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Dx Amblyopia

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Dx Amblyopia WE CAN WIPE OUT AMBLYOPIA IN OUR LIFETIMES OVERVIEW Amblyopia Characteristics/Therapy Most Clinico-Legal Problems for OD s Infantile Esotropia-A Case ... – PowerPoint PPT presentation

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Title: Dx Amblyopia


1
Dx Amblyopia
  • WE CAN WIPE OUT AMBLYOPIA IN OUR LIFETIMES

2
OVERVIEW
  • Amblyopia Characteristics/Therapy
  • Most Clinico-Legal Problems for ODs
  • Infantile Esotropia-A Case
  • The Infant Examination Sequence
  • Infantile Esotropia Characteristics
  • Infantile Esotropia Therapy
  • The Older Esotrope
  • Exotropia Congenital Functional

3
AMBLYOPIA
  • Caused by Anisometropia and Strabismus and what
    most eye care practitioners are interested in
    treating
  • Rule Out Pathology

4
Ocular and Neurologic Disease Masquerading as
Functional Vision Disorders
  • Amblyopia
  • Strabismus
  • Brain Tumors Bitemporal Field Loss
  • Vascular Accidents
  • Ocular and/or Visual Pathway Diseases

5
Amblyopia
  • Amblyopia A Diagnosis of Exclusion. Make sure
    there is no pathology first.
  • Amblyopia may improve with vision therapy even
    with pathology
  • Always do visual fields of both eyes of amblyopes
    (color and neutral density)
  • Must have 1. Anisometropia, 2. Constant
    Unilateral Strabismus, 3. Bilateral RE, 4.
    Deprivation Hx

6
Bilateral Amblyopia-Careful
  • Bilateral Retinal Schisis--X-Linked
  • Electrodiagnostics
  • ERG Electroretinogram
  • VEP Visual Evoked Potential
  • Pictures
  • X Rays
  • CT Scans
  • MRIs
  • OCT

7
Amblyopia Differential Dx
  • Block-Line-Letter VA s Better with letters
  • Contrast Typically not impacted in Amblyopia
  • Psychometric VA s Sigmoid Curve
  • Neutral Density Filters Devastates VA
  • Macular Integrity Tester No Brush
  • Magnification 2.5 Telescope really improves VA
    beyond what is expected
  • Color Vision Normal
  • Normal Amsler Grid and Electrodiagnostics

8
Special Visual Acuity Charts
  • Psychometric Chart
  • Flom Chart Cs
  • Wesson-Davidson Chart Es
  • Bailey-Lovie log MAR
  • Relative Separation
  • High and Low Contrast
  • Contrast Sensitivity
  • LEA
  • B-VAT

9
Amblyopia and VA
  • Acuity improves with isolated letters
  • First and last letter seen more often
  • Letters read out of order
  • Letters change as chart is viewed
  • Chart appears gray, dim or poor quality
  • Refraction Better but I just cannot read it
  • LARGE JNDs

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Amblyopia
  • 2.5 of population
  • A problem of binocularity
  • Fixation--Binocularity
  • Anisometropia
  • Constant Unilateral Strabismus

16
Amblyopia Timelines
  • Critical Period Birth to 6 moTreat now
    Blind-Nystagmus
  • Treat PathologyFixate with each eye
  • Sensitive Period 6 mo to 8 yr. Treat Visually
    Impaired
  • Susceptible Period 8 to 18 yr.Treat if
    compliantmay return
  • Residual Plasticity Period 18 yr.gt not likely
    (Lee R. Adult Amblyope JBO 12/99 pp115-131)

17
Amblyopia is Developmental A BINOCULAR Dx
  • Not just a reduction in VA but in total vision
  • Poor Eye Movements
  • Poor Accommodation
  • Poor Spatio-Temporal IntegrationTrouble judging
    distances and lengthsCrowding
  • Requires more than just patching

18
Clinical Classification of Amblyopia
  • Organic (Organic)
  • Form Deprivation (Structural)
  • Strabismus (Spatial Conflict)
  • Refractive
  • Isometropic and Anisometropic
  • Psychogenic
  • Voluntary (Malingering)
  • Involuntary Hysterical and Streffs Syndrome

19
Amblyopic Clinical Pearls
  • Problems within 1st 6 months most
    dangerous---Congenital Cataracts-Critical
  • Early dense cataracts-a true critical
    intervention
  • Late onset not as severe-Sensitive-Can be
    amblyopic up to about 8 years
  • Treatment at any time but less certain
    outcomes-Requires a motivated patient

20
Streffs Bilateral Juvenile Amblyopia
  • Refracts -.5 to 1D may help
  • VA Far 20/25 to 20/400Walk around
  • VA Near Worse than Far c
  • Habitual RD 10 in or less/Peers moves RD out
  • Dynamic Ret Dull reflexes and increased lag
    improves reflexes
  • Fixation Unstable central stability

21
Streffs Bilateral Juvenile Amblyopia
  • Pursuit Refixations improves
  • Pen in Cap Misses improves
  • Yoked Base preferred
  • Ball Catching improves timing
  • VO Star Poor Centration improves
  • History High achiever, females, around puberty,
    at exam time, holidays and spring

22
Streffs Syndrome in Animals
23
Tx Amblyopia
24
Amblyopia Efficacy of VTx .1 Significance at 16
for 4 linesBirnbaum et al. JAAO May 77
25
Congenital esotropia vs. amblyopia surgery or
noneHelveston, EM. Origins of congential
esotropia. J Ped Ophthalmol Strab 199330215-232
26
Treatment of Amblyopia
  • Isometropic gt-5D eventual full Rx but in
    steps. Consider underminusgt 2D Temper Rx by
    age, amount, in steps, keep symmetricalThink in
    terms of keeping 2D of hyperopia uncorrected...
    Cylinder gt1.25 Temper Rx as with symmetrical
    and lowalways trial framePROBE LENS TESTING

27
Amblyopia
  • Anisometropia gt-2D or 1D consider CL
    (depending on the age and responses)
  • Eventual full Rx may be much more balanced
  • MOST ANSIO AMBLYOPIA from gt 1
  • Keep symmetrical and spherical equivalents
  • Keep Rxs Small and Simple

28
Occlusion
  • Full Time Direct Occlusion
  • 1 day for each year of life and no patch the
    other day for the anisometropic amblyope
  • For the strabismic amblyope indirectly patch the
    other eye for one day
  • Partial Occlusion
  • Bi-Nasal Occlusion
  • Patch for hours rather than days

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Treatment Modalities for Amblyopia
  • Patching verses Penalization
  • Big advantage of Penalization-it can be done
  • Binocularity is not destroyed
  • Penalization
  • Bangerter Foils
  • Fingernail Polish
  • Scotch Tape
  • Extra Plus
  • Meds

31
Penalization
  • Foils
  • Colored Filters (Mono in Binocular Field)
  • Wesson Method
  • Extra Plus
  • Clear Finger Nail Paint
  • Cycloplegia
  • Bi-Nasal Occlusion
  • Bi-Temporal Occlusion
  • Atropine

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Rxs for the older Amblyope and Esotrope
  • Always try to balance Rx
  • Use minimal Rx to plateau VA
  • Use minimal Rx to plateau Angle of turn
  • Hold off Rxing lenses until some VT has been
    attempted (weeks)
  • Plan to titrate UP on esotropes and
    anisometropes

35
Contact Lenses and Amblyopia
  • Knapps Law Predicts image size based upon
    length of the eye--spectacles more appropriate
  • Think CL even with Knapps Law
  • More likely to wear than odd glasses
  • better image quality
  • No prismatic or Centration problems

36
Amblyopia Therapy Press
  • Refractive Amblyopia
  • Normally responds quicker than strabismus
  • Passive Suppression
  • Binocular integration present
  • Less occlusion time needed
  • Loss of resolution - little spatial distortion
  • Knows where and how far the target is
  • Like looking in smoked glass or cellophane

37
Amblyopia Therapy
  • Strabismic Amblyopia
  • Loss of resolution and spatial confusion
  • Takes more time
  • Must develop central fixation first
  • Active suppression
  • Poor performance

38
Summarized Early Phases -Tx
  • Rx
  • Monocular activities
  • Patching/Penalization
  • Accommodation
  • Ocular Motility
  • Form Recognition (Modified Updegrave)
  • Perceptual Discrimination (Size, Shape, Feely
    Meely, etc)

39
Later Phases Tx Amblyopia
  • Monocular Fixation in a Binocular Field
  • Biocular Therapy
  • Binocular Therapy
  • Intersensory Integration

40
Monocular Therapy
  • Press Recommends 3 Levels
  • Gross Motor (Use Sparingly with Patching)
  • Balance Board
  • Walking Rail
  • Oculomotor
  • Accommodative

41
Monocular Therapy
  • Oculomotor
  • Hart Chart saccades
  • Michigan tracking
  • Pointer in Straw
  • Monocular Prism Jumps
  • Geo Boards, Groffman tracing
  • AN Pointing
  • Line Counting
  • Perceptuomotor Pen
  • MIT

42
Monocular therapy
  • Accommodative
  • Near Far Hart Charts
  • Free Space Push Up
  • Loose Lens Rock
  • Sequential Minus (JNDs)
  • Minus Lens and Marsden Ball

43
Mono Tx Perceptual Discrim
  • Hidden Pictures
  • Similarities and Differences
  • Monocular Contour Interaction (Back off and read
    letters/numbers)
  • Random Count All of certain or letters
    (Michigan Tracking)
  • Tachistoscope
  • Form Tracing with Crowding -Kedzia Card
  • Visual Search Sequential find correct one
  • Space Matching Distance to Chalkboard

44
Monocular Tx in Binocular Field
  • Anaglyphic TV Trainer (Projected Light)
  • Sherman VT Playing Cards (1/2 Cards)
  • Lens rock with single Vectogram VA
    (corresponding to amblyopic eye)
  • Quoits
  • Clown/Spirangle
  • Wayne Fixator and Anaglyph
  • Anaglyphic Tracing
  • Haidinger Brush/MIT
  • Kedzia Cards

45
WHY DO VT ON AMBLYOPES If Patching gives good
VA
  • Krumholtz FitzGerald. Efficacy of treatment
    modalities in refractive amblyopia. J AOA 1999
    70 399-404
  • VAs the same with Patching full Rx or Patching,
    full RxVT (2 line 20 ArcSec)
  • Both Patching and Patching VT group better than
    Optical Correction alone
  • ONLY VT GROUP HAD BETTER STEREO

46
Efficacy of Tx on AmblyopiaKrumholtz I,
FitzGerald D. Efficacy of treatment modalities
in refractive amblyopia J am Optom Assoc 1999
70 399-404
  • Compare (6 mo) Rx Rx Patch Rx/VT N78
  • 2 Line and 20 sec increase the criterion
  • Patch and VT have similar VAs
  • VT shows significantly greater stereo
  • ConclusionPatching aloneimprovement of visual
    acuity, binocular performance is significantly
    better when vision therapy is included in the
    treatment regimen.

47
FitzGerald AmblyopiaKrumholtz I, FitzGerald D.
Efficacy of treatment modalities in refractive
amblyopia. J Am Optom Assoc 199970399-404
  • Amblyopia from Refractive (Aniso)
  • 2 lines 20arcsec Improvement
  • Tx
  • Do Nothing
  • Rx
  • Rx Patch and Eye Hand
  • Rx Patch and Eye Hand and VTx
  • Retrospective
  • 4 to 6 weeks after
  • 2 to 4 months
  • 6 months to 12 months
  • Note in all Tx Some make dramatic improvement
    and some never move
  • Patch and VTx are the Same for Amblyopia Tx
  • Rx alone was not as effective

48
FitzGerald Amblyopia VA StereoKrumholtz I,
FitzGerald D. Efficacy of treatment modalities in
refractive amblyopia. J Am Optom Assoc
199970399-404 S
  • Optical Correction Alone 41 VA and 18 Stereo
  • Optical Correction and Patch 69 VA and 30
    Stereo
  • Optical Correction Patch and VTx 67 and 67

49
FitzGerald Improvement Refractive Amblyopia VA
StereoKrumholtz I, FitzGerald D. Efficacy of
treatment modalities in refractive amblyopia. J
Am Optom Assoc 199970399-404
50
FitzGerald Refractive AmblyopiaFitzGerald DE,
Krumholtz I. Maintenance of improvement gains in
refractive amblyopia a comparison of treatment
modalities. Optometry 2002 73 153-9.
  • Maintenance of Visual Acuity Gains over Time
    (From 1 to 2 years)
  • Optical Correction 50
  • Optical Correction Patching with Eye Hand
    Activities 60
  • Optical Correction Patching with Eye Hand
    Activities and Vision Therapy 100
  • 94 of those who maintained their VAs maintained
    their stereo

51
FitzGerald Refractive AmblyopiaFitzGerald DE,
Krumholtz I. Maintenance of improvement gains in
refractive amblyopia a comparison of treatment
modalities. Optometry 2002 73 153-9.
52
Rx, Rx Patch, Rx VTKrumholtz, FitzGerald 1999
53
Maintenance of Gains AmblyopiaFitzGerald DE,
Krumholtz I. Maintenance of improvement gains in
refractive amblyopiaOptometry 2002 73 153-9.
  • Records of 6 month study retrospectively at 1 to
    2 years to see if gains are holding
  • Holding Gains N23
  • 50 with Rx
  • 60 with Rx and Patching
  • 100 with Rx and VT
  • Oldest age held the best

54
VA Gains over Time for Amblyopia (of those
improved)FitzGerald Krumholtz 2002
55
VA Gains over Time for Amblyopia (of those
improved)
56
Amblyopia Tx and Compliance (N52) 3 mo
Occlusion, previous failure in VA
improvementMinsAmblyopia Moo Ko.Proc 8
Japan-Korea Ophthal 1996
57
Summary Amblyopia Tx
  • Consider a modified Rx
  • Consider some type of Patching/Penalization
  • Central and Stable Fixation
  • Central Fixation and Monocular Tx
  • Equality between eyes
  • Monocular Tx
  • Monocular training in a binocular field
  • Biocular Tx
  • Suppression Therapy
  • Biocular Tx
  • Binocular integration
  • Binocular Therapy

58
Infantile Esotropia
59
1st Case Subjective
  • 19 mo White Female
  • Esotropia from 6 months
  • Full Term Pregnancy No problems with pregnancy
    or birth-First Child
  • Crawled at 6 months
  • Walked at 10 months
  • Threw tantrums and wanted things her way when
    tired

60
1st Case Subjective Continued
  • O-MD exam at 6 months
  • Healthy Eyes
  • Congenital Esotropia
  • Cycloplegic Rx dispensed (2.25D sph OU) and told
    to return in 6 months if not straight surgery
    would be suggested

61
1st Case Objective
  • Hyperactive Child
  • Present RX 2.25
  • Retinoscope at far 1.50
  • EOMs full--OS less accurate
  • Head Movement
  • Uncoordinated Visual Motor Patterns (Body)
  • Eyes Healthy

62
1st Case Assessment Infantile Esotropia OS
with Hyperopia
63
1st Case Plan
  • Lenses
  • Home Vision Therapy
  • 2/week
  • Later 1/week as a progress examination

64
1st Case Education
  • No Guarantees
  • Goal
  • Straight Eyes
  • Diminish the Rx if Possible

65
1st Case Initial Tx
  • Periodic Patching (short periods of time-more OD
    than OS)
  • Movement Patterns of Head, Neck and Body
  • Prone Neck Rotations
  • Dry Land Swimming
  • Crawling
  • Bright Objects---Cross Patterning--VT depends on
    motivation (Time at Task)
  • Sleep Patterns

66
1st Case Early Progress Exams
  • 2 Weeks Change Rx to 1.50 c 0.75 add
  • Mother reports eyes are straighter
  • 6 Weeks Change 1.50D with Bi-Nasals
  • Mother reports steady improvement of eyes-eyes
    are straighter longer
  • 9 Weeks Change Rx to 0.75 c 0.75 Add
  • 14 Week Change Rx to 0.75 and released without
    bi-nasal occlusion

67
1st Case Later Progress Exams
  • 1 month post release
  • Goes without lenses
  • Eye does not turn normally
  • Turns if tired or excited
  • 3 months post release
  • Eyes seldom turn
  • Seldom wears Rx

68
Long Term Follow Up
  • All State Basketball
  • All State Tennis
  • Full scholarship Southern Miss Tennis
  • Real Estate Agent/Broker Gulfport/Wiggins
  • 34 years of Age
  • Mother of 2

69
Strabismus
  • Infantile-(within 6 months of age) 1-2 of
    population
  • Accommodative esotropia (typically 2 to 3 years)
    seen in 2-2.5 of population
  • Most common-Pseudo-esotropia--
  • Provide Reassurance
  • It is good to photo-document the Pseudo-esotropia
    (Epicanthal Folds)

70
Tropia at BirthHainline etal Chap 15 Simon Early
Visual Development Normal and Abnormal Oxford
Press 1993
71
Visual Acuities
  • Follows light and or bright object
  • Will reach for a candy bead
  • Optokinetic Nystagmus-Temporal/Nasal
  • Preferential Looking
  • Cereal Card
  • Broken Wheel
  • Lea

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Pathologies
  • PUPILS and MOTILITIES
  • Around the eye
  • Anterior Segment
  • Posterior Segment
  • Ophthalmoscopy should always be last!

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Refractive Error
  • Bruckner (Also Alignment)
  • Photorefraction
  • Mohindras Retinoscopy
  • Cartoons
  • Nearpoint Retinoscopy
  • Cycloplegic

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Lens Prescription
  • Very Conservative
  • Develop Fixation in Each Eye for Anisometropia,
    Amblyopia and Emmetropization
  • Prescribe Equal Minimal Spheres
  • Titrate Up or Down the Rx Bi-Monthly
  • WHEN IN DOUBT, ASK FOR HELP FROM YOUR PEDIATRIC
    O. D.
  • Smith et al. UH Refractive Errors

94
Ocular Motilities
  • Parent Moves Baby
  • Horizontal, Down, Up, Rotational
  • Bright Object
  • Black and White Early in Life-Later Colors
  • Noisy Object
  • Bright and Noisy Object
  • Broad H

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Binocularity
  • No child is binocular at birth
  • ???Congenital Esotropia???
  • Convergence indicates both Cortical Fusion and
    Stereopsis
  • Critical Periods???Maybe not as Critical???

99
Must Reading
  • Helveston E. 19th Annual Costenbader Lecture on
    Congenital Esotropia. J Ped Opthtalmol Strab
    1993 215-232.
  • Thorn F, et.al. The development of alignment,
    convergence and sensory binocularity. Invest
    Ophthalmol Vis Sci 1994 544-553.

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Developmental Milestones
  • Ocular Motilities Present at 12 weeks
  • Visual Motor
  • Eye-Hand Coordination
  • Denver Developmental Screening
  • Developmental Clusters
  • Gross Motor
  • Fine Motor
  • Social
  • Language

103
Visual Expecteds At 6 Months
  • VA 20/80 to 20/200
  • Retinoscopy Pl to 1.25 Highly Variable
  • Pupils Normal and Reactive
  • Alignment Always
  • Follows Moving Target in Sitting Position
  • NPC to the Nose
  • No Internal or External Pathologies

104
Conclusions
  • Assure that Child is Developing Correctly
  • No Pathology
  • No Amblyopic Predispositions
  • No High Refractive Situations
  • No Abnormal Binocular Developments
  • No Abnormal Ocular Motor Functions
  • WHEN IN DOUBT, CALL A FRIEND YOUR PEDIATRIC
    OPTOMETRIST

105
Esotropia Child Development
  • What is normal at birth? And
  • What should one expect as the child grows and
    matures? And
  • What should be done if one sees that the child is
    not growing/maturing as it should?

106
Esotropia Characteristics
  • A high incidence in the first year
  • An increase in incidence in the 2 to 3 year range
  • great majority of esotropia is present by school
    age
  • Esotropia presenting after school age is very
    likely to be non-functional

107
Incidence of Esotropia Keiner
108
Prevalence of Esotropia Keiner
109
Prevalence of Esotropia Scobee
110
Incidence of Infantile Esotropia by
CorrelationWt lt2500g Gest lt37 wks Apgar lt
7Mohney et al. CongenitalMinnesota. Ophthalmol
1998 846-50
  • Smoking Mother 2.2 to 1
  • Short Gestation 11.5 to 1
  • Low Birth Weight 4.6 to 1
  • Apgar Score 1 minute 4.3 to 1
  • Apgar Score 5 minutes 6.3 to 1
  • Family History 3.5 to 1

111
Incidence of Infantile Esotropia by
CorrelationWt lt2500g Gest lt37 wks Apgar lt
7Mohney et al. CongenitalMinnesota. Ophthalmol
1998 846-50
112
Odds Ratio Confidence Intervals for Identified
Birth Variables
  • Variable Odds C I
  • Prematurely 10.13 1.89 54.1
  • Decreased Birth Weight (lt2500 gm) 5.91 1.09
    31.97
  • Use of Supplemental Oxygen 5.79 1.35 24.85
  • Caesarian Section 3.85 1.09 12.57
  • Augmented Labor of any type 3.60 1.06 12.22
  • Vacuum/Forceps Delivery 2.95 0.49 17.73

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Odds Ratio Confidence Intervals Childs Hx
  • Variable Odds C I
  • Cardiovascular Disease 9.60 1.05 87.78
  • Any Systemic Disease 7.78 0.87 69.49
  • Gastrointestinal Disease 5.65 0.58 55.08
  • Otitis Media 3.95 1.24 12.57
  • Respiratory Disease 3.45 1.02 11.67
  • Secondary Ocular Dis. ( 4D) 2.14 0.69 6.63
  • Perinatal Complications 1.73 0.45 6.65

114
Odds Ratio Confidence Interval Family/Pregnancy
Hx
  • Variable Odds C I
  • Strabismus/Amblyopia in Family 9.82 2.31 41.71
  • High Blood Pressure in Pregnancy 6.11 0.63 58.88
  • Prenatal Care 1.36 0.11 16.21
  • No Prenatal Care 0.74 0.06 8.77
  • No Rx Taken in Pregnancy 1.35 0.25 7.40
  • No Acetaminophen Taken 1.33 0.44 4.03
  • Over the Counter Rx Taken 1.25 0.18 1.80
  • No Over the Counter Rx Taken 1.74 0.56 5.46

115
Odds Ratio Confidence Interval
Genetic/Environment
  • Variable Odds C I
  • Genetic
  • Male Gender 4.01 1.22 13.17
  • Mother 20 years or older 1.43 0.42 4.81
  • Mother younger than 20 years 0.70 0.21 2.37
  • (No mother older than 35 years)
  • Environmental
  • Smoker in the Home 0.56 0.11 2.90
  • No Smoker in the Home 1.80 0.35 9.40
  • No Breast Feeding 1.52 0.49 4.71

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Esotropia at Birth
  • True Congenital ET VERY RARE!
  • Typically the neonate will show
  • Esotropia after 4 months
  • Exotropia after 6 months

117
General Principles of FusionHainline etal Chap
15 Simon Early Visual Development Normal and
Abnormal Oxford Press 1993
  • Motor Fusion (Chavasse-Learned Reflex)
  • Sensory Fusion (Worth-Innate Fusion)
  • Sensory binocularity develops from periphery
    toward fovea-Depends on Binocular Cells but not
    Disparity Sensitive
  • Cortical Dominance Columns only partial
    segregated at 4 Mo. but adult like at 60 Mo.
  • Idea that stable ocular alignment requires high
    quality sensory input, is not correct

118
Two stages Alignment Held Chap 15 Early Visual
Development Normal and Abnormal. Simons Oxford
Press 1993
  • PrimitiveLocal summation of binocular signals
    form corresponding retinal loci may occur
  • Mature Complex processing of disparity,
    interocular inhibition and global processing
  • The step from Primitive to Mature is a Problem

119
Onset of Stereopsis1993 Chap 15 Held Simon
Early Visual Development Normal and Abnormal
Oxford Press
  • Abrupt at 10-15 weeks
  • Rapid increase in Stereo acuity
  • Can occur in absence of increased VA
  • Fusion begins as opposed to rivalry
  • Thalmo-Cortical Axons of each eye at entrance
    layer of eye (4) Axons of both eyes overlap
  • Ocular Dominance Columns completed then eyes
    correspond to disparity selectivity
  • Segregation of eyes necessary but not sufficient
    to account for stereopsis

120
Stereo Vision1993 Chap 15 Held Simon Early
Visual Development Normal and Abnormal Oxford
Press
  • Indicates in neonate disparity processing
  • Sensory Binocularity and Vergence Control is
    dependent upon MATURATION of the neuronal
    mechanism for binocular vision
  • Could it be that the transition period, when the
    vergence maintaining mechanisms switch control is
    the time at which the eye movement system is most
    susceptible to that loss of alignment which
    characterizes infantile esotropia?

121
Tychsen Chap 23 Simon Early Visual Development
Normal and Abnormal Oxford Press 1993
  • Infantile Esotropia
  • Rare before 4 months
  • Most divergent strabismus then to straight
  • Months 0-3 Unstable Eye Alignment and Immature
    Binocularity
  • No compensatory vergence movement seen to
  • No binocular Summation

122
WHY EYES STRAIGHTENTychsen Chap 23 Simon Early
Visual Development Normal and Abnormal Oxford
Press 1993
  • Two Major Possibilities Working Together
  • Active Process
  • Motion Pathways (Magnocellular-Where Is It)
  • Eyes driven inwardly N-T OKN Monocular)
  • The driving force for inward turning
  • Disparity Pathways (Magnocellular ?????)
  • The check to stop the inward turning

123
What is Happening and Why?Tychsen Chap 23 Simon
Early Visual Development Normal and Abnormal
Oxford Press 1993
  • Temporal to Nasal more Phylogenetic
  • Subcortical retina-brainstem pretectum-Maybe
  • Can measure T to N in very young
  • Can see a bias as to speed of movement
  • Speed is cortical not brainstem
  • Cortex initiates the movement--then brainstem
  • Nasal to Temporal more Ontogenetic
  • Fibers for N-T are fewer and develop later

124
Two stages Alignment Held Chap 15 Early Visual
Development Normal and Abnormal. Simons Oxford
Press 1993
  • PrimitiveLocal summation of binocular signals to
    form corresponding retinal loci may occur
  • Mature Complex processing of disparity,
    interocular inhibition and global processing
  • The step from Primitive to Mature is a Problem
    (See Helveston)

125
Development of Binocularity
  • Newborn does not demonstrate stereopsis
  • Newborn does not demonstrate cortical fusion
  • Infants cannot converge the eyes
  • Around 13 weeks, the eyes begin to converge
  • After convergence is demonstrated Every child
    seen demonstrated both stereopsis and cortical
    fusion

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Critical Time for Binocularity
  • 4 months Critical hinge point for the
    development of binocularity Looking up and out
  • If binocularity is present, each day one goes
    with binocularity, the more likely binocularity
    will be retained and/or restored
  • Increased incidence of esotropia seen at 2-3
    years (Scobee Keiner) when accommodation
    activity increases Begins to Reach out to the
    World

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Congenital Esotropia DefinedHelveston J Ped
Ophth 1993 215-232
  • 10-90
  • Normal neurology
  • does not eliminate tropia
  • Present by 6 mo
  • Not Congenital but Infantile

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VonNoordens Criteria
  • CURE FOR STRABISMUS RARELY ABSOLUTE
  • Subnormal Binocular vision
  • Microtropia
  • Small angle tropia
  • Large angle tropia

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VonNoorden Says
  • Surgery should be completed before 2 years of age
    on infantile esotropes
  • Functionally useful vision is possible after this
    age however
  • Optimal Desirable Groups Added together is
    better after 4 years
  • of unacceptable surgical outcomes less when
    surgery performed after age 4

130
VonNoorden Criteria
  • Subnormal Binocular (Optimum)
  • 0/Asymptomatic phoria---20/20 Each
    Eye--NRC--Fusional Amps--Foveal
    suppression--Low/no Stereo--Stability of
    alignment
  • Microtropia (Desirable)
  • Undetectable shift on cover-Mild
    amblyopia-ARC-Fusional amplitudes--EF--Low/no
    Stereo-Some Stability on Alignment
  • Small Angle Tropia (Acceptable)
  • Less than 20 --Amblyopia--80 ARC

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Surgery Pre-Post 2 YearsVonNoorden
  • N358
  • Only those corrected (not the failures)
  • all treated patientsincluded, fewer
    patientsobtained such good results
  • Included
  • Assumed 100 at 6 months
  • Stereo on vectographs or Worth 4 dot fusion
  • Residual tropia of lt 10

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Age surgery performed (/-10 Initially)VonNoord
en
133
Surgical Outcome by Age (VonNoorden) Percentage
134
VonNoorden Optimal/Desirable vs Acceptable
(lt20) or Unacceptable
135
VonNoorden lt20 or better by age
136
Hippocrates 5th Century B.C.First do no harm
  • abstain from whatever is deleterious and
    mischievous.abstain from every voluntary act of
    mischief and corruption

137
Dangers of SurgeryPerioperativePatient. Olitsky
et al.J Ped Ophth Strab 1997 126-8
  • Scleral Perforation
  • Post Operative Retinal Detachment
  • Cellulitis Abscess
  • Endophthalmitis
  • Lost/Slipped Muscle

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Helvestons Quotable Quotes Reoperation rates
up to and including the 1960s was 50Medial
rectus insertion site was found to have no
relationship to the angle of deviation in
esotropic patients
139
Helveston Reports from a variety of diverse
sources have in common the following
  • No patient with a confirmed congenital esotropia
    has completely normal binocularity after
    treatment
  • A wide array of seemingly unrelated motor
    anomalies develop after treatment, frequently
    after a latent period and in spite of early and
    accurate alignment

140
Helveston untreatedcongenitally esotropic
patientsteens or older
  • Esotropia remained but only 6 were amblyopic
  • Of those treated Amblyopia was 35 and 41 in a
    series of treated congenital esotropia patients

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Congenital esotropia vs. amblyopia surgery or
none
142
Congenital Esotropia?
  • Not common in new born (0/500)
  • High percentage new born have transient exotropia
  • Nixon (N1,219) neonate exams-not 1 case

143
deviations characteristic of congenitalesotropia
are not present at birthrather an anomalous
developmental process resulting in esotropia
occurs in the first few weeks or months of life
  • Nixon, Helveston, Miller, et. al. Incidence of
    strabismus in neonates. Am J Ophthalmology
    1985100798-801.

144
Conclusions Helveston
  • 1. Congenital ET not at birth
  • 2. 2/3 newborns XT
  • 3. Transient Eso resolves 2-4 mo
  • 4. Tx Eso after 4 mo Exo after 6 mo
  • 5. ET occurs in infant confirmed straight
  • 6. True Congenital ET 0.1
  • 7. Neonatal VI palsy transient/benign
  • 8. XT ET both in same neonate
  • 9. Orthotropization curve shows dynamics

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Development of binocularity Helveston
  • Stereo a factor of an inborn template
  • Congenital ET
  • Within 2 weeks of surgery Transient Stereo
  • After 2 weeks from surgery No Stereo
  • some believecongenital esotropia and
    asymmetric OKN are linked in etiology caused by
    anomalies in the magnocellular othersunbalanced
    stimulus to the nucleus of the optic track in the
    pretectal area

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Judicious Care First Do No Harm
  • Of Course, Insure there is no Pathology
  • Try the least invasive method first
  • Develop Alternation to solve Anisometropia and
    Amblyopia
  • Develop Bilateral and Biocular skills for equal
    neurological movement patterns
  • Labyrinthine
  • Neck/Body/Head Coordinated Interaction-- Eyes
    Guide Body

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Treatment of the Infantile Esotropia
  • Traditional Care
  • Lenses Full Plus and Excess Plus c Cyclo
  • Direct/Indirect Patching
  • No recommended VTx
  • Visual Hygiene and Environmental Modification
  • Judicious Care
  • Minimal, symmetrical lenses (Smith)
  • Minimal Patching with Penalization-Bi-Nasal
  • VTx
  • Mono/Bino OMD VTx
  • Gross Motor Activities
  • Visual Hygiene and Environmental Modification

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Judicious Care of Infantile Esotropia
  • WHY NOT???????
  • High Plus
  • Often times does not address the turn (young)
    AC/A not well developed
  • Potential for hyperopia
  • Can always add more plus-Difficult to take away
  • Titrate Up

149
Judicious Care of Infantile Esotropia
  • WHY NOT???
  • Occlusion
  • May develop amblyopia of the good eye
  • Strabismus and Amblyopia are binocular problems
    and occlusion causes one to be monocular
  • Does not address binocularity
  • Binasals/Equal Fixation Skill

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Judicious Tx Infantile ET
  • Try VT first
  • Go light on the ... certainly at first
  • When the ET manifests itself is important as to
    lens efficacy and effectiveness of VT
  • Amblyopia rare with alternation
  • Anisometropia rare with alternation
  • To prevent amblyopia/
  • anisometropia, teach alternation

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Judicious Care of Infantile Esotropia
  • Surgery
  • WHY NOT???
  • Best resultssub-normal binocular vision
    (VonNoorden)
  • Surgery success not significant until after 2
    years
  • Multiple Surgeries are often required
  • Complications such as Exotropia and Hypertropia
    and Restrictions often occur
  • VTx First

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Judicious VT for Infantile ET
  • Develop Alternation
  • Minimal Occlusion
  • Bi-nasal Occlusion-Asymmetric to Symmetric
  • Stimulation of the non dominant side
  • Wide excursions to all sides
  • Develop equal fixation

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Judicious VT for the Infant ET
  • Magnocellular function is impeded
  • Hering and Sherringtons Laws does not develop
    properly at some neurological level
  • Law of Developmental Direction
  • Reflexes
  • Mass Activity
  • Labyrinthine stimulation most primitive way to
    input EOM coordination

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Infantile Visual Hygiene
  • Fixate the human face (Black-White)
  • Encourage fixation of each eye
  • Mother moves face laterally close to babys face
    while mother talks to the baby
  • Checker type bumpers for cribs
  • Gentle bilateral massage
  • Stimulation of both sides of the body alternately
    and simultaneously
  • Move crib often and keep in center of room
  • Allow freedom of movement

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VT For the Infant/Toddler Esotrope
  • Monocular Pursuits and Saccades (Wide
    Excursions---Slap the Sockets)
  • Binasal Patching (Binocular)
  • Peripheral Stimulation
  • Food Handling-toys to non dominant side
  • Bilateral Activities
  • Give Me 5, Balance Board, Creeping, Crawling,
    Rolling, Trampoline, Basic Body, etc

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Infantile Vision Therapy
  • Bilateral massage
  • Left-right neck motion (Mother talking)
  • Beach ball roll
  • Penlight flash left-right, up-down, in-out
  • Cat bell (hand bell) saccades and pursuits
  • Convergence
  • Near Far Near (converge then rapidly take target
    away)

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