Title: EXOTROPIA
1EXOTROPIA
GEORGE N PAPANIKOLAOU SHO OPHTHALMOLOGY SINGLETON
HOSPITAL SWANSEA
2BURIANS CLASSIFICATION
- INTERMITTENT
- Basic
- Divergence excess
- Convergence insufficiency
- Simulated or Pseudo-Divergence excess
3KUSHNERS CLASSIFICATION
Type Description
Basic DN 37
Tenacious proximal fusion DgtN 60 min occlusion DN 40
High AC/A ratio DgtN 5
Proximal convergence DgtNAC/A normal 4
Low AC/A ratio NgtD 11
Fusional convergence insufficiency NgtD lt1
Pseudo-Convergence insufficiency NgtD 60 min occlusion DN lt1
4 5- CONSTANT CONCOMITANT
- End-stage decompensated intermittent
- Infantile (NEUROLOGICAL IMPAIRMENT)
- Sensory
- Consecutive
- DHD
6- III palsy
- Duane type II
- Primary monofixational exo
- Craniofacial abnormalities/ orbital pathology
- INO
- MG
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9- PSEUDOEXOTROPIA
- Positive angle kappa without ocular abnormalities
- Wide IPD
- Positive angle kappa ocular abnormalities
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11DIAGNOSTIC WORK-UP
- VA
- Motility
- Measurements (N, 6m, distance)
- Refraction
- Pupils/ Slit-lamp/ Fundus (sensory)
- Proptosis
- CT/ MRI
- Tensilon test
12CLINICAL CHARACTERISTICS
INTERMITTENT (IDEX) Age 6/12- 4y/ FgtM/ gt10?/
uni-, bilateral 1 of population ? Progressive/
stable/ improve Bright light A and V patterns/
hypertropias No amblyopia/ Good stereopsis No
diplopia when exo (suppressionARC) Panoramic
vision (large angle/ no confusion) Fatigue/
illness/ day dreaming/ visual distraction-inattent
ion/ distance viewing/ alcohol/ sedatives
13- HISTORY
- Family history
- Age of onset
- Progression
- Frequency/ Triggers
- Control
- Good
- Fair
- Poor
- NCS
14EVALUATION OF IDEX
- Convergence
- PCT (primaryD, N/ lateral gaze (incomitance)
- N/D disparity AC/A ratio
- Far distance measurements
- DN after 30-60min monocular occlusion (max)
- Binocular VA at 6m
- Min. 3 visits
15MANAGEMENT
- PROBLEMS
- Lack of standard definition of success
- Variability of classification systems
- Multiple treatment approaches
- Paucity of long term data
- Undefined natural history of disease
- Absence of randomised evidence
16- NON-SURGICAL
- lt20?
- Very young
- ?AC/A ratio
17OPTIONS
- Treat amblyopia/ anisometropia/myopia/ gt 4.00D
- Minus lenses/ Bifocals
- BI prisms
- Tinted gls
- BTX
- Part time patching (passive orthoptic Rx)
- Active orthoptic Rx
18- SURGICAL
- gt20?
- gt50 of time
- Deterioration of control for near
- Failure of non-surgical
- Problems at school
- Early
- Late (gt5y)
- BEST RESULTS (sensory)
- lt4 years
- Success 60-70
19GENERAL PRINCIPLES
- Overcorrection (10-15 ?)
- Operate on the largest distance deviation
- Lateral incomitance gt10 ? reduce surgical
dosage - gt35- 50? 3 muscles
- Adjustable sutures
- Large RR induce incomitance
20CLASSIC TEACHING
Divergence excess BLR
Basic RR
Simulated divergence excess RR
Convergence insufficiency BMR
21MANAGEMENT BASED ON KUSHNERS CLASSIFICATION
Type Rx/PROGNOSIS
Basic BLR recession or R and R
Tenacious proximal fusion BLR recession/ GOOD
High AC/A ratio Overcorrecting minus lens spectacles with bifocals/ consecutive eso at near
Proximal convergence BLR recession
Low AC/A ratio Poor response
Fusional convergence insufficiency Convergence trainining
Pseudo-Convergence insufficiency BLR recession
22Surgical dosages (symmetrical surgery)
Angle (?) Recess LR (mm) Resect MR(mm)
15 4.0 3.0
20 5.0 4.0
25 6.0 5.0
30 7.0 6.0
40 8.0 6.0
23Surgical dosages for monocular recess-resect
procedures
Angle Recess LR (mm) Resect MR(mm)
15 4.0 3.0
20 5.0 4.0
25 6.0 5.0
30 7.0 6.0
40 8.0 6.0
50 9.0 7.0
60 10.0 8.0
70 10.0 9.0
80 10.0 10.0
24BENEFITS OF TREATMENT
- Some binocularity achieved
- Psychosocial impact
- Compromise in occupational and professional life
25- MANAGEMENT OF CONSECUTIVE ESOTROPIA
- alternate occlusion
- prisms
- BTX (one MR/ if fusion present)
- re-operation after 6/12
26- MANAGEMENT OF UNDERCORRECTION
- non- surgical
- surgical (same dosage as if for primary)
- MANAGEMENT OF RECURRENT EXOTROPIA (usually within
6/12) - prisms minus lenses
- re-operate
27Main Results No studies were found that met our
selection criteria and therefore none were
included for analysis. Reviewers' conclusions
The available literature consists mainly of
retrospective case reviews. These are difficult
to compare and analyse due to a large variation
in the definition of intermittent distance
exotropia, intervention criteria and outcome
measures. However there seems to be general
agreement that non-surgical treatment is most
appropriate in small angle deviations or as a
supplement to surgery. Studies were found
supporting both early and late surgical
intervention so the optimal timing of surgical
intervention cannot be concluded. Recent work
indicates that bilateral surgery may be the most
effective surgical procedure in these cases.
There is clearly a need for carefully planned
clinical trials to be undertaken to improve the
evidence base for the management of this
condition. This review should be cited
asRichardson S, Gnanaraj L Interventions for
intermittent distance exotropia (Cochrane
Review). In The Cochrane Library, Issue 4, 2003.
Chichester, UK John Wiley Sons, Ltd.
28RCTS PLEASE!!!!
THANKS