Strabismus Surgery and

the Late ElderlyLogan MitchellLionel Kowal

RVEEH, MelbournePrivate Eye Clinic, Melbourne

“Elderly” - who?

Older than me? Older than my parents?

WHO: No definition

Geriatric literature Early elderly = 65 – 75 years old Late elderly = ≥75 years old

“Elderly” - how many?

Australian population data

22.5 million (2010 est.) Life expectancy at birth:

82 yrs

Ageing population 65 yrs and older

13.5% (2009 est.) = 3 million

25% (2042 est.) = 6.2 million

“Elderly” and Strabismus

Prevalence ~ 4% (adult strabismus) No population-based data on “elderly” population

6600 Medicare-billed strabismus operations

27 million eligible patients

2.4%

“Elderly” and Strabismus

Prevalence of strabismus in >65 year olds (assumptive) 4% prevalence adult strabismus 120,000 in 2009 250,000 in 2042

Elderly Strabismus – the literature

4 papers

Paper #1 Repka JAAPOS 2007 as described 70% horizontal surgery 14% reported as re-operations (?low)

Elderly Strabismus – the literature

Paper #2: Magramm & Schlossman JPOS 1991 Retrospective 104 pts

mean 69 yrs old (60-89) ¼ cosmetic indication, ¾ diplopic 1/3 childhood onset Adult onset

Mean delay to

surgery 8 yrs

32

27

23

117

neuroparalyticrestrictivesensorypost cataractdecompensation

Aetiologies

Elderly Strabismus – the literature Paper #3: Dawson et al Strabismus 2001

Retrospective 111 patients

mean 67 yrs old (60-90) ½ cosmetic, ½ diplopic 1/3 childhood onset Adult onset – similar aetiologies Outcomes

~60% orthotropic +/- 10∆ 21% re-operation rate

Elderly Strabismus – the literature Paper #4: Rutar & Demer JAAPOS 2009

“Heavy eye syndrome” in elderly A la, but different from, ‘myopic strabismus fixus’ Degeneration of SR-LR aponeurotic band

Adult Strabismus (as substitute)

Adults delay seeking surgical correction Mean delay 19 years

diplopic 15 yrs vs 28 yrs non-diplopic Reasons

27

23

11

8

not offeredoffered but declinednever sought care“not suitable”

Strabismus Surgery in the 'Late Elderly' Aim

To Identify the characteristics and outcomes of patients undergoing strabismus surgery aged 75 years or older between October 2005 – October 2010

Methods Retrospective chart review Locations

Private Eye Clinic (Dr Lionel Kowal) RVEEH

Results

35 patients Age: mean 79 years

(75-95) Male:Female 16:19 Indications

Cosmesis – 6 (17%) Diplopia – 29 (83%)

Duration of symptoms: mean 12 years (0-69)

19 done with adjustable sutures

3 surgeries performed under regional anaesthetic

Results

Previous surgeries

(plus 2 with previous botox)

29

4

1 1

0

5

10

15

20

25

30

35

0 1 2 3

Aetiology of Strabismus

39%

23%

20%

6%3% 9%

neuroparalytic

restrictive

decompensated phoria

consecutive

sensory

unknown

Neuroparalytic Strabismus 14 patients

CNVI in 9 patients 5 compressive

2 ICA aneurysm (1 previous

surgery) 2 meningioma 1 ependymoma

3 ischaemic / uncertain cause

1 traumatic (CHI) (1 previous surgery)

CNIV in 6 patients 3 congenital

1 with 2 previous surgeries

Remaining 2: average duration of diplopia = 6 years

3 uncertain aetiology CNIII in 1 patient

Combined with CNVI in ICA aneurysm patient

Restrictive Strabismus 8 patients

3 thyroid eye disease Mean duration on symptoms: 1.3 years

4 traumatic / iatrogenic 2 previous retinal detachment surgery 1 previous sinus surgery 1 previous orbital trauma

1 Brown’s syndrome Symptoms for >50 years

Decompensated Phoria 7 patients

5 with decompensated intermittent exotropia 2 decompensated divergence insufficiency

Mean duration of symptoms: 37 years

Consecutive Exotropia Only 2 patients

Childhood esotropia Previous surgery x 1, and x 3 Mean duration of misalignment: >40 years

Outcomes Mean follow-up 8 months “Overall”

31%

37%

29%

3%

Perfect

Significant improvement

Little/no improvement

Worse

Outcomes Diplopia

35%

3%

42%

3%

17%

Free of diplopia

(with AHP)

(with prism)

(with AHP and prism)

DIPLOPIC

Outcomes in Neuroparalytic Cases “Overall” result

Diplopia

Perfect 3 (21%)

Significant improvement 2 (14%)

Little/no improvement 8 (57%)

Worse 1 (7%)

Free of diplopia 11 (79%)

(with AHP) 2 (14%)

(with prism) 6 (43%)

(with AHP and prism) 1 (7%)

Diplopic 3 (21%)

Outcomes in Other Cases “Significant improvement” or better

Restrictive strabismus 88% Decompensated phoria 86% Consecutive exotropia 100%

Complications Couldn’t find a muscle (2)

Post-childhood trauma, consecutive XT Re-operations (3 = 8.6%)

2 on one patient (SOP), 1 on 95 year old lady (XT)

Recurrences (6) Dealt with prisms in 4 cases

No known systemic complications

Conclusions (I) Strabismus in the very elderly

Exists Is not extremely rare

Will increase Is under-represented in the literature

Diplopia is a frequent indication for surgery Patients delay surgery

Often at our (medical) behest Varied aetiologies

Neuroparalytic causes common (note compressive causes)

Conclusions (II) Surgical considerations

Systemic risk of general anaesthetic ?risk of regional anaesthetic

Thinner conjunctiva Risk of anterior segment ischaemia

Probably 2 muscles maximum Diplopic indication common

More accurate surgery, adjustable sutures

Conclusions (III) Surgery is reasonably successful

Very low risk of making things worse (1/35)

68% achieved at least significant improvement ?More guarded success in neuroparalytic patients

83% free of diplopia (with/without prisms/AHP)

Thank You