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WHICH OPERATION FOR ESOTROPIA? EVIDENCE- BASED RECOMMENDATIONS SOME RECOMMENDATIONS HAVE LOTS OF EVIDENCE OTHERS HAVE L PowerPoint Presentation
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WHICH OPERATION FOR ESOTROPIA? EVIDENCE- BASED RECOMMENDATIONS SOME RECOMMENDATIONS HAVE LOTS OF EVIDENCE OTHERS HAVE L - PowerPoint PPT Presentation


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WHICH OPERATION FOR ESOTROPIA? EVIDENCE- BASED RECOMMENDATIONS SOME RECOMMENDATIONS HAVE LOTS OF EVIDENCE OTHERS HAVE LESS. LIONEL KOWAL RANZCO 2008. BMR vs. Rc-Rs. If D = N & ≤ 35∆ : little / no difference

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WHICH OPERATION FOR ESOTROPIA?EVIDENCE- BASED RECOMMENDATIONSSOME RECOMMENDATIONS HAVE LOTS OF EVIDENCEOTHERS HAVE LESS

LIONEL KOWAL

RANZCO 2008

bmr vs rc rs
BMR vs. Rc-Rs
  • If D = N & ≤ 35∆ : little / no difference
  • If N > D [high AC/A, convergence Xs,..] most [inc. many Rc-Rs enthusiasts] will do BMR (usually augmented in some way)
  • Densely amblyopic ET N>D:

Augment the MR Rc part of Rc-Rs with Faden or pulley suture

what happens when mr is recessed in et
What happens when MR is recessed in ET?

New position of globe : rotates f/w in the orbit

Reduced torque : less chance of recurrent ET

No LR Rs

  • LR: As globe rotates forward, LR insertion rotates posteriorly in orbit & LR now has some slack. Takes up slack quickly. 1-2w to see final effect

LR Rs

  • LR tension matches MR tension

Slight LR tension in next 2-4w..to see final effect

bmr reliability of surgical tables
BMR Reliability of surgical tables
  • Over range 15 - 50 ∆

In month 2: orthotropia achieved in ~80% of cases with poor / no motor fusion & >> 80% with some/ good motor fusion [‘capture range’]

  • PAT study: sensory fusion postop [and preop with ∆] larger factor in alignment outcome than surgical dose
bmr fudging the tables
BMR Fudging the tables
  • Parks: augment BMR dose in conv Xs

Parks: Distance mm + 1mm OU

Most: Usual tables for near angle

bmr fudging the tables for
BMR Fudging the tables for +

Wright: augment BMR dose for low+ in hope of reducing spectacle dependence

  • ≥ +3 : no fudging for +
  • ~+2: add 0.5mm to one muscle, not the tighter one. Any consec XT should be lessened by uncorrected +
  • +1: do not increase BMR dose. No + to soak up any consec XT
fudging for big small globes
Fudging for big / small globes
  • >24mm: add 10% to dose
  • <20mm: cut 10%
bmr fudging the tables8
BMR Fudging the tables
  • Roth:

reduce MR dose for a tight muscle

how far can a medial rectus safely be recessed
How far can a medial rectus safely be recessed?
  • J Pediatr Ophthalmol Strabismus. 1994Kushner BJ…
  • .. MR Rc up to 1.5 mm posterior to equator should not produce postoperative MR underaction ..[and] .. overcorrection
  • MR Rc > 1.5 mm posterior to equator may do so.
  • Need K’s, axial length and a table
  • LK: 6.5 mm [AL <20: 6mm]
long term consec xt after bmr
Long term consec XT after BMR
  • Infants straightened <12 mo age: ~1% p.a. rate of consecutive XT

Reasons

  • 1. Over-recessed or surgical mishap
  • 2. New post- surgery geometric relationship that  orthotropia @ age 12 mo doesn’t grow ‘perfectly’ over next 10 - 20y
  • 3. Scar b/w MR & sclera stretches
rc rs
Rc - Rs
  • No tables for > 35∆

Possibly less consec XT

  • Any tendency to scar stretching will apply to both LR & MR

Acquired vertical

  • 2° to inadvertent inf obl capture
rc rs c f bmr
Rc - Rs c.f. BMR

Refractive effects:

  • More temporary astigmatism 20+%

Might make amblyopia worse

Lid changes

  • More noticeable if involves one eye than with small symmetric changes of BMR
up to 35
Up to 35∆
  • BMR or Rc-Rs?
  • Do the procedure you do better
35 50
35 - 50 ∆

BMR

  • 35 ∆: 5mm
  • 50 ∆: 6mm

In between, can do

  • 40 ∆: 5 / 5.5
  • 45 ∆: 5.5 / 6

LK: Smaller dose on the tighter MR

slide15
60 ∆
  • BMR 6mm for 50 ∆
  • Each MR 6mm: 25 ∆
  • BLR resect 5 mm: 20 ∆
  • Each LR resect 5 mm: 10 ∆
  • 60 ∆: BMR 6mm plus one LR resect 5mm
slide16
60 ∆
  • BMR 6
  • 2.5 u Botox for one MR
  • 70 ∆
  • …each MR
one medial rectus
One medial rectus
  • Up to 4mm : for ~10 ∆
  • Little experience
  • LK worries about lateral incomitance
et d n divergence xs
ET : D>NDivergence Xs

Options

  • Prism adaptation to see if will augment for N with view to doing BMR or
  • Rc-Rs or LR Rs OU
numerous other variables
Numerous other variables
  • Personal surgical technique esp. Rs
  • Generic “Vicryl”
  • Scar formation

……………

Thank you!