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STRABISMUS REOPERATION : A SECOND CHANCE. PRE-OPERATIVE EVALUATION LIONEL KOWAL MELBOURNE AUSTRALIA. STRABISMUS REOPERATION : A SECOND CHANCE. Starting points: This will be difficult I need to be careful and accurate in my evaluation My pt’s expectations may be unrealistically high.

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strabismus reoperation a second chance
STRABISMUS REOPERATION : A SECOND CHANCE

PRE-OPERATIVE EVALUATION

LIONEL KOWAL

MELBOURNE AUSTRALIA

strabismus reoperation a second chance2
STRABISMUS REOPERATION : A SECOND CHANCE

Starting points:

This will be difficult

I need to be careful and accurate in my evaluation

My pt’s expectations may be unrealistically high

strabismus reoperation a second chance3
STRABISMUS REOPERATION : A SECOND CHANCE

PRE-OPERATIVE EVALUATION

  • How did the pt get to this point?
  • Full exam
  • Surgical plan
  • Patient’s expectations = Dr’s
the need for re operation is it anyone s fault
THE NEED FOR RE-OPERATIONIS IT ANYONE’S FAULT?

CONG ET

NEED FOR RE-OPERATION CAN BE PART OF THE NATURAL HISTORY OF ALIGNMENT SURGERY

part of the natural history of alignment surgery
PART OF THE NATURAL HISTORY OF ALIGNMENT SURGERY

CIANCIA’S EXTRAORDINARY PERSONAL SERIES OF CONG ET

  • BMR SOME: OTHER MUSCLES ALSO
  • WEEK 1: 90% ORTHOTROPIA
  • 5Y: 10% CONSEC XT
  • 15+Y: 30% CONSEC XT

Follow up about 50%

natural history of successful alignment surgery in cong et
NATURAL HISTORY OF SUCCESSFUL ALIGNMENT SURGERY IN CONG ET
  • THAT AMOUNT OF MEDIAL RECTUS REPOSITIONING REQUIRED FOR ALIGNMENT IN CONG ET WILL, WITH SUBSEQUENT GROWTH OF EYE, MUSCLE, ORBIT

→ REDUCEDMR FUNCTION IN 30%

→ XT NEEDING TREATMENT

natural history of successful alignment surgery in cong et7
NATURAL HISTORY OF SUCCESSFUL ALIGNMENT SURGERY IN CONG ET
  • SUCCESSFUL HORIZONTAL STRAIGHTENING DOES NOT PRECLUDE SUBSEQUENT DEVPT OF DVD REQUIRING Rx
the need for re operation is it anyone s fault exotropias
THE NEED FOR RE-OPERATIONIS IT ANYONE’S FAULT? EXOTROPIAS
  • ET : MR ALWAYS TIGHT & MR Rc ADDRESSES THE BASIC PROBLEM.
  • XT DUE TO ‘ABNORMAL BALANCE OF FASCIAL FORCES WITHIN THE ORBITS’
  • XT : LR NOT ALWAYS TIGHT.
  • LR SURGERY DOESN’T ALWAYS ADDRESS THE BASIC PROBLEM IN XT → HIGHER LONG TERM FAILURE RATE THAN ET
the need for re operation is it anyone s fault9
THE NEED FOR RE-OPERATIONIS IT ANYONE’S FAULT?

SURGERY MECHANICALLY REALIGNS THE EYES

EYES THEN HELD STRAIGHT BY:

  • STABLE MUSCLE- SCLERA UNION

LUDWIG: NOT ALWAYS SO

  • NORMAL MUSCLE MECHANICS

5mm recess may function better than 7mm recess

  • FUSIONAL VERGENCE – KEEPS ANY MISALIGNMENT AS A PHORIA
sensory factors in maintaining straightness
SENSORY FACTORS IN MAINTAINING STRAIGHTNESS
  • GOOD SENSORY FUSION NEEDED FOR

GOOD MOTOR FUSION

  • HIGH AMETROPIA esp high+→

POOR PERIPHERAL FUSION →

SPONT / CONSEC XT MORE COMMON

  • POOR VISION →

POOR PERIPH & POOR CENTRAL FUSION →

SPONT XT MORE COMMON

pre operative evaluation history
PRE OPERATIVE EVALUATION:HISTORY

REOPERATION FOR DIPLOPIA

ACCURATE HISTORY : HOW TROUBLESOME IS IT?

Diplopia itself Sore neck?

COMMONLY MISSED BARRIERS TO FUSION:

** TORSION

** ANISEIKONIA

predisposition to diplopia
PREDISPOSITION TO DIPLOPIA

REALIGNMENT IN PT WITHOUT DIPLOPIA:

TESTS WITH probably GOOD Pos Pred Value FOR POST OP SINGLE VISION

1. CAN THE PT RECALL SINGLE VISION WHEN PERFECTLY ALIGNED?

2. PRISM & PAT

3. Botox testing [UK]

pre operative evaluaion history time course of strab
PRE OPERATIVE EVALUAION:HISTORYTIME COURSE OF STRAB

Recurrence / overcorrection seen early has different etiology / Rx / expectations to that seen late

Accurate history supported by Family Album Test important

pre operative evaluaion history time course of strab14
PRE OPERATIVE EVALUAION:HISTORYTIME COURSE OF STRAB

CASE 32 YO [XT], WORSE IF TIRED.

ET & THICK GLS WHEN YOUNG

RECALLS PARENTS’ / DOCTORS’ CONCERN ABOUT ADDUCTION IN Week 1 AFTER BMR age 7.

NOW : LMR UA > RMR UA

Manifest Refraction + 2 DS OU.

Uncorrected vision 20/20.

pre operative evaluation history stretched scar of ludwig
PRE OPERATIVE EVALUATION HISTORY STRETCHED SCAR OF LUDWIG
  • POOR SCAR MATURATION / ILLNESS / MALNUTRITION INTERFERES WITH INTEGRITY OF MUSCLE/ SCLERA UNION → STRETCHED SCAR
  • LOOKS LIKE MUSCLE HAS SLIPPED WITHIN ITS TENDON
  • POTENTIALLY HAZARDOUS DURING SURGERY [‘SNAP!’]
pre operative evaluation history stretched scar of ludwig16
PRE OPERATIVE EVALUATION HISTORY STRETCHED SCAR OF LUDWIG
  • ONE CAUSE OF CONSEC XT AFTER BMR
  • EXAMINE EASILY VISIBLE SURGICAL SCARS ON SKIN - ?THIN ATROPHIC SCARS MAY REFLECT MUSCLE / SCLERA UNION ? XS STRETCHMARKS
  • NON-ABSORBABLE SUTURES FOR REOP
pre operative evaluation the plan
PRE OPERATIVE EVALUATION:THE PLAN

40 yo WCF consec XT

No baby photos – looked too bad

4 surgeries ages 2,8,12,13

variously ET /XT

Never had diplopia

‘perfectly’ aligned ages 13-29

1st pregnancy @ 29: XT develops

pre operative evaluation the plan18
PRE OPERATIVE EVALUATION:THE PLAN

40 yo WCF consec XT

BCVA +3 etc 20/30+, +4 etc 20/40

XT 30Δ, XT’ 40Δ

Smooth pursuit asymmetry

RMR UA > LMR UA

Scars all H recti

pre operative evaluation the plan19
PRE OPERATIVE EVALUATION:THE PLAN

40 yo WCF consec XT

EXPECTATIONS

? Over Rc MR OU ? Stretched scar

SURGICAL PLAN

Explore MR OU with great care

Make MR function normal

Early ET desirable = best result

2nd best result : larger early ET

pre operative evaluation the examination
PRE OPERATIVE EVALUATION: THE EXAMINATION
  • DO AN ACCURATE / COMPLETE STRAB EXAM
  • CHECK GLS FOR Δ & PALs
  • NEUTRALISE STRAB WITH Δ & CHECK SENSORY RESPONSE
pre operative evaluation the examination factors that may modify the surgical plan
PRE OPERATIVE EVALUATION:THE EXAMINATION : FACTORS THAT MAY MODIFY THE SURGICAL PLAN
  • IF LATERAL / VERTICAL INCOMITANCES LOOK FOR ALL THE USUAL ASSOCIATED FACTORS TO MAKE SURE IT ALL ‘FITS’
pre operative evaluation the examination factors that may modify the surgical plan22
PRE OPERATIVE EVALUATION:THE EXAMINATION : FACTORS THAT MAY MODIFY THE SURGICAL PLAN
  • VERSION / DUCTION DEFICITS / OVERACTIONS
  • IS A DEFICIT DUE TO UA OR RESTRICTION?
  • MR UA looks like tight LR
  • FORCEPS TESTING – IS DUCTION DEFICIT DUE TO WEAKNESS OR RESTRICTION?
  • Rc LR when the MR is weak → result won’t last
pre operative evaluation special and fancy tests
PRE OPERATIVE EVALUATION:SPECIAL AND FANCY TESTS
  • RISK OF ISCHAEMIA

NEED TO OPERATE ON ADJACENT MUSCLES

  • NORMAL IRIS ANGIOGRAM ENCOURAGING
pre operative evaluation special and fancy tests24
PRE OPERATIVE EVALUATION:SPECIAL AND FANCY TESTS
  • WHEN TO SCAN
  • EVOLVING
  • IF THINGS DON’T ‘FIT’
pre operative evaluation
PRE OPERATIVE EVALUATION
  • Reops are difficult for patient and Dr
  • Careful complete assessment
  • Careful pt education
  • 2nd opinions sensible for difficult cases
  • Starting with humility is easier than having it thrust on you