Strabismus and Eye Muscle Surgery G. Vike Vicente M.D. Eye Doctors of Washington G.Vicente,MD

Strabismus Strabismus and Eye Muscle Surgeryand Eye Muscle Surgery

G. Vike Vicente M.D.Eye Doctors of Washington

G.Vicente,MD

• Dr. Vicente Strabismus review outline:• Horizontal strabismus

– Anatomy review– Nomenclature review– Accommodative esotropia

• Pediatric Bifocals?– Infantile esotropia– Viral & Diabetic esotropia– Sensory strabismus– Pseudostrabismus – Duane’s syndrome– Exotropia– Convergence insufficiency– Phorias– Tropias– Eye Muscle Surgery

• Recession• Resection

• Vertical Strabismus– Parks’ Three step test– Superior Oblique Palsy– Brown Syndrome– Inferior Oblique Overaction– DVD- Dissociated Vertical Deviation– Blow out Fracture

SkinConjunctivaTenon’s layer

Eye MusclesLeft eye

G.Vicente,MD

Eye MusclesLeft eye

Superior Oblique/Trochlear Muscle

Superior Rectus Muscle

Lateral Rectus Muscle

Inferior Rectus Muscle

Inferior Oblique Muscle

Medial Rectus Muscle

G.Vicente,MD

NomenclatureNomenclature

• Orthorphoria o• Esophoria E• Esotropia ET• Intermittent Esotropia E(T)

• Exophoria X• Exotropia XT• Intermittent Exotropia X(T)• At near X(T)’

• Right Hypertropia RHT

convergent

divergent

G.Vicente,MD

Right Hypertropia

G.Vicente,MD

Strabismus Why is it Strabismus Why is it Important?Important?• Preserving Stereo acuity 8 yo with Preserving Stereo acuity 8 yo with

worsening X(T) Intermittent Exotropia.worsening X(T) Intermittent Exotropia.

• Enlarging Visual field Enlarging Visual field – for Pts with ET. for Pts with ET.

• AppearanceAppearance– Would you hire me? Would you hire me? – Would you date me?Would you date me?– Is there something wrong with you?...Is there something wrong with you?...

• DiplopiaDiplopia

G.Vicente,MD

Strabismus Why operate?Strabismus Why operate?

DiplopiaCan be a very debilitating symptom affecting lifestyle and quality of life.

G.Vicente,MD

Accommodative esotropiaAccommodative esotropia

Typically presents around age 2 years, may Typically presents around age 2 years, may present acutely.present acutely.

Always put +3.00 sph OU when you see an ET for Always put +3.00 sph OU when you see an ET for the first time. the first time.

If its improved or resolved think Accom ET!If its improved or resolved think Accom ET! Why is there ET with Accommodation?Why is there ET with Accommodation? Eyes will usually converge when accommodation Eyes will usually converge when accommodation

is attempted.is attempted. If high hyperope then must accommodate, if If high hyperope then must accommodate, if

accommodating then will converge, cross, accommodating then will converge, cross, specially at near.specially at near.

Accommodative ETAccommodative ET Use cyclogyl to measure Rx (wait 40 Use cyclogyl to measure Rx (wait 40

minutes)minutes) Recheck 4 weeks later with glasses, Recheck 4 weeks later with glasses, If still some ET present, use Atropine to If still some ET present, use Atropine to

make sure you measured the full CRxmake sure you measured the full CRx Tell parents they eyes will continue to cross Tell parents they eyes will continue to cross

every time the glasses come off.every time the glasses come off. Always give full CRx, cycloplegic refraction Always give full CRx, cycloplegic refraction

for suspected Accom ET.for suspected Accom ET. Child might not like full CRx Child might not like full CRx Use Atropine when using hyperopic glasses Use Atropine when using hyperopic glasses

for the first time, it will break the for the first time, it will break the accommodative spasm and allow the pt to accommodative spasm and allow the pt to get used to the glasses.get used to the glasses.

emmetropia

+3D

CRx = +5D hyperopia, no accommodation

+5D hyperopia (lets say the pt is able to accommodate 3D, so effectively they are only +2D hyperope)

+3D

+5D +3D+5D Rx +3D accom spasm = +8D, pt is only a +5.00 soPt ends up feeling like a -3.00D myope with your RxMy son does not like the glasses you recommended,The optician was right, they are too strong

+5D +3D

+5D +0D With Atropine, no accommodation, no convergence for distancePt happy, MD happy

Accommodative ET, AC/AAccommodative ET, AC/A

AC/A = AC/A = Accommodative convergence / accommodationAccommodative convergence / accommodation An accom ET crosses because he/she has normal AC/A.An accom ET crosses because he/she has normal AC/A. Ie of high AC/A: Ie of high AC/A:

an emmetrope, WRx = plano OU pt an emmetrope, WRx = plano OU pt At Distance they are orthoAt Distance they are ortho At near they are 25PD ETAt near they are 25PD ET’’ They are over converging for a normal amount of They are over converging for a normal amount of

accommodation.accommodation. This is a high AC/A ratio.This is a high AC/A ratio.

AC/AAC/A

Example of a pt with low AC/A? Example of a pt with low AC/A? who underconverges?who underconverges?

+8.00 hyperope who is ortho at near +8.00 hyperope who is ortho at near and distance. and distance.

They have adapted to their They have adapted to their hyperopia by under converging.hyperopia by under converging.

Infantile EsotropiaInfantile EsotropiaSyndromeSyndrome

Aka congenital esotropiaAka congenital esotropia Esotropia usually present by age 6 Esotropia usually present by age 6

monthsmonths Not improved with hyperopic RxNot improved with hyperopic Rx Most pts will never have good Most pts will never have good

stereostereo Associated with inferior oblique Associated with inferior oblique

over actionover action And DVD, dissociated vertical And DVD, dissociated vertical

deviation.deviation. The 2 latter conditions may not be The 2 latter conditions may not be

present initially must remember to present initially must remember to warn parents that if they occur in warn parents that if they occur in the future it is not the surgeonthe future it is not the surgeon’’s s fault.fault.

Infantile esotropia Infantile esotropia continuedcontinued

Must rule out other causesMust rule out other causes CN 6 palsy from birth? Often CN 6 palsy from birth? Often

spontaneous resolutionspontaneous resolution Remember some variable, Remember some variable,

intermittent strabismus is expected intermittent strabismus is expected until 4 months of age.until 4 months of age.

Esotropia associated with Viral Esotropia associated with Viral illnessillness

Often self limited, will spontaneously Often self limited, will spontaneously resolve in 3-6 months.resolve in 3-6 months.

AcuteAcute Not improved with hyperopic glasses.Not improved with hyperopic glasses. Consider ruling out neoplastic causes.Consider ruling out neoplastic causes. Treat/prevent amblyopia in the mean Treat/prevent amblyopia in the mean

timetime

Esotropia associated with Esotropia associated with DiabetesDiabetes

Abducens, lateral, CN 6 usually Abducens, lateral, CN 6 usually affected.affected.

Isolated unilateral palsyIsolated unilateral palsy IschemicIschemic Usually resolves after 4-6 months.Usually resolves after 4-6 months. Consider Botox in the meantime, to Consider Botox in the meantime, to

which muscle…which muscle…The medial rectus

Botox injection to Medial RectusFor temporary lateral rectus ischemic palsy

Sensory strabismus - PedsSensory strabismus - Peds

Young pts with poor monocular vision Young pts with poor monocular vision will often develop esotropia in that eye.will often develop esotropia in that eye.

OKAP NOTE::::::::OKAP NOTE:::::::: DOES YOUR PEDS PT HAVE ESOTROPIA DOES YOUR PEDS PT HAVE ESOTROPIA

BECAUSE THEY CAN NOT SEE OUT OF BECAUSE THEY CAN NOT SEE OUT OF THAT EYE?THAT EYE?

WHY? CATARARCT, RETINOBLASTOMA, WHY? CATARARCT, RETINOBLASTOMA, MACULAR SCAR, ANISOMETROPIA?MACULAR SCAR, ANISOMETROPIA?

Sensory strabismus- adultsSensory strabismus- adults Adult with poor Adult with poor

monocular vision will monocular vision will often develop exotropia.often develop exotropia. Think dense cataract X 5 Think dense cataract X 5

yearsyears Warn pt about possible Warn pt about possible

post op diplopia and need post op diplopia and need for strabismus surgeryfor strabismus surgery

Pt may have lost the Pt may have lost the ability to fuse.ability to fuse.

Think monovision, or Think monovision, or unilateral under correction unilateral under correction Lasik pt who had Lasik pt who had undiagnosed intermittent undiagnosed intermittent exotropia.exotropia.

Pseudo ET

Orthophoria

Esotropia

G.Vicente,MD

Initially the baby has a “button nose, with a very flat nasal bridge.The baby lids cover the medial white part of the eyes causing the appearance of the eyes being crossed.As the nasal bridge develops and grows forward it will drag the medial portion of the lids inward reducing the appearance of the eyes being crossed.

1

Pseudo ET

G.Vicente,MD

Initially the baby has a “button nose, with a very flat nasal bridge.The baby lids cover the medial white part of the eyes causing the appearance of the eyes being crossed.As the nasal bridge develops and grows forward it will drag the medial portion of the lids inward reducing the appearance of the eyes being crossed.

2

Pseudo ET

G.Vicente,MD

Initially the baby has a “button nose, with a very flat nasal bridge.The baby lids cover the medial white part of the eyes causing the appearance of the eyes being crossed.As the nasal bridge develops and grows forward it will drag the medial portion of the lids inward reducing the appearance of the eyes being crossed.

3

Pseudo ET

G.Vicente,MD

Initially the baby has a “button nose, with a very flat nasal bridge.The baby lids cover the medial white part of the eyes causing the appearance of the eyes being crossed.As the nasal bridge develops and grows forward it will drag the medial portion of the lids inward reducing the appearance of the eyes being crossed.

4

Pseudo ET

G.Vicente,MD

ExotropiaExotropia

Intermittent is very commonIntermittent is very common How symptomatic are they?How symptomatic are they? Make sure they have BCVA glassesMake sure they have BCVA glasses Diplopia? Diplopia? Often familial, so what? Dad had it too. Often familial, so what? Dad had it too. ““What hump?What hump?”” Intermittent exotropia can breakdown over time, Intermittent exotropia can breakdown over time,

check serial stereo. If worsening think surgery. check serial stereo. If worsening think surgery. Most common time of pediatric surgery is 7 Most common time of pediatric surgery is 7

years old.years old. Can the pt converge?Can the pt converge?

Convergence insufficiencyConvergence insufficiency

Seen in kids who have trouble readingSeen in kids who have trouble reading Adults with ParkinsonAdults with Parkinson’’s diseases disease Consider Consider

Convergence exercises by a pediatric Convergence exercises by a pediatric optometrist, or at home exercises with special optometrist, or at home exercises with special softwaresoftware

Decreasing add in bifocals to extend reading Decreasing add in bifocals to extend reading distance (holding reading material further distance (holding reading material further away) away)

Prisms, may used at times.Prisms, may used at times.

NomenclatureNomenclature

• Orthorphoria o• Esophoria E• Esotropia ET• Intermittent Esotropia E(T)

• Exophoria X• Exotropia XT• Intermittent Exotropia X(T)• At near X(T)’

• Right Hypertropia RHT

convergent

divergent

G.Vicente,MD

Cover – Uncover test

Orthophoria, normal

No complaints, asymptomatic

G.Vicente,MDG.Vicente,MD

Cover – Uncover test

Esophoria, abnormal, common

Only seen when eye is covered

Often asymptomatic, no complaints

Note OS does not move.

G.Vicente,MD

Cover – Uncover test

Exophoria, abnormal, common

Only seen when eye is covered

Note OS does not move

Often asymptomatic, no complaints.

G.Vicente,MD

Alternate cover test

• Remember to allow the pt time to fixate on the target, give them a minute.

• Then quickly cover the other eye to prevent the pt from regaining fusion.

• But do not go back and forth quickly because the pt will not have time to refixate.

Alternate Cover test

Exotropia, intermittent

May be visible with or without alternate cover

May have intermittent diplopia, especially when tired or sick

Mom sees misalignment every now and then.

G.Vicente,MD

Alternate Cover test

Exotropia, Constant

May be visible with or without alternate cover

May or may not have constant diplopia

G.Vicente,MD

Cover Uncover test

Left Exotropia, Constant

May be visible with or without alternate cover

Right eye preference

G.Vicente,MD

Cover Uncover test

Left Exotropia, Constant

May be visible with or without alternate cover

Right eye preference

Note: no eye movement, so be sure to check both sides G.Vicente,MD

Normal Convergence

Convergence Insufficiency

G.Vicente,MD

Constant StrabismusConstant StrabismusWorkup, acute presentation, nerve palsy– (Case of newly acquired left CN 6 in a 55 yo male)– Ischemic, GCA– Neoplastic

• Invasive• Paraneoplastic • Compressive• Nerve regeneration

– Longstanding breakdown.– Sensory– Degenerative CNS, Parkinson’s, MS– Infectious

• Myositis (trichinosis)– Iatrogenic

• Post non-strabismus surgery• Cataract, retrobulbar blocks (nerve damage vs. contracture)• Glaucoma, valves• Lasik

– Mechanical• Trauma• Blow out Fracture• Tumor

G.Vicente,MD

More Types of StrabismusMore Types of Strabismus

– Convergent, Esotropia• Accommodative• Congenital or infantile • Acquired, CN 6 palsies

– Divergent, Exotropia– Vertical, Torsional and Oblique

• Parks 3 Step test• Superior Oblique Palsies

– Tucks vs. IO recessions• Inferior Oblique Over action (V patterns)• DVD’s Dissociated Vertical Deviation

– Complex Cases• Adjustable vs Fixed sutures.• Re-ops

– Different measurements based on eye fixation • Optics• Angle Kappa

G.Vicente,MD

Alternate Cover test with Prism

Exotropia, Constant

Use prism to quantitate the deviation.

Change prism power until movement is neutralized.

Use this number to plan surgery

20

How much to operate…

G.Vicente,MD

Exotropia

• Remember to measure while fixating at a far distance.

• Also use +3.00 sph in front of each eye to eliminate the accommodative convergence component at distance.

• Consider 30 minute patch test to break fusion and really see how bad the XT can get.

How much to operate?

– How much to operate

• Tables:

• Personal experience

• Dosages (surgical) • bilat , 2 muscles• ie for ET 40PD recess 5.5mm both MR• ET XT • PD Rec Rst Rec Resect • 15 3 3 4 2.5 • 20 3.5 4 5 3• 25 4 5 6 4 • 30 4.5 6 7 5 • 35 5 7 7.5 5.5 • 40 5.5 7.5 8 6 • 50 6 8 9* 7 • 60 6.5 8.5 10* 8

Where to operate?Where to operate?Option A: recess, loosen bilateral MR Medial Recti.

Option B: recess Left MR and resect, tighten Left Lateral Rectus LLR

RMedial RectusLMedial Rectus

L Lateral Rectus

G.Vicente,MD

Large ET (65PD) , bilateral MR Large ET (65PD) , bilateral MR recession, and LLR resectionrecession, and LLR resection

preop

1 month post op

3 d post op

G.Vicente,MD

How much to operateHow much to operate-Patient preference-Patient preference

Case of monocular 85 yo Case of monocular 85 yo BF with sensory XTBF with sensory XT

one eye or two?one eye or two? Pt wished to Pt wished to notnot have OD have OD

operated, understood risk operated, understood risk of under correction.of under correction.

Therefore only recessed Therefore only recessed LMR 7mm and LLR 6mm.LMR 7mm and LLR 6mm.

Pt had some residual XT Pt had some residual XT 15-20 PD, but was happy, 15-20 PD, but was happy, therefore surgeon was therefore surgeon was happy too.happy too.

G.Vicente,MD

Surgical NotesSurgical Notes Sutures: Sutures:

– Most stitches used in eye surgery are thinner than human Most stitches used in eye surgery are thinner than human hairs.hairs.

– They will dissolve on their own over 6 weeks. They may make They will dissolve on their own over 6 weeks. They may make your eye feel scratchy for the first few weeks. your eye feel scratchy for the first few weeks.

– The antibiotic ointment and a cool compresses will alleviate The antibiotic ointment and a cool compresses will alleviate this symptom if it occurs. this symptom if it occurs.

– Adjustable suturesAdjustable sutures What to expect after surgeryWhat to expect after surgery

– Some double vision is normal for the first few weeks after eye Some double vision is normal for the first few weeks after eye muscle surgery.muscle surgery.

Precaution:Precaution:– General post op hygieneGeneral post op hygiene– Eye rubbingEye rubbing– Can my child swim after his or her eye surgery?Can my child swim after his or her eye surgery?

Length of surgery and recoveryLength of surgery and recovery

G.Vicente,MD

Notes on AnesthesiaNotes on Anesthesia

– Notes on AnesthesiaNotes on Anesthesia GeneralGeneral Pediatric anesthesia doctorsPediatric anesthesia doctors Risk of Gen. Anesthesia in childrenRisk of Gen. Anesthesia in children

Primary MD clearancePrimary MD clearance

G.Vicente,MD

Complications and Risks or surgeryComplications and Risks or surgery

Infection (1 in 3 years, Tx oral Abx)Infection (1 in 3 years, Tx oral Abx) Nausea (Tx: Phenergan, etc.)Nausea (Tx: Phenergan, etc.) Blood loss Blood loss

– (what blood loss, maybe a little more than corneal (what blood loss, maybe a little more than corneal surgery)surgery)

Loss of sight? (globe perforation)Loss of sight? (globe perforation) Scar tissueScar tissue DiplopiaDiplopia Residual or consecutive strabismusResidual or consecutive strabismus Oculo-Cardiac Reflex – BradycardiaOculo-Cardiac Reflex – Bradycardia

– Tx: AtropineTx: Atropine

G.Vicente,MD

When to operate? Or …When NOT to When to operate? Or …When NOT to operate?operate?

• PrismsPrisms– FresnelsFresnels– Permanent prismsPermanent prisms

• Occlusion (non-operable, CNS disease)Occlusion (non-operable, CNS disease)

• BCVA (sharp image will often help pt fuse)BCVA (sharp image will often help pt fuse)

G.Vicente,MD

When When notnot to operate cont. to operate cont.

• Botox Botox – best for small, new, noncontractile strabismus, ie best for small, new, noncontractile strabismus, ie

ischemic CN 6 palsy.ischemic CN 6 palsy.– Or very variable strabismus ie cerebral palsy, to Or very variable strabismus ie cerebral palsy, to

prevent contracture and save time.prevent contracture and save time.

• Exercises, best for convergence insufficiency X(T)Exercises, best for convergence insufficiency X(T)’’..• Small Magnitude (<8 PD)Small Magnitude (<8 PD)• Tolerability, symptomsTolerability, symptoms

– head position, career, lifestylehead position, career, lifestyle

• Surgeon aggressiveness, cut, cut, cutSurgeon aggressiveness, cut, cut, cut• Pre-existing Amblyopia Pre-existing Amblyopia

– (how much to treat before surgery?)(how much to treat before surgery?)

• Angle Kappa pseudo XT…Angle Kappa pseudo XT…