Congenital infantile esotropia

Congenital infantile esotropia

• 1.
  { Congenital Infantile Esotropia Presenter -Dr. Om Patel Moderator – Dr. Varshini Shanker
• 2.
  Introduction  The termis derived from 2 Greek words: ésò, meaning inward, and trépò, meaning turn  In esotropia, the eyes are crossed; that is, while one eye looks straight ahead, the other eye is turned in toward the nose  Esodeviations are the most common type of ocular misalignment  Represents 50% of ocular deviations in pediatric age group
• 3.
  Introduction  Three commonlyrecognized forms  Esophoria  Intermittent Esotropia  Esotropia
• 4.
   Latent esodeviationthat is controlled by fusional mechanisms  Eyes remain properly aligned under normal binocular viewing conditions Esophoria
• 5.
   Is anesodeviation that is intermittently controlled by fusional mechanisms  Manifest under certain conditions such as fatigue,illness ,stress or tests that interfere with the maintenance of normal fusional abilities {such as covering one eye} Intermittent Esotropia
• 6.
  Esotropia  Esodeviation thatis not controlled by fusional mechanisms so that deviation is constant
• 7.
  Types of Esotropia Congenital infantile esotropia  Accommodative esotropia  Acquired non accommodative esotropia  Cyclic esotropia  Divergence Insufficiency  Sensory esotropia
• 8.
  PSEUDOSTRABISMUS  Wide nasalbridge  Prominent epicanthal folds  Narrow interpupillary distance  With the formation of the bridge of the nose, pseudo- strabismus disappears
• 9.
  Definition & Incidence Large angle esotropia present before 6 months of age  Prevalence: 27/ 10,000
• 10.
  Associated factors  EssentialCongenital esotropia : most common form of strabismus  Incidence : 1 to 2 per cent  Sex distribution : Uniform  Family history positive but no well defined genetic pattern  Concordance in monozygous twins to be 81 per cent, compared with 9 per cent in dizygotic
• 11.
   Incidence --higher in patients with cerebral palsy, hydrocephalus (30% )  Maternal cigarette smoking and low birth weight linked to the development of esotropia  More prevalent in low birth weight, premature infants, perinatal hypoxia  Increased risk of development of mental illness by early adulthood
• 12.
  Etiology  WORTH THEORY Congenital absence of cortical fusion potential  Lack of binocular fusion  CHAVASSE THEORY Have potential for high grade stereopsis Primary motor misalignment Disruption of binocular vision
• 13.
  Clinical Features  Withinfirst 6 months of life  Large angle esotropia  Alternate fixation:  Target to right, fixates with the left eye  Target to the left, fixates with the right eye  Apparent limitation of abduction
• 14.
  Clinical Features  Associatedwith vertical divergence & inferior oblique over-action over the period of time  Mild to moderate amblyopia  Small degree of hyperopia
• 16.
  Examination  Amblyopia assessment Check extra ocular movements to rule out VI N palsy  Verify abduction deficit with vestibular stimulation:  Dolls head phenomenon test  Rotating the child gently
• 18.
  Examination If it persists- perform Abduction saccades  Brisk saccades - LR functioning but restricted  Absent saccades - weak LR due to VI nerve palsy
• 19.
   Large anglecongenital esotropia with cross fixation ,in which both eyes appear to be “stuck” in towards the nose Features : ~ Large angle deviation ( >60PD) ~ Bilateral limited abduction ~ Fixing eye in adduction ~ Nystagmus on attempted abduction, not adduction ~ Face turn to side of fixing eye CIANCIA SYNDROME
• 21.
  Congenital Esotropia ObservationalStudy (CEOS)  Infantile esotropia < 40 pd and intermittent or variable frequently resolves spontaneously at less than 20 weeks of age  Cases with a constant deviation > 40 pd presenting after 10 weeks of age -- spontaneous resolution less likely
• 22.
  Treatment Non – SurgicalMeasures • Correction of refractive errors • More than +2.00 D, should be corrected in small angle cases • More than +3.00 D, should be corrected in large angle esotropia • Miotics in uncooperative infants • Amblyopia therapy
• 23.
  Surgical Treatment Time OfSurgery  Standard approach - Between 6 months to 2 years to age  Peripheral fusion is achieved in most cases if operated before 2 years of age  Recent studies favour early surgery as soon as diagnosis is made  Wait upto 6 months of age in intermittent esotropia or small to moderate angle deviations
• 24.
  Before proceeding tosurgery :  Deviation should be constant and stable  Fixation should be alternating  Accomodative element should be absent  Sensory esotropia should have been ruled out  Amblyopia should be treated optimally
• 25.
  Surgical Approach  BilateralMedial rectus recession  Max of 8mm recession can be done  MR recession with lateral rectus (LR ) resection  Inferior oblique overaction : muscle weakening procedures  Alignment within 7-8 Δ of orthophoria: acceptable
• 26.
  Deviations B/l MR recession (mm) Recession ofMR Resection of LR 15 3 3 4 20 3.5 3.5 5 30 4.5 4.5 6 40 5.5 5.5 7 50 6 6 8 60 6.5 6.5 9 70 7 7 10
• 27.
  Post Surgical Outcomes SubnormalBinocular Vision  Best possible outcome  Orthophoria or asymptomatic heterophoria with stable alignment  Normal Visual Acuity  Peripheral fusion eventually develops which allows a low grade stereopsis  Normal retinal correspondence  Do not require any further treatment besides amblyopia therapy and/or correction of refractive errors
• 28.
  Post Surgical Outcomes Smallangle residual esotropia or exotropia  Considered as an acceptable treatment  Deviation less than 15 PD are cosmetically acceptable  About 80 % patients develops anomalous retinal correspondence  Stereopsis is of low grade or absent  No further treatment is required except amblyopia prevention
• 29.
  Post Surgical Outcomes Largeangle residual esotropia  Due to undercorrection  Esotropia more than 20 D  Leads to suppresion amblyopia  Absent stereopsis  Needs repeat surgery within 3 months  Bilateral LR resection in case primary MR recession has been done else LR resection with MR recession in the other eye
• 30.
  Post Surgical Outcomes LargeAngle Consecutive Exotropia  Due to over correction  In children below 2 years, surgery should be done early to give a chance for development of peripheral fusion  In patients above 8 years of age, wait for about 6 to 8 weeks, surgery only if deviation is more than 20 PD  Surgical Options  LR recession with advancement of previously recessed MR  Bilateral LR recession  LR recession + MR resection of the other eye
• 31.
  Botulinum Toxin  Tocreate a incomitant deviation so that patient could adopt a face turn and attain fusion  Multiple injections may be required  Alignment and sensory outcomes not comparable to surgery  Complications include  Secondary ptosis  Initial consecutive exotropia lasting up to 2 to 3 months
• 32.
  ACQUIRED ESOTROPIAS  Onsetin few years of life  Insignificant refractive error & accomodative factor  Three types :  Basic Esotropia  Convergence excess esotropia  Divergence Insuffiency Esotropia  Therapy : treatment of amblyopia and surgical treatment of the underlying deviation  Rule out a CNS lesion in case of acquired esotropia
• 33.
  NYSTAGMUS BLOCKAGE SYNDROME  Patientswith congenital nystagmus may use accommodative convergence to dampen their nystagmus  Have straight eyes with congenital nystagmus on distance fixation  But on near fixation, they manifest a variable esodeviation while using accommodative convergence to dampen the nystagmus and improve vision
• 34.
   Nystagmus isinversely proportional to angle of deviation  Appears as fixing eye moves from adduction to abduction  Fixation occurs with the adducting eye  Head tilt towards the side of fixating eye NYSTAGMUS BLOCKAGE SYNDROME
• 35.
  CYCLIC ESOTROPIA Acquired esotropiawhich occurs most frequently between 2-6 years of age  Strabismic & non strabismic phase of 24 hrs each  Lasts for months to years Strabismic phase :  Large deviation(40-70PD)in early childhood  Suppression in deviated eye Non Strabismic phase :  No manifest deviation, normal fusion and stereopsis
• 36.
   These patientsare actually esotropic but able to maintain fusion periodically  Correcting for the deviation therefore does not cause over correction on orthophoric days; patient has enough compensatory divergence  Not associated with any phoria on normal days no accommodation / fusional component CYCLIC ESOTROPIA
• 37.
  Treatment  B/L medialrectus recession  MR recession + LR resection
• 38.
  DIVERGENCE PARALYSIS  Commitantesotropia for distant fixation in patients with normal ductions & versions  Idiopathic condition  CNS disease: polio, neoplasms
• 39.
  Divergence Paralysis  Suddenonset diplopia at distant fixation  Commitant esotropia  Unrestricted field of vision  Abduction & versions are normal Treatment:  Self limiting: disappear in 5 -6 months  Base out prisms: relieve diplopia  B/L LR resection if > 6months
• 40.
  SENSORY ESOTROPIA  Esotropiasecondary to poor visual function in one eye in childhood  Monocular lesions which prevent normal binocular vision development  Congenital cataracts, corneal opacities, retinoblastoma, optic atrophy
• 41.
  Treatment  Evaluate thegood eye fully for refractive errors  Treat underlying causes, along with management of amblyopia before squint surgery  MR recession +/- LR resection  Inform patient about recurrence chances
• 42.
  Consecutive esotropia  Resultsfrom over correction of exodeviations  For deviations <20 P.D. no active management  Deviations > 20 PD wait for 6 months if no improvement occurs surgical correction is required  Use of adjustable sutures recommended in these cases  In very large esodeviation presenting immediately after surgery ,it is important to remember muscle detachment from new site of insertion