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Binocular vision YR 3 > management of concomitant esotropia > Flashcards

management of concomitant esotropia Flashcards

1
Q

how will you correctly diagnose someone with the correct type of esotropia with refraction

A

Refraction with cycloplegia

  • 0.5% cyclo under 6/12 of age
  • 1% cyclo over 6/12 of age
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2
Q

as well as cyclopegic refraction and glasses with correction, what else must you do in order to correctly diagnose someone with a concomitant esotropia

A

by reviewing the px after the cyclo refraction and carrying out a fundus check to rule out any pathology

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3
Q

how is vision taken in order to manage a patient with a concomitant esotropia

A
  • Best possible visual acuity in either eye
  • Full hyperopic correction with glasses
  • Treat amblyopia with patching if need be or glasses - aim is equal VA ( but may not always be possible if had poor vision to begin with, treatment can be difficult)
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4
Q

why must you improve the alignment of the visual axes when managing a concomitant esotropia

A

To:

  • Restore Binocular Single Vision (BSV) - if they have late onset esotropia
  • Enhance Abnormal Retinal Correspondence (ARC)

OR

  • Achieve an acceptable cosmetic outcome (if no potential for BSV or ARC, can use botox or do surgery etc)
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5
Q

list the 3 things needed to be taken into consideration for the management of esotropia

A
  • Cycloplegic refraction
  • best possible VA’s in either eye
  • improve the alignment of the visual axes
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6
Q

list the 5 possible management options for treating a concomitant esotropia

A
  • Optical - Full hyperopic correction too all px with esot/prisms
  • Orthoptic Exercises
  • Surgery
  • Botulinum Toxin Type A injections
  • Combination of the above
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7
Q

when is orthoptic exercises a good management option for a concomitant esotropia and why

A
  • it is good especially if the patient has a decompensating deviation
  • because they have more potential to correct the angle of deviation
  • especially in those with a near or distance esot
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8
Q

for which type of concomitant esotropia is surgery a good option for and for which is it not a good option for

A
  • good for all esotropias except for accommodative esotropia
  • it is good for large angle esotropia and convergence excess esotropia
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9
Q

on which type of patients will you carry out botox on more and under which procedure conditions

A
  • carried out on children more than adults

- patient has to be on general anaesthetic if they’re below the age of 12

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10
Q

why is a full hyperopic correction given to patients with an esot and which group of patients is it given to more

A
  • Relax accommodation and thus reduce convergence

- Most common in children

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11
Q

which 3 possible effects will a full hyperopic correction/glasses have on a squint when worn

A
  • 1/3rd children fully correct squint
  • 1/3rd partially correct squint
  • 1/3rd have no effect on angle of squint
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12
Q

on which type of squint will a hyperopic correction fully correct

A
  • a child with a fully accommodating esot
  • this type of child will have BSV/ESOP with the spectacle correction on
  • no exercises or surgery is needed
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13
Q

on which type of squint will a full hyperopic correction only partially correct the squint

A
  • a child with a partially accommodating esot
  • this type of child will still be manifest
  • however the squint will be reduced and hence not as noticeable with glasses
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14
Q

on which type of squint will a full hyperopic correction have no effect on the angle of the squint

A
  • a child with a non-accommodating esot

- this type of child will be manifest with the same amount of angle with or without the correction

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15
Q

which type of prism will you give to a patient with a concomitant esotropia

A
  • base out prism

- either as Fresnels prisms or incorporated into glasses

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16
Q

which type of patients will you give a prism to for correcting their esot

A
  • patients with a late onset esot, where they will have diplopia
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17
Q

which type of patients is prisms rarely used on

A
  • in paediatric patients

- as we don’t want them to get used/dependent on them

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18
Q

other than to permanently correct someone with an esot with prisms, which 2 other occasions will you use prisms on a patient with an esot

A
  • Investigate binocular function before proceeding with surgery i.e. on a patient with a late onset esotropia: done using fresnel prisms, if when angle of deviation is corrected by surgery, are they still going to get double vision?
  • Assess risk of diplopia post-operatively: if they will get diplopia or are they suppressing with a prism bar
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19
Q

what will orthoptic exercises be used to improve

A
  • negative relative convergence

- due to patients with over accommodation, to help them diverge more

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20
Q

which type of esot/squint will orthoptic exercises work on only

A

Only used in INTERMITTENT convergent squint

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21
Q

name 2 appliances that can be used for orthoptic exercises to improve negative relative convergence

A
  • stereo grams

- dot pad

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22
Q

on which acting muscles will surgery for correcting an esot be performed on, and which type of surgery on which type of muscles

A
  • Usually performed on horizontally acting muscles

Recession (weakening) of medial rectus

Resection (strengthening) of lateral rectus

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23
Q

which type of surgery is conducted on someone with a esot greater at near

A

Both medial rectus recessions

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24
Q

which type of surgery is conducted on someone with a esot greater at distance

A

Both lateral rectus resections

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25
Q

which type of surgery is conducted on someone with a esot where near angle = distance angle

A

MR recession and LR resection on one eye/each eye

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26
Q

what type of treatment is a Botulinum Toxin Type A injection (BTXA)

A

an outpatient treatment

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27
Q

what is Botulinum Toxin Type A

A

a neuro-toxin which paralyses muscle into which it is injected

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28
Q

how is Botulinum Toxin Type A used to treat a strabismus

A
  • strabismus it is injected into one or more of the EOM to cause paralysis thus giving the antagonist an advantage
  • injected into the medial rectus for esotropia
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29
Q

how will Botulinum Toxin Type A be used on a patient with a small esot and a moderate esot

A
  • small esot: inject into one MR of the affected eye

- moderate esot: inject into MR of both eyes

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30
Q

list 4 advantages of Botulinum Toxin Type A for use in esot

A
  • Preferred by many patients with consecutive /residual or secondary deviations
  • Useful in cases where previous surgery undertaken
  • Very useful if diplopia is suspected (post-op diplopia test)
  • Used when patient is unfit for GA
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31
Q

what is the post-operative management for an amblyopic esotropic child

A

Monitor amblyopia until the end of visual development (8 years)
- maintenance occlusion

i.e. we still want to continue with occlusion treatment if are undergoing already, so want to carry on to get the best outcome

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32
Q

what is the post operative management for Residual and Consecutive deviations

A

they may need treatment in the future

  • Residual: their post-operative esotropia will be better than their pre operative deviation, however they can suddenly decompensate and get a large angle esotropia, therefore may need more treatment in the future
  • Consecutive: they can become an executive exotropia post operatively, and if it’s fairly small angled then you don’t need to do anything about that
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33
Q

what is the two classifications of primary esotropia

A
  • constant
    or
  • intermittent
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34
Q

what is the management of an intermittent accommodative esotropia, and name the 2 types of accommodative intermittent esotropia that this management falls into

A

Order full plus, allow only for working distance

  • Fully accommodative esotropia: when they’re straight and binocular with their specs, and esotropic without their specs
    and
  • Convergence excess esotropia: they’re straight and binocular at distance with their full +ve rx, but esotropic at near when they’re accommodating but could be straight at near when looking at a non-accommodative target (e.g. to a light)
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35
Q

what do children who have an intermittent accommodative esotropia usually do if they’re 5 y/o

A
  • if under 5 years old, the child will usually suppress when removing their glasses
  • if over 5 years old, the child may complain of diplopia when removing their glasses
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36
Q

what are fully accommodative esotropias able to do without their glasses

A

able to relax accommodation (BSV but vision blurred)

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37
Q

what will happen if a fully accommodative esotropia exerts accommodation without their glasses

A

they will have an esotropia

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38
Q

which power of glasses will a child with fully accommodative esotropia need to wear their glasses forever

A

If >+3.00 DS and 1 DC

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39
Q

what can you teach a fully accommodative esotropic px that is wearing glasses less than +3.00DS and 1 DC to do to make their eyes look straight and what are the 3 ways of achieving this

A

can teach control without glasses i.e. straight eyes without glasses for photos etc

  • Recognition of diplopia
  • Relaxation of accommodation to give ONE blurred image “misty and clear” (makes the image blurry and hence the eyes straight)
  • Improve BVA by exertion of negative relative convergence using exercises
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40
Q

what can you teach a fully accommodative esotropic px that is wearing glasses of more than +3.00DS to do to make their eyes look straight

A

the “misty and clear” method (taught to older children)

if the px takes their glasses off and makes the image clear, then this means their accommodating and hence will be squinting, however if they take their glasses off and keep the image blurry, their eyes will be straight

you can also get the patient to recognise the real image of their diplopia without their glasses, if they do appreciate the diplopia, then the eyes are over accommodating and hence will be turning in

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41
Q

what treatment is never indicated in children with fully accommodative esotropia and why

A

surgery is never indicated

because the full hypermetropic rx is perfectly controlling their esotropia

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42
Q

which type of esotropia can be managed my optometrists and why

A

fully accommodative esotropia

because the patient does not need any further treatment apart from their full hypermetropic correction

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43
Q

what should be treated with a convergence excess esotropia, even if theres any or even slight (due to it being intermittent esotropia)

A

any amblyopia

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44
Q

what is the reason for someone having a convergence excess esotropia

A

they have a high AC/A ratio

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45
Q

what is the aim of treatment for someone with a convergence excess esotropia

A

to give BSV at all distances with the glasses if hypermetropic i.e. turn into fully accommodative esotropia

46
Q

why is amblyopia rare or slight in a convergence excess esotropia

A

because it is an intermittent esotropia

47
Q

when does the esotropia occur in a convergence excess esotropia

A

on accommodation at near

48
Q

when is no deviation seen with a convergence excess esotropia

A
  • when fixating on a light at near, as the px is not accommodating
    and
  • on distance fixation with hyperopic correction
49
Q

what does the high AC/A ratio present in someone with a convergence excess cause

A

esotropia at near on accommodation

50
Q

which type of treatment is suitable for patients with convergence excess esotropia and how is this treated

A
  • Executive Bifocals – give minimum extra +ve for reading to achieve a BVA of 6/6 with reduced Snellens
  • The amount of add is slowly reduced e.g. by –0.50DS every 6 months (on average), this is done by putting up a -0.50D lens in front of reading rx and see if px is still orthophoric
51
Q

what is the aim of bifocals which are reduced by -0.50D every 6 months to treat a convergence excess esotropia

A

to achieve BSV for near and distance with a single focus lens

52
Q

what is the contra indication of using bifocals to treat a convergence excess esotropia

A

If there’s a large deviation and very high level of the AC/A >10:1

you can’t give the patient any bifocal add

53
Q

as well as bifocals, what else is available as treatment for a convergence excess esotropia and what type

A
  • surgery

- both medial rectus recessed (weakened as larger angle for near than distance)

54
Q

when may a patient need further surgical operation for a convergence excess esotropia

A

if the px still has a manifest deviation

55
Q

what is considered to be a normal AC/A ratio

A

2-4:1

56
Q

when may a convergence excess esotropia px still need to use bifocals post-operatively

A

if they’re still becoming esotropic for near on accommodation

they will be straight at distance but will have a small esot at near
therefore treatment can be a combination of surgery and bifocals if surgery not 100% successful (in cases of very high AC/A ratios)

57
Q

what is normal in a non-accommodative esotropia and what is the symptom/sign of a non-accommodative esotropia

A

Normal AC/A ratio

straight and binocular for distance but manifest and suppression at near

58
Q

what is a non-accommodative esotropia for near not related to and what is it more commonly related to

A
  • not related to accommodation
  • convergence excess is much more common

if you shine a light into the px eye, they will still be esotropic, these patients have a normal AC/A ratio (which is the difference with non-accommodative and convergence excess esotropia)

59
Q

what is the treatment option for someone with a non-accommodative esotropia and which type

A

Surgery

Recess both medial recti

60
Q

which group of patients is a non-accommodative distance esotropia usually found in

A

adults

61
Q

what happens to someone with a non-accommodative distance esotropia over time

A

gradually increases

62
Q

what must you ensure that a patient with a non-accommodate distance esotropia does not have and how is this seen

A

a LR/6th nerve palsy i.e. their abduction should be full

63
Q

what 2 things is a non-accommodative distance esotropia associated with

A
  • age
    or
  • myopia
64
Q

what are the 2 treatment options for someone with a non-accommodative distance esotropia

A

Prisms - Base out

Surgery - Resect both lateral recti

65
Q

why will you use base out prisms to treat a patient with a non-accommodative distance esotropia and when will you use this over surgery

A
  • because they’re adults, base put prisms is needed to manage their diplopia
  • prisms used over surgery especially if the esotropia is gradually increasing
66
Q

when will surgery be suitable for a person with a non-accommodative distance esotropia

A

if its a large stable esotropia

67
Q

what is non-specific non-accommodating esotropia

A

Esotropia intermittently occurs for near and distance

68
Q

which group of patients is a non-specific non-accommodating esotropia more common in

A

adults

69
Q

what can be used to treat a non-specific non-accommodating esotropia if the deviation isn’t too large

A

If glasses are worn may be able to use base out prisms

70
Q

other than base out prisms in glasses, what other treatment option is there for a non-specific non-accommodating esotropia

A
  • BTXA but surgery more likely

Surgery on one eye medial rectus recession and lateral rectus resection

71
Q

what type of surgery is carried out on someone with a non-specific non-accommodating esotropia

A

on one eye medial rectus recession and lateral rectus resection

72
Q

when will BTXA be used on a patient with a non-specific non-accommodating esotropia and which muscles will it be injected in

A
  • if its a large angle and decompensating more readily compared to it being straight and binocular
  • BTXA is injected into the medial rectus muscle to correct this
73
Q

what is a cyclic esotropia

A
  • a esotropia thats related to time
  • The “cycle” is usually 24hrs initially
    i. e. esotropia one day and straight with BSV/suppression the next day
  • Pattern becomes disrupted over time and the deviation becomes constant
74
Q

what can happen to a cyclic esotropia over time

A

the 24 hour pattern becomes disrupted and the deviation becomes disrupted

75
Q

when will you manage a patient with cyclic esotropia and that will the management be

A
  • when the patient’s esotropia becomes constant esotropia from the cyclic esotropia
  • Surgery is indicated on one eye
    Medial rectus recession and lateral rectus resection
76
Q

what type of surgery is indicated on someone with a constant esotropia from having a cyclo esotropia first

A

Medial rectus recession and lateral rectus resection on one eye only

77
Q

at what age is the onset of a constant non-accommodative esotropia most commonly found

A

Esotropia onset >6 months of age – usually onset at approx 1 year

78
Q

what is not found in a constant non-accommodative esotropia

A

no hypermetropic correction

79
Q

what is the aim of surgery in a child who has a constant non-accommodative esotropia and why

A

Surgery in childhood aiming to leave slightly esotropic/under corrected to delay the risk of consecutive exotropia and encourage development of ARC

80
Q

what is the treatment option for an older child and adult patient with a constant non-accommodative esotropia

A

BTXA

for younger children, can do under general anaesthetic

81
Q

what is the aim of surgical treatment for a constant non-accommodative esotropia/infantile/early onset esotropia

A

to align the eyes surgically within the first 2 years of life as may develop some anomalous BV

so want to rectify the esotropia as quickly as possible

82
Q

what are the 2 surgery options for someone with a constant non-accommodative esotropia/infantile/early onset esotropia

A

Either:
- bi-MR recessions
OR
- MR recession and LR resection (surgery preference)

83
Q

when will a bi medal rectus recession be done on a child with a constant non-accommodative esotropia/infantile/early onset esotropia

A

if the esotropia is greater at near than at distance

84
Q

when will a MR recession and LR resection be done on a child with a constant non-accommodative esotropia/infantile/early onset esotropia

A

if the esotropia is equal at distance and at near

85
Q

why is it important to monitor a child who had a constant non-accommodative esotropia/infantile/early onset esotropia post operatively

A

as surgery often disrupts pattern of alternation – amblyopia develops and so need occlusion therapy

86
Q

list 4 reasons why the follow up monitoring of a child who has undergone surgery for a constant non-accommodative esotropia/early onset/infantile is important

A
  • Occlusion: to rectify any amblyopia they have post-operatively and regular refraction: annually under cycloplegic refraction
  • Development of Inferior oblique overreaction
  • Development of Dissociated Vertical Deviation (DVD) which may need surgery (where the eye elevates under the cover)
  • Development of latent nystagmus: which is present with both eyes open
87
Q

when does a constant non-accommodative late onset esotropia usually present

A

over the age of 4 years old

88
Q

what is the 2 treatment options for a patient with a constant non-accommodative late onset esotropia and explain under what conditions each treatment is done

A
  • In sudden onset esotropia without any pathology, BTXA is used with excellent results for restoring BSV, but px still needs a cycloplegic refraction and fundus examination
  • Surgery if esotropia returns after toxin wears off
    MR recession + LR resection

but if once the botox has worn off and the eyes are still straight and binocular, then nothing else needs to be done

89
Q

what type of surgery is done on a px who has a constant non-accommodative late onset esotropia

A

MR recession + LR resection

90
Q

what is a constant accommodative esotropia sign

A

Esotropia which reduces but is not fully corrected when wearing hypermetropic correction

91
Q

what other esotropia is a constant accommodative esotropia more common than

A

than non-accommodative esotropia

92
Q

what must be treated for a child with a constant accommodative esotropia

A

amblyopia - by patching

93
Q

what 2 things does further treatment of a child with a constant accommodative esotropia depend on

A
  • size of squint

- retinal correspondence

94
Q

when do you not need to do anything in terms of treatment with a patient who has a constant accommodative esotropia and why and what just needs to be done instead

A
  • do not need to do anything regarding a small angle esotropia with ARC
  • this is because they should have good cosmesis and some form of retinal correspondence
  • just make sure the patient has up to date glasses and any amblyopia is corrected
95
Q

what is there a risk of with surgery for someone who has a small angle less than 20 prism dioptres of constant accommodative esotropia if treating with surgery and what should be done instead to avoid this

A

theres a risk of consecutive divergence/exotropia with surgery so BTXA injection indicated to medial rectus

96
Q

what are larger deviations of someone with a constant accommodative esotropia unlikely to have and therefore what treatment option is best for these patients

A
  • ARC or NRC
  • surgery is indicated to improve cosmesis
  • MR recession and LR resection
97
Q

what type of surgery is done on a patient with a constant accommodative esotropia

A

MR recession and LR resection

98
Q

what 2 reasons may you use BTXA in older patients with a constant accommodative esotropia for

A
  • BTXA diagnostically to assess risk of post-operative diplopia
    and
  • therapeutically as alternative to surgery

if they do have a high risk post operatively, you don’t want to do anything regarding that initial angle of squint, all you need to do is to wait for the injection to wear off and once its worn off, the squint will go back to its original angle and the patient will be suppressing

99
Q

what cases is BTXA useful in for patients with a constant accommodative esotropia

A

where the patient has had multiple surgical procedures and still remains significantly esotropic

100
Q

what is a consecutive esotropia

A

Esotropia as a result of surgical overcorrection of an exotropia

101
Q

what 2 types of consecutive esotropia are there, and which type is more common

A
  • constant
    or
  • intermittent

more common/most likely to be constant

102
Q

what does a patient with a consecutive esotropia have no form of and what is done to avoid this problem

A
  • they have no binocular vision ARC or NRC when they have a consecutive esotropia
  • Aim: Slight esotropia is the desired outcome of a surgery, so over correct the patient if the patient is exotropic, this is because exotropia tends to become more divergent over time
103
Q

why should you watch carefully in a child who has had an intermittent exotropia that is now is a consecutive esotropia

A

as BV can be lost and amblyopia develop

104
Q

what is 3 possible treatment/management options for if a large angle consecutive esotropia deviation persists and is cosmetically unacceptable

A
  • Duction exercises if abduction limited
  • Botulinum toxin injection (to correct it post operatively)
  • Further surgery
105
Q

what is a secondary esotropia

A

Esotropia secondary to loss or impairment of vision

106
Q

what are the 2 treatment/management options for someone with a secondary esotropia and why

A

Surgery and/or BTXA

for cosmetic alignment

107
Q

what type of procedure is surgery for a secondary esotropia

A
  • a uniocular procedure
  • MR recession and LR resection (in one eye) as near and distance angle is fairly similar in both eyes and in adults adjustable sutures are used
108
Q

what is the aim of surgery on someone with a secondary esotropia and why

A

Eso deviations tend to reduce with the passage of time so aim to leave slightly eso to delay development of consecutive exotropia

109
Q

overall, what 2 things is the various methods to manage esotropia dependent on

A
  • potential binocular status
    and
  • cosmetic alignment
110
Q

having previous surgery to treat an esotropia does not…..

A

prevent further surgery later in life, it is normal to have three or more procedures over a life time

111
Q

BTXA can be used as an alternative to…..

A

surgery

Binocular vision YR 3 (20 decks)

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