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EXOTROPIA. GEORGE N PAPANIKOLAOU SHO OPHTHALMOLOGY SINGLETON HOSPITAL SWANSEA. BURIAN’S CLASSIFICATION. INTERMITTENT Basic Divergence excess Convergence insufficiency Simulated or Pseudo-Divergence excess. KUSHNER’S CLASSIFICATION. CONSTANT CONCOMITANT

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EXOTROPIA

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EXOTROPIA

GEORGE N PAPANIKOLAOU

SHO OPHTHALMOLOGY

SINGLETON HOSPITAL

SWANSEA


BURIAN’S CLASSIFICATION

  • INTERMITTENT

  • Basic

  • Divergence excess

  • Convergence insufficiency

  • Simulated or Pseudo-Divergence excess


KUSHNER’S CLASSIFICATION


  • CONSTANT CONCOMITANT

  • End-stage decompensated intermittent

  • Infantile (NEUROLOGICAL IMPAIRMENT)

  • Sensory

  • Consecutive

  • DHD


  • CONSTANT INCOMITTANT

  • III palsy

  • Duane type II

  • Primary monofixational exo

  • Craniofacial abnormalities/ orbital pathology

  • INO

  • MG


  • PSEUDOEXOTROPIA

  • Positive angle kappa without ocular abnormalities

  • Wide IPD

  • Positive angle kappa+ ocular abnormalities


DIAGNOSTIC WORK-UP

  • VA

  • Motility

  • Measurements (N, 6m, distance)

  • Refraction

  • Pupils/ Slit-lamp/ Fundus (sensory)

  • Proptosis

  • CT/ MRI

  • Tensilon test


CLINICAL CHARACTERISTICS

INTERMITTENT (IDEX)

Age: 6/12- 4y/ F>M/ >10/ uni-, bilateral

1% of population

? Progressive/ stable/ improve

Bright light

A and V patterns/ hypertropias

No amblyopia/ Good stereopsis

No diplopia when exo (suppression+ARC)

Panoramic vision (large angle/ no confusion)

Fatigue/ illness/ day dreaming/ visual distraction-inattention/ distance viewing/ alcohol/ sedatives


  • HISTORY

  • Family history

  • Age of onset

  • Progression

  • Frequency/ Triggers

  • Control

  • Good

  • Fair

  • Poor

  • NCS


EVALUATION OF IDEX

  • Convergence

  • PCT (primary:D, N/ lateral gaze (incomitance)

  • N/D disparity: AC/A ratio

  • Far distance measurements

  • D+N after 30-60min monocular occlusion (max)

  • Binocular VA at 6m

  • Min. 3 visits


MANAGEMENT

  • 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


  • NON-SURGICAL

  • <20

  • Very young

  • AC/A ratio


  • OPTIONS

    • Treat amblyopia/ anisometropia/myopia/ > +4.00D

    • Minus lenses/ Bifocals

    • BI prisms

    • Tinted gls

    • BTX

    • Part time patching (passive orthoptic Rx)

    • Active orthoptic Rx


    • SURGICAL

    • >20

    • >50% of time

    • Deterioration of control for near

    • Failure of non-surgical

    • Problems at school

    • Early

    • Late (>5y)

    • BEST RESULTS (sensory)

    • <4 years

    • Success: 60-70%


    GENERAL PRINCIPLES

    • Overcorrection (10-15 )

    • Operate on the largest distance deviation

    • Lateral incomitance >10  : reduce surgical dosage

    • >35- 50: 3 muscles

    • Adjustable sutures

    • Large R+R: induce incomitance


    CLASSIC TEACHING


    MANAGEMENT BASED ON KUSHNER’S CLASSIFICATION


    Surgical dosages (symmetrical surgery)


    Surgical dosages for monocular recess-resect procedures


    BENEFITS OF TREATMENT

    • Some binocularity achieved

    • Psychosocial impact

    • Compromise in occupational and professional life


    • MANAGEMENT OF CONSECUTIVE ESOTROPIA

    • alternate occlusion

    • prisms

    • BTX (one MR/ if fusion present)

    • re-operation after 6/12


    • 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


    Main ResultsNo studies were found that met our selection criteria and therefore none were included for analysis.

    Reviewers' conclusionsThe 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 as:Richardson S, Gnanaraj L Interventions for intermittent distance exotropia (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd.


    RCT’S

    PLEASE!!!!

    THANKS


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