Strabismus Surgery and the Late Elderly
Post on 09-Jan-2016
31 Views
Preview:
DESCRIPTION
Transcript
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
top related