Kimberley Lovelace, MD Ophthalmology Update - PowerPoint Presentation

Slide1

Kimberley Lovelace, MDOphthalmology UpdateMarch 3, 2018

Strabismus

-Why Can’t we work togetherSlide2

http

://www.human-anatomy99.info/eye-muscles-anatomy/Slide3

Visual Acuity: BTL (blinks to light) F&F (fixes and follows)

CSM (central, steady, maintained) can have u for

uncentral or unsteady or unmaintained)Worth 4 dot: 2 red = suppression of left eye 3 green = suppression of right eye 4 dots at near with 2 or 3 at near = monofixation syndrome 5 dots = diplopiaStereoacuity:

9/9 circles = 40 seconds of arc or vision of 20/25 in both eyes

ET often have none and will not get it back after strab surgery XT worsens as eyes deviateTonometry with iCareCycloplegic refractionDilated fundus examination

ExaminationSlide4

Light reflexCover uncoverAlternate coverPrism cover

Hirshberg

KrimskyConvergence/divergenceDouble Maddox RodRed Filter4 Base out prism

Strabismus ExaminationSlide5

PseudoesotropiaInfantile esotropia

Accommodative

esotropiaNystagmus and esotropia (Nystagmus Blockage SyndromeNonaccommodative esotropiaBasic (acquired)

Acute

CyclicSensory deprivationDivergence insufficiencyConsecutiveIncomitant (6th nerve palsy)

EsodeviationsSlide6

Onset < 6 months of ageLarge angle (>30 prism diopters)Positive family history of strabismus

Cross fixate

Children are otherwise normal (occurs in up to 30% of children with neurologic and developmental problems, such as CP and hydrocephalus)IOOA and DVD associated in >50%Treatment:Full cycloplegic refractionSurgery early

Infantile

EsotropiaSlide7

Onset 6 months – 7 years of age (usually 2.5)Intermittent early and becomes constantOften hereditary

Sometimes precipitated by trauma or illness

Frequently associated with amblyopiaDiplopia may occur early but develops suppression scotoma in the deviating eyeTreatment:Full cycloplegic refractionSurgery on any non-accommodative component (r/o and latent uncorrected hyperopia)

High AC/A – bifocals

Accommodative EsotropiaSlide8

Acute – Need head scanCyclic – rare (1:3-5,000)onset in preschool

usually present every other day (48 hour cycle)

surgery is usually curative with unpredictable response to other therapiesDivergence insufficiency – onset in adultET greater at distance than at nearprimary isolated version - in pts > 50 yoa & resolves spontaneouslysecondary needs treatment of underlying disorder, such as GCA or IIH

Consecutive ET

Incomitant ETOther EsodeviationsSlide9

PseudoXTExophoria

Intermittent XT

Constant XTInfantileSensoryConsecutiveDissociated Horizontal Deviation (DHD)Convergence insufficiencyConvergence paralysis

ExodeviationsSlide10

Onset usually prior to 5 yoaEarly on XT greater at distance than near

Associated with IOOA

Treatment:Eventually need surgeryMyopic spectacle correctionConvergence exercisessurgery when deviating 50% or more of time, stereoacuity decreasing, socially unacceptable

Intermittent XTSlide11

Infantile XT – associated with other neurologic abnormalitiesSensory XT – common, treatment is surgicalConvergence insufficiency

Convergence paralysis – usually 2/2 intracranial lesion, normal adduction and accommodation with XT & diplopia, acute onset

Other ExodeviationsSlide12

Inferior oblique overaction – V pattern XTSuperior oblique

overaction

– A patternDissociated vertical deviationSuperior oblique palsy – head tiltInferior oblique palsyMonocular elevation palsy – one eye cannot elevateOrbital floor fractures - restrictive

Vertical DeviationsSlide13

Associated with V-pattern exotropiaTreatment: surgery to weaken the inferior oblique

Inferior Oblique

Overaction/ Superior Oblique PalsySlide14

Duane SyndromeBrown Syndrome3rd

nerve palsy

6th nerve palsyThyroid eye diseaseChronic progressive external ophthalmoplegiaMyasthenia GravisCongenital Fibrosis syndromeMobius syndrome

ET associated with high myopia

Special Forms of StrabismusSlide15

Can appear alone or in association with other systemic defects Caused by a defect in development occurring in 4

th

week of gestation Congenital cranial dysinnervation disorders (Mobius and congenital fibrosis syndrome)Sporadic (5-10% AD)Females, left eyeNucleus of the 6th nerve is absent, aberrant branch of 3

rd

innervates lateral rectusType 1 – limitation of abductionType 2 – limitation of adductionType 3 – limitation of abduction and adductionTreatment: surgery reserved for primary position deviation, face turn, marked globe retraction, large upshoots or downshoots

Duane SyndromeSlide16

Most cases are congenitalBilateral in 10% of casesMild case – no

hypotropia in primary gazeSevere case – chin-up posture or face turn away from the affected eye = surgery

Brown Syndrome

http://marineyes.com/anatomy/muscles.htmlSlide17

Causes:Children: congenital 40-50% of time, trauma, inflammation, viral infection, migraine, following inoculations, (rare) neoplastic lesions

Adults: intracranial aneurysm, microvascular infarction, vasculitis, diabetes, inflammation (

sardoidosis), trauma, infection (meningitis), tumor/infilatration (lymphoma, carcinoma)A nontraumatic 3rd

nerve palsy with pupil involvement is caused by aneurysm until proven otherwise!

Needs CTA/MRA.Third nerve palsySlide18

Clinical signs: Limited adduction, elevation and

depression, eye is down & out

Ptosis+/- Pupil involvement (complete results from loss of parasympathetic input = dilated pupil that responds poorly to light)Can be associated with painAbherent regeneration confuses the

pictureThird Nerve PalsySlide19

Isolated involvement of either superior or inferior division – usually from a lesion of the anterior cavernous sinus or possibly the posterior orbit – check MRIAberrant regeneration:

Classic finding: eyelid retraction with adduction or pupillary

miosis with elevation, adduction and depressionCommon after trauma or compression by an aneurysm/tumor (not from microvascular infarct)Primary aberrant regeneration – slowly expanding parasellar lesion, most commonly meningioma or carotid aneurysm within the cavernous sinus = neuroimaging

Third Nerve PalsySlide20

Most frequent cause of an isolated ocular motor palsyIsolated palsy in adults > 50 yoa

Usually ischemic

Resolve within 3 monthsNeuroimaging is NOT required, unless persisting >3 monthsMedical evaluation is appropriateYounger adults should have neuroimaging, think neuromuscular junction

dz

(MG), restricted MR (TED)Children: leukemia or brainstem gliomaAdolescents & young adults: demyelinationLesions of the pontine angle usually involve 6th nerve plus other cranial nerves

6

th

nerve palsySlide21

Fibrosis of EOM due to lymphocytic infiltrationRestricted motilityCompressive optic neuropathy

Surgical order:

1. Optic nerve decompression2. Strabismus - Need stability of 6 months prior to sx3. Eyelids

Thyroid Eye DiseaseSlide22

Slowly progressive to total paralysis of eyelids and EOMsOnset in childhoodTrue

pigmentary

retinal dystrophy usually absent but constricted fields and ERG abnormalitiesKearns-Sayre syndrome: retinal pigmentary changes, CPEO, cardiomyopathyMedical evaluation of cardiac status essentialChronic Progressive External

OphthalmoplegiaSlide23

Unusual in children90% of ocular cases have both ptosis and limited ocular rotationsRapid fatigue of muscles

Ptosis increases with looking upward for 30 seconds

Sleep test: ptosis resolves after 20-30 minutes in dark room with eyelids closedCogan twitch: overshoot of eyelid when pt looks straight ahead after looking down for several minutesIce test: 2-5 minutes of ice improves levator function

Tensilon

test: edrophonium (neostigmine = alternative with prolonged effect)Tx: mestinon (physostigmine), surgery if stable strab measurements, needs medical evaluation

Myasthenia GravisSlide24

One of the congenital cranial dysinnervation disordersTreatment: Surgery to release fibrosis and place eyes in primary position

Congenital

Fibrosis Syndrome Slide25

Esotropia associated with high myopiaInferior displacement of the lateral rectus

Progressive ET with restrictive abduction

Treatment: surgery

Convergent Strabismus

FixusSlide26

If null point causes abnormal head posture, then strabismus surgery is performed to set null point in primary positionKestenbaum-Anderson procedure

NystagmusSlide27

Recession – to weaken or loosen the muscle by moving it posteriorlyResection – to strengthen or tighten the muscle by shortening itBotox

Superior oblique tendon spacer

Inferior oblique recession and anteriorizationStrabismus SurgerySlide28

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