PALSIES

Question 1

6th non surgical

Answer 1

Conservative for first 6-12mo or until stable
Relieve dip and uncomfortable CHP

Prisms – mild palsies and more concom, specific placement, sectional/ dist only
Occlusion – large angle, pre-empting increase in angle

BOTOX – short term re-establishment of bsv alongside surgery (transposition, reduces risk of ant seg ischaemia), no evidence that improves recovery, leakage causes vert dev

Late management
Those with chronic 6NP
- Continue with AHP
- Fresnel/ incorp
- Repeat botox injections
- Occlusion

Factors affecting
- Age , aetiology, GH, Occupation
- Ocular – severity of symptoms, duration since onset, presence and size of AHP, binoc functions, cosmesis

Question 2

partial 6th surgical

Answer 2

concom
-> angle <=30^ -> surgery on 1/2 muscles LR resect/ MR recess
–> angle >30 = surgery on 3/4 muscles

incom
MR contracture –> ipsilateral MR recession +/- LR resection

NO MR contracture –> contra MR post. fix suture
OR
Recession and ipsilateral LR resection

Question 3

TOTAL 6TH SURGICAL

Answer 3

high ant. seg ischaemia risk
–> part muscle vertical rectus transposition +MR recession

Low ant. segment ischaemia risk
–> full vertical rectus transposition

OR

MR contracture absent –> no augmentation

Mild/Moderate MR contracture - BOTOX to MR or Foster suture

Severe MR contracture - staged MR recession

Question 4

4th non surgical

Answer 4

prognosis - 90% chance unilateral acquired spontaneously within 6mo

conservative and monitor

Early
prisms -> full or nearly full as vert, tilted prism, specific placement

occlusion - very incom, torsion barrier to fusion

chronic 4th
-> continue c AHP, Fresnel/incorp, sector occlusion

Question 5

4th Surgical

Answer 5

Considerations before surgical treatment
- Wait until no further recovery
- Unilateral or bilateral
- Congenital or acquired
- Type of muscle sequelae
- Presence or absence of BSV

How much SO limitation
· > -2, strengthening needed especially if V-pattern & excyclo

Torsion – strengthening SO (one or both)

Horizontal deviation size
· E >10^ - recess MR
· V-pattern with XT – recess IOs
· V-pattern with ET – strengthen SOs or MR inferoplaced if no torsion

Question 6

effect of SO tuck vs Harada Ito

Answer 6

Vertical deviation corrected (in field of SO) 15^ (0-40^) vs 5^

Iatrogenic Brown’ 16% vs Insignificant

Cyclodeviation 6° vs 10°

V-Esotropia 15^ vs 12^

Question 7

Congenital 3rd

Answer 7

CONGENITAL
Prevent stimulus deprivation &/or strabismic amblyopia
- high incidence of amblyopia, about 50% achieve 6/12 in amblyopic eye
May adopt AHP
Squint surgery to improve cosmesis
Ptosis surgery – shortening of the muscle or tendon
Prognosis usually poor for BSV development

Conservative for first 6 months or until stable
Monitor

Question 8

early 3rd non surgical

Answer 8

Relieve diplopia
Uncomfortable AHP

• Prisms – often limited benefit
  • Depends on size and type of deviation
• Occlusion
  • Incomitant
  • Too large for prisms
  • Intermediate as lid lifts
    Ptosis props if affected eye is only seeing eye

Question 9

late 3rd non surgical

Answer 9

Prisms

* Complete palsy – limited use

* Partial palsy – possible reposition field of BSV Occlusion Some find it easy to ignore the second remote image/suppression in longstanding Photophobia due to mydriasis

* Tinted glasses

* Pilocarpine 1%

* Painted contact lens with smaller pupil Ptosis

* Ptosis crutches fitted to glasses frames – bilateral ptosis or only seeing eye Botulinum Toxin

* Improve alignment

* Investigate BSV potential

* Often repeat injections needed – little benefit found in cases of total palsy

Not until stable (at least 6 months)

Question 10

• Total or partial palsy

Answer 10

• Residual muscle function – alignment improved with conventional resection of palsied muscle + recession of antagonist
• Type and extent of muscle sequelae
  Squint surgery always before ptosis surgery
  • pseudo ptosis due to hypo
  • exposure keratitis if any recovery to lid function