CONGENITAL ESOTROPIA by fionan

VIEWS: 304 PAGES: 41

									CONGENITAL ESOTROPIA
               CAUSE
• Subtle neurological
  developmental
  problem
• Nearly always in
  isolation




  CONGENITAL        Kowal 2005   3
  ESOTROPIA
  CONGENITAL ESOTROPIA
          CET
• ONSET < 3 MONTHS: RARE

• USUAL ONSET 3+ MONTHS




CONGENITAL   Kowal 2005    4
ESOTROPIA
             CORE DEFECTS
•   NOT ET!
•   Sensory: N-T asymmetry
•   Motor: N-T asymmetry, LMLN [T&H]
•   poor devpt of binocularity




CONGENITAL        Kowal 2005           5
ESOTROPIA
    CONGENITAL ESOTROPIA
            CET
•   Large angle ET
•   N- T asymmetry
•   Amblyopia ?30%
•   Cross fixation : LE used for right gaze,
    RE for L gaze



CONGENITAL           Kowal 2005                6
ESOTROPIA
  CONGENITAL ESOTROPIA
          CET
• Usual range of refraction
• 25% caucasian neonates > +4
• ? Higher + more prone to CET




CONGENITAL       Kowal 2005      7
ESOTROPIA
              RACIAL
• Caucasians: poor binocularity +
  hyperopia : cong ET is commonmest
  type of cong strab

• No good comparative population studies



CONGENITAL       Kowal 2005            8
ESOTROPIA
             ASSOCIATIONS
• Down’s
• Severe neonatal course IVH /HC
• PVL




CONGENITAL       Kowal 2005        9
ESOTROPIA
             IS IT CONGENITAL :
              SMOOTH PURSUIT
                 ASYMMETRY
• All neonates develop N-T asymmetry,
  sensory and motor
• Age 6-8 mo: asymmetry lost in normals
• Persists  CET
• a/w reduced potential for sensory &
  motor fusion


CONGENITAL          Kowal 2005            10
ESOTROPIA
    Motion detection: normal
     infants & CET infants
• Bosworth & Birch. Vision Res. 2005
• Asymmetry in detection of horizontal
  motion in normals and CET
• Motion detection thresholds measured
  in 75 normals and 36 eyes of 27 infants
  with CET
• FPL with random-dot patterns.

CONGENITAL        Kowal 2005            11
ESOTROPIA
             Motion detection:
              normal infants
• Asymmetries in sensitivity for nasalward (N) vs.
  temporalward (T) directions of motion were compared
  in normals & CETs, age 1 mo to 5 y.
• NORMALS : N = T under 2.5 mo
• N > T motion preference between 3.5 and 6.5 mo.
• N advantage gradually diminished to T = N by 8 mo
  = adults.




CONGENITAL             Kowal 2005                  12
ESOTROPIA
    Motion detection: normal
     infants & CET infants
• No asymmetry in 15 normal infants who
  performed the task binocularly, hence, the
  asymmetry was not a L - R bias.
• In the youngest CET patients tested [5 mo], a
  nasalward superiority in motion detection was
  observed and was equivalent to that of same-
  age normal infants.



CONGENITAL          Kowal 2005                13
ESOTROPIA
  Motion detection: normal
infants and infants with CET
• Unlike normals, this asymmetry persists in
  older CET patients and is close to the ‘root’
  cause / association of CET




CONGENITAL           Kowal 2005                   14
ESOTROPIA
             VERTICALS IN CET
• > 2 types:
• 1. DVD:
Non fixing eye drifts up
• 2. Oblique dysfunction
Usu IO OA
Can be SO OA

CONGENITAL         Kowal 2005   15
ESOTROPIA
   VERTICALS IN CET : DVD




CONGENITAL   Kowal 2005     16
ESOTROPIA
   VERTICALS IN CET : DVD
• Common pattern:
• Right fixation: L
• L fixation: R 

• End result of ‘braking’ the torsional
  component of LMLN in the fixing eye to
  try and improve acuity
CONGENITAL         Kowal 2005              17
ESOTROPIA
  CONGENITAL ESOTROPIA
          CET
• Head turns / face tilts




CONGENITAL         Kowal 2005   18
ESOTROPIA
INFANTILE ET                    COCHRANE
•   Cochrane Database Syst Rev. 2005
•   ? most effective type of intervention
•   ? age at intervention
•    SELECTION CRITERIA: Randomised
    trials comparing any surgical or non-
    surgical intervention for infantile
    esotropia

CONGENITAL         Kowal 2005               19
ESOTROPIA
INFANTILE ET                     COCHRANE
• NO adequate studies were found
• CONCLUSIONS: ..literature on interventions
  for IE are either retrospective studies or
  prospective cohort studies.
• ..not been possible to resolve controversies
  regarding type of surgery, non-surgical
  intervention and age of intervention …need
  for good quality trials to be conducted to
  improve the evidence base
CONGENITAL          Kowal 2005                   20
ESOTROPIA
     The clinical spectrum of
      early-onset esotropia:



• If it looks like CET: is it CET?




CONGENITAL        Kowal 2005         21
ESOTROPIA
     The clinical spectrum of
      early-onset esotropia:
•   Congenital Esotropia Observational
    Study.PEDIG. Am J Ophthal. 2002
•   RESULTS: 175 infants. 3  1 mo.
•   55% constant, 25% variable, 20% intermittent
•   50% ≥ 40∆
•   Most larger angle ET constant
•   Most smaller angle ET intermittent or variable.




CONGENITAL                Kowal 2005                  22
ESOTROPIA
     CET Observational Study -
            PEDIG #1
• Most first seen > 12 w constant ET (65%)
• Most seen <12 w intermittent or variable ET(57%)
• Amblyopia in 19% of patients
• CONCLUSION: ET in early infancy shows more
  variation in size & character than previously
  appreciated.
• A minority of infants diagnosed < 20 w have the
  commonly accepted profile for congenital esotropia of
  a large-angle constant ET.
• Amblyopia is frequent

CONGENITAL              Kowal 2005                   23
ESOTROPIA
     CET Observational Study -
            PEDIG #2
• Am J Ophthalmol. 2002
• PURPOSE: To determine the probability of
  spontaneous resolution of CET
• Eligibility:ET≥ 20∆ @ age 4 to < 20 w.
• Primary outcome : alignment at 28 to 32 w.
• ET ‘resolved’ : ≤ 8 ∆ with/-out glasses




CONGENITAL          Kowal 2005                 24
ESOTROPIA
     CET Observational Study -
       PEDIG #2 RESULTS

• 170/ 175 followed up. 27% resolved
• Most ‘resolved’ : intermittent or variable at
  enrollment.
• ‘Resolved’ #1: 1/ 42 cases that had constant
  ET ≥40∆ on both baseline & first follow-up
  examination & refraction ≤ +3DS.
• #2: ET 35 ∆ @ baseline and 40 ∆ @ at the
  outcome examination, ET resolved
  subsequent to the outcome examination.
CONGENITAL           Kowal 2005                   25
ESOTROPIA
     CET Observational Study -
       PEDIG #2 RESULTS

• CONCLUSIONS: ET with onset in early
  infancy frequently resolves in patients first
  examined at less than 20 w of age when the
  deviation is < 40 ∆ and is intermittent or
  variable.
• ET ≥40 pd presenting after 10 w of age have
  a low likelihood of spontaneous resolution.
• surgical correction at 3 to 4 mo of age could
  reasonably be considered in some CETs
CONGENITAL           Kowal 2005                   26
ESOTROPIA
     TIMING OF TREATMENT
•   Early
•   Very early
•   Late
•   How late




CONGENITAL       Kowal 2005   27
ESOTROPIA
    Stereopsis & duration of
      misalignment in CET
• .Ing M, JAAPOS 2002
• Titmus c.f. duration of misalignment [DOM]
  and age @ alignment
• 90 pts surgically aligned by 24 m.
• Patients aligned by 6 or 12 m or w/in 6 or 12
  m of DOM did not differ in % with stereopsis.
• Alignment after 12 m of age did show a
  decrease percentage with stereopsis

CONGENITAL           Kowal 2005                   28
ESOTROPIA
             Ing : Stereo, age @
               alignment, DOM
• The quality of stereo decreased for pts DOM
  ≥ 12 m
• CONCLUSION:
• Alignment within 1 year of age or within 12 m
  of misalignment favorably affects the % of
  CET patients who develop stereo.
• The quality of the stereopsis result is affected
  by DOM rather than the age @ alignment


CONGENITAL            Kowal 2005                 29
ESOTROPIA
CONGENITAL   Kowal 2005   30
ESOTROPIA
   Why does early alignment
    improve stereoacuity
     outcomes in CET?
• J AAPOS. 2000 Birch EE, Fawcett S, Stager
  DR.
• 129 consecutive patients enrolled in a
  prospective study of infantile esotropia who
  were followed up for a minimum of 5 years. At
  ages 5 to 9 years : Randot stereo
• DOM [but not age at alignment or onset] was
  a significant factor in determining RDS
  outcomes.
CONGENITAL          Kowal 2005               31
ESOTROPIA
    Why does early alignment
        improve stereoacuity
•
          outcomes in CET? a 2nd
    patients with stereo less likely to need
  surgery [p=0.05] and less likely to have DVD
  (P <.001).
• better stereopsis occurs because early
  surgery minimizes DOM, not because
  alignment is achieved during an early critical
  period of visual maturation
• RDS can also be achieved if DOM is not
  prolonged.

CONGENITAL           Kowal 2005                32
ESOTROPIA
CONGENITAL   Kowal 2005   33
ESOTROPIA
     OVERVIEW OF MGMT
• Check vision - any obvious amblyopia
• Amblyopia Rx: FTO 1w/y of life then
  review eg age 10 mo: patch for 50+% of
  waking hours for 5 days before the next
  visit
• Amblyopia may not respond with large
  ET

CONGENITAL        Kowal 2005            34
ESOTROPIA
             OVERVIEW 2
•   Measure angle ≥ 2 times
•   Check refraction
•   >+3 : try anti- accommodative Rx
•   Gls / pilo / phospholine
•   AIM: alignment within a few months of
    onset

CONGENITAL          Kowal 2005              35
ESOTROPIA
             OVERVIEW
•   Many variables
•   Bimedial recession - reliable to 50∆
•   Recess / resect
•   Augment for very large angles - botox,
    1-2 extra muscles



CONGENITAL          Kowal 2005               36
ESOTROPIA
             OVERVIEW
• Day surgery
• Check within 24-36 hours re: slipped
  stitch
• Recurrent / residual ET often
  accommodative
• Consceutive XT with time


CONGENITAL        Kowal 2005             37
ESOTROPIA
CONGENITAL   Kowal 2005   38
ESOTROPIA
                                    Case 1
•   >I saw today a 15 week old baby with typical cong ET.
•   >Confident exam findings
•   >Little / no amblyopia.
•   >Accurate measurement of misalignment of 45^.
•   >Cyclo +4-2x180 OU
•   >
•   >My normal practice would be to tentatively book BMR 2-4 weeks hence and
•   >see child again pre-op to confirm measurements
•   >
•   >This is however the youngest child I have seen with cong ET
•   >Previously operated a 21 week child many years ago - ended up with
•   >random dot stereo
•   >
•   >Any tips / thoughts about operating in 2-3 weeks at age 17-18 weeks?




CONGENITAL                                Kowal 2005                           39
ESOTROPIA
               Case 1 - Alan Scott
•   1 Glasses trial for 2 weeks with over correction, say, +4, ou.
•   Forget the astigmatism, it changes all the time at this age. Yes it could be
    accommodative and I have seen glasses work at this age. You may well
    need them later in any case.
•   2 Botox 3 units to each MR. This has a 60-80% chance of correction
    under age 6 mo. An office procedure under local as with adults.
•   3 BMR recession if the Botox doesnt hold.




CONGENITAL                          Kowal 2005                                     40
ESOTROPIA
               Consec XT - Ciancia
•   > Thank you for your interest in my results in operated Infantile Esotropia.
•   >The percent of secondary XT was as follows:

•   >Immediate                   1%
•   >At 6 months                  2,3%
•   >At 1 year                  3,5%
•   >At 2 years                 5,4%
•   >At 3 years                 10%
•   >At 4 years                 8,2%
•   >At 5 years                 10% (roughly)
•   >At 10 years                 20%    "
•   >At 15 to 27 years             30%    "




CONGENITAL                                 Kowal 2005                              41
ESOTROPIA
CONGENITAL   Kowal 2005   42
ESOTROPIA

								
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