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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…