Consecutive exotropia 1 general comments 2 surgical audit
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Consecutive Exotropia 1. General comments 2. Surgical audit. Lionel Kowal, Director Elaine Wong, 2005 Registrar & 2006 Fellow OCULAR MOTILITY CLINIC & CERA, RVEEH, MELBOURNE. CONSECUTIVE XT. Any XT happening after previous ET [usually after ET surgery] Rare: spontaneous consecutive XT.

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Consecutive Exotropia 1. General comments 2. Surgical audit

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Consecutive exotropia 1 general comments 2 surgical audit

Consecutive Exotropia 1. General comments2. Surgical audit

Lionel Kowal, Director

Elaine Wong, 2005 Registrar & 2006 Fellow

OCULAR MOTILITY CLINIC

& CERA, RVEEH, MELBOURNE


Consecutive xt

CONSECUTIVE XT

  • Any XT happening after previous ET [usually after ET surgery]

  • Rare: spontaneous consecutive XT

Old medial rectus

Surgery


Consecutive xt why

CONSECUTIVE XT - WHY?

  • Ciancia: CET. n=390.

    perfect early alignment after Cong ET surgery  30% consec XT over next 25y

  • Reason #1:

    If repositioned MR successfully aligns the eyes, subsequent growth of globe, muscle, orbit may alter this mechanical ‘balance’  mechanical disadvantage of repositioned MR *

    The ET correction doesn’t ‘grow’ with the pt *

    *Speculative - no evidence


The et correction doesn t grow with the pt

The ET correction doesn’t ‘grow’ with the pt

  • Globe growth:? Rc changes the way the sclera anterior to the new insertion subsequently grows : a 5mm Rc becomes a 7mm Rc *

    *Speculative - no evidence


Core defect in consec xt

Core defect in consec XT

  • Usually medial rectus underaction

  • Rx: Have to make MR function normal [or near- normal] for satisfactory long term result


1 l xt a pattern l r mr ua so oa ou

#1 : L XT ‘A’ pattern L>R MR UASO OA OU

Sup obl

OA OU

L XT

XT greater

on downgaze

‘A’ pattern

MR UA

L > R


2 rmr ua

#2, RMR UA

R XT

RMR UA

Right Gaze

LMR normal


3 rmr ua

#3, RMR UA

RMR UA

R XT


4 lmr ua

#4, LMR UA

LMR UA

L XT


Early consec xt why more reasons

Early consec XT - WHY?More reasons

  • #2: Wrong surgical dose

    Surgical tables assume normal globe size, average muscle stiffness [L-T curve], average scleral rigidity, average mechanical response of antagonist, ….

  • #3: Poor surgical technique

  • #4: Knots come undone

  • #5: Poor / aberrant early healing

    Vicryl hydrolysis not uniform


Delayed consec xt why

Delayed consec XT - WHY?

Reason #6

  • ‘Stretched scar’ - look for stretchmarks, healing of other surgical scars, ….

  • Scar remodelling is an ongoing lifelong process

  • Scar is metabolically more active than tendon

  • Ludwig IH J AAPOS. 2000 & Trans Am Ophthalmol Soc. 1999

    • Use non- absorbable sutures -  recurrence of stretched scar

      Reason #7: Scar migration* [Ludwig]

      *Speculative - no evidence


Audit of consecutive xt

Audit of Consecutive XT

  • LK private pts, 2y to Oct 2005:

  • 91 cases of consec XT

  • Av time to XT ~ 8 y

  • 58/91 : XT surgery by LK

  • 32 : follow up ≥1 y

  • Number of surgeries: 1- 4

    • Median: 1

    • Average:1.3

    • Botox for consec ET : 4 (10%)

    • Adjustables: 19 (57 %)


These are difficult cases

These are difficult cases

  • Need to make MR function normal or XT will recur

  • Difficult to dissect out tendons

  • Muscle ‘meat’ can be 20+ mm from limbus

  • Adjustables often necessary [57%]

  • Fat may be present

  • NO surgical tables

  • Guide: Early ET ≥ 10 ∆


Pre op range 6 66 xt av 31xt post op range 18et 45xt av 0 2 32 ended up worse work in progress

Pre-op: Range 6 – 66 XT; Av 31XTPost-op: Range 18ET – 45XT; Av 02/32: ended up worse! - work in progress


Consecutive exotropia 1 general comments 2 surgical audit

22/32 ≤ ± 10 ∆

3/32 10% poor result


Consecutive exotropia 1 general comments 2 surgical audit

Amblyopia no guide to surgical outcome


Consecutive exotropia 1 general comments 2 surgical audit

Hyperopia no guide to surgical outcome


Consecutive exotropia 1 general comments 2 surgical audit

Younger pts less likely to get bad results


Results 1

RESULTS 1

  • Gomez De Liano Sanchez et al

  • Consecutive exotropia surgery

    Arch Soc Esp Oftalmol. 2001

  • Retrospective n= 30

  • Before surgery, 53% amblyopia, 67% rotation limitation.

  • LR Rc OU for < 35 ∆

  • Advance 1-2 MR if > 35 ∆

  • 70%: ≤± 10∆> 50% one surgery.


Results 2

RESULTS 2

  • Donaldson MJ, Forrest MP, Gole GA

    Surgical management of consec XT

    J AAPOS. 2004

  • n=59. F/up ≥ 6w [mean 16 mo]

  • Sx : LR Rc, MR adv to original insertion

  • Time to XT Sx mean 14y (4mo-47 y) LK 8y

  • Mean preop XT 32 ∆ LK 31∆

  • Result ≤±10∆ : 71% @ final follow-up LK 71%

  • 66% : exodrift after surgery - mean 8 ∆


Spontaneous consecutive xt

Spontaneous consecutive XT

  • 2 cases of spontaneous consecutive XT

    • 2% of all consecutive XT

    • High +, amblyopia, cong ET

  • # 1 : 10 yo F, infantile ET

    • XT first noted ~ 2 yo

    • Now XT 10Δ with V

    • R +8.75, L +7.00

    • R amblyopia 6/12

    • No surgery


Spontaneous consec xt

Spontaneous consec XT

  • # 2

    • 30 yo F

    • Infantile ET ? Age onset XT

    • RXT 35Δ

    • R +7.50, L +4.50

    • R 6/45

    • R Rc/ Rs : RET 7Δ


Spontaneous consec xt1

Spontaneous consec XT

  • Alan Scott : unpublished series n= 19

  • ET ≤ 20 ∆Onset ≤ 2y

  • ≥ + 4 DSAmblyopia ≥ 1 line

  • 12/19 : spontaneous consec XT

  • Only 4/19 stayed ET

  • ET usually declined ≥ age 5

  • “This set you don’t want to touch surgically at an early age”

  • LK: 70 pts with ET > +6 2003-5

  • 2/70 spontaneous consec XT


Summary consec xt

SUMMARY - CONSEC XT

  • Difficult

  • Common in a dedicated strabismus practice

  • Common in a cong ET population

  • Expect 70% to do very well

  • Expect 10% not to do very well


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