_and eye muscle surgery pediatric 斜视眼肌手术小儿课件

Strabismus Strabismus and Eye Muscle Surgeryand Eye Muscle Surgery G. Vike Vicente M.D. Eye Doctors of Washington G.Vicente,MD Dr. Vicente Strabismus review outline: Horizontal strabismus Anatomy review Nomenclature review Accommodative esotropia Pediatric Bifocals? Infantile esotropia Viral & Diabetic esotropia Sensory strabismus Pseudostrabismus Duanes syndrome Exotropia Convergence insufficiency Phorias Tropias Eye Muscle Surgery Recession Resection Vertical Strabismus Parks Three step test Superior Oblique Palsy Brown Syndrome Inferior Oblique Overaction DVD- Dissociated Vertical Deviation Blow out Fracture Skin Conjunctiva Tenons layer Eye Muscles Left eye G.Vicente,MD Eye Muscles Left eye Superior Oblique/Trochlear Muscle Superior Rectus Muscle Lateral Rectus Muscle Inferior Rectus Muscle Inferior Oblique Muscle Medial Rectus Muscle G.Vicente,MD NomenclatureNomenclature Orthorphoriao Esophoria E Esotropia ET Intermittent Esotropia E(T) ExophoriaX Exotropia XT Intermittent Exotropia X(T) At near X(T) Right HypertropiaRHT convergent divergent G.Vicente,MD Right Hypertropia G.Vicente,MD Strabismus Why is it Important?Strabismus Why is it Important? Preserving Stereo acuity 8 yo with Preserving Stereo acuity 8 yo with worsening X(T) Intermittent Exotropia.worsening X(T) Intermittent Exotropia. Enlarging Visual field Enlarging Visual field for Pts with ET. for Pts with ET. AppearanceAppearance Would you hire me? Would you hire me? Would you date me?Would you date me? Is there something wrong with you?.Is there something wrong with you?. DiplopiaDiplopia G.Vicente,MD Strabismus Why operate?Strabismus Why operate? Diplopia Can be a very debilitating symptom affecting lifestyle and quality of life. G.Vicente,MD Accommodative esotropiaAccommodative esotropia n n Typically presents around age 2 years, may present Typically presents around age 2 years, may present acutely.acutely. n n Always put +3.00 sph OU when you see an ET for the Always put +3.00 sph OU when you see an ET for the first time. first time. n n If its improved or resolved think Accom ET!If its improved or resolved think Accom ET! n n Why is there ET with Accommodation?Why is there ET with Accommodation? n n Eyes will usually converge when accommodation is Eyes will usually converge when accommodation is attempted.attempted. n n If high hyperope then must accommodate, if If high hyperope then must accommodate, if accommodating then will converge, cross, specially at accommodating then will converge, cross, specially at near.near. Accommodative ETAccommodative ET n n Use cyclogyl to measure Rx (wait 40 minutes)Use cyclogyl to measure Rx (wait 40 minutes) n n Recheck 4 weeks later with glasses, Recheck 4 weeks later with glasses, n n If still some ET present, use Atropine to make If still some ET present, use Atropine to make sure you measured the full CRxsure you measured the full CRx n n Tell parents they eyes will continue to cross Tell parents they eyes will continue to cross every time the glasses come off.every time the glasses come off. n n Always give full CRx, cycloplegic refraction for Always give full CRx, cycloplegic refraction for suspected Accom ET.suspected Accom ET. n n Child might not like full CRx Child might not like full CRx n n Use Atropine when using hyperopic glasses for Use Atropine when using hyperopic glasses for the first time, it will break the accommodative the first time, it will break the accommodative spasm and allow the pt to get used to the spasm and allow the pt to get used to the glasses.glasses. emmetropia +3D CRx = +5D hyperopia, no accommodation +5D hyperopia (lets say the pt is able to accommodate 3D, so effectively they are only +2D hyperope) +3D +5D+3D +5D Rx +3D accom spasm = +8D, pt is only a +5.00 so Pt ends up feeling like a -3.00D myope with your Rx My son does not like the glasses you recommended, The optician was right, they are too strong +5D+3D +5D+0D With Atropine, no accommodation, no convergence for distance Pt happy, MD happy Accommodative ET, AC/AAccommodative ET, AC/A n n AC/A = AC/A = Accommodative convergence / accommodationAccommodative convergence / accommodation n n An accom ET crosses because he/she has normal AC/A.An accom ET crosses because he/she has normal AC/A. n n Ie of high AC/A: Ie of high AC/A: n n an emmetrope, WRx = plano OU pt an emmetrope, WRx = plano OU pt n n At Distance they are orthoAt Distance they are ortho n n At near they are 25PD ETAt near they are 25PD ET n n They are over converging for a normal amount of accommodation.They are over converging for a normal amount of accommodation. n n This is a high AC/A ratio.This is a high AC/A ratio. AC/AAC/A n n Example of a pt with low AC/A? Example of a pt with low AC/A? n n who underconverges?who underconverges? n n +8.00 hyperope who is ortho at near and +8.00 hyperope who is ortho at near and distance. distance. n n They have adapted to their hyperopia by They have adapted to their hyperopia by under converging.under converging. Infantile EsotropiaInfantile EsotropiaSyndromeSyndrome n n Aka congenital esotropiaAka congenital esotropia n n Esotropia usually present by age 6 Esotropia usually present by age 6 monthsmonths n n Not improved with hyperopic RxNot improved with hyperopic Rx n n Most pts will never have good stereoMost pts will never have good stereo n n Associated with inferior oblique over Associated with inferior oblique over actionaction n n And DVD, dissociated vertical And DVD, dissociated vertical deviation.deviation. n n The 2 latter conditions may not be The 2 latter conditions may not be present initially must remember to present initially must remember to warn parents that if they occur in the warn parents that if they occur in the future it is not the surgeonfuture it is not the surgeon s fault.s fault. Infantile esotropia continuedInfantile esotropia continued n n Must rule out other causesMust rule out other causes n n CN 6 palsy from birth? Often spontaneous CN 6 palsy from birth? Often spontaneous resolutionresolution n n Remember some variable, intermittent Remember some variable, intermittent strabismus is expected until 4 months of strabismus is expected until 4 months of age.age. Esotropia associated with Viral Esotropia associated with Viral illnessillness n n Often self limited, will spontaneously Often self limited, will spontaneously resolve in 3-6 months.resolve in 3-6 months. n n AcuteAcute n n Not improved with hyperopic glasses.Not improved with hyperopic glasses. n n Consider ruling out neoplastic causes.Consider ruling out neoplastic causes. n n Treat/prevent amblyopia in the mean timeTreat/prevent amblyopia in the mean time Esotropia associated with DiabetesEsotropia associated with Diabetes n n Abducens, lateral, CN 6 usually affected.Abducens, lateral, CN 6 usually affected. n n Isolated unilateral palsyIsolated unilateral palsy n n IschemicIschemic n n Usually resolves after 4-6 months.Usually resolves after 4-6 months. n n Consider Botox in the meantime, to which Consider Botox in the meantime, to which musclemuscle The medial rectus Botox injection to Medial Rectus For temporary lateral rectus ischemic palsy Sensory strabismus - PedsSensory strabismus - Peds n n Young pts with poor monocular vision will Young pts with poor monocular vision will often develop esotropia in that eye.often develop esotropia in that eye. n n OKAP NOTE:OKAP NOTE: n n DOES YOUR PEDS PT HAVE ESOTROPIA DOES YOUR PEDS PT HAVE ESOTROPIA BECAUSE THEY CAN NOT SEE OUT OF BECAUSE THEY CAN NOT SEE OUT OF THAT EYE?THAT EYE? n n WHY? CATARARCT, RETINOBLASTOMA, WHY? CATARARCT, RETINOBLASTOMA, MACULAR SCAR, ANISOMETROPIA?MACULAR SCAR, ANISOMETROPIA? Sensory strabismus- adultsSensory strabismus- adults n n Adult with poor monocular Adult with poor monocular vision will often develop vision will often develop exotropia.exotropia. n n Think dense cataract X 5 Think dense cataract X 5 yearsyears n n Warn pt about possible post Warn pt about possible post op diplopia and need for op diplopia and need for strabismus surgerystrabismus surgery n n Pt may have lost the ability to Pt may have lost the ability to fuse.fuse. n n Think monovision, or Think monovision, or unilateral under correction unilateral under correction Lasik pt who had undiagnosed Lasik pt who had undiagnosed intermittent ermittent exotropia. Pseudo ET Orthophoria Esotropia G.Vicente,MD Initially the baby has a “button nose, with a very flat nasal bridge. The baby lids cover the medial white part of the eyes causing the appearance of the eyes being crossed. As the nasal bridge develops and grows forward it will drag the medial portion of the lids inward reducing the appearance of the eyes being crossed. 1 Pseudo ET G.Vicente,MD Initially the baby has a “button nose, with a very flat nasal bridge. The baby lids cover the medial white part of the eyes causing the appearance of the eyes being crossed. As the nasal bridge develops and grows forward it will drag the medial portion of the lids inward reducing the appearance of the eyes being crossed. 2 Pseudo ET G.Vicente,MD Initially the baby has a “button nose, with a very flat nasal bridge. The baby lids cover the medial white part of the eyes causing the appearance of the eyes being crossed. As the nasal bridge develops and grows forward it will drag the medial portion of the lids inward reducing the appearance of the eyes being crossed. 3 Pseudo ET G.Vicente,MD Initially the baby has a “button nose, with a very flat nasal bridge. The baby lids cover the medial white part of the eyes causing the appearance of the eyes being crossed. As the nasal bridge develops and grows forward it will drag the medial portion of the lids inward reducing the appearance of the eyes being crossed. 4 Pseudo ET G.Vicente,MD ExotropiaExotropia n n Intermittent is very commonIntermittent is very common n n How symptomatic are they?How symptomatic are they? n n Make sure they have BCVA glassesMake sure they have BCVA glasses n n Diplopia? Diplopia? n n Often familial, so what? Dad had it too. Often familial, so what? Dad had it too. n n “ “What hump?What hump?” ” n n Intermittent exotropia can breakdown over time, Intermittent exotropia can breakdown over time, check serial stereo. If worsening think surgery. check serial stereo. If worsening think surgery. n n Most common time of pediatric surgery is 7 years old.Most common time of pediatric surgery is 7 years old. n n Can the pt converge?Can the pt converge? Convergence insufficiencyConvergence insufficiency n n Seen in kids who have trouble readingSeen in kids who have trouble reading n n Adults with ParkinsonAdults with Parkinson s diseases disease n n Consider Consider n n Convergence exercises by a pediatric optometrist, or Convergence exercises by a pediatric optometrist, or at home exercises with special softwareat home exercises with special software n n Decreasing add in bifocals to extend reading distance Decreasing add in bifocals to extend reading distance (holding reading material further away) (holding reading material further away) n n Prisms, may used at times.Prisms, may used at times. NomenclatureNomenclature Orthorphoriao Esophoria E Esotropia ET Intermittent Esotropia E(T) ExophoriaX Exotropia XT Intermittent Exotropia X(T) At near X(T) Right HypertropiaRHT convergent divergent G.Vicente,MD Cover Uncover test Orthophoria, normal No complaints, asymptomatic G.Vicente,MD G.Vicente,MD Cover Uncover test Esophoria, abnormal, common Only seen when eye is covered Often asymptomatic, no complaints Note OS does not move. G.Vicente,MD Cover Uncover test Exophoria, abnormal, common Only seen when eye is covered Note OS does not move Often asymptomatic, no complaints. G.Vicente,MD Alternate cover test Remember to allow the pt time to fixate on the target, give them a minute. Then quickly cover the other eye to prevent the pt from regaining fusion. But do not go back and forth quickly because the pt will not have time to refixate. Alternate Cover test Exotropia, intermittent May be visible with or without alternate cover May have intermittent diplopia, especially when tired or sick Mom sees misalignment every now and then. G.Vicente,MD Alternate Cover test Exotropia, Constant May be visible with or without alternate cover May or may not have constant diplopia G.Vicente,MD Cover Uncover test Left Exotropia, Constant May be visible with or without alternate cover Right eye preference G.Vicente,MD Cover Uncover test Left Exotropia, Constant May be visible with or without alternate cover Right eye preference Note: no eye movement, so be sure to check both sides G.Vicente,MD Normal Convergence Convergence Insufficiency G.Vicente,MD Constant StrabismusConstant Strabismus Workup, acute presentation, nerve palsy (Case of newly acquired left CN 6 in a 55 yo male) Ischemic, GCA Neoplastic Invasive Paraneoplastic Compressive Nerve regeneration Longstanding breakdown. Sensory Degenerative CNS, Parkinsons, MS Infectious Myositis (trichinosis) Iatrogenic Post non-strabismus surgery Cataract, retrobulbar blocks (nerve damage vs. contracture) Glaucoma, valves Lasik Mechanical Trauma Blow out Fracture Tumor G.Vicente,MD More Types of StrabismusMore Types of Strabismus Convergent, Esotropia Accommodative Congenital or infantile Acquired, CN 6 palsies Divergent, Exotropia Vertical, Torsional and Oblique Parks 3 Step test Superior Oblique Palsies Tucks vs. IO recessions Inferior Oblique Over action (V patterns) DVDs Dissociated Vertical Deviation Complex Cases Adjustable vs Fixed sutures. Re-ops Different measurements based on eye fixation Optics Angle Kappa G.Vicente,MD Alternate Cover test with Prism Exotropia, Constant Use prism to quantitate the deviation. Change prism power until movement is neutralized. Use this number to plan surgery 20 How much to operate G.Vicente,MD Exotropia Remember to measure while fixating at a far distance. Also use +3.00 sph in front of each eye to eliminate the accommodative convergence component at distance. Consider 30 minute patch test to break fusion and really see how bad the XT can get. How much to operate? How much to operate Tables: Personal experience Dosages (surgical) bilat , 2 muscles ie for ET 40PD recess 5.5mm both MR ET XT PD Rec Rst Rec Resect 15 3 3 4 2.5 20 3.5 4 5 3 25 4 5 6 4 30 4.5 6 7 5 35 5 7 7.5 5.5 40 5.5 7.5 8 6 50 6 8 9* 7 60 6.5 8.5 10* 8 Where to operate?Where to operate? Option A: recess, loosen bilateral MR Medial Recti. Option B: recess Left MR and resect, tighten Left Lateral Rectus LLR RMedial Rectus LMedial Rectus L Lateral Rectus G.Vicente,MD Large ET (65PD) , bilateral MR Large ET (65PD) , bilateral MR recession, and LLR resectionrecession, and LLR resection preop 1 month post op 3 d post op G.Vicente,MD How much to operateHow much to operate -Patient preference-Patient preference Case of monocular 85 yo Case of monocular 85 yo BF with sensory XTBF with sensory XT one eye or two?one eye or two? Pt wished to Pt wished to notnot have OD have OD operated, understood risk operated, understood risk of under correction.of under correction. Therefore only recessed Therefore only recessed LMR 7mm and LLR 6mm.LMR 7mm and LLR 6mm. Pt had some residual XT Pt had some residual XT 15-20 PD, but was happy, 15-20 PD, but was happy, therefore surgeon was therefore surgeon was happy too.happy too. G.Vicente,MD Surgical NotesSurgical Notes Sutures: Sutures: Most stitches used in eye surgery are thinner than human Most stitches used in eye surgery are thinner than human hairs.hairs. They will dissolve on their own over 6 weeks. They may make They will dissolve on their own over 6 weeks. They may make your eye feel scratchy for the first few weeks. your eye feel scratchy for the first few weeks. The antibiotic ointment and a cool compresses will alleviate The antibiotic ointment and a cool compresses will alleviate this symptom if it occurs. this symptom if it occurs. Adjustable suturesAdjustable sutures What to expect after surgeryWhat to expect after surgery Some double vision is normal for the first few weeks after eye Some double vision is normal for the first few weeks after eye muscle surgery.muscle surgery. Precaution:Precaution: General post op hygieneGeneral post op hygiene Eye rubbingEye rubbing Can my child swim after his or her eye surgery?Can my child swim after his or her eye surgery? Length of surgery and recoveryLength of surgery and recovery G.Vicente,MD Notes on AnesthesiaNotes on Anesthesia Notes on AnesthesiaNotes on Anesthesia GeneralGeneral Pediatric anesthesia doctorsPediatric anesthesia doctors Risk of Gen. Anesthesia in childrenRisk of Gen. Anesthesia in children Primary