2014 common motility problems

Common Motility Problems

Alvina Pauline D. Santiago, MD

Pediatric Ophthalmology & Adult Strabismus

AP Santiago, MD PGH Clinical Course 2014

www.books.google.com(now fully downloadable)

http://books.google.com.ph/books?id=6jqOihYJvCoC&printsec=frontcover&dq=clinical+strabismus+management&hl=en&sa=X&ei=X5bXU-T2H8TooATF4oKgBg&redir_esc=y#v=onepage&q=clinical%20strabismus%20management&f=false

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


http://www.telemedicine.orbis.org/

http://www.cybersight.org/

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


Repeatable & Reproducible Measurements

Appropriate correction

Accommodative target above threshold

Distance

Plastic Prisms

Above threshold e.g. Snellen acuity

20/20

present 20/50


The Ideal Target

With sufficient detail and contour

Should sustain interest


Toys as Targets

One toy one look

With detail

May be coupled with a light

Sounds for tracking but not vision testing


Principles of Strabismus Surgery

Weaken an overacting muscle

Strengthen a weak muscle

Release a restriction

Transposition for total palsy


Weakening procedures

Recession

Myotomy/myectomy

Anterior transposition

Tenotomy/tenectomy

Superior oblique spacers


Fig from Rosenbaum & Santiago 1999

Strengthening procedures

Resection

Tuck



Transposition Procedures

Duane syndrome

VI nerve palsy

Double elevator palsy

Double depressor palsy

Third nerve palsy


Transposition Procedures



Transposition Surgery



Common Strabismus Problems

Infantile esotropia

Accommodative esotropia

Paretic esotropia

Monofixation Syndrome

Infantile exotropia

Intermittent exotropia

Paretic exotropia

Superior oblique palsy


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



Infantile esotropia

Rate limiting factors: amblyopia Measurements stability patient cooperation distance fixation


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


• 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


Inferior Oblique Surgery: Elliot & Nankin’s Anterior

Transposition


ww

w.telem

edicine.org

Inferior Oblique Transposition


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w.telem

edicine.org

Inferior Oblique Surgery: Parks Recession


ww

w.telem

edicine.org

Inferior Oblique Surgery: Myotomy/Myectomy

Myotomy Myectomy



Full hyperopic prescription

Repeat full cycloplegic refraction

Bifocals if with distance fusion

AP Santiago, MD PGH Clinical Course 2014Fig from Rosenbaum & Santiago 1999


Surgery for residual esotropia > 15PD

Faden or posterior fixation

Surgery for MR contracture

Same rate limiting factors


Fadenoperation or Posterior Fixation



VI nerve palsy

Do not forget correction

Differentiate from Duane syndrome and MR contracture

Primary vs secondary deviation


VI Nerve Palsy: Primary vs Secondary

Deviation



VI nerve paresis vs restriction

Recess-resect if with residual lateral rectus function

transposition if total palsy


VI Nerve Palsy: post transposition



Infantile exotropia

Poorer sensory prognosis than ET

Differentiate from visual developmental delay

Usually large exotropia 30PD



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





Distance stereoacuity deterioration

Near stereoacuity changes are late signs

Early surgery better prognosis

May become monofixator


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


III nerve paresis



III nerve paresis

Resect partially paretic muscle

May combine with transposition for stronger effect


III nerve paresis: post transposition

with resection



Paralytic Exotropia: III nerve palsy



III nerve palsy

Only IV and VI nerve functioning

SO transposition

VI nerve transposition?


Paralytic Exotropia: III nerve palsy postop




Measure in non preferred posture

If with large fusional amplitudes, may need prolonged patching

Same rate limiting factors

Usually with inferior oblique overaction




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



If with redundant superior oblique tendon, will have to perform tuck



Superior oblique tuck



If with spread of comitance, may do well with SR weakening in hypertropic eye

or IR weakening in hypotropic eye


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


Common Motility Problem

Ciliary Muscle Spasm

Induced myopia/astigmatism

Headache

Focusing/defocusing

Fluctuating visual acuity

Can mimic SOL


Thank youAP Santiago, MD PGH Clinical Course 2014

Thank you!

2014 common motility problems

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