What is a Partially accommodative esotropia?
Patients that show a reduction in the angle of esotropia with glasses but have residual esotropia (deviation
... [Show More] remains manifest)
Onset: 1-3 years
Amblyopia is common
What is the management for a Partially accommodative esotropia? - recent onset
- Correct full plus
- urgent referral to Orthoptist to check binocular function
- if Simultaneous perception and fusion present = surgery for functional results
- if amblyopia present: patching part time, misty/clear
What is the management for a Partially accommodative esotropia? - onset is NOT recent
Refer to orthoptist = non-urgent
No BSV = surgery for COSMETIC purpose (this is done when child is older)
Treat any amblyopia present
Misty/clear
Prism adaptation prior to surgery and monitoring of density of suppression - don't want to bring them out of suppression
6 month old presents to practice with a history of a eye turning in towards the nose from 4 months old
No significant family history
CT - N+D = large alternating esotropia
OM - Full = cross fixates on lateral gaze
What additional questions would you ask on history and symptoms? And what answers would you expect?
- constancy? - most likely constant
- worse with particular tasks? - probably not age this age
- full term birth/premature < 32 weeks, low birth weight (5x more risk of esoT)
- orbital trauma during birth delivery? Forcep/vacuum assisted delivery (VI nerve palsy)
- previous treatment?
- GH - fatigue, poor GH, nausea/vomiting, general malaise, growth/weight changes, Down's Syndrome, Cerebral Palsy, Gross Developmental Delay
- General observation of px - head turn, tilts, facial palsy, ptosis?
6 month old presents to practice with a history of a eye turning in towards the nose from 4 months old
No significant family history
CT - N+D = large alternating esotropia
OM - Full = cross fixates on lateral gaze
Is this child likely to have a refractive error?
NO, but if any hypermetropia correct the full amount
6 month old presents to practice with a history of a eye turning in towards the nose from 4 months old
No significant family history
CT - N+D = large alternating esotropia
OM - Full = cross fixates on lateral gaze
What size might the deviation measure on PCT?
>30 diopter, very large angles squint
6 month old presents to practice with a history of a eye turning in towards the nose from 4 months old
No significant family history
CT - N+D = large alternating esotropia
OM - Full = cross fixates on lateral gaze
What differential diagnosis would you make and why?
INFANTILE ESOTROPIA
large angle esotropia, alternate, cross fixation present before end of first year
6 month old presents to practice with a history of a eye turning in towards the nose from 4 months old
No significant family history
CT - N+D = large alternating esotropia
OM - Full = cross fixates on lateral gaze
What management would you suggest for this patient?
-Monitor and treat any Rx
-Monitor the angle and advise parents on surgery for improved cosmesis, poor outcome for regaining BSV, although some reports say early treatment can regain some stereopsis if surgery done in first year
-Monitor VA and treat amblyopia if required
6 month old presents to practice with a history of a eye turning in towards the nose from 4 months old
No significant family history
CT - N+D = large alternating esotropia
OM - Full = cross fixates on lateral gaze
What other signs might you also see?
- latent or manifest/latent nystagmus
- asymmetric Optokinetic responses N to T (eye movements)
- DVD -dissociated vertical deviation
4 year old child attends your practice as parents have noted RE turning in over the last few months.
Refraction
RE: +5.50DS LE:+4.50DS
VA RE 6/48 LE 6/12
CT with specs N+D sm esophoria
W/O specs N+D mod R esotropia
What further questions would you ask in history and symptoms?
Symptoms unlikely as suppression usually occurs
Clumsiness, poor judgement of distance
May close one eye
May get distressed when squint is manifest
May complain of headaches/sore eyes/Diplopia but much more likely to suppress in childhood
Constancy?
Worse with particular tasks?
Family and birth history - premature? Or tubal trauma? Forcep/vacuum delivery?
Previous treatment?
GH - fatigue, poor GH, nausea/vomiting, HAs, growth/weight changes, diabetes, DS, CP, GDD
4 year old child attends your practice as parents have noted RE turning in over the last few months.
Refraction
RE: +5.50DS LE:+4.50DS
VA RE 6/48 LE 6/12
CT with specs N+D sm esophoria
W/O specs N+D mod R esotropia
What treatment would this px receive?
-FULL PLUS RX and full time wear
-May require amblyopia tx, give period of refractive adaptation before referral to orthoptics
-Review VA every 4-6 weeks and refer once VA plateaus after less than 0.1 logMAR (6/7.5) improvement on two consecutive visits
-Young px to discuss awareness of misty/clear and diplopia w/o specs
4 year old child attends your practice as parents have noted RE turning in over the last few months.
Refraction
RE: +5.50DS LE:+4.50DS
VA RE 6/48 LE 6/12
CT with specs N+D sm esophoria
W/O specs N+D mod R esotropia
What other investigations would you carry out?
Level of binocular functions with specs - sim perc, fusion, stereopsis
Measurement of deviation - PCT
Check recovery of CT with specs to assess compensation of phoria
20 and 4 prism dioptre tests
4 year old child attends your practice as parents have noted RE turning in over the last few months.
Refraction
RE: +5.50DS LE:+4.50DS
VA RE 6/48 LE 6/12
CT with specs N+D sm esophoria
W/O specs N+D mod R esotropia
What diagnosis would you make?
FULLY ACCOMMODATIVE ESOTROPIA
some form of acc. Esotropia
Esotropia present without specs but absent with glasses at distance and near = FULLY ACC.
Not partially acc. as that would have a smaller esotropia present at distance and near
Not acc. excess as that would still have esotropia at NEAR
4 year old child attends your practice as parents have noted RE turning in over the last few months.
Refraction
RE: +5.50DS LE:+4.50DS
VA RE 6/48 LE 6/12
CT with specs N+D sm esophoria
W/O specs N+D mod R esotropia
How would your management differ if there was small R esotropia D&N with glasses?
-FULL PLUS RX AND FULL TIME SPECS
-Needs referred to orthoptics as eyes not aligned with glasses, Rx adaptation will only work a limited amount as squint still manifest
-in this case, onset over the last few months - urgent referral?? - if you think there's potential for functional results with surgery refer urgently
-VA is 6/48 with only 1.00D of anisometropia - squint is more long-standing than a few months...
-if long-standing = no potential for functional result - routine referral
-orthoptics conduct occlusion therapy and assessment for surgery if cosmetic it will be postponed until child is older
4 y/o attends with history of intermittent convergent squint over last year
Hyperopia present in family
Dry refraction +2.00DS R+L
CT with specs:
N (to light) sm esophoria good rec
N (to target) mod left esotropia
D slight esophoria with gd rec
W/O specs:
N mod L esotropia
D mod esophoria / sm left esotropia on dissociation
Why is there esophoria to light, esotropia to target?
Light is not a stimulus to accommodation, target stimulates accommodation and convergence
4 y/o attends with history of intermittent convergent squint over last year
Hyperopia present in family
Dry refraction +2.00DS R+L
CT with specs:
N (to light) sm esophoria good rec
N (to target) mod left esotropia
D slight esophoria with gd rec
W/O specs:
N mod L esotropia
D mod esophoria / sm left esotropia on dissociation
What initial assessment would you undertake?
Cycloplegic refraction to ensure that px has max PLUS Rx to aid control at near
4 y/o attends with history of intermittent convergent squint over last year
Hyperopia present in family
Dry refraction +2.00DS R+L
CT with specs:
N (to light) sm esophoria good rec
N (to target) mod left esotropia
D slight esophoria with gd rec
W/O specs:
N mod L esotropia
D mod esophoria / sm left esotropia on dissociation
What differential diagnosis would you make?
Assuming no change to the Rx is found, convergence excess Esotropia
Some form of accommodative esotropia
Fully acc. = no esotropia at distance or near with Rx
Partially acc. = have esotropia at distance and near but smaller with Rx
4 y/o attends with history of intermittent convergent squint over last year
Hyperopia present in family
Dry refraction +2.00DS R+L
CT with specs:
N (to light) sm esophoria good rec
N (to target) mod left esotropia
D slight esophoria with gd rec
W/O specs:
N mod L esotropia
D mod esophoria / sm left esotropia on dissociation
What further treatment would this patient receive?
Bifocal lens giving max add up to +3.00DS that the px needs for BSV at near
The aim would be to reduce the add each time BSV is gained and maintained and return px to SVD
Other options: miotics, CLs, exercises to work negative fusional reserves (dust stereograms, bar reading)
Surgery if no responses to conservative treatment
4 y/o attends with history of intermittent convergent squint over last year
Hyperopia present in family
Dry refraction +2.00DS R+L
CT with specs:
N (to light) sm esophoria good rec
N (to target) mod left esotropia
D slight esophoria with gd rec
W/O specs:
N mod L esotropia
D mod esophoria / sm left esotropia on dissociation
If surgery is required, what muscles would they work on and how?
Bilateral medial reclusive recessions (lengthening of muscle to weaken a ability to converge)
5 year old boy has sore eyes when watching TV. Father notices 'lack of eye coordination at times'
VA equal with no Rx
CT:
N sm exophoria with slow rec = 12 dioptres
D mod exophoria, mod exotropia = 30 dioptres
Far distance large exotropia = 50 dioptres
OM: V-pattern
CONV: binocular to 14cm then L eye diverges with diplopia
What further questions would you ask?
Symptoms? - I likely if suppression occurs
Clumsiness, poor judgement of distance
May close one eye, particularly in bright light
May get distressed when squint is manifest
May complain of HAs/sore eyes/DIP
Increase in field of view
And the usual questions on birth history, eye turning in or out?, worse with particular tasks? Previous treatment? GH?
5 year old boy has sore eyes when watching TV. Father notices 'lack of eye coordination at times'
VA equal with no Rx
CT:
N sm exophoria with slow rec = 12 dioptres
D mod exophoria, mod exotropia = 30 dioptres
Far distance large exotropia = 50 dioptres
OM: V-pattern
CONV: binocular to 14cm then L eye diverges with diplopia
What diagnosis would you make?
Intermittent distance exotropia
DD between constant exotropia, non-specific D>N, therefore intermittent distance exo
5 year old boy has sore eyes when watching TV. Father notices 'lack of eye coordination at times'
VA equal with no Rx
CT:
N sm exophoria with slow rec = 12 dioptres
D mod exophoria, mod exotropia = 30 dioptres
Far distance large exotropia = 50 dioptres
OM: V-pattern
CONV: binocular to 14cm then L eye diverges with diplopia
What further tests would you need to undertake to confirm differential diagnosis?
PCT at distance
1 hours of occlusion or 1 hour if +3.00 Lens to relax accommodation PVT at near - true or simulated distance exotropia
True - will remain exophoria at near
Simulated- will break down to exotropia at near once control with accommodation and convergence is lost
5 year old boy has sore eyes when watching TV. Father notices 'lack of eye coordination at times'
VA equal with no Rx
CT:
N sm exophoria with slow rec = 12 dioptres
D mod exophoria, mod exotropia = 30 dioptres
Far distance large exotropia = 50 dioptres
OM: V-pattern
CONV: binocular to 14cm then L eye diverges with diplopia
What treatment would you suggest?
-Increased convergence, pen to nose exercises to enable patient to gain better distance control
-Positive stereograms to increase positive relative convergence
-Minus lenses to stimulate accommodation/conv
-Monitor VA and control, surgery may be indicated if control does not improve or decompensates to constant exotropia
-Amblyopia treatment if required
-Sunglasses
-Base in prism
21 year old male
CT N+D large left exotropia ( by CR's left eye doesn't fixate when right eye covered) cosmetically poor
VA: RE 6/5 LE PL
History of traumatic penetrating injury at 10 years old with associated corneal scarring traumatic cataract removed IOL implanted
What type of deviation does this patient have?
Secondary left exotropia as a result of visual loss in LE, no movement with CT suggests Px unable to fixate due to profound vision loss
21 year old male
CT N+D large left exotropia ( by CR's left eye doesn't fixate when right eye covered) cosmetically poor
VA: RE 6/5 LE PL
History of traumatic penetrating injury at 10 years old with associated corneal scarring traumatic cataract removed IOL implanted
What treatment would you suggest?
Surgery for the cosmetically poor squint
21 year old male
CT N+D large left exotropia ( by CR's left eye doesn't fixate when right eye covered) cosmetically poor
VA: RE 6/5 LE PL
History of traumatic penetrating injury at 10 years old with associated corneal scarring traumatic cataract removed IOL implanted
What precautions would you need to take when assessing px?
Post op. DIP test will correct angle and the px should be unaware of any diplopia pre-op to give a desirable post-op outcome
Need to be careful of intractable diplopia
21 year old male
CT N+D large left exotropia ( by CR's left eye doesn't fixate when right eye covered) cosmetically poor
VA: RE 6/5 LE PL
History of traumatic penetrating injury at 10 years old with associated corneal scarring traumatic cataract removed IOL implanted
What muscles might be adjusted during surgery?
Possible media, rectors resection (strengthening) or lateral rectors recession (weakening) [Show Less]