Jampolsky A
Smith-Kettlewell Eye Research Institute, San Francisco.
Trans Am Ophthalmol Soc. 1994;92:349-73; discussion 373-6.
A series of clinical questions and stated hypotheses suggested in the pre-1960s regarding the differences between stimuli of occlusion and diffusion are presented (Part I) and are answered and confirmed by a series of experiments and data in animals and humans. A diffusion stimulus is extremely destructive to development of the acuity system in an eye per se (as well as producing myopia), and a unilateral diffusion stimulus is also destructive to development of the binocular system. Real occlusion is a no-stimulus condition that can be used to preserve normal acuity and binocular development, and as a delay tactic to successfully counteract the detrimental effect of diffusion. Binocular input differences (especially if one is a diffusion stimulus) are a major cause of strabismus in both the immature and mature binocular systems. The hypothesis was proposed that preoperative full-time alternate occlusion in infantile esotropia enhanced the binocularity outcome (for which supportive experimental data in animals and humans from our laboratories are discussed in Part III). Animal experiments during the 1960s and 1970s are reviewed relative to the confusion and conflict generated (Part II), since many of these experiments were based on the false assumptions that the unilateral eyelid closure model was a no-stimulus condition (because of the small amount of light transmitted). In fact, it was a worst-case severe stimulus with both monocular and binocular detrimental consequences. And the unilateral eyelid closure model usually produced either undetected or ignored strabismus in the animal experiments, with such strabismus severely compounding the detrimental effects of the eyelid closure model. Further confusion was added by the amblyopia therapeutic model in animals of "reverse eyelid occlusion" (which was really reverse diffusion) and which the author maintains was a gross distortion of the clinician's real occlusive patch over the better eye in the therapy of amblyopia of the poorer eye. These confusions and conflicts were at variance with long-standing clinical percepts. Part III provides data from the series of animal and human experiments from our laboratories at Smith-Kettlewell Eye Research Institute, which clarify the confusion and conflicts of some of the animal experiments described. Our data support the original hypotheses (Part I) enabling the clinician to use occlusion measures in selected patients to expand the therapeutic timing options and to improve visual outcomes. Binocular system outcomes are shown to be improved by our recent data in animal and human experiments, thus supporting the beneficial sensory effects of preoperative full-time alternate occlusion regimes in infantile esotropia.
本文（第一部分）呈现了20世纪60年代以前提出的一系列关于遮盖刺激与弥散刺激差异的临床问题及既定假设，并通过一系列动物和人体实验及数据进行解答和证实。弥散刺激本身对眼睛敏锐度系统的发育具有极大破坏性（同时还会导致近视），单侧弥散刺激对双眼系统的发育也具有破坏性。真正的遮盖是一种无刺激状态，可用于保持正常的敏锐度和双眼发育，并作为一种延缓策略，成功抵消弥散的有害影响。双眼输入差异（尤其是如果其中一个是弥散刺激）是未成熟和成熟双眼系统中斜视的主要原因。有人提出假说，即婴儿型内斜视术前进行全时交替遮盖可提高双眼视效果（第三部分将讨论我们实验室在动物和人体中获得的支持性实验数据）。回顾了20世纪60年代和70年代的动物实验中所产生的混淆和冲突（第二部分），因为这些实验中的许多都基于错误的假设，即单侧眼睑闭合模型是一种无刺激状态（因为透过的光线量很少）。实际上，它是一种最坏情况的严重刺激，对单眼和双眼都有有害影响。而且在动物实验中，单侧眼睑闭合模型通常会产生未被发现或被忽视的斜视，这种斜视会严重加剧眼睑闭合模型的有害影响。动物弱视治疗模型中的“反向眼睑遮盖”（实际上是反向弥散）进一步加剧了混淆，作者认为这是临床医生在治疗较差眼睛的弱视时，在较好眼睛上真正使用遮盖眼罩的严重扭曲。这些混淆和冲突与长期以来的临床认知不一致。第三部分提供了史密斯-凯特尔韦尔眼科研究所我们实验室的一系列动物和人体实验数据，这些数据澄清了所描述的一些动物实验中的混淆和冲突。我们的数据支持了最初的假设（第一部分），使临床医生能够在选定的患者中使用遮盖措施，以扩大治疗时机选择并改善视觉效果。我们最近在动物和人体实验中的数据表明双眼系统的结果得到了改善，从而支持了婴儿型内斜视术前全时交替遮盖方案的有益感觉效应。
