Consecutive exotropia 1 general comments 2 surgical audit
Download
1 / 24

Consecutive Exotropia 1. General comments 2. Surgical audit - PowerPoint PPT Presentation


  • 110 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Consecutive Exotropia 1. General comments 2. Surgical audit' - teenie


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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


22/32 ≤ ± 10 ∆

3/32 10% poor result





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 DS Amblyopia ≥ 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


ad