior oblique muscle. The remaining 7 ended at the superior border of the muscle.     

Helicobacter pylori infection in recurrent abdominal pain

The superior and inferior gemellus muscles were examined as to their forms and the patterns of nerve supply in 13 human cadavers (20 specimens). The superior gemellus muscle (Gs) was absent in 3 specimens, but showed no accessory slip or fusion with the internal obturator muscle (Oi). The nerve to the Gs originated from the nerve to the Oi (OiN) in 7, the nerve to the quadratus femoris muscle (QfN) in 4, or both in 6 specimens. The inferior gemellus muscle (Gi) was present in all, but fused with the Oi in 3 specimens. In one specimen, an accessory muscle bundle was observed between the Gi and Oi. The Gi always received branches from the QfN at its anterior surface, but received an additional nerve supply at its posterior surface from the OiN or the pudendal nerve in one specimen each, and the accessory bundle was supplied by a branch from the OiN at its posterior surface. In a well preserved specimen, a branch to the Gi from the QfN entered the Oi and communicated with the OiN after supplying and leaving the Gi. The frequency of the dual innervation of Gs by the OiN and QfN was 29.3%, but that of the Gi and Oi could not be determined, because of the occurrence of the fused part, the accessory bundle and nerve communication. There existed some gross anatomical differences between both gemelli muscles; they are considered to be parts of the internal obturator muscle in a broad sense.     

Long-term observation of ablatio-prophylaxis with kryopexy (author''s transl)

Five cases of laceration of an extraocular muscle without involvement of the globe or significant involvement of the adnexa occurred after injury with a pencil, mower blade, screen door, and building nail, and at surgery when the surgeon operated on the wrong muscle. The inferior rectus muscle was involved in three cases, the lateral rectus muscle in one, and the medial rectus muscle in one, Traumatic muscle laceration involves the inferior or medial rectus muscles more often than the other muscles. This may occur for two reasons: these muscles are closer to the corneoscleral limbus, and they are more visible during the protective blink with associated upward and usually outward movement of the globe (Bell's phenomenon). When the lacerated muscle could be found, it was repaired either by reinsertion to the sclera or reunion of the severed muscle segments. When the muscle could not be found, a muscle transfer procedure was carried out. Patients with fusion before injury regained fusion in part of the visual field after muscle repair.     

Rab5 GTPase and endocytosis

PURPOSE: We studied the effect of horizontal transposition of the vertical rectus muscles on incyclotropia and excyclotropia in terms of the amount of correction obtained and the stability of the outcome. METHOD: Preoperative measurements for cyclotropia were compared in 11 patients with measurements during the immediate postoperative period and last follow-up. Excyclotropia was treated with nasal transposition of the inferior rectus muscle and incyclotropia with nasal transposition of the superior rectus muscle, to which we added temporal transposition to the inferior rectus muscle in one patient to enhance the effect. RESULTS: Fusion in all gaze positions was restored in six patients and functional improvement occurred in five. The average effect of horizontal transposition of one vertical rectus muscle for cyclotropia was a correction of 7 degrees in primary position and of 11 degrees in depression. This effect remained stable after a mean follow-up of 17 months, and additional improvement occurred in one patient. One patient developed a hypertropia, eliminated by an additional operation, in the treated eye. CONCLUSIONS: For excyclotropia, nasal transposition of the inferior rectus muscle is a viable alternative to lateral and anterior transposition of the anterior portion of the superior oblique tendon. It becomes the procedure of choice when surgery on the superior oblique tendon is precluded, either by the tendon's congenital absence or by previous surgery on the tendon. Nasal transposition of the superior rectus muscle or temporal transposition of the inferior rectus muscle is ideally suited for incyclotropia. No comparably effective operation exists.     

The superior orbital fissure: a microanatomical study

The superior orbital fissure (SOF) is a small (3 x 22 mm), but functionally very important, region. The microsurgical anatomy of the SOF was studied on five adult, formalin-fixed cadavers. The vascular structures of three of them were injected with latex. The SOF contains the third, fourth, and sixth nerves, the ophthalmic branch of the fifth nerve, and the superior orbital vein. It is divided by the two tendons of the lateral rectus muscle: the superior part contains the fourth nerve, the frontal and the lacrimal branches of the ophthalmic division of the fifth nerve, and the superior orbital vein; the inferior part contains the superior and inferior branches of the third, the nasociliary, and the sixth nerves. In regard to surgical access to lesions involving the SOF, the question is often raised as to whether the dissection should be started from the cranial or the orbital side. The following procedure is recommended: 1) frontotemporo-orbital craniotomy; 2) resection of the lesser wing of the sphenoid bone, of the anterior clinoid, and of the superolateral part of the orbital roof and opening of the dura along the Sylvian fissure, with an extension to the frontal lobe and another extension to the temporal lobe; 3) incision of the periorbita in its superolateral part and identification of the frontal nerve; and 4) dissection of the frontal nerve in an anteroposterior direction. The fourth nerve will be found medially and inferiorly to the frontal nerve. The third nerve will be found inferomedially to the frontal nerve in the SOF, and the sixth nerve will be found inferiorly to the inferior branch of the third nerve.     

Cardiovascular responses to treadmill exercise testing in anemia

Gunshot wounds are rare in Japan because of few regulatory laws against the possession of guns. Nevertheless such wounds are increasing in prevalence these days. Reports on the microscopic findings concerning these intracerebral lesions are fewer than those on the macroscopic findings in the scalp, the skull and the intracranial cavity. In this study we evaluated computed tomographical and histopathological findings in craniocerebral gunshot injuries. CASES: Nine patients with gunshot wounds to the head were presented. All were male and the age ranged from 17 to 66 years. Four were suicides and four were attempted murders and the last one was of unknown etiology. Morphological examination was performed on 5 autopsy cases. The distance of the bullet from the cranial cavity was as follows: long distance, 4 cases; close contiguity, 5 cases. The calibers of the weapons were as follows: 38 mm in 6 cases, 45 mm in 1 case and unknown in 2 cases. RESULTS: CT scans were examined in six cases, which revealed a missile track, hemorrhagic contusion, traumatic subarachnoid hemorrhage and marked tension pneumocephalus. In some cases, CT scan also revealed bony and metallic fragments, some deep within the cranial cavity. In the histopathological study, we found marked swollen brain (brain weight over 1500 mg) and hemorrhagic contusion in the vicinity of the missile track and interhemispheric fissure, and widespread traumatic subarachnoid hemorrhage and intraventricular hematoma. We would like to emphasize especially the remote contusion seen in the distant part of the missile track as well as massive exsudation and hemorrhage around the nerve fiber bundles. Remote contusion was observed in the inferior surface of the fronto-temporal lobes, and bilateral hemorrhagic contusion was seen in the vicinity of the superior longitudinal fissure on CT scans and autopsy findings. In one case, the bullet rotated within the intracranial cavity. In conclusion, nine cases of craniocerebral gunshot injuries were examined, while we also reviewed the medical literature concerning the shearing injury produced by gunshot brain wounds. The head injuries were further delineated by the correlation between autopsy and computerized tomography findings.     

Industrial hygiene and occupational health studies in Australian (New South Wales) shipyards

Twenty one subjects with sistemic arterial hypertension and arteriographic signs of obstructive lesion of the renal artery were studied and classified in 3 groups: group A, 13 cases with bilateral renovascular lesions; group B, 4 patients with unilateral renovascular stenosis and group C, formed by 4 subjects with a segmental branch stenosis of a renal artery. In all cases an special protocol was followed to measure plasma renin activity (PRA) in blood taken from a peripheral vein, inferior vena cava and both renal veins and also to determine 24 hrs. urinary excretion of aldosterone (UEA). PRA and UEA were clasified as high, normal and low by comparing the results with those of normal subjects in a nomogram estimated in the same laboratory in which PRA and UEA values were correlated with 24 hrs. urinari sodium excretion. Besides, R greater than /R less than index (highest PRA of renal vein blood/PRA of contralateral renal vein) and V-A A index (V = PRA of renal vein blood; A = PRA of inferior vena cava) were calculated. Forty eight and thirty eight percentage of the cases had either high renin in peripheral venous blood or high UEA. Similar data in patients with essential hypertension previously studied in the same laboratory were 12 and 10% respectively. V-A A index was incongruent with the arteriographic image in 3 cases of group B; 4 cases of group A and 2 of group B had a pattern of bilateral stenosis, and one case in each group A and C had a unilateral stenosis pattern. In the other patients the samples were "non representative" due to a high level of PRA in the inferior vena cava blood comparable to PRA of the renal veins. Six cases of group A had a R greater than /R less than index superior to 1.5, which suggested a predominant vascular lesion in one side not always congruent with the arteriographic findings. In 3 cases of group B this index was higher than 1.5 in favor of the ipsilateral lesion. Three cases of group C had a normal R greater than /R less than index and one with a total oclussion of a segmental artery presented an index superior to 1.5, ipsilateral to the lesion. The latter index was of value in the diagnosis of renovascular arterial hypertension.     

Neuronal nicotinic receptor operates slow Ca2+ mobilization at mouse muscle endplate

The authors describe the anatomical characteristics of the levator labii superioris muscle by dissection in cadavers. PURPOSE: We describe the characteristics of these muscle, the details and relations, hopefully contributing to the study of muscle of the face. METHODS: Twenty faces of cadavers were dissected. The following features were studied: origin, insertion, length, width, thickness, relations, innervation and blood supply. RESULTS: In all cases the muscle originated from the inferior orbital margin. Two insertions were observed: via lateral fibers, superficial to the orbicularis oris muscle and via deep fibers than form part of the raphe at the corner of the mouth (70%); via superficial fibers to the orbicularis oris muscle (30%). The average of the length was 24.66 mm and the average of the thickness was 3.57mm. The width at its insertion was 11.2mm, and at the origin was 15.96mm. The levator labii superioris muscle was found to be anterior to the levator anguli oris; it was posterior to the distal portion of the zygomaticus minor (90%) and posterior to the mid portion of the zygomaticus minor (10%). The innervation was from the inferior branch of the zygomatic nerve (facial nerve) and from the infraorbital nerve (trigeminal nerve). The inferior portion of the muscle is supplied by branches of the angular artery and the superior part from branches of the infraorbital artery.     

Superior gluteal vessel as recipient for free flap reconstruction of lumbosacral defect

When the lumbosacral soft-tissue defect cannot be closed with a local flap, the option of a free flap should be considered. However, very few cases of free flaps have been reported, the reason being mainly difficulties in finding a suitable recipient vessel. Several vessels, such as inferior gluteal vessel, extension of thoracodorsal vessel with vein graft were reported as recipient vessels, but each one had its own drawbacks. The superior gluteal vessel has been used as a donor vessel in breast reconstruction after mastectomy but is thought to be undesirable as a recipient for microvascular anastomosis, mainly because of technical difficulty. From May of 1993 to March of 1997, five patients (one man and four women) received microvascular transfer of latissimus dorsi myocutaneous flaps using the superior gluteal vessel as a recipient. Their ages ranged from 11 to 64 years (mean 44 years of age). The causes of lumbosacral defects were tumor (1), trauma (1), radiation (2), and pressure sore (1). Before free flap transfer, the patients received an average of 2.8 operations for sacral lesions. Mean follow-up period was 12.4 months (2 to 40 months). A lateral approach was used to the superior gluteal vessel after elevation and retraction of gluteus maximus muscle. A thoracodorsal artery and vein were anastomosed to superior gluteal artery and vein in three cases, whereas in two cases, one artery and two veins could be anastomosed. All the flaps survived with complete recovery from sacral lesions. During the follow-up period, one case of partial skin graft necrosis and one case of a small superficial pressure sore developed, but there was neither dehiscence nor recurrence. The superior gluteal vessel is large in caliber, constant, with numerous branches, lying in proximity to the lesion, and relatively unaffected despite previous radiation. The technical difficulties with the deep location and short pedicle length can be overcome with some modifications in approach to the vascular pedicle. The superior gluteal artery and vein can be used as a recipient for the free tissue transfer when the lumbosacral defects cannot be covered with a conventional method.     

Secondary tumor of the temporal bone with internal auditory meatus involvement--histopathological study

Nineteen cases of secondary tumor of the temporal bone with involvement of the internal auditory meatus (IAM) were studied. The cases were classified into 4 invasion modes; direct extension from head and neck tumors (12 cases), hematological dissemination (3 cases), diffuse leptomeningeal carcinomatosis (3 cases), and direct extension of tumors from the intracranium (1 case). There were some differences in the manner in which the tumor had spread among these 4 modes. In most cases involving "direct extension from head and neck tumors", the tumor had invaded the pyramis, and then the Eustachian tube and the middle ear. When the inner ear or the IAM was involved, it was directly invaded by massive tumor. In all cases of "hematological dissemination", metastatic tumor was found bilaterally, but there were some differences in the manner of invasion between the two sides. In "leptomeningeal carcinomatosis" and "intracranial tumor", the tumor had invaded the temporal bone bilaterally via the IAM. In the IAM, cochlear and inferior vestibular nerves were more vulnerable to tumor invasion than facial and superior vestibular nerves. It was suggested that there are some differences in vulnerability to tumor invasion between the superior and inferior vestibular nerves. The bottom of the IAM presented a barrier-like effect against the spread of tumor from the IAM to the labyrinth. In some cases, however, there was massive tumor invasion of the internal ear directly from the IAM. Whether denervation of the ganglionic neurons (spiral or vestibular) causes secondary degeneration of peripheral sensory endorgans remains controversial. In some cases in our series, degeneration of the auditory or vestibular peripheral organs might be attributed to denervation of neurons in the spiral or vestibular ganglia. In other cases, however, auditory and vestibular peripheral organs remained intact despite severe degeneration of ganglionic neurons.     

Reticular afferents from vestibular nuclei

The purpose of the present study is to observe the electromyogram (EGM) manifestations of the lateral pterygoid muscle (LPM) in monkey during mouth opening and closing movements. The lateral pterygoid muscle of five healthy monkeys (macaques) was exposed by operation under general anesthsia and the electropolar needles were placed into the superior and inferior head of LPM respectively. The EMG manifestations of the superior and inferior head of LPM were recorded by O.T.E. Biomedica EMG Recorder during the natural condition and the movements of opening and closing mouth after complete recovery from anesthesia. It has been found that the two heads acted synergistically only in opening movement and no activity was noted in closing movement. This finding disagrees with the previous viewpoint that the function of the superior and inferior head of LPM is independent.     

Service-mix in general dental practice in Japan: a survey in a suburban area

The authors describe a supernumerary muscle in each orbit of an elderly male subject. There appear to be no previous reports of this muscle; most reports of anomalies of extraocular muscles describe hypoplasia or aplasia. Thirty-five formalin-fixed cadavers assigned to medical students for dissection were studied. The orbits were dissected by a superior approach which involved removal of the orbital plate of the frontal bone and the superior orbital margin. A supernumerary extraocular muscle was seen in each orbit of one cadaver, located between the superior oblique and levator palpebrae superioris muscles. It originated on the inferior surface of the lesser wing of sphenoid bone and was inserted into the skin of the medial one-third of the upper eyelid. It was innervated by a branch from the superior division of the oculomotor nerve. The insertion of the muscle into the upper eyelid produced a crease running obliquely upwards and medially, from the junction of the medial one-third and lateral two-thirds of the lid margin, towards the medial part of the superior orbital fold. The authors suggest the name levator palpebrae superioris accessorius for this muscle in view of its topography and action as tested in the cadaver. The significance of the findings is discussed and the literature on the development of the muscles supplied by the oculomotor nerve is reviewed.     

Repeat angiography and magnetic resonance imaging (MRI) of dissecting aneurysms of the intracranial vertebral artery. Report of four cases

We here present 4 cases with dissecting aneurysm (DA) of the intracranial vertebral artery, who were followed up by repeat cerebral angiography and MRI. The patients consisted of 2 males and 2 females, and the mean age was 43 years. Two cases were associated with polyarteritis nodosa (PN) and hypertension, respectively. Three of the cases developed subarachnoid haemorrhage (SAH), while the other one suffered from lateral medullary syndrome. In cerebral angiography, "pearl and string" signs were revealed in all cases, while a "double lumen" indicating a true diagnostic sign of DA was demonstrated in only one case. Repeat angiography showed that a bleb formation with a bulging of the aneurysmal sac was seen in 2 cases, and an irregularity of the wall in one case. On the other hand in one case, the ectatic part shrank, while the stenotic part was restored. In magnetic resonance imaging (MRI), a hyperintensity mass on T 1-weighted image (T 1-WI) adjacent to flow void suggesting either an intramural haematoma or a linear shape hyperintensity on T 1-WI were demonstrated in 3 cases. In the follow up MRI done in 2 cases, a serial change in the intensity from iso-intensity to hyperintensity on T 1-WI was observed in one case suggesting intramural haemorrhage, while an enlargement of the ectasic flow void was seen in the other case. Three of 4 cases were operated on by trapping of the aneurysms. One, who had systemic vascular diseases due to PN, and repeat angiography showed a regression of the aneurysm, was conservatively treated.(ABSTRACT TRUNCATED AT 250 WORDS)     

Déjà vu all over again: the re-analysis of epidemiologic data

BACKGROUND: An extraocular muscle palsy is conventionally characterized by a deviation of the visual axes, this being greater when measured with the affected eye fixing. By definition and illustrating Hering's law, this secondary angle of deviation is greater than the primary one, measured with the sound eye fixing. We present here a comparative study of the amount of subjective excyclodeviation measured in patients suffering from IVth nerve palsy, with the sound or affected eye fixing. METHODS: Two groups of patients were entered into the study: Group 1 (N = 54) for superior oblique palsies studied retrospectively and Group 2 (N = 14), for a prospective study of those recently acquired (post-traumatic) and followed over 6 months. In both groups, measurements were made at two stages, early (1 to 7 weeks after onset) and late (4 to 6 months later). RESULTS: In both groups, the majority of cases showed a greater secondary torsional deviation, the difference between this and the primary deviation lessening on late stage measurements. CONCLUSION: In both groups, the difference between primary and secondary torsional deviation was not statistically significant.     

How occupational therapists teach older patients to use bathing and dressing devices in rehabilitation

PURPOSE: Brown's syndrome is a form of anatomical strabismus, or retraction syndrome. It is defined by active and passive limitation of upward gaze in adduction in the field of action of the inferior oblique muscle. The etiology of Brown's syndrome remains unknown. The defect lies at the level of the superior oblique's tendonis trajectory via the trochlea. We studied the frequency of clinical signs and results after surgery in patients presenting congenital Brown's syndrome. PATIENTS AND METHODS: Our study involved 18 children. They all underwent complete ophthalmological examination with orthoptic testing, pre and postoperatively. RESULTS: Neither sidedness nor predominance of sex was noted. Compensatory head posture was noted in 7 of 18 cases. Limitation of upward gaze in adduction was a constant finding, with a positive duction test. Eleven cases underwent superior oblique recession. Results of surgery were satisfactory, with resolution of compensatory head posture in over 80% of cases. CONCLUSION: The etiology of congenital Brown's syndrome remains unknown. The different surgical techniques give inconstant results. Operative indication is decided only when in the presence of well defined clinical manifestations: CHP, deviation in primary position with alteration of binocular vision.     

Spatial orientation and the representation of space with parietal lobe lesions

Damage to the human parietal cortex leads to disturbances of spatial perception and of motor behaviour. Within the parietal lobe, lesions of the superior and of the inferior lobule induce quite different, characteristic deficits. Patients with inferior (predominantly right) parietal lobe lesions fail to explore the contralesional part of space by eye or limb movements (spatial neglect). In contrast, superior parietal lobe lesions lead to specific impairments of goal-directed movements (optic ataxia). The observations reported in this paper support the view of dissociated functions represented in the inferior and the superior lobule of the human parietal cortex. They suggest that a spatial reference frame for exploratory behaviour is disturbed in patients with neglect. Data from these patients' visual search argue that their failure to explore the contralesional side is due to a disturbed input transformation leading to a deviation of egocentric space representation to the ipsilesional side. Data further show that this deviation follows a rotation around the earth-vertical body axis to the ipsilesional side rather than a translation towards that side. The results are in clear contrast to explanations that assume a lateral gradient ranging from a minimum of exploration in the extreme contralesional to a maximum in the extreme ipsilesional hemispace. Moreover, the failure to orient towards and to explore the contralesional part of space appears to be distinct from those deficits observed once an object of interest has been located and releases reaching. Although patients with neglect exhibit a severe bias of exploratory movements, their hand trajectories to targets in peripersonal space may follow a straight path. This result suggests that (i) exploratory and (ii) goal-directed behaviour in space do not share the same neural control mechanisms. Neural representation of space in the inferior parietal lobule seems to serve as a matrix for spatial exploration and for orienting in space but not for visuomotor processes involved in reaching for objects. Disturbances of such processes rather appear to be prominent in patients with more superior parietal lobe lesions and optic ataxia.     

Selective ablation of immature blood vessels in established human tumors follows vascular endothelial growth factor withdrawal

In the guinea pig, lateral deviation of the head is a cardinal symptom of the vestibular syndrome caused by unilateral labyrinthectomy. In the course of recovery from this syndrome (vestibular compensation), lateral deviation of the head disappears completely in 2-3 days. Because this symptom is known to be due to the lesion of the horizontal semicircular canal system, and since obliquus capitis inferior (OCI) muscle is activated predominantly by yaw rotation (horizontal vestibulocollic reflex), we hypothesized that changes in the activity of this muscle could be at least in part responsible for the lateral head deviation caused by unilateral labyrinthectomy. In order to test this hypothesis, electromyographic (EMG) activities of the right and left OCI muscles, as well as eye movements, were recorded in 12 head-fixed alert guinea pigs at various times after left surgical labyrinthectomy (performed with the animals under halothane anesthesia). After the operation, a decrease in tonic EMG activity was observed in the right (contralateral to the lesion) OCI muscle while an increase in tonic EMG activity was detected in the left (ipsilateral) OCI muscle. In addition, phasic changes in EMG activity associated with ocular nystagmic beats occurred in the OCI muscles. These phasic changes were in the opposite direction to those of the tonic changes. There were bursts of activity in the right OCI and pauses in the left OCI. From measurements of rectified averaged EMG activities which took into account both parts (tonic and phasic) of the phenomenon, it was concluded that the labyrinthectomy-induced asymmetry between the activities of the left and right OCI muscles was high enough and lasted long enough to be an important mechanism in the lateral deviation of the head caused by unilateral labyrinthectomy.     

Inferior rectus recession--an effective procedure?

AIMS: To examine the postoperative stability of inferior rectus recession, with particular reference to the incidence of progressive overcorrection. METHODS: The results of consecutive patients undergoing inferior rectus recession over a 3 year period were reviewed. RESULTS: 21 patients underwent inferior rectus recession, using an adjustable suture technique in all but three cases. In 16 patients additional vertical muscle surgery was performed at the time of the inferior rectus recession. All patients were followed for a minimum of 3 months postoperatively, with a mean follow up of 9.3 months. At the final postoperative visit 11 patients were well aligned, eight were undercorrected, and two were overcorrected. In five of the eight undercorrected cases, the residual deviation was the result of postoperative drift in the direction of the preoperative deviation, following an initially good alignment. Review of the results failed to reveal any factor predictive for this postoperative drift. CONCLUSION: The risk of postoperative overcorrection following inferior rectus recession should be considered, but in this study, undercorrection occurred more frequently than overcorrection. The possible reasons for overcorrection and undercorrection are discussed.     

Diagnostic assays in cytomegalovirus retinitis

The aim of the work is to inspect the influence of the treatment by using hyper-correcting prisms on the vertical deviations of the eyes and on the head's position in persons with nystagmus. We observed 4 persons with nystagmus without strabismus and 3 persons with convergent squint. In persons without strabismus the prismatic correction placed with an edge in the direction of the "calm's zone" (quiet's zone) to obtain the straight position of the head when looking forwards was applied. Twice a day during 10 minutes the patients were making the movement's exercises in the vertical and horizontal direction looking by the prism separately by each eye. This prism (often 35 D prism) was placed with the edge in the direction of greater deviation of the oblique inferior muscles and the left rectus inferior muscle. Patients with convergent strabismus were treated according to the principles of localization method with consideration of the localize exercises by using hyper-correcting prisms in the vertical and horizontal directions. Two patients had a surgery in order to eliminate not aesthetic and strong prisms which were applied because of large horizontal squint. One patient with convergent alternate squint with hyperactivity of both inferior oblique muscles and inferior rectus muscle of the left eye was treated without surgery, only by the conservative treatment with prisms. In all patients we obtained a straight position of the head despite of the nystagmus still existing during the eyes movements in some directions. The treatment by using hyper-correcting prisms can completely replace the surgical treatment or is able to supplement it and prevent relapses.