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Motility Bloick 10 > Strabismus In NM Abnormalities > Flashcards

Strabismus In NM Abnormalities Flashcards

1
Q

Infancy ocular instability (split)

A

Normal
Variable, transient, intermittent angle strabismus
-seen in 2-3 months
-resolves by 4 months
-suspect problem if deviation persists, is constant and/or larger

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2
Q

Esodeviation

A

Could be a tropia or a phoria

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3
Q

A latent esodeviation controlled by fusional vergences so eyes are aligned in binocular conditions/fusion

A

Eso phoria

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4
Q

Manifest deviation not properly controlled by fusional vergences

A

Eso tropia

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5
Q

Deviations can come from

A

NM abnormalities can be due to innervation, anatomical, mechanical, refractive, accommodative or genetic problems

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6
Q

Fusional vergences allow

A

Fusion and alignment

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7
Q

Appearance of ET when eyes are actually straight

A

Pseudoesotropia

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8
Q

Pseudoesotropia

A

Hirschberg and CT will be normal

  • seen in children with wide, flat nose bridge with prominent epicanthal folds and small interpupillary distance
  • pinch the most bridge
  • appearance approves with age
  • these children may actually have a deviation
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9
Q

Onset is between birth and 6 months, has a larger constant esotropia, there may be a family Hx of ET

A 
Infantile (congenital) ET
Usually LARGE (60 prism D)
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10
Q

Many children with infantile ET have

A

Other Neuro or developmental condition, cerebral palsy, hydrocephalus, prematurity
-many have cross fixation, using the addicted eye to look into the contralateral view

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11
Q

Many kids with this use cross fixation

A

Infantile congenital ET

-using the addicted eye to look into the contralateral view

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12
Q

Amblyopia and infantile ET

A

Amblyopia may develop in the constantly deviated eye (even with cross fixation)

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13
Q

This has a HUGE deviation

A

Infantile ET

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14
Q

Why kind of refractive error is associated with infantile ET

A

Hyperopia

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15
Q

What test do you do to see how the eyes are moving in infantile ET

A

Dolls head

-see the eyes to see abduction (appears difficult because of cross fixation)

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16
Q

Pathogenisis of infantile ET

A

Could be sensory or motor

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17
Q

Other variable findings in infantile esotropia

A 
Amblyopia 
A or V pattern 
Dissociated vertical deviation (DVD)
OIO (overaction of IO)
Nystagmus
AHP

About 30-50% of all esotropes

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18
Q

This makes up about all 30-50% of all kids with esotropia

A

Infantile ET

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19
Q

Management considerations in strabismus

A
  • correction of refractive error
  • added lenses (bifocal, plus, minus)
  • prism
  • occlusion
  • VT
  • pharmacological (Botox)
  • surgery (esp for large angles)
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20
Q

Infantile ET management

A

Comprehensive eval
Full cyclo refraction
Ask mother about pregnancy
Surgery allows some degree of fusion after surgery

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21
Q

Purpose of full cyclo refraction in infantile eso

A

This is to rule out early onset accommodative ET. Smaller, variable intermittent ET angles are likely to respond

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22
Q

Deviation in accommodative esotropia

A

Associated with the accommodative reflex

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23
Q

When does accommodative eso tropia occur

A

Between 6 months and 7 years (average age of onset is 2.5 years)

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24
Q

How does accommodative ET start

A

Intermittently and then may become constant, often hereditary , trauma can precipitate it

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25
Q

Amblyopia and diplopia and accommodative ET

A

Often present with large constant and unilateral angles, diplopia may result, but then there is active suppression

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26
Q

Refractive accommodative ET

A

Due to high hyperopia

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27
Q

Non refractive accommodative ET

A

Due to high AC/A

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28
Q

Mixed accommodative ET

A

Due to high hyperopia and high AC/A

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29
Q

About 50% of all ET have a _______ component

A

Accommodative

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30
Q

Due to uncorrected hyperopia and insufficient fusional vergence and diverge

A

Refractive accommodative ET

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31
Q

Uncorrected hyperopia causing refracting accommodative ET

A

Forces the patient to accomodate to sharpen retinal images, this leads to accommodative convergence
-ET develops if patient doesn’t have enough fusional divergence to counter the increases concvergence

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32
Q

Size of ET in refractive accommodative ET

A

20-20PD

Could be intermittent, alternating with asthenopia

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33
Q

Deviation at distance and near for refractive accommodative ET

A

Similar deviation at d and n

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34
Q

Average hyperopia that can cause refractive accommodative AT

A

+4D

Can be as little as +3 and as much as +6

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35
Q

If hyperopia is >6D in refractive accommodative ET

A

Isometropic amblyopia develops because patient has too much blur and will be unable to try to accommodate

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36
Q

Management of refractive accommodative ET

A
  • comprehensive eval
  • cyclo refraction: get out all the plus you possibly can. Offer full hyperopia correction for full time wear ASAP, if not some of the esodeviation will not longer respond to hyperopia correction
  • can reduce plus later to aid emmetropization
  • start amblyopia tx if VA doesn’t fully improve with Rx
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37
Q

Due to a high AC/A ratio

A

Non refractive accommodative ET

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38
Q

What causes a non refractive accommodative ET

A

An increase in accommodation at near drives convergence, but there is insufficient vergence to diverge

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39
Q

When is ET greater in non refractive accommodative ET

A

Greater at near because of the need for accommodation at near, always important to eval angle at distance and near, may be intermittent and alternating angle

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40
Q

What kind of refractive error is ssen with non refractive accommodative ET

A

Moderate hyperopia to myopia is seen, similar to general population

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41
Q

Amount of convergence induced by a change in accommodation

A

AC/A

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42
Q

A change in accommodation is accompanied by a change in

A

Vergence

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43
Q

What permits clear stable single binocular vision across range of viewing distances

A

Accommodation and vergences

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44
Q

What helps evaluation the strength between the accommodative and vergences systems

A

AC/A

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45
Q

Where are abnormal AC/A ratios seen

A

In binocular problems

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46
Q

Calculating AC/A ratio,

A

Look at the notes

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47
Q

Management of non refractive accommodative ET

A
  • Treat underlying refractive error
  • bifocals reduce accommodation and thereby accommodative convergence (Rx based on AC/A ratio)
  • seg height must bisect the pupil
  • repeat cyclo yearly
  • surgery contraindicated
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48
Q

Why is surgery contraindicated in no refractive accommodative ET

A

May be weaned off add if there is improved alignment at near (start about 7 years)

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49
Q

Why do we want to bisect the pupil with the bifocal in kids with non refractive accommodative ET

A

To force them to look through the bifocal. Kids will try to look over the top of it

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50
Q

Combination of refractive acocmmodation and non refractive accommodative findings, high hyperopia and high AC/A

A

Mixed accommodative esotropia

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51
Q

Management of mixed accommodative ET

A

Full hyperopia correction of kid
Bifocal based on AC/A
Surgery contraindicated (unless residual larger angle bc glasses started too late)

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52
Q

Where will the ET be for a mixed accommodative ET

A

Distance and near!

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53
Q

Accommodation contributes to, but does not account for the entire deviation

A

Partial accommodative ET

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54
Q

There is a reduction in the angle, but there is residual ET after treatment. This may result after delayed treatment of truly accommodative ET

A

Partial accommodative ET

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55
Q

What is the ET in partially accommodative ET

A

Constant, unilateral, suppression, ARC common

56
Q

Early onset non accommodative esotropia and acute acquired ET

A

Non accommodative ET (basic ET), acocmmodation not driving here

57
Q

Early onset nonaccommodative ET onset

A

After 6 months of age to before age 2

-clinically similar to infantile ET, but the onset is later.

58
Q

ET in early onset non accommodative ET

A

ET same at distance and near, commitment

59
Q

Accommodative and refractive component to early onset non accommodative ET

A

No acommodation invovled

Insignificant amount of hyperopia

60
Q

Management of early onset of non accommodative ET

A
  • correct refractive error, consider prisms or bifocal
  • amblyopia tx
  • VT to improve ranges
  • consider surgery
  • consider Neuro cases (even if child appears healthy)
61
Q

What kind of ET in acute acquired ET

A

Comitancy, unilateral and constant moderate angle (20-30pd)

62
Q

Onset of acute acquired ET

A

Sudden onset from 3-5 yo (or older)

63
Q

Refractive error in acute acquired ET

A

Refractive error similar to general population

64
Q

What could be the result of acute acquired ET

A

Illness, stress, aging

65
Q

Management of acute acquires ET

A
  • neuro eval asap
  • correction
  • prism or surgery since pt probably had BV before the ET
  • amblyopia tx, if needed
66
Q

Other esodeviations

A 
Sensory ET
Divergence insufficiency ET
Micro tropia (ultra small ET)
Consecutive ET
Decompensating ET (fusional vergences no longer able to maintain EP)
67
Q

An esotropia that develops due to vision loss in one eye

A

Sensory ET

68
Q

Pathology of sensory ET

A

Pathology prevents clear, focused, retinal images. Prevents symmetrical visual stimulation OU

69
Q

VA in sensory ET

A

Poor VA in affected eye

70
Q

ET in sensory ET

A

Constant unilateral deviation and can be very large (10-45)

-poor cosmetic

71
Q

Decreased of vision loss in one eye can be die to any of the following

A 
Congenital cataract 
Corneal scarring 
Optic atrophy
Prolonged blue 
Retinal/macular disease 
Anismetropia amblyopia
Ptrosis 
PHPV
72
Q

Management of sensory ET

A
  • eliminate pathology as early as possible
  • polycarbonate lens for full time wear (monocular precautions)
  • treat secondary amblyopia
  • surgery can be for any residual deviation (or basically for cosmesis)
73
Q

A non accommodative esodeviation greater at distance then near

A

Divergence insufficiency ET

74
Q

ET in divergence insufficiency ET

A 
Comitancy 
Onset in adults 
Decreases fusional divergence at distance 
Diplopia complains at distance 
HA
75
Q

Refractive error in divergence insufficiency ET

A

Refractive similar or normal population, no sensory adaptatios since late onset

76
Q

Sensory adaptations in divergence insufficiency ET

A

None since late onset

77
Q

Management of divergence insufficiency ET

A
  • NEURO REFERRAL
  • thorough eval (neuro concerns from head trauma, increased ICP)
  • correct refractive error
  • VT
  • Botox
  • sx not indicates since deviation only at distance
78
Q

Esodeviation after exo strabismus surgery

A

Consecutive ET

79
Q

Symptoms of consecutive ET

A

Patient could be symptomatic
Amblyopia could develop
Mag varies
Unilateral or alternating

80
Q

Management of consecutive ET

A
  • spontaneous improvement could occur
  • treat refractive error
  • try BO prism or plus lenses
  • repeat surgery for large or symptomatic consecutive deviations
81
Q

6h nerve palsy

A

Non comitant esodeviation, Duane’s syndrome

82
Q

A latent exodeviation controlled by fusional vergences

A

XP

83
Q

Manifest deviation exodeviation

A

XT

84
Q

Exodeviations are signs of

A

NM abnormalities that can result from innervation, anatomical, mechanical, refractive, accommodative or genetic problems

85
Q

Prevalence of Xdeviation

A

Varies by ethnic groups

86
Q

There is proper alignment, but positive angle kappa, wide pupil;Larry distance give appearance of Xdeviation

A

Pseudoesotropia

87
Q

Latent deviation, controlled with fusional vergences

A

XP

88
Q

If fusional vergevens are not adequate in XP

A

XT could result or XP becalmed symptomatic

89
Q

Treatment for XP

A

Needed if there is asthenopia or diplop[ia

90
Q

in childhood, XT larger at distance and seen prominently when target is at a distance

A

Intermittent XT: divergence excess type XT

91
Q

In adults, XT same at distance and near in adults

A

Basic XT, intermittent XT

92
Q

In adults, XT larger at near

A

Convergence insufficiency XT (intermittent XT)

93
Q

Most common XT

A

Intermittent XT (85%)

94
Q

Deviation is latent at times and then becomes manifest, onset before 5 (XT)

A

Intermittent XT

95
Q

When does intermittent XT becalmed manifest

A

During visual inattention, fatigue, or stress because compensating fusional factors are not active
-could occur late int he day, with fatigue, when daydreaming, when drowsy.

96
Q

Bright light in intermittent XT

A

Bright light may cause reflex closure of one eye

97
Q

Can be asssociated with small hypersand/or A/V pattern

A

Intermittent XT

98
Q

Untreated intermittent XT

A

Can led to constant XT it will start to manifest at lower levels of fatigue and occurs for longer

99
Q

Sensory adaptations of intermittent XT

A

May occur after some diplopia, replaced with suppression or anomalies retinal correspondence in DE and Basic

  • reduce stereo
  • amblyopia possible
100
Q

Eval of intermittent XT

A
  • comprehensive Hx- age of onset, FREQUENCY or tropia, circumstances when it is manifested
  • CT at d and n-IXT may be greater at distance because of some fusion at near keeping eyes straight
  • controls assessment: good control (XT only on CT), fair control (XT on CT, fusion regained after blinking ore refixation), poor control (XT manifests spontaneously and for an extended period of time)
101
Q

Eval of intermittent XT: sensory testing

A

In sensory testing, you could get good stero and normal retinal correspondence if control is good

102
Q

Diplopia with good control in intermittent XT

A

Not common

103
Q

Management of intermittent XT

A
  • correct significant hyperopia, myopia, and astig
  • mild myopia correction could make deviation better
  • mild hyperopia correction could make deviation worse (so not typically Rx)
104
Q

Mild hyperopia correction in intermittent XT

A

Could make the deviation worse

105
Q

Moderate hyperopia in intermittent XT

A

Needs to be corrected bc a child may be unable to accommodate through this, resulting in blue and thereby a manifest XT

106
Q

Minus lenses and intermittent XT

A

Can be added to correction to stimulate accommodation and stimulate accommodative convergence to control XT

107
Q

Optical correction of intermittent XT

A

May actionalty make retinal image better and thereby improve XT

108
Q

Patching for amblyopia in intermittent XT

A

Could improve control

109
Q

VT inintermittent XT

A

Fusional vergence training, antisupression/diplopia awareness can be instituted with pathching, minus lenses, can be done before surgery

110
Q

Prisms in intermittent XT

A

In the absence of suppression, can be used to promote fusion, but not long term because it reduced fusional vergence amplitueds

111
Q

Surgery in intermittent XT

A

When XT gets progressively worse with decreasing stereoacuity and control. Deviation >50% of the time is concerning

112
Q

Botox in intermittent XT

A

Can be used as well, but needs multiple treatments

113
Q

XT greater at near than distance, usually an intermittent alternating deviation at near, low AC/A, poor near fusion convergence amplitudes and receded NPC

A

Convergence insufficiency XT

114
Q

Symptoms of convergence insufficiency XT

A

Asthenopia, diplopia and blurred near vision- all common during reading

115
Q

VT in convergence insufficiency XT

A

Successful in these cases- pencil push ups, convergence based computer programs

116
Q

Convergence insufficiency XT prism

A

BI reading glasses could be used

117
Q

Commonly seen in older patients with a sensory XT or patients with a longstanding XT that has decompensating (decompensating XP)

A

Constant XT

118
Q

Surgery in constant XT

A

May be indicated

119
Q

Large visual field in constant XT

A

Some patients like it

120
Q

Examples of constant XT

A

Infantile XT

Sensory XT

121
Q

Large, constant angle (30-80PD), could alternate, XT

A

Infantile XT

122
Q

Which is more common, infantile ET or XT

A

ET

123
Q

When is infantile XT present

A

Before 6 months of age

124
Q

What kind of problems likely in infantile XT

A

Neuro issues or craniofacial disorders

125
Q

Adduction on versions in infantile XT

A

Poor, full on ductions

126
Q

DVD and OIO in infantile XT

A

Common

127
Q

What kind of Hx needed for infantile XT

A

Good developmental Hx is needed and consider neuro consult

128
Q

Management of infantile XT

A

Treat refractive error

Treat amblyopia

129
Q

Surgery for infantile XT

A

Performed for these children, early to promote some form of sensory cooperation, since prognosis for BV is poor (even if it is a monofixation or micro tropia)

130
Q

Any condition that causes vision loss in one eye can lead to sensory XT

A

Sensory XT

131
Q

Why do some people have sensory XT vs ET

A

Not sure

132
Q

Symptoms of sensory XT

A

Poor VA
Poor cosmesis
Constant and unilateral
Larger angle

133
Q

Management of sensory XT

A

Need to determine if VA can be improved since this may improve alignment with peripheral fusion

134
Q

If VA can be improved in sensory XT

A

Surgery can be useful for better alignment

135
Q

If VA cannot be improved for sensory XT

A

Misalignment could occur again after surgical correction

136
Q

This is common post surgery- could occur after months or years of surgery

A

Consecutive XT

137
Q

Consecutive XT before another surgery

A

Need to consider type and amount of previous surgery, any duction limitation/scarring or on comitancy

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