Strabismus and Eye Muscle Surgery

7/28/2019 Strabismus and Eye Muscle Surgery

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Strabismus

and 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



SkinConjunctiva

Tenon’s layer

Eye Muscles

Left 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



Nomenclature

• 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



Strabismus Why is it Important?

• Preserving Stereo acuity 8 yo withworsening X(T) Intermittent Exotropia.

•Enlarging Visual field

– for Pts with ET.

• Appearance

– Would you hire me?

– Would you date me?

– Is there something wrong with you?...

•Diplopia

G.Vicente,MD



Strabismus Why operate?

Diplopia

Can be a very debilitating symptom affecting lifestyle and

quality of life.G.Vicente,MD



Accommodative esotropia

Typically presents around age 2 years, may presentacutely.

Always put +3.00 sph OU when you see an ET for the

first time. If its improved or resolved think Accom ET!

Why is there ET with Accommodation?

Eyes will usually converge when accommodation is

attempted. If high hyperope then must accommodate, if

accommodating then will converge, cross, specially atnear.



Accommodative ET Use cyclogyl to measure Rx (wait 40 minutes) Recheck 4 weeks later with glasses, If still some ET present, use Atropine to make

sure you measured the full CRx

Tell parents they eyes will continue to crossevery time the glasses come off.

Always give full CRx, cycloplegic refraction forsuspected Accom ET.

Child might not like full CRx Use Atropine when using hyperopic glasses for

the first time, it will break the accommodativespasm and allow the pt to 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 so

Pt ends up feeling like a -3.00D myope with your Rx

My son does not like the glasses you recommended,

The optician was right, they are too strong



Accommodative ET, AC/A

AC/A =

Accommodative convergence / accommodation

An accom ET crosses because he/she has normal AC/A.

Ie of high AC/A: an emmetrope, WRx = plano OU pt

At Distance they are ortho

At near they are 25PD ET’

They are over converging for a normal amount of accommodation.

This is a high AC/A ratio.



AC/A

Example of a pt with low AC/A?

who underconverges?

+8.00 hyperope who is ortho at near anddistance.

They have adapted to their hyperopia byunder converging.



Infantile Esotropia Syndrome

Aka congenital esotropia

Esotropia usually present by age 6months

Not improved with hyperopic Rx Most pts will never have good stereo

Associated with inferior oblique overaction

And DVD, dissociated verticaldeviation.

The 2 latter conditions may not bepresent initially must remember towarn parents that if they occur in thefuture it is not the surgeon’s fault.



Infantile esotropia continued

Must rule out other causes

CN 6 palsy from birth? Often spontaneous

resolution

Remember some variable, intermittentstrabismus is expected until 4 months of

age.



Esotropia associated with Viral

illness Often self limited, will spontaneously

resolve in 3-6 months.

Acute

Not improved with hyperopic glasses.

Consider ruling out neoplastic causes.

Treat/prevent amblyopia in the mean time



Esotropia associated with Diabetes

Abducens, lateral, CN 6 usually affected.

Isolated unilateral palsy

Ischemic

Usually resolves after 4-6 months.

Consider Botox in the meantime, to whichmuscle…

The medial rectus



Botox injection to Medial Rectus

For temporary lateral rectus ischemic palsy



Add droopy lid



Sensory strabismus - Peds

Young pts with poor monocular vision willoften develop esotropia in that eye.

OKAP NOTE:::::::: DOES YOUR PEDS PT HAVE ESOTROPIA

BECAUSE THEY CAN NOT SEE OUT OFTHAT EYE?

WHY? CATARARCT, RETINOBLASTOMA,MACULAR SCAR, ANISOMETROPIA?



Duane’s Syndrome

G. Vike Vicente, MD



Duane’s Syndrome ALL FORMS RETRACT IN ADDUCTION

• Abda Dubba Deux• Type I: deficit in abduction and retraction in adduction

(due to co-contraction of MR and LR

• Type II: deficit in adduction

• Type III: both.

• Watch for strabismus, face turn: attitude

• Usually sporadic, also think Goldenhars, Wildervancksyndromes

• OS more common than OD• Females > males

• Watch also for vertical pull, leashing phenomenom.

• Occasional absent CN 6 nucleus.

G.Vicente

Duane’s Syndrome Type I: OS



Duane s Syndrome Type I: OS

limited abduction,

retraction in adduction

G.Vicente

Duane’s Syndrome Type I



Duane s Syndrome Type I

limited abduction,

retraction in adduction: superior view

notice co-contraction of LMR & LLR

Dr. G.Vicente

OS OD



Duane’s Syndrome Type I

retraction in adduction limited abduction, superior view

OS OD

G.Vicente

Duane’s Syndrome Type II: OS



Duane s Syndrome Type II: OS

limited adduction


G.Vicente

Duane’s Syndrome Type III: OS



Duane s Syndrome Type III: OS

limited adduction and abduction


G.Vicente



Funny Story…

• 15 yo wm

• Bad attitude…

• ortho…? Right gaze,

Left face turn…



Funny Story…

• 15 yo wm

• Bad attitude…

• ortho…?

• 30 PD LET actually,

• But can fuse in rightgaze, left head turn

And I forgot to

Check his ductions…

1ry gaze



Funny Story…

• 15 yo wm

• Bad attitude…

• ortho…?

• 30 PD LET actually,

• But can fuse in rightgaze, left head turn

• And, I forgot to notice

the limited abduction

and narrow fissure inadduction

Left gaze,

Right face turn…

Duane’s Syndrome Type I: OS



Duane s Syndrome Type I: OS

limited abduction,


G.Vicente



Duane’s treatment

• If strabismus in 1ry position

– ET>XT

• Or significant head turn: attitude.

• Never resect LR if no abduction.

– This will worsen globe retraction and not

improve abduction.

G.Vicente



Sensory strabismus- adults Adult with poor monocular

vision will often developexotropia. Think dense cataract X 5

years Warn pt about possible post

op diplopia and need forstrabismus surgery

Pt may have lost the ability tofuse.

Think monovision, orunilateral under correctionLasik pt who had undiagnosed

intermittent exotropia.



Pseudo ET

Orthophoria

Esotropia

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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 theappearance of the

eyes being crossed.

1

Pseudo ET

G.Vicente,MD





a very flat nasal



of the eyes causing

the appearance of

the eyes being


develops and grows



the lids inward


eyes being crossed.

2

Pseudo ET

G.Vicente,MD





a very flat nasal



of the eyes causing

the appearance of

the eyes being


develops and grows



the lids inward


eyes being crossed.

3

Pseudo ET

G.Vicente,MD





a very flat nasal



of the eyes causing

the appearance of

the eyes being


develops and grows



the lids inward


eyes being crossed.

4

Pseudo ET

G.Vicente,MD



Exotropia

Intermittent is very common

How symptomatic are they?

Make sure they have BCVA glasses

Diplopia?

Often familial, so what? Dad had it too.

“What hump?”

Intermittent exotropia can breakdown over time,check serial stereo. If worsening think surgery.

Most common time of pediatric surgery is 7 years old.

Can the pt converge?



Convergence insufficiency

Seen in kids who have trouble reading Adults with Parkinson’s disease Sometimes over diagnosed by some vision

therapy developmental optometrist. Consider

Convergence exercises by an orthoptist, or software Decreasing add in bifocals to extend reading distance

(holding reading material further away) Prisms, etc. pencil pushups.



Nomenclature

• 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,MD




Esophoria, abnormal, common

Only seen when eye is covered

Often asymptomatic, no complaints

Note OS does not move.

G.Vicente,MD




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


alternate cover

May or may not have constant

diplopiaG.Vicente,MD



Cover Uncover test

Left Exotropia, Constant


alternate cover

Right eye preference

G.Vicente,MD



Cover Uncover test

Left Exotropia, Constant


alternate cover

Right eye preference

Note: no eye movement, so besure to check both sides G.Vicente,MD



Normal Convergence

Convergence Insufficiency

G.Vicente,MD

C t t St bi



Constant 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 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

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 convergencecomponent at distance.

• Consider 30 minute patch test to break

fusion and really see how bad the XT canget.



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?

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

L ET (65PD) bil t l MR



Large ET (65PD) , bilateral MR

recession, and LLR resection

preop

1 month post op

3 d

post op

G.Vicente,MD

H h t t



How much to operate

-Patient preference

Case of monocular 85 yoBF with sensory XT

one eye or two?

Pt wished to not have ODoperated, understood riskof under correction.

Therefore only recessed

LMR 7mm and LLR 6mm. Pt had some residual XT

15-20 PD, but was happy,therefore surgeon washappy too.

G.Vicente,MD



Surgical Notes Sutures:

– Most stitches used in eye surgery are thinner than humanhairs.

– They will dissolve on their own over 6 weeks. They may makeyour eye feel scratchy for the first few weeks.

– The antibiotic ointment and a cool compresses will alleviatethis symptom if it occurs.

– Adjustable sutures What to expect after surgery

– Some double vision is normal for the first few weeks after eyemuscle surgery.

Precaution:

– General post op hygiene – Eye rubbing

– Can my child swim after his or her eye surgery?

Length of surgery and recovery

G.Vicente,MD



Notes on Anesthesia

– Notes on Anesthesia

General

Pediatric anesthesia doctors

Risk of Gen. Anesthesia in children

Primary MD clearance

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Complications and Risks or surgery

Infection (1 in 3 years, Tx oral Abx)

Nausea (Tx: Phenergan, etc.)

Blood loss – (what blood loss, maybe a little more than corneal

surgery) Loss of sight? (globe perforation)

Scar tissue

Diplopia

Residual or consecutive strabismus Oculo-Cardiac Reflex – Bradycardia

– Tx: Atropine

G.Vicente,MD



When to operate? Or …When NOT to operate?

• Prisms – Fresnels

– Permanent prisms

• Occlusion (non-operable, CNS disease)

• BCVA (sharp image will often help pt fuse)

G.Vicente,MD



When not to operate cont.

• Botox – best for small, new, noncontractile strabismus, ie ischemic CN 6

palsy.

– Or very variable strabismus ie cerebral palsy, to preventcontracture and save time.

• Exercises, best for convergence insufficiency X(T)’.

• Small Magnitude (<8 PD)

• Tolerability, symptoms – head position, career, lifestyle

• Surgeon aggressiveness, cut, cut, cut• Pre-existing Amblyopia – (how much to treat before surgery?)

• Angle Kappa pseudo XT…



How to operate

Go to Recession and Resection Lectures

G.Vicente,MD



Add skew deviations and

Different angle measured depending on

fixation.

Strabismus and Eye Muscle Surgery

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