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Binocular Vision
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ESO DEVIATION
Prepared by:
Anis Suzanna Binti Mohamad
Optometrist
B.Sc (Hons) UKM
Different type of deviations
Convergent Squint
Divergent Squint
Vertical Squint
ESOTROPIA
Eso Deviation
Eso
Tropia Phoria
1° 2 ° Consec. i. Conv. ExcessConstant ii. Div. Weaknessi. withAccom. Elem. iii. Non-specificii. without Accom. Elem. Intermittenti.Accom.
ii. Distance - near eso
- distance esoiii. Time - cyclic/alternate day squintiv. Non-specific
Fully Accom. Esotropia
Normal BSV for all distances when hypermetropia is corrected.
Manifest convergent dev. – without hypermetropic correction.
Fully Accom. Esotropia
Aetiology :Low uncorrected hypermetropia (<3DS)
- squint not develop if patient has sufficient base in fusional vergences.
Moderate degrees hypermetropia (3-5DS) – amount of NFR not enough to overcome conv. esotropia.
High degree hypermetropia (>5DS) – insuperable hypermetropia – patient remain straight or occasionally diverge.
Fully Accom. Esotropia
Investigation :Age of onset – 2-3 years old – starts to be
interested in close work.FH Refraction VA – may be reduced in deviating eye.HirschbergCT – with and without glasses.OM Convergence – with glasses – binoc. to 6cm.
Fully Accom. Esotropia
- Strength of BSV – BVA, PFR, synopthophore.- PCT – with and without glasses.
Management
-Prescribe fully hypermetropic lenses-Gls. worn full time-Occlusion – if amblyopia present-Orthoptic exercises – to strengthen BSV
Fully Accom. Esotropia
Convergence Excess Esotropia
Normal BSV at distance and esotropia on accommodation for near fixation.
Aetiology :- *High AC/A ratio (5/6 times normal
amount)- Remote near point of accom.- Onset – 3-5 years of age
Convergence Excess Esotropia
Investigation :- Fundi and Media check- Refraction- VA – likely to be equal- CT - - OM- Convergence- Assessment of strength of BSV- PCT- AC/A ratio
Convergence Excess Esotropia
Management :
-Prescribe hypermetropic correction if required
-Treat any amblyopia
-Surgery
-Other methods :
- Bifocals – combine with orthoptic exercise
- Contact lens
Near Esotropia
- also known as non-accom. conv. excess eso
- Manifest deviation at near (irrespective of accom.) and BSV at distance.
- Aetiology : excess tonic convergence
Near Esotropia
Investigation :- Fundi and Media check- Refraction- VA- CT- OM- Convergence- Assessment of BSV- PCT
Near Esotropia
Management :
- Surgery
Distance Esotropia
- Manifest convergent deviation at distance
- BSV at near
- Has to be differentiated from mild 6th nerve palsy, Accom./convergence spasm and divergence paralysis.
Distance Esotropia
Investigation :- Fundi and Media check- Refraction- VA- CT- OM- Convergence- Assessment of BSV- PCT
Distance Esotropia
Management :
- rare type of deviation
- Important to differentiate from mild 6th nerve palsy.
- Surgery done generally : Bilateral LR resection.
Primary Cyclic Esotropia
Esotropia occurs at regular intervals (48hrs)Onset : 4-5 years oldEmmetropic and equal VA
Management :- deviation generally becomes more constant.- Surgery : MR recess + LR resect- Prognosis : good, even when surgery done on
straight day.
Primary Constant Esotropia
Esotropia with accom. Element
- eso increase on accom.
- eso may be reduced with any necessary
hypermetropic correction.
- also known as partial accom. esotropia.
Primary Constant Esotropia
Esotropia without accom. Element
- deviation unaffected by accom.
- significant ref. error unlikely to be
present
- Types : infantile esotropia, acquired
non-accom. esotropia, nysragmus
blockage syndrome, normo-sensorial late
onset esotropia.
Primary Constant Esotropia
Normosensorial late onset esotropia
- onset – 2-4 years of age
- NRC
- normal sensory and motor fusion
Management :
- Surgery – when dev. Stable (if indicated).
Primary Constant Esotropia
Nystagmus Blockage syndrome- use conv. to block manifest nystagmus- Nystagmus – congenital, horizontal,
manifest.- Nystagmus – increase in intensity on
abduction and blocked on adduction.- Esotropia – non-accom., variable.- Face turn towards fixing eye
Primary Constant Esotropia
- BE appears conv. Though esotropia is unilat.- DVD rare- Commonly associated with neurological disorders.- Results of strabismus – unpredictable
Management:- full correction- Treat amblyopia- Surgery
Primary Constant Esotropia
General Investigation :
Aim : - to make diagnosis
- assess whether potential for BSV present.
- gain further information to base
management upon.
Primary Constant Esotropia
- Fundi and Media check- Refraction- Case history- VA- CT- OM- Conv.- Suppression- Fixation
Primary Constant Esotropia
Management :- Order any glasses necessary- Treat amblyopia- Determine if pot. BSV present :If present :- Prismotherapy
- advocated if deviation <25PD. - Strength of prism – latent dev. on CT and demonstrable BSV.
Primary Constant Esotropia
- aim : to reduce - may be combine with surgery- Orthoptic treatment to strengthen BSV.
If absent :
- surgery – to obtain cosmetically acceptable dev.- preferably small undercorrection.
Essential Infantile Esotropia
Primary Constant Esotropia
Essential Infantile Esotropia
- onset : first 6 month of life- Esotropia of unknown origin- Stable large angle eso > 30PD- Alternating with crossed fixation- Poor prognosis of BSV
Primary Constant Esotropia
- Commonly associated with DVD, o/action oblique muscles, AHP
- Amblyopia if not alternating
Management :- Full correction- Treat amblyopia- Surgery Primary Constant Esotropia
Primary Constant Esotropia
General Investigation :
Aim : - to make diagnosis
- assess whether potential for BSV present.
- gain further information to base
management upon.
Primary Constant Esotropia
- Fundi and Media check- Refraction- Case history- VA- CT- OM- Conv.- Suppression- Fixation
Primary Constant Esotropia
Management :- Order any glasses necessary- Treat amblyopia- Determine if pot. BSV present :If present :- Prismotherapy
- advocated if deviation <25PD. - Strength of prism – latent dev. on CT and demonstrable BSV.
Primary Constant Esotropia
- aim : to reduce - may be combine with surgery- Orthoptic treatment to strengthen BSV.
If absent :
- surgery – to obtain cosmetically acceptable dev.- preferably small undercorrection.
Secondary Esotropia
Esotropia following loss/impairment of vision
Blind at birth convergent/divergent deviation
Childhood blindness convergent
Secondary Esotropia
Possible cause :- Injuries- Corneal opacities- Congenital/Traumatic unilateral cataract- Optic Atrophy- Untreated anisometropia/amblyopia- Retinal detachment
Secondary Esotropia
Aims of investigation :- Assess VA of each eye – dictates test can
be carried out- Assess whether case is functional or
cosmetic (2º dev. rarely functional)- Assess angle of deviation
Secondary Esotropia
Investigation :- Refraction- History- VA- CT- OM- Measurement of the angle- State of BV (functional/cosmetic)- Post-op diplopia testManagement : surgery
Consecutive Esotropia
Esotropia in a patient who previously had an exotropia/exophoria.
Generally occur as a result of surgery- immediate or long term.
Consecutive Esotropia
Post-Operative Consecutive Esotropia
- may be deliberate
- may be due to over-liberal surgery e.g
LR recession or MR resection.
Management depend on whether the case is
functional or cosmetic.
Consecutive Esotropia
Aim :
Functional cases :- To assess presence of diplopia- To assess angle of deviation- To assess any amblyopia present- To assess BF/pot. for BSV- To assess suppression
Consecutive Esotropia
Cosmetic case :
Ultimate aim – cosmeticaaly good angle without diplopia.
- to assess angle of deviation- to assess any diplopia present- to assess suppression
Consecutive Esotropia
Investigation :- Fundus and Media check- History – patient may return many
years after original surgery. Historyrelating previous treatment important. Read operation notes if available. Ask if patient has symptoms – diplopia.
- VA – relate to vision pre-op.
Consecutive Esotropia
- CT – assess with care. If control present at any distance-do BSV test at that distance. Note if diplopia appreciated – note the type.
- OM – restriction, scars. Note if diplopia can be joined with AHP.
- Convergence
Consecutive Esotropia
- Suppression – density and area of suppression in functional case. Cosmetic case – if angle is small and suppressing – nothing to be done. If angle large and need resurgery – assess post-op diplopia test.
- Measurement of angle – near and distance. If diplopia present – see if it can be joined with prism.
Consecutive Esotropia
- AC/A ratio – in functional case –may influence type of treatment.