We have been studying nystagmus for many years, and the principles of nystagmus surgery designed by He Yushi, a famous expert in nystagmus research in China in the 1980s, were established for “idiopathic nystagmus”, and the principles of surgery at that time were one: the corrected visual acuity of the bilateral compensated head position is two or more lines higher than the corrected visual acuity of the head position. The second principle of surgery is: nystagmus must be impulsive nystagmus, and the patient must have a nystagmus-free zone in a certain direction, that is, what ophthalmologists usually call the “middle zone” of nystagmus, that is, the patient must have a nystagmus-free zone. This principle has been the “gold standard” of surgical treatment for ophthalmologists in China. With the large number of patients with nystagmus in outpatient clinics, we found that a large number of patients and children with compensatory head position in outpatient clinics are not all impulsive nystagmus, and there is no absolute “middle band”, and some patients do not necessarily have corrected vision to improve two lines of vision after surgery. Therefore, many patients who wish to correct their head position through treatment are excluded from surgical treatment, and there are very few ophthalmologists in China who are engaged in the study of nystagmus. Moreover, the problem of improving the corrected visual acuity of surgery has always troubled ophthalmologists. The problem of surgical treatment for these special nystagmus patients has always been a challenge in nystagmus treatment. To be honest, the treatment of nystagmus is very difficult and the treatment effect is not ideal, especially in young children with nystagmus. As an ophthalmologist, we hope that the quality of vision of these children can be improved and enhanced after systematic treatment. Later, we had the opportunity to observe and get acquainted with Professor Hertle and Professor deongshengyang, two famous nystagmus experts in the United States, who have been researching nystagmus for many years and have achieved remarkable results. Through the introduction of Prof. deongshengyang, we participated in many international nystagmus webinars and held video exchanges with international nystagmus experts from the Internet, where experts from different countries exchanged ideas about the characteristics and types of nystagmus, surgical treatment methods, and conservative treatment methods. After the exchange, discussion, and reflection, I gained a new understanding and appreciation of the surgical efficacy of nystagmus surgery. We also began to revisit the expectations of patients after nystagmus surgery and the criteria for assessing surgical outcomes. Below we present our experience with various treatments for nystagmus over time, as well as the latest foreign trends in nystagmus. We would like to share with you that nystagmus is a complex disease that is a worldwide problem. The causes of nystagmus and the manifestations of nystagmus are diverse and involve many disciplines. The most closely related to ophthalmology is congenital nystagmus, and the treatment of nystagmus has been a problem for ophthalmologists and for children and parents for many years. Over the years, we have conducted more in-depth research and clinical practice on this disease. Here we summarize the latest treatment progress of nystagmus and the questions parents often ask us, and communicate with parents in the hope of helping them better understand the disease and be able to detect it early and treat it better with early treatment to achieve better treatment results. 1, parents ask: mom and dad do not have nystagmus, why would the child occur? Many nystagmus parents ask experts why my baby has nystagmus, which is summarized as the following two reasons: Reason 1: Some scholars believe that congenital nystagmus is a failure of the slow-motion control subbranch system of the eye (sfoweyemovementsubsystem), which is active under abnormal conditions of high gain, and this particular abnormality may manifest itself as an extraocular muscle proprioceptive This particular abnormality may be manifested by the feedback of the signals about eye position and movement speed from the receptors, which results in an unstable eye position and deviation of the eye from the positive position, which constitutes the slow phase of the tremor. Cause 2: Other scholars believe that the defect in the subcortical optokinetic system causes the eye to deviate from the gaze position due to the instability of the gaze, and that correcting the eye movement brings the eye back to the gaze position. Recent studies by Dell’osso et al, a leading nystagmus expert, have shown that patients with congenital nystagmus have a strong fixation reflex, normal smoothpursultmotion, and good vestibular glance reflex function. They concluded that although the exact function of the incoming impulses to the proprioceptors of the extraocular muscles is not known, it has an effect on both eye position and velocity of movement in the feedback loops, and therefore congenital nystagmus may be due to instability in the peripheral portion of these feedback loops. The details of the pathogenesis of congenital nystagmus need to be further investigated in the future. Since the control of eye movements is a circular feedback mechanism, multiple links can control eye movements, including the structure of the eye, afferent pathways, diseases of the central brain, and diseases affecting vestibular function can all cause nystagmus; for example, visual impairment nystagmus, otogenic nystagmus, and central nystagmus. It is not a common or frequent disease, but it is not rare clinically, and such diseases are serious. 2. Parents ask: Which eye diseases can cause nystagmus in children: Class I: From the ophthalmology point of view, there are the following categories: (1) albinism, (2) congenital cataract, (3) optic nerve dysplasia, (4) macular degeneration, (5) retinitis pigmentosa (6) congenital glaucoma (7) corneal (6) congenital glaucoma (7) corneal leukoplakia and other diseases that seriously affect visual acuity can cause nystagmus. (8) Nystagmus of unknown etiology (2) Special types of nystagmus: 1) Vertical nystagmus, 2) Seesaw-like nystagmus, 3) Periodic nystagmus The above nystagmus is caused by central lesions in the brain, such as occupational lesions, inflammation, hemorrhage, etc. These diseases must be seen in the neurology department of specialized hospitals to avoid delays and treatment. Experts remind that when a child is found to have nystagmus, it should be carefully examined. If the nystagmus is found to be vertical or rotational, the child should be taken to a neurological consultation to exclude various intracranial diseases (including occupational diseases) affecting the visual function, appearance, and mobility of the patient. Director Yu Gang reminds parents that the pathogenesis of nystagmus is very complex and is still inconclusive and in the research stage. 3. Why is proprioceptive resection surgery able to treat nystagmus? Currently, one of the main surgical procedures for nystagmus is proprioceptive resection, so what is a proprioceptive? Why can the removal of proprioceptors improve nystagmus? The proprioceptors are receptors located in muscles, tendons and joints that sense changes in body movement and position in space and provide information to the center. When the eye moves, the mechanical stretching of the muscle and tendon becomes a suitable stimulus for the proprioceptors and transmits the degree of stretching to the center. It may be due to the instability of the peripheral part of these feedback loops. Through current international basic and clinical research, it has been found that removal of the proprioceptors can improve the frequency and amplitude of nystagmus to a certain extent without causing any serious complications in children, and has become a mainstream surgical procedure for the treatment of nystagmus. Dr. Qian Wu, chief physician, introduced: i. After proprioceptor removal, some patients are able to improve the frequency of nystagmus, and some patients have unsatisfactory results. ii. There is no major damage to the child from the proprioceptor removal surgery, and parents should be prepared before the surgery. 4. Why are albino children afraid of light Usually we see that many children with albinism are afraid of sunlight, why is this? In this regard, foreign nystagmus experts study a lot of albino fundus is a group of monogenic recessive genetic disorders related to melanin biosynthesis, manifested as a lack of eye, skin and hair melanin. In addition to ocular pigment deficiency and associated ocular symptoms, patients with oculocutaneous albinism have significant pigment deficiency in both skin and hair, such as fair skin and white, blond or brown hair. The lack of melanin can cause a range of abnormal ocular manifestations. Children with albinism have pale or absent iris and retina color, and appear to have significant photophobia, translucent iris, insufficient fundus coloration, nystagmus, high refractive error, low vision, poor stereo vision, and other clinical manifestations. The iris of albinism patients is usually blue or gray, and some children with lack of iris pigment have a purple iris when exposed to direct light. The translucency of the iris not only scatters the light entering the eye, making it difficult for the patient to focus, but also allows a large amount of light to enter the eye, causing the patient to be particularly sensitive to light, known as “photophobia. Yu Gang, director of the Department of Refractive Surgery, explained that the iris has less pigment, just like a blackout curtain, and more light from the outside enters the eye, thus causing photophobia. For these children, we can fit them with contact lenses that are transparent in the middle and opaque around the periphery, which are like the “pupil” glasses that some of our young girls wear today. Two. There is also a foreign color-changing glasses like swimming goggles, for albino children to wear, you need to test the vision in advance, according to the ability to bear the vision, choose a different color difference color-changing glasses. 5.How many kinds of surgeries are available for children with nystagmus? After many years of practical experience, we have also compiled and referred to the types of surgery performed by several famous foreign nystagmus specialists, and summarized a total of 9 types of nystagmus surgery, which are proposed for discussion by fellow ophthalmologists and for the parents’ reference: 1, surgery for nystagmus without compensatory head position 2|, surgery for nystagmus with head-up visualization head position 3, surgery for head position with low visualization head position 4, surgery for horizontal head position Surgical treatment 5.Surgical treatment with rotational head position 6.Surgical treatment of nystagmus with combined strabismus 7.Surgical treatment of nystagmus with combined head position and strabismus 8.Surgical treatment of nystagmus with pooling block 9.Surgical treatment of nystagmus with compound head position Experts remind that the surgical selection of nystagmus should be designed according to the type of nystagmus of the child, and each child with nystagmus needs individualized surgery. 6. Can the amplitude of nystagmus change after nystagmus surgery? According to a recent study by dell’osso and Professor Hertle, a leading nystagmus specialist in the United States, nystagmus surgery was performed on an animal model of nystagmus and encouraging results were achieved. Then they performed surgery on patients with nystagmus and found very good results, and the article was published in a journal. Each patient has a different type and degree of nystagmus and different combined other diseases, so the treatment of nystagmus is diverse and individualized, and the treatment plan is designed according to each patient’s own situation. The results are still very good! A comparison of the nystagmograms before and after surgery shows that the amplitude of the nystagmus is reduced and its frequency is slowed down! The child’s visual quality has improved to varying degrees! 7. Can nystagmus surgery improve vision? What is the purpose of the surgery? Some parents who consult their ophthalmologist about the effectiveness of nystagmus surgery in improving vision often get an inaccurate answer and are therefore confused as to why surgery is necessary if nystagmus surgery does not improve vision significantly. Nystagmus specialists in the United States have been studying nystagmus surgery for decades, and from the national and international literature, it appears that patients who are better off after surgery generally have 1 to 3 lines of vision improvement after surgery than before surgery! Because there are various underlying eye diseases in children with nystagmus, the degree of vision of patients before surgery is different, and therefore the degree of improvement in vision after surgery is also different. The goal of nystagmus surgery is not to simply improve vision, but to have a child with a better quality of vision than before surgery. From a professional point of view, the human eye sees with the most precise structure, the macula. This is also known as the “time window of gaze”. Director Yu Gang said: Our surgery has two purposes: First. The first is to weaken the proprioceptors of the child’s muscles, hoping to reduce the nystagmus through this action. Second, on the other hand, we widened the “gaze time window”, which simply means that we increased the gaze time of the central macular sulcus, and although the vision of some children after the surgery did not improve significantly, the quality of the child’s gaze improved. Before the surgery, the child was not interested in distant things, but after the surgery, the child became interested in distant things. 2. 4.The children used to read books almost in front of their eyes, but after the surgery, they can read books at a far distance. 5.Some children’s heads were very tilted when they looked at an object carefully, but after the surgery, their heads were not very tilted anymore. These are the effects of nystagmus surgery, so we suggest that there are four important aspects to evaluate the effect of surgery on children: 1) whether the head tilt has improved 2) whether they can read books farther 3) whether they can watch TV farther 4) whether their personality is more lively These are the effects of nystagmus surgery, so for some children after surgery, parents should not only focus on the changes in the vision chart, but these changes are the surprises brought to the child after surgery. These changes are all surprises to the child after surgery. 8. What is the minimum age for nystagmus surgery? Many parents ask us how old is the right age to have surgery for their child. According to Prof. Hertle, there is no strict age limit for surgery, but a comprehensive assessment of the child is needed to weigh the pros and cons of surgery. Dr. Wu Qian believes that surgery at around two years of age is more appropriate! The reasons for this are the following: 1. If it is too early, the child’s ability to cooperate with the examination is insufficient, and the examination of the head position cannot be fully cooperated with 2. Surgery cannot be performed too late, because the child’s visual development still has a very strict time limit, and beyond the sensitive period of visual development, the child’s brain development as well as the development of the visual center may then stop. 3, nystagmus children’s vision is not too good, after the surgery, not all things are over, later there is a corresponding training of amblyopia, and the corresponding training of brain cognitive ability! Therefore, having surgery too late can be detrimental to the child’s future visual development. The following is a summary of the literature we have cited from foreign experts on early surgery for nystagmus patients, which is consistent with our treatment philosophy! 9. Can all nystagmus be treated surgically? As modern research progresses and new theories of nystagmus are proposed, some scholars believe that congenital nystagmus is a result of the slow-motion control subbranch system of the eye ( This particular abnormality may be manifested by the feedback of signals about eye position and movement speed from the proprioceptors of the extraocular muscles, and the result of the feedback instability causes the eye position to be unstable and the eye to deviate from its proper position, which constitutes the slow phase of the nystagmus, and the fast sweeping motion The fast sweeping motion interrupts this slow phase and returns to the gaze position, which constitutes the fast phase of the tremor. Other scholars believe that the defect in the subcortical optokinetic system causes the eye to deviate from the gaze position due to the instability of the gaze, and that correcting the eye movement will bring the eye back to the gaze position. Recent studies by Dell’ et al, a leading American professor of nystagmus, have shown that patients with congenital nystagmus have a strong fixation reflex, normal smoothpursultmotion, and good vestibular glance reflex function. They concluded that although the exact function of the incoming impulses to the proprioceptors of the extraocular muscles is currently unknown, it has an effect on both eye position and velocity of movement in the feedback loop, and therefore, congenital nystagmus may be due to instability of the peripheral portion of these feedback loops. With the in-depth study of the theory for patients who were not considered for surgery before, surgical treatment can be performed, expanding the scope of surgery to patients who previously did not have a treatment method, and improving the visual function of patients. Currently, foreign nystagmus experts believe that proprioceptive resection has a better surgical effect on nystagmus without an intermediate band, and most children with nystagmus are able to reduce their nystagmus after surgery. Dr. Wu Qian believes that most nystagmus can be treated surgically, and there are four main goals of surgery: first, to reduce the intensity of nystagmus, second, to improve head position, third, to treat the combined strabismus, and fourth: to improve the quality of vision to some extent. 10. Which nystagmus is not suitable for eye surgery? Not all patients with nystagmus need surgery. The following nystagmus cannot be treated surgically: 1) otogenic nystagmus, 2) central nystagmus, 3) special types of nystagmus, 4) seesaw nystagmus, 5) upward jumping nystagmus, these special types of nystagmus are not suitable for ophthalmic nystagmus surgery. It is necessary to go to a specialized hospital for examination and evaluation to determine whether surgery is indicated. President Zhang Feng reminds parents that nystagmus is a very complex eye disease and should be carefully examined by a doctor specializing in nystagmus and strabismus to rule out any specific types of nystagmus and to personalize treatment. 11.Non-surgical treatment of nystagmus Nystagmus currently has some other treatment methods besides eye muscle surgery 1.Optical treatment of nystagmus, the first thing you need to do is to give your baby a dilated eye exam to correct the refractive error, as nystagmus babies are often combined with severe refractive error, many babies’ vision improves significantly after wearing the right corrective glasses. 2, can be given to the younger children with nystagmus trial wearing corneal contact lenses, corneal contact lenses have three advantages: first, can provide refractive correction, second, can reduce the intensity of nystagmus to some extent, third, with the iris of the corneal contact lenses can improve the phenomenon of photophobia in children with albinism. On the other hand, for children with pooling block, wearing a bilaterally oriented trigeminal lens can stimulate convergence and reduce nystagmus. In addition, recent studies have shown that eye drops with carbonic anhydrase inhibitors can also inhibit nystagmus. With the advancement of technology, it is believed that more and more treatments will be available to bring good news to nystagmus babies. 12. Can nystagmus be treated surgically? Some parents ask: I have been to many hospitals before and they all say that nystagmus cannot be treated surgically. There is no good treatment method, which is a worldwide treatment problem, and can only be observed on a follow-up basis. In the previous treatments, some ophthalmologists performed some surgical treatments. From the summary of the literature, because of the preliminary work, there is no theoretical support, fewer hospitals in China are engaged in nystagmus surgery, mainly because the improvement of vision after nystagmus surgery is not very obvious, as well as people’s limited understanding of nystagmus, leading to the helplessness of many ophthalmologists in China for such patients. With the successful development of many new nystagmus instruments, new research findings, new theories, and encouraging experimental results in animal experiments, domestic and foreign experts have carried out a variety of new surgical methods, which have been practiced in nearly 1,000 cases. The parents of the children are still satisfied with the clinical results achieved after the surgery! 13.What are the causes of nystagmus? In general, the main causes of congenital nystagmus include congenital malformation of the eye, albinism, cataract, total color blindness, macular damage, etc. The nystagmus is called oculogenic nystagmus because it has no ability to fixate on the target and the eye is mostly horizontal. In contrast, acquired nystagmus is mainly caused by central nervous system or vestibular lesions, such as cerebellar diseases and vestibular nucleus lesions, which are called central nystagmus. In the case of middle ear or inner ear diseases, horizontal or rotational nystagmus can occur due to irritative or inhibitory disorders of the vagus, which is called vagal nystagmus. Although it does not affect the life expectancy of the child, it has a serious impact on the visual quality of the child, because a large part of the information in daily life is obtained from the eyes. The low quality of vision inevitably affects the quality of life of the affected children, and a conservative estimate of the number of such patients worldwide is about 22 million, which brings great obstacles to the life, study and employment of such patients and increases the burden on society and families. Due to the previous knowledge of these diseases and the lack of effective theory, basic research, there is no better treatment strategy. The Nystagmus Research and Treatment Group of Beijing Children’s Hospital has been working on this project in light of the recent progress in foreign research, and has had many consultations with foreign experts! We hope that children with nystagmus in China will be treated as soon as possible. Our aim in conducting nystagmus is not simply to improve visual acuity, but to improve vision and quality of life. President Zhang Feng reminds us that since there are more and more methods of nystagmus, early visual treatment for children with nystagmus is very crucial. Many children’s visual acuity has improved by 1 or 5 lines or more. 15.Is there no need for treatment after nystagmus surgery? Is nystagmus surgery a one-time solution? Is there no need for other treatments after surgery? Our answer is no: nystagmus is an extremely persistent visual impairment that requires long-term treatment. The purpose of surgery is to reduce the amplitude and frequency of nystagmus, to form a stable central concave gaze, to increase the gaze time, to form a smooth visual conduction pathway, or to improve the head position, to play a positive role in the development of the child’s face and spine, to improve the quality of life, some children are younger, after surgery, the visual function is still in the developmental stage, we need to carry out visual function rehabilitation training to improve vision. At the same time, nystagmus surgery has about 20% chance of secondary surgery. If residual head position, overcorrected head position, strabismus regression, etc. are found after surgery, they need secondary surgery to solve the problem. 16.Is nystagmus only a problem of the eye? The Nystagmus Specialist Research and Treatment Group believes that various parts of the visual pathway that affect nystagmus can cause nystagmus, including otogenic nystagmus, as well as nystagmus caused by the central brain. Especially if nystagmus occurs later in life, there is a high suspicion of a combination of other systemic disorders, so nystagmus is not just a problem of the eyes! With such diseases should be treated as early as possible! Seek medical attention to avoid delays! 17.Is nystagmus hereditary? Some parents of children ask: I am a patient with congenital nystagmus and would like to ask: If I have a child, what are the chances that the child will get this disease? The Nystagmus Research and Treatment Group believes that congenital nystagmus is a genetically predisposed disorder and that the mode of inheritance includes X-linked, autosomal dominant, and autosomal recessive inheritance. In addition certain eye diseases or X-linked genetic disorders can also manifest as congenital nystagmus, such as albinism, color blindness, etc. Patients with sporadic cases can be the result of a mutation in a gene that can be inherited in an autosomal dominant manner to their offspring. Patients are advised to undergo genetic counseling before having children to minimize the recurrence of nystagmus in the next generation. The problem of nystagmus inheritance is very complex and no clear evidence can be presented to prove the chance of inheritance. 18. Principles of trigeminal treatment for congenital nystagmus: Trigeminal treatment for congenital nystagmus varies from person to person and for different types of nystagmus. Presence of pooling block: If the patient has congenital nystagmus with pooling block nystagmus, significant improvement in distance visual acuity will be achieved through the use of a bottom-out trigeminal prism. If the patient has an improvement in vision, the prism and negative spherical lens prescription should be added to the glasses prescription.