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Clinical Course Lecture 2014, Philippine General Hospital, Sentro Oftalmologico Jose Rizal. Discusses universal strabismus treatment guidelines, infantile and accommodative (acquired) esotropia, infantile and intermittent exotropia, paralytic strabismus, IV nerve palsy, III nerve Palsy, VI nerve palsy, Duane syndrome, ciliary muscle spasm
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Common Motility Problems
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology & Adult Strabismus
AP Santiago, MD PGH Clinical Course 2014
www.books.google.com(now fully downloadable)
http://books.google.com.ph/books?id=6jqOihYJvCoC&printsec=frontcover&dq=clinical+strabismus+management&hl=en&sa=X&ei=X5bXU-T2H8TooATF4oKgBg&redir_esc=y#v=onepage&q=clinical%20strabismus%20management&f=false
References
www.telemedicine. org
www.cybersight.org
Helveston’s Atlas of Strabismus
Wright’s Atlas of Strabismus
Von Noorden’s Binocular Vision and Ocular Motility
AP Santiago, MD PGH Clinical Course 2014
Universal Surgical Guidelines
Perform surgery if and only if: Significant refractive error is corrected Glasses have been allowed to work Amblyopia treatment maximized/instituted Measurements stable and repeatable
AP Santiago, MD PGH Clinical Course 2014
Repeatable & Reproducible Measurements
Appropriate correction
Accommodative target above threshold
Distance
Plastic Prisms
Above threshold e.g. Snellen acuity
20/20
present 20/50
AP Santiago, MD PGH Clinical Course 2014
The Ideal Target
With sufficient detail and contour
Should sustain interest
AP Santiago, MD PGH Clinical Course 2014
Toys as Targets
One toy one look
With detail
May be coupled with a light
Sounds for tracking but not vision testing
AP Santiago, MD PGH Clinical Course 2014
Principles of Strabismus Surgery
Weaken an overacting muscle
Strengthen a weak muscle
Release a restriction
Transposition for total palsy
AP Santiago, MD PGH Clinical Course 2014
Weakening procedures
Recession
Myotomy/myectomy
Anterior transposition
Tenotomy/tenectomy
Superior oblique spacers
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Strengthening procedures
Resection
Tuck
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Transposition Procedures
Duane syndrome
VI nerve palsy
Double elevator palsy
Double depressor palsy
Third nerve palsy
AP Santiago, MD PGH Clinical Course 2014
Transposition Procedures
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Transposition Surgery
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Common Strabismus Problems
Infantile esotropia
Accommodative esotropia
Paretic esotropia
Monofixation Syndrome
Infantile exotropia
Intermittent exotropia
Paretic exotropia
Superior oblique palsy
AP Santiago, MD PGH Clinical Course 2014
Congenital EsotropiaPEDIG 2002
Early onset ET resolved in 27%
More common if ET less than 40PD, intermittent, variable
Constant deviation >40PD, hyperopia <+3.00, after 10 wks: low likelihood of resolution
Published:Pediatric Eye Disease Investigator Group. The clinical spectrum of early-onset esotropia: experience of the Congenital Esotropia Observational Study. Am J Ophthalmol 2002;133:102-8.Pediatric Eye Disease Investigator Group. Spontaneous resolution of early-onset esotropia: experience of the Congenital Esotropia Observational Study. Am J Ophthalmol 2002;133:109-18.
Infantile esotropia
Operate by age 2 y for best sensory prognosis
Do not have to wait for age 2--earlier surgery better results
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Infantile esotropia
Rate limiting factors: amblyopia Measurements stability patient cooperation distance fixation
AP Santiago, MD PGH Clinical Course 2014
Infantile ET: angle stability
PEDIG 2008, 2009
46% unstable
20% stable
34% uncertain
Pediatric Eye Disease Investigator Group. Instability of Ocular Alignment in Childhood Esotropia. Ophthalmology 2008;115(12):2266-74.Pediatric Eye Disease Investigator Group. Interobserver Reliability of the Prism and Alternate Cover Test in Children With Esotropia. Arch Ophthalmol 2009;127(1):59-65.
Acquired ET: angle stability
PEDIG 2008, 2009
Non Accom ET
22% unstable
37% stable
42% uncertain
Partially Accom ET
15% unstable
39% stable
46% uncertain
Pediatric Eye Disease Investigator Group. Instability of Ocular Alignment in Childhood Esotropia. Ophthalmology 2008;115(12):2266-74.Pediatric Eye Disease Investigator Group. Interobserver Reliability of the Prism and Alternate Cover Test in Children With Esotropia. Arch Ophthalmol 2009;127(1):59-65.
Infantile Esotropia
AP Santiago, MD PGH Clinical Course 2014
• DVD• Manifest
latent nystagmus
Video courtesy of Paderna N
DVD Surgery
With IO overaction: Weakening of IO
Without IO overaction: Weakening of IO if no SO OA Graded SR Recession
AP Santiago, MD PGH Clinical Course 2014
Inferior Oblique Surgery: Elliot & Nankin’s Anterior
Transposition
AP Santiago, MD PGH Clinical Course 2014
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Inferior Oblique Transposition
AP Santiago, MD PGH Clinical Course 2014
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Inferior Oblique Surgery: Parks Recession
AP Santiago, MD PGH Clinical Course 2013
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Inferior Oblique Surgery: Myotomy/Myectomy
Myotomy Myectomy
AP Santiago, MD PGH Clinical Course 2013
Accommodative esotropia
Full hyperopic prescription
Repeat full cycloplegic refraction
Bifocals if with distance fusion
AP Santiago, MD PGH Clinical Course 2014Fig from Rosenbaum & Santiago 1999
Accommodative esotropia
Surgery for residual esotropia > 15PD
Faden or posterior fixation
Surgery for MR contracture
Same rate limiting factors
AP Santiago, MD PGH Clinical Course 2014
Fadenoperation or Posterior Fixation
AP Santiago, MD PGH Clinical Course 2013
Fig from Rosenbaum & Santiago 1999
VI nerve palsy
Do not forget correction
Differentiate from Duane syndrome and MR contracture
Primary vs secondary deviation
AP Santiago, MD PGH Clinical Course 2014
VI Nerve Palsy: Primary vs Secondary
Deviation
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
VI nerve paresis vs restriction
Recess-resect if with residual lateral rectus function
transposition if total palsy
AP Santiago, MD PGH Clinical Course 2014
VI Nerve Palsy: post transposition
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Infantile exotropia
Poorer sensory prognosis than ET
Differentiate from visual developmental delay
Usually large exotropia 30PD
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Infantile exotropia
Patching for amblyopia and suppression
Best results for fusion if surgery done within the first few months
If reoperation required, align before age 2
Reoperations common
AP Santiago, MD PGH Clinical Course 2014
Intermittent exotropia
AP Santiago, MD PGH Clinical Course 2014
Intermittent exotropia
Distance stereoacuity deterioration
Near stereoacuity changes are late signs
Early surgery better prognosis
May become monofixator
AP Santiago, MD PGH Clinical Course 2014
Paralytic exotropia: III nerve palsy
Do not forget correction and on-axis refraction
Associated vertical and torsional problems common
Very limited field of single binocular vision
AP Santiago, MD PGH Clinical Course 2014
III nerve paresis
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
III nerve paresis
Resect partially paretic muscle
May combine with transposition for stronger effect
AP Santiago, MD PGH Clinical Course 2014
III nerve paresis: post transposition
with resection
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Paralytic Exotropia: III nerve palsy
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
III nerve palsy
Only IV and VI nerve functioning
SO transposition
VI nerve transposition?
AP Santiago, MD PGH Clinical Course 2014
Paralytic Exotropia: III nerve palsy postop
AP Santiago, MD PGH Clinical Course 2014
Fig from Rosenbaum & Santiago 1999
Superior oblique palsy
Measure in non preferred posture
If with large fusional amplitudes, may need prolonged patching
Same rate limiting factors
Usually with inferior oblique overaction
AP Santiago, MD PGH Clinical Course 2013
Superior oblique palsy
AP Santiago, MD PGH Clinical Course 2014
Parks 3-step Test (LHT)
I. Of 8 cyclovertical muscles: 4 LSO, LIR, RSR, RIO
II. Of 4 cyclovertical muscles: 2 increase on R gaze:
LSO, RSR
III. Of 2 cyclovertical muscles: 1 increase of L tilt: LSO
AP Santiago, MD PGH Clinical Course 20134
Superior oblique palsy
If with redundant superior oblique tendon, will have to perform tuck
AP Santiago, MD PGH Clinical Course 2013
Fig from Rosenbaum & Santiago 1999
Superior oblique tuck
AP Santiago, MD PGH Clinical Course 2013
Superior oblique palsy
If with spread of comitance, may do well with SR weakening in hypertropic eye
or IR weakening in hypotropic eye
AP Santiago, MD PGH Clinical Course 2013
Masked bilateral superior oblique palsy
V pattern esotropia
Reversal of hyperdeviation
Lack of prominent head tilt
Reversal on head tilts
Oblique fields should be checked
AP Santiago, MD PGH Clinical Course 2014
Common Motility Problem
Ciliary Muscle Spasm
Induced myopia/astigmatism
Headache
Focusing/defocusing
Fluctuating visual acuity
Can mimic SOL
AP Santiago, MD PGH Clinical Course 2014
Thank youAP Santiago, MD PGH Clinical Course 2014
Thank you!