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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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Presentation Transcript
slide1

EXOTROPIA

GEORGE N PAPANIKOLAOU

SHO OPHTHALMOLOGY

SINGLETON HOSPITAL

SWANSEA

slide2

BURIAN’S CLASSIFICATION

  • INTERMITTENT
  • Basic
  • Divergence excess
  • Convergence insufficiency
  • Simulated or Pseudo-Divergence excess
slide5

CONSTANT CONCOMITANT

  • End-stage decompensated intermittent
  • Infantile (NEUROLOGICAL IMPAIRMENT)
  • Sensory
  • Consecutive
  • DHD
slide6

CONSTANT INCOMITTANT

  • III palsy
  • Duane type II
  • Primary monofixational exo
  • Craniofacial abnormalities/ orbital pathology
  • INO
  • MG
slide9

PSEUDOEXOTROPIA

  • Positive angle kappa without ocular abnormalities
  • Wide IPD
  • Positive angle kappa+ ocular abnormalities
slide11

DIAGNOSTIC WORK-UP

  • VA
  • Motility
  • Measurements (N, 6m, distance)
  • Refraction
  • Pupils/ Slit-lamp/ Fundus (sensory)
  • Proptosis
  • CT/ MRI
  • Tensilon test
slide12

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

slide13

HISTORY

  • Family history
  • Age of onset
  • Progression
  • Frequency/ Triggers
  • Control
  • Good
  • Fair
  • Poor
  • NCS
slide14

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
slide15

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
slide16

NON-SURGICAL

  • <20
  • Very young
  • AC/A ratio
slide17

OPTIONS

  • Treat amblyopia/ anisometropia/myopia/ > +4.00D
  • Minus lenses/ Bifocals
  • BI prisms
  • Tinted gls
  • BTX
  • Part time patching (passive orthoptic Rx)
  • Active orthoptic Rx
slide18

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%
slide19

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
slide24

BENEFITS OF TREATMENT

  • Some binocularity achieved
  • Psychosocial impact
  • Compromise in occupational and professional life
slide25

MANAGEMENT OF CONSECUTIVE ESOTROPIA

  • alternate occlusion
  • prisms
  • BTX (one MR/ if fusion present)
  • re-operation after 6/12
slide26

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
slide27

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.

slide28

RCT’S

PLEASE!!!!

THANKS

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