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9/1/15
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Management of Esotropia For the Primary Care Eye Doc
Susan Cotter, OD, MS, FAAO
SCCO at MBKU
Financial Disclosures
¤ No commercial relationships
¤ Salary support from NIH/NEI
¤ Most photos removed for handout
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Course Objec1ves
• Examina1on 1ps • Differen1al diagnosis strategy for ET • Treatment overview – primary care perspec1ve
– What to do? In what sequence? – When to co-‐manage? – Best surgical candidates?
ET Management: What Do I Do? Fundamental Principles of Treatment
• All ET’s are not the same • Treatment is based on:
– Type of ET – Diagnos1c profile including sensory fusion status
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Diagnos1c Tips: A Primary Care Perspec1ve
Ocular Alignment / Mo1lity
• Observa1on • Random dot stereopsis • Cover tes1ng • Hirschberg/Krimsky • EOM’s
Head Tilt or Turn? Chin Tip? Cover Tes1ng -‐ Near
Near Target & Instruc1ons
Stress Clarity
Alternate Cover Tes1ng -‐ Near
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Cover Tes1ng -‐ Distance Hirschberg Test
Hirschberg Test Krimsky Test
Stereopsis Tests Random Dot vs. Lateral Disparity
RDS: No monocular cues; typically must be bifoveal
• RandotLang I/II • Random Dot E • Randot Preschool • Randot LEA • PASS
Titmus Fly
!
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Randot Stereotest Random Dot Test (LEA)
RDS Stereotests Versions: Extraocular Muscles
Versions for EOMs
Versions
Monocular Visual Acuity
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Cycloplegic Refrac1on Is Essen1al
Non-‐nego1able!
Re1noscopy with other eye occluded
Esotropia? Ocular Health Evalua1on
Other Tes1ng
• Comitancy – Cover test in different fields of gaze – Maddox rod in different fields of gaze
• Second-‐degree fusion – In-‐instrument & free space – With & without neutralizing prism (added lenses)
• Correspondence • Monocular fixa1on if amblyopic
Based on History & Diagnos1c Evalua1on………..
What Kind of ET?
Classify the Esotropia
• Pseudo • Infan1le (Congenital) • Accommoda1ve • Par1ally Accommoda1ve • Acute-‐Onset Comitant • Sensory • Abducens (VI CN) Paresis • Duane's Retrac1on Syndrome I • Microtropia/Monofixa1on Syndrome
Pseudoesotropia
• 10-‐19% later diagnosed with esotropia • Serial examina1ons & parent educa1on recommended
Anwar et al. Strabismus 2012; 20(3):124-‐26;Silbert et al. AAPOS 2012;16(2):118-‐9.
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PseudoET: Differen1al Dx
• Rule out other forms of bonafide ET • Eye alignment & random dot stereopsis tes1ng • Follow-‐up
Infan1le (Congenital) Esotropia
• Neurologically intact child with constant non-‐accommoda1ve larger-‐angle ET
• Develops by 6 months of age − Typically not present at birth, but develops at 2-‐4 months of age*
*Archer et al. Ophthalmol 1989; 96:133-‐137. *Nixon et al., Am J Ophthalmo 1985; 100:798-‐801
Infan1le ET Consistent Characteris1cs
• Onset < 6 months • Large (30-‐70∆) rela1vely stable angle • Normal CNS
Infan1le ET Variable Characteris1cs
• OIO ≥ 72% (> 1 yr) • DVD 50-‐75% (> 2-‐3 yrs) • A-‐ or V-‐parern • Latent or m-‐latent nystagmus • Amblyopia 35-‐72% • Apparently defec1ve abduc1on • Crossed fixa1on
Overac1ng Inferior Obliques Dissociated Ver1cal Devia1on (DVD)
hrp://telemedicine.orbis.org/bins/volume_page.asp?cid=1-‐916-‐923-‐1569
Spontaneous turning of 1 or both eyes upward when fa1gued, inaren1ve, or fusion disrupted by covering that eye
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A Parern Esotropia Infan1le ET Variable Characteris1cs
• OIO ≥ 72% (> 1 yr) • DVD 50-‐75% (> 2-‐3 yrs) • A-‐ or V-‐parern • Nystagmus • Amblyopia 35-‐72% • Apparently defec1ve abduc1on • Crossed fixa1on
Infan1le ET: Diagnosis
• Onset < 6 months • Large (30-‐70∆) rela1vely stable angle • Normal CNS • Rule out accommoda1ve & other forms of ET!
– Prescribe max plus (lower limit?)
Infan1le ET: Prognosis
• Poor for normal BV • Reasonable for cosme1c alignment & peripheral fusion
Infan1le ET: Management
• Suggest refer to Peds OD prior to surgical referral….
• Definite surgical candidate – Timing of surgery?
Surgery: Timing for Infan1le ET
• In general, early surgery seems to give berer chance of berer stereopsis – Typically gross stereo
• CAVEATS: – Early surgery doesn’t guarantee good stereo – Mul1ple surgeries ouen required – Advocates of <12 mos don’t advocate <6 mos – Unstable / inaccurate measures in infants
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Spontaneous Resolu1on of Early-‐Onset ET: CEOS
• Prospec1ve observa1onal study (n=170) to determine predictors of spontaneous resolu1on
• Enrolled at 4-‐20 weeks, ≥ 20∆ ET • Outcome at 30 weeks (7-‐8 mons age)
PEDIG. Am J Ophthalmol 2002:133:109-‐118
Spontaneous Resolu1on of Early-‐Onset ET: CEOS
• 25% (43/170) resolved (0-‐8∆ ET) – 4 accommoda1ve ET – Most others: <40∆ & intermirent or variable size
• Constant ET ≥40∆ present auer 10 weeks on 2 examina1ons and ≤ 3.00 D hyperopia unlikely to resolve
PEDIG. Am J Ophthalmol 2002:133:109-118
Accommoda1ve ET-‐ Characteris1cs
• Ave onset = 2-‐3 yrs (4 mo -‐ 7 yrs) • Onset intermirent • Gradual ↑ frequency & dura1on • Moderate size (≈20-‐40 ∆); varies w/ physical state / accommoda1on
• Near ET ≥ Distance ET
Accommoda1ve ET -‐ Characteris1cs
• Ini1ally no sensory adapta1ons • Sns/sx: int diplopia, asthenopia, closing eye w/ close work, none
Accommoda1ve Esotropia • Accommoda1ve – Refrac1ve (normal AC/A) – Non-‐refrac1ve (high AC/A) – Combined
• Par1ally Accommoda1ve
Accommoda1on in Young Children
• Slope of accommoda1ve demand-‐response and amount of lag mature by 6 months of age
Haynes et al., Visual Accommoda4on in Human Infants. Science, 1965;148:528-‐30.
Accommoda1ve demand
Accomm Response
0-‐1 mo 1-‐2 mos. 2-‐3 mos. 3-‐4 mos.
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Accommoda1ve Esotropia
• Prognosis typically excellent if s1ll….. – Intermirent – Short dura1on
Accommoda1ve ET: Treatment
• Surgery contraindicated • Consider full cyclo Rx (esp. if constant) • Consider add at near (if high AC/A)è
Angle AC/A Ra1o Distance = Near = IPD (cm); normal More eso at near > IPD (cm); high More exo at near < IPD (cm); low
Kurt: 3 years Georgia -‐ 2 years old
• 2nd opinion
Suspected Accommoda1ve ET
• Follow up is crucial - Cover tes1ng & RDS stereopsis tes1ng
Par1ally Accommoda1ve ET • Accommoda1ve component, but residual ET following full correc1on of ametropia
• Verify refrac1on carefully • Follow up crucial; likely to have/develop amblyopia, suppression, AC
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Par1ally Accomm ET: Prognosis
• Depends on goal: cosme1c vs. normal BV • Refer to Peds OD if residual ET
– Consider other tx: add, prism, VT, surgery
Acute-‐Onset Comitant ET
• Onset ouen sudden; can be variable/intermirent over several weeks
• Typically, larger angle • Not related to refrac1ve error • Normal AC/A • Diplopia likely, but most not report, but may close / wink an eye
Acute-‐Onset Comitant ET: E1ology
• Following aggressive occlusion • Post physical, emo1onal shock, or stress • Idiopathic • Neurological causes
Neurological Causes of Acute-‐Onset Comitant ET
• Neurological e1ologies – non localizing lesions: Cerebellar astrocytoma; cerebellar medulloblastoma; pon1ne glioma
Pseudotumor; posterior fossa pilocy1c astrocytoma; nasopharyngeal angiofibroma
• Most have neurological signs & symptoms • Rare but can have no other signs except the acute-‐onset ET
Williams A., Hoyt C. (1989). Archives of Ophthalmology. 107: 376-‐378
Liu, GT, Hertle, RW, Quinn, GE, Schaffer, DB (1997) J AAPOS. 1(3): 143-‐6
Acute-‐Onset Comitant ET
• Rule-‐out underlying neurological cause • Neurological signs / symptoms warran1ng definite referral – Headache – ONH edema – Clumsiness, ataxia, gait imbalance – Nystagmus, APD – Nausea or vomi1ng – Enlarged head size
Acute-‐Onset Comitant ET: Diagnosis
• Ocular mo1lity examina1on
• Comitancy not rule out underlying neuro disease!
• Rule-‐out longstanding ET and all other forms
– No amblyopia, suppression, AC if recent
• Other systemic or neurological symptoms?
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Prognosis & Management Acute-‐Onset Comitant ET
• Prognosis: very good for normal BV (if no CNS pathology)
• If neuro consult nega1ve and Rx’ed full plus and ET s1ll present → consult with Peds OD – Prism, VT, surgery
Sensory Esotropia
• 2° to severe VA reduc1on caused by eye abnormality – Congenital / trauma1c cataracts – Corneal opaci1es – ONH or re1nal lesions – Macular disease – Uncorrected anisometropia
Sensory ET: Characteris1cs
• VA = 20/60 -‐ LP • Amblyopia may be superimposed • Magnitude of ET varies
• Sensory ET vs. XT? Based on age of onset?
Sensory Esotropia
• 2nd most common presen1ng sign of re1noblastoma
• DFE should be performed at 1st visit for all tropias
Diagnosis of Sensory ET
• Rule out other forms of ET • Eye health evalua1on is key • Prognosis for normal BV – usually guarded, but excep1ons
• Consult with Peds-‐OD before surgeon – Although not best surgical candidates, some benefit cosme1cally
Abduc1on Deficits
• 6th nerve palsy • Duane’s Syndrome I
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Abducens (VI CN) Paresis Clinical Characteris1cs
• Noncomitant ET • Abduc1on deficit • Esotropia
– Largest in affected field of gaze – Larger with affected eye fixing – Not always tropic
• ± Horizontal face turn toward involved eye CN Palsy Trauma Congenital Neoplasm Postviral ? Other Total
VI* 3 1 2 2 4 0 12
*Holmes et al. AJO 1999;127:388-‐92 – Incident cases in children
6th Nerve Palsy
Homes et al (1999)
*
Ddx VI Nerve Paresis
• Comitancy tes1ng • Other neurological signs ?
– Papilledema – Op1c neuropathy – Hemiparesis – Hx of metasta1c CA
VI Nerve Paresis: Management
• Neuro consult • If suspect head trauma -‐ check for signs of child abuse
• Surgery -‐ postpone at least 6 months • Refer to Peds OD in mean1me
– Prisms, VT – esp. monoc abduc1on
Duane Retrac1on Syndrome: Type 1 + Abduc1on: limita1on or absence + Adduc1on: + Retrac1on of globe + Narrowing of palpebral fissure ± Upshoot or downshoot
± ET 1° gaze; Face turn toward involved eye
★
Duane Retrac1on Syndrome I
*
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Duane’s: Management
• Objec1onable head turn or ET in primary gaze? – NO → no treatment; reassurance – YES → refer Peds OD
• Prism • Vision therapy • Surgery
Management of Esotropia
Op1mum Rx
Amblyopia Tx +/or Equalize Monocular Skills
Constant ET Intermirent ET
Estab. normal peripheral sensory fusion at <D • Eliminate AC / Establish NC • Eliminate peripheral suppression
Increase peripheral fusional vergence ranges around <D
Establish S/M fusion in free space Consider lens change or prism or surgery
Improve S/M fusion in free space • Eliminate any suppression • Increase vergence ranges / facility
Dismiss and Rx maintenance HVT
Consider prism and/or added lenses if needed to obtain goals Estab. normal central S/M fusion at <D
• Eliminate central suppression • Increase vergence ranges around <D
Modified Caloroso/Rouse
Sequence
Esotropia: Sequen1al Treatment Plan
Op1mum Ini1al Prescrip1on
Improve Monocular Visual Func1on
Develop Sensory & Motor Fusion
Establish Binocular Vision in Free Space
Sequen:al Management
1
2
3
4
Primary Care
Phase 1: Establish Ini1al Op1cal Rx
• Rx op1mum lenses that: – Correct refrac1ve error – Maximally reduce size of ET (D & N)
• Distance SRx – push plus (age dependent)
• Consider plus add for near
• Consider prism IF normal sensory fusion
ET: Guidelines for Rxing Lenses • Hyperopia – Most plus to correct ametropia & decrease eso at D/N - ≤ 5-‐6 yrs full cyclo (usually works) - ≥ 7 yrs max plus without distance blur accepted
• Myopia -‐ least minus to BVA • Anisometropia -‐ full Rx • As1gma1sm -‐ full Rx • CE ET -‐ Bifocal
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ET: Guidelines for Rxing Lenses
• If ET & cannot accept full distance plus, consider: - Cut distance and give add - Cyclotherapy - Gradual change in Rx (specs or CLs)
Op1cal Rx: Consider Bifocals for ET • Plus Add at Near - Calculated AC/A ra1o - Cover tes1ng at near - +3.00D if young child
• Flat-‐top 28 typically Age
(Years) Bifocal height*
< 5 Mid-‐pupil
6-‐7 Lower pupil margin
≥ 8-‐9 Lower lid margin or PAL
Age (Yrs) PAL height*
< 7 4mm above mid pupil
≥ 8 2mm above mid pupil
*Caloroso & Rouse, Clinical Management of Strabismus 2007
Lens Correc1on: General Guidelines
• Young kiddo’s ability to adapt to new op1cal correc1on totally different from adults
• Age: BV more important than emmetropiza1on
• Consider CL's for significant aniso
-‐6.00
-‐4.00
-‐2.00
0.00
2.00
4.00
6.00
8.00
0 3 6 9 12 15 18 21 24 27 30 33 36
Age (months)
Sphe
rical Eq.
Refrac1ve Error (D)
Mu�, DO. To emmetropize or not to emmetropize? Optom Vis Sci 2007;84:97–102.
BIBS: SEQ by Age
Op1cal Rx: Consider Prism
• Only if normal sensory fusion!
• Horizontal relieving prism only if BV can be established/stabilized in free space - Smallest magnitude to achieve fusion - For 6-‐20∆ ET, leave residual vergence demand of 4-‐6∆*
*Caloroso’s residual vergence demand criterion for esodevia1ons Caloroso & Rouse, Clinical Management of Strabismus, 1997
Follow-‐up: 4-‐6 weeks Post Op1cal Rx • Evaluate sensory fusion – Stereopsis: RDS preferable ++ – 2° fusion (Worth Dot / Peds flashlight)
• Cover tes1ng • If residual ET, revaluate fusion with ∆
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Follow-‐up: 4-‐6 weeks post Op1cal Rx • Evaluate sensory fusion – Stereopsis: RDS preferable ++ – 2° fusion with Worth Dot or Peds flashlight (w/ & w/o prism if residual ET)
• Cover tes1ng • Over refrac1on & Visual Acuity – May need repeat cycloplegic refrac1on – Treat amblyopia (if applicable) (Phase 2) – If not amblyopic: correspondence & in-‐instrument sensory fusion evalua1on**
Phase 2: Improve Monocular Visual Func1on
• Treat amblyopia
• Normalize accommoda1on
Amblyopia: Refrac1ve Correc1on Guidelines
• Based on 1% cyclopentolate refrac1on
• Full anisometropia, as1gma1sm, myopia
• Hyperopia - Fully correct (primarily for ET)
OR - Under-‐correct symmetrically*
*no more than 1.50 D for most PEDIG studies
Evidence-‐Based, Step-‐Wise Management Strategy for Amblyopia
When maximum VA, taper or stop treatment & monitor for amblyopia recurrence
If persists, consider increasing patching from 2 to 6 hours daily* Follow every 4-‐8 weeks un1l no further improvement
If persists, ini1ate addi1onal treatment (2 hrs daily patching, weekend atropine, or Bangerter filter); FU every 4-‐8 wks un1l no further improvement
Spectacle correc1on; FU every 4-‐8 weeks un1l no further improvement
Moderate amblyopia due to anisometropia and/or strabismus
*Alterna1ves: changing to atropine or Bangerter filter
Op1mum Ini1al Prescrip1on
Improve Monocular Visual Func1on
Develop Sensory & Motor Fusion
Establish Binocular Vision in Free Space
Sequen:al Management
1
2
3
4
Primary Care
Phase 3
Eliminate anomalous correspondence
Eliminate peripheral suppression
Improve/stabilize peripheral sensory fusion &
increase motor fusion
Develop Normal Peripheral SMF
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How About Surgery? What are the Indica1ons?
Surgery for Esotropia
• Best surgical candidates: – Wearing maximum hyperopic correc1on – No to minimal amblyopia – Normal sensory fusion – Good motor fusion around <D
• Post-‐surgical follow-‐up
Phases 3 & 4
Strabismus Surgery Post Surgery
• Consider lenses, prism, VT if indicated
Conclusions
• All ET’s are not created equal • Prognosis depends on many things, including:
– History / age – Diagnos1c profile / type of ET – Treatment(s) to be undertaken
• Op1mal refrac1ve correc1on is essen1al • Amblyopia should be eliminated • Iden1fy a local Peds OD & Peds ophthalmologist to work with
Thank You!
