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Summer Final-VT > Strabimus Managment > Flashcards

Strabimus Managment Flashcards

1
Q

Goal of strabismus

A

Fusion and alignment

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2
Q

How can we manage strabismus

A
  • correction of refractive error
  • added lenses
  • prism (NRC)
  • occlusion-for amblyopia or suppression treatment
  • VT (accommodation, suppression, or vergence ranges)
  • Botox
  • surgery (large angle)
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3
Q

Strabismus prognosis

A

-the early the intervention after the onset, the lower the chance of sensory adaptation

Sensory adaptations

  • amblyopia
  • suppression
  • anaomalous correspondence
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4
Q

Strab prognosis is worse with

A

Esotropia
ARC
Constant unilateral strabismus

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5
Q

Sensory adaptations

A

Amblyopia
Suppression
ARC

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6
Q

Importance of strab management

A
  • to prevent debilitating consequences

- to improve quality of life

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7
Q

How could strab affect quality of life

A

Lower self esteem
Symptoms
Unable to perform hobbies or task
Appearance

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8
Q

Management for strab needed to

A

Offer better acuity
Offer some fusion
Provide better appearance (cosmetic goal)
Eliminate adaptations such as head turn or tilts, or anomalous correspondence

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9
Q

Correction of refractive error in strab

A
  • to offer the best acuity for BV and clarity
  • fully correct anisometropia and astigmatism
  • full hyperopia easier to accept in younger children
  • in older children, give the amount of plus that offer best alignment
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10
Q

Why would you not fully correct an older child

A

If not accepting full plus

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11
Q

Cutting plus on refractive error

A

Cut anisometropia by the same amount

  • could take down the amount of plus in the future, as long as alignment is maintained
  • follow up for VA, fusion and deviation
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12
Q

If someone has an esotropia, full or partial correction

A

Full

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13
Q

Cutting plus in someone with anisometropia and no strab

A

But by the same amount

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14
Q

Added lenses for strab

A
  • additional alignment and fusion
  • for example in children with high AC/A, addled lenses could offer affiiotnal alignment
  • bisect the pupil in bifocal in younger children
  • recommended full time wear
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15
Q

Where should the add be placed in kids with strab

A

Bisect the pupil

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16
Q

Added lenses for strab (plus or minus)

A
  • added minus can be used in chidlren with IXT (since there is already some level of fusion)
  • the accommodative drive is increased and the fusional vergence collapses the angle
  • works very well in IXT kids
  • do not want to over minus in cases of convergence insufficiency or presbyopia or accomodative problems
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17
Q

Prism for strab

A
  • shift the image to the fovea
  • prism can be fresnel or ground in
  • do not over do it. Can try prism in cases with deviations as much as 16-18PD. Greater than this needs surgery because the deviation becomes visible
  • for it to work, VA has to be good, no AC and/or suppression
18
Q

When can fresnel prisms be used

A

In acute strab, but larger amounts can compromise the VA

19
Q

What else could prism be good for

A

Also useful in anomalous head positioning in nystagmus, palsies, decompensatiyng phorias

20
Q

VT for strab

A
  • to improve fusional abilities, acommodation
  • work on suppression
  • has to be tailored to the patient
  • may work well in patients with existing fusion
  • works well with convergence insufficnicy, XT
  • if not in a VT practice, you can refer
  • can try home orthoptic programs as well
21
Q

Botox for strab

A
  • binds to nerve endings to interfere with ACH action
  • there is a temporary paralysis of the muscles and there is some contracture of the opposing muscle, this could be permanent
  • varying repsosne and improvement compared to surgery
  • only have 4 randomized controlled trials on this
22
Q

Referral for surgery for strab

A
  • surgery to achieve close to normal alignment
  • for large angles (more than 15PD)

Referral after addressing

  • refraction correction
  • the use of added lenses
  • the use of prisms
  • VT (as needed)
23
Q

Why do we not want to give large amounts of prism in glasses

A

Because it will be too heavy

-above 15PD is too much

24
Q

Surgery contraindicated for

A

Accommodative esotropes

Watch intermittent exotropia s that have good control

No surgery for smaller angles until every thing possible has been tried

Make sure the amblyopia is treated

VT can be done before nad after to build fusional vergences

25
Q

Timing for referral for surgery

A
  • the early the referral the better for infantile strab. Offers better chance to retain BV
  • educate the family that there could be a need for revisions in the future
26
Q

Strab surgery performed to

A

Tighten or loosen the muscles

27
Q

Recession

A

The muscle is detached and reattached further back

28
Q

Resection

A

The muscel is shortened and reattached to its original insertion site

29
Q

Adjustable sutures

A

Alignment can be adjusted while the patient is in recovery (vs permanent)

  • to fine tune
  • to reduce reoperation rebates
30
Q

Spiral of tillaux and surgery

A

Need to know how far from the limbus the muscles are to know how much they can recess it

31
Q

Other management considerations for strab

A
  • full eval to rule out other pathology
  • managemtn must be tailored for each child
  • may habe to combine differnt treatment options for desirable results
32
Q

Pseudoesotropia

A
  • appearance of ET when eyes are actually straight
  • hirschberg and cover test wil be normal
  • seen in children with wide, flat nose bridges with prominent epicanthal folds and small interpupillary distance
  • pinch the nose bridge
  • the appearance improves with age
  • these children may actually have a deviation though
33
Q

Infantile esotropia

A
  • onset is between birth and 6 months
  • large constant esotropia (>30PD)
  • family Hx of ET likely
  • other neurological or developmental conditions seen in these children (cerebral palsy, hydrocephalus, prematurity)
  • many have cross fixation- using the addicted eye to look into the contralateral view
34
Q

Other variable findings of infantile esotropia

A
  • amblyopia likely in constantly deviated eye (even with cross fixation)
  • A or V pattern
  • DVD-dissociated vertical deviation
  • OIO-over action of inferior oblique
  • latent nystagmus
  • anomalous head positioning
  • low hyperopia may be present
  • about 30-50% of all esotropes
35
Q

Management of infantile esotropia

A
  • comprehensive eval
  • full cyclo refraction. Rules out early onset of accommodative ET
  • surgery allows some degree of fusion
36
Q

Accomodative ET

A
  • onset between 6 months and 7 years (average age of onset is 2.5y ears)
  • starts intermittently and then may beceoms constant
  • family Hx
  • trauma can precipitate it
  • amblyopia often present with large constant and unilateral angles
  • diplopia May result, followed by active suppression
37
Q

Types of accommodative ET

A
  • refractive accommodative ET (due to high hyperopia)
  • non refractive accommodative ET (due to AC/A high)
  • mixed accommodative ET (due to higher hyperopia and high AC/A)

About 50% of all ET have an accommodative component

38
Q

Refractive accommodative ET (high hyperopia)

A
  • due to uncorrected hyperopia and insuffienct FV to diverge
  • ET could be about 20-30PD
  • could be intermittent, alternating with asthenoopia
  • similar deviations at D and N
  • due to hyperopia as little as +2.00D or more

If hyperopia is >5D, isoametropia amblotia devleoeps because patient has too much blur and will be unable to try to acommodative

39
Q

prevalence of ET and amount of hyperopia

A

As amount of hyperopia in the less hyperopic eye goes up, increased prevalence of amblyopia

40
Q

Managemtn of refractive accommodative ET

A
  • comprehensive eval
  • cyclo
  • full hyperopic Rx for full time wear ASAP. If not, residual ET may no longer respond to hyperopic correction
  • start amblyopia treatment if VA doesnt full improve Rx

Summer Final-VT (10 decks)

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