Post on 15-Dec-2014
description
Common Motility Problems
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology & Adult Strabismus
AP Santiago, MD PGH Clinical Course 2014
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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
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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
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Repeatable & Reproducible Measurements
Appropriate correction
Accommodative target above threshold
Distance
Plastic Prisms
Above threshold e.g. Snellen acuity
20/20
present 20/50
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The Ideal Target
With sufficient detail and contour
Should sustain interest
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Toys as Targets
One toy one look
With detail
May be coupled with a light
Sounds for tracking but not vision testing
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Principles of Strabismus Surgery
Weaken an overacting muscle
Strengthen a weak muscle
Release a restriction
Transposition for total palsy
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Weakening procedures
Recession
Myotomy/myectomy
Anterior transposition
Tenotomy/tenectomy
Superior oblique spacers
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Fig from Rosenbaum & Santiago 1999
Strengthening procedures
Resection
Tuck
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Fig from Rosenbaum & Santiago 1999
Transposition Procedures
Duane syndrome
VI nerve palsy
Double elevator palsy
Double depressor palsy
Third nerve palsy
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Transposition Procedures
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Fig from Rosenbaum & Santiago 1999
Transposition Surgery
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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
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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
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Fig from Rosenbaum & Santiago 1999
Infantile esotropia
Rate limiting factors: amblyopia Measurements stability patient cooperation distance fixation
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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
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• 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
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Inferior Oblique Surgery: Elliot & Nankin’s Anterior
Transposition
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Inferior Oblique Transposition
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Inferior Oblique Surgery: Parks Recession
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Inferior Oblique Surgery: Myotomy/Myectomy
Myotomy Myectomy
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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
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Fadenoperation or Posterior Fixation
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Fig from Rosenbaum & Santiago 1999
VI nerve palsy
Do not forget correction
Differentiate from Duane syndrome and MR contracture
Primary vs secondary deviation
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VI Nerve Palsy: Primary vs Secondary
Deviation
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Fig from Rosenbaum & Santiago 1999
VI nerve paresis vs restriction
Recess-resect if with residual lateral rectus function
transposition if total palsy
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VI Nerve Palsy: post transposition
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Fig from Rosenbaum & Santiago 1999
Infantile exotropia
Poorer sensory prognosis than ET
Differentiate from visual developmental delay
Usually large exotropia 30PD
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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
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Intermittent exotropia
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Intermittent exotropia
Distance stereoacuity deterioration
Near stereoacuity changes are late signs
Early surgery better prognosis
May become monofixator
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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
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III nerve paresis
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Fig from Rosenbaum & Santiago 1999
III nerve paresis
Resect partially paretic muscle
May combine with transposition for stronger effect
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III nerve paresis: post transposition
with resection
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Fig from Rosenbaum & Santiago 1999
Paralytic Exotropia: III nerve palsy
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Fig from Rosenbaum & Santiago 1999
III nerve palsy
Only IV and VI nerve functioning
SO transposition
VI nerve transposition?
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Paralytic Exotropia: III nerve palsy postop
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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
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Superior oblique palsy
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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
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Superior oblique palsy
If with redundant superior oblique tendon, will have to perform tuck
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Fig from Rosenbaum & Santiago 1999
Superior oblique tuck
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Superior oblique palsy
If with spread of comitance, may do well with SR weakening in hypertropic eye
or IR weakening in hypotropic eye
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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
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Common Motility Problem
Ciliary Muscle Spasm
Induced myopia/astigmatism
Headache
Focusing/defocusing
Fluctuating visual acuity
Can mimic SOL
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Thank youAP Santiago, MD PGH Clinical Course 2014
Thank you!