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Ditropan-associated Esotropia. Dr. Elaine Wong Dr. Lionel Kowal Ocular motility clinic, RVEEH CERA, Uni Melb, RVEEH. Ditropan-associated ET. 5 yo girl PMHx Hypothyroidism – on oroxine Enuresis HOPC Recent onset intermittent ET Closing L eye when drawing or reading

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ditropan associated esotropia

Ditropan-associated Esotropia

Dr. Elaine Wong

Dr. Lionel Kowal

Ocular motility clinic, RVEEH

CERA, Uni Melb, RVEEH

ditropan associated et
Ditropan-associated ET
  • 5 yo girl

PMHx

  • Hypothyroidism – on oroxine
  • Enuresis

HOPC

  • Recent onset intermittent ET
  • Closing L eye when drawing or reading
  • Recently started on Ditropan (Oxybutynin) for enuresis
examination @ presentation
Examination @ presentation
  • VAR 6/8 VAL 6/8
  • Near VAR 6/9 VAL 6/8
  • Stereopsis: Titmus fly 100”
  • CT: D) RET 15Δ N) RET’ 35Δ
  • OM: normal
  • Polarised 4 dot test: R suppression
  • Cycloplegic refraction:
  • R: +3.25; L + 2.75
ditropan associated et1
Ditropan-associated ET
  • After cessation of Oxybutynin
  • VAR 6/8 VAL 6/8
  • Near VAR 6/6 VAL6/8
  • CT: D) orthophoria
  • N) orthophoria
  • ELAINE : CHECK THE DATA ON THIS SLIDE PLS
  • Polarised 4 dot test: Fusion
  • Stereopsis: Titmus fly 100”
discussion oxybutynin
Discussion - Oxybutynin
  • Muscarinic receptor antagonist often used for overactive bladder
  • COMMONLY PRESCRIBED
  • Anticholinergic systemic SE
  • Ocular effects
    • Ciliary ganglion – accomodation
    • Pterygopalatine ganglion – lacrimation
ocular side effects of tolterodine and oxybutynin a single blind prospective randomized trial
Ocular side-effects of tolterodine and oxybutynin, a single-blind prospective randomized trial

Altan-Yaycioglu et al. Br J Clin Pharmacol 95:5, 588-592

  • 52 patients, 104 eyes
  • Randomised into
    • Tolterodine 2mg bd – 28 pts
    • Oxybutynin 5 mg tds – 24 pts
  • All examined by ophthalmologists
    • Schirmer’s
    • Accomodative amplitude
    • Pupillary diameter PD
discussion
Discussion

Tolterodine Oxybutynin

Accom amp (DS) 2.06 to 1.65 2.18 to 1.80

(p = 0.07) (p = 0.003)

Schirmer’s (mm) 12.82 to 12.32 12.21 to 14.83

(p = 0.698) (p = 0.342)

PD bright (mm) 1.94 to 2.02 2.07 to 2.08

(p = 0.174) ( p = 0.953)

discussion1
Discussion
  • In this case Oxybutynin
    • Impairs accommodation
    • Pre-existing moderate uncorrected +
    • To accommodate sufficiently to see, the pt converges, and the CA/C ratio then generates accommodation
    • hence ESOTROPIA!!!
    • ? Is Tolterodine (Detrusitol) safer
ditropan
Ditropan
  • Frequently prescribed
  • Has never been described as cause of ET!
  • Likely to cause accommodation and  convergence
  • Dit + hyperopia likely to cause ET
  • Almost certainly underrecognised