Ramji pandey EXOTROPIA PPT
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This document presents a case study of intermittent exotropia in a 3-year-old female patient. On examination, the patient was found to have an alternating exotropia when measuring the angle of deviation at distance and near. She was diagnosed with intermittent exotropia. For treatment, the patient underwent 6 weeks of patching therapy and showed orthotropia on follow up visits. She later underwent bilateral lateral rectus recession surgery, with good control of exotropia observed at subsequent reviews. The document also provides background information on intermittent exotropia including prevalence, etiology, symptoms, classification, evaluation, treatment options, and surgical outcomes.
Ramji pandey EXOTROPIA PPT
- 1. Case presentation on Intermittent Exotropia PRESENTER- RAMJI PANDEY 1
- 2. DEMOGRAPHIC DATA MR NO :- P062657 AGE: -3YEARS GENDER -FEMALE 2
- 3. CHIEF COMPLAINTS AND HISTORY Informer – Mother C/O (OS) Outward deviation of eye noticed by mother since 6 months of age . No H/O using glasses. No H/O any ocular or head injury. No H/O recent ophthalmic consultation Ocular or systemic surgeries/allergy /systemic disease/family history –Nil. Birth history – Normal. 3
- 4. OCULAR EXAMINATION OD OS Un VA DISTANCE NEAR 20/20. 6/6 With NC @ 30cm under RI. 20/20. 6/6 with NC @ 30 cm under RI. RETINOSCOPY(DRY) RETINOSCOPY (WET) Clear glow ±/-0.25@ 180 Clear glow ±/-0.25@180 ACCEPTANCE ±Plano 20/20 ±Plano 20/20 LACRIMAL SAC No W/R/D NO W/R/D OCULAR MOTILITY Full , free ,painless Full , free ,painless
- 5. CONTINUE HBT - ORTHOTROPIA. Cover test for distance and near -Alternate exotropia. Prefer OD for fixation.
- 6. OCULAR EXAMINATION OD OS LIDS Flat Flat CONJUNCTIVA Quiet Quiet CORNEA Clear clear A/C VHGIV/Quiet VHGIV/Quiet PUPIL R/R/R R/R/R LENS Clear Clear IOP DIG N @ 12:00 pm. DIG N @ 12:00 pm. FUNDUS Retina ON C:D -0.4:1 HNRR Retina ON C:D -0.4:1 HNRR
- 7. DIAGNOSIS AND TREATMENT DIAGNOSIS Intermittent exotropia TREATMENT OD patching 6 hourly/day for 6 weeks
- 8. REVIEW 1.5 YEARS • Sub :Patient has come for review. • No complaints. • Unaided V/A (Distance) :OD &OS 20/20. For Near OD 6/6 , OS 6/6 @ 30 cm with NC under RI. • SLE (OU) • ANT SEG : WNL CRX • IOP : DIG N @ 3:00 pm. NIL • HBT – ORTHO • CT distance & near : alternate XT ADVICE • Prefers OD for fixation OU LR recession under • IMP GA PBCT (distance& near):50 to 60 PD XT.
- 10. • S/P: (OU) LR recession under GA on 15/6/16 • SUB : (OU) feels better • UNAIDED V/A: (OU) 20/25p • SLE (OU). • Lids: Flat • Conj : Sub conjunctival haemorrage • Ant Seg : WNL • IOP : DIG N • HBT-ortho • CT (D&N) –Flick XT • ADVICE (OU) • E/D Pred forte - 5/4/3/2 each week. • E/D Refresh liquigel - QID . • Follow up after 4 weeks . 10 POST OP:1 WEEK
- 11. POST OP:5 WEEKS • S/P: (OU) LR recession under GA on 15/6/16 • SUB : (OU) feels better Crx (OU) • UNAIDED V/A: (OU) 20/25p 1. E/D Pred forte BD. • SLE (OU) 2. E/D Refresh liquigel –QID • Lids: Flat • Conj : Sub Conjunctival haemarrage superiorly • Ant Seg : WNL • IOP : DIG N @ 10:00 am. • HBT- Ortho • CT (D) –ortho (N) : flick XT • ADVICE • (OD) : Patching 4 hourly/day • Review after 4 weeks.
- 12. DISCUSSION INTERMITTENT EXOTROPIA Outward drifting of either eye. Most common form of divergent strabismus . Onset before 5 years of age. Manifest during – - Visual in attention - Fatigue - Illness - Daydreaming - Drowsiness upon awakening
- 13. Prevalence Comprises 50-90% of cases of Exotropia Affects 1 % of general population. Nearer a country is to the equator the higher the prevalence of exo deviations .
- 14. ETIOLOGY Innervational and Mechanical factors. Role of defective fusion. Role of AC/A ratio. Theory of hemiretinal suppression. Role of refractive error.
- 15. SYMPTOMS Transient Diplopia. Asthenopic symptoms Diplophotophobia Micropsia
- 16. CLASSIFICATION Basic : • Same at near and distant fixation. Divergence Excess : Greater at distance fixation than at near. Convergence Insufficiency : Greater at near than at distance.
- 17. CONTINUE…. Simulated or Pseudo-divergence Excess: When deviation is greater at distance than near but after monocluar occlusion near deviation increase within 10 prism diopter after 30-60 min.
- 18. Natural History Remains obscure Some cases First at distance and then at near Not all the cases are progressive, may be constant or even improve EXOPHORIA INTERMITENT EXOTROPIA CONSTANT
- 19. Evaluation History Visual acuity Measurement of deviation Ocular motility Slit lamp examination Fundoscopy Stereoacuity
- 20. ASSESSING CONTROL OF INTERMITTENT SQUINT • Subjective method Control score Control score description 5 Constant XT during a 30-sec observation period (before dissociation) 4 XT > 50% of the time during a 30-sec observation period(before dissociation) 3 XT < 50% of the time during a 30-sec observation period(before dissociation) 2 No XT unless dissociated(10 sec):recovery in >5 sec 1 No XT unless dissociated(10 sec):recovery in 1-5 sec 0 Pure phoria: < 1 sec recovery after 10-sec dissociation
- 21. Example of Measuring Control of IXT XT For 10 of 30Sec (33% of 30 Sec) <50% control score=3 1.2.3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20 21.22.23.24.25.26.27.28.29.30
- 22. 1..2..3..4..5..6..7..8..9..10..11..12..13..14..15..16..17..18..19..20.. 21..22..23..24..25..26..27..28..29..30.. Step2:repeat 30 second observation before dissociation at near
- 24. CLINICAL CONTROL • Good control • Fair control • Poor control
- 25. MEASURING ANGLE OF DEVIATION • Patch test • +3.00 near add test (lens gradient method) • Far distance measurement
- 26. PATCH TEST • Used to control the tonic fusional convergence to differentiate pseudo- divergence excess from true divergence excess and to reduce the angle variability.
- 27. +3.00 Near add test • Also known as lens gradient method. • This test has been devised to diagnosed the practice of divergence excess type who have true divergence excess due to high AC/A ratio. • This test should be resorted to in patient who have a distance deviation greater than near.
- 28. Far distance measurement • Measuring the deviation by fixating a far object reduces measuring variability and helps uncover the full deviation by reducing near convergence. • Combining the patch test and far distance measurement can greatly reduce under – corrections and has improved the overall result.
- 29. Treatment Two types- • Non-surgical • Surgical
- 30. Spectacle correction of refractive error Correction of significant myopia, astigmatism and hypermetropia. Correction of mild myopia. Mild to moderate degrees of hypermetropia not routinely corrected.
- 31. Overcorrecting minus lens therapy Stimulates accommodative convergence & control exodeviation Usually 2-4 D beyond refractive error correction Advantage – Promotes fusion & delay surgery Disadvantage – Asthenopia
- 32. Part-time patching of dominant eye Converts intermittent exotropia to phoria. Done 4 – 6 hours/day. Advantage - Delays surgical intervention. Disadvantage - Prevents fusion & accelerate progression.
- 33. Prism therapy Base-in prism used
- 34. • Gross convergence • Fusional vergence • Anti-suppression therapy, including diplopia awareness when XT Vision therapy to establish sensory fusion
- 35. Pencil push up Brock string Gross Convergence
- 37. ANTI SUPRESSION THERAPY • Pathological diplopia • Use Red & Green filter in a dark room Flash light, Penlight, Candle • Prism insertion/removal
- 38. INDICATIONS FOR SURGERY- Gradual loss of fusional control Increased frequency of manifest phase Increase size of the basic deviation Development of suppression Decrease of Stereoacuity
- 39. SURGERY Bilateral lateral rectus recession . Unilateral lateral rectus recession with ipsilateral medial rectus resection . Unilateral lateral rectus recession .
- 40. POST OPERATIVE COMPLICATION Over Correction : • Persistant esotropia 3-4 weeks after surgery. • Treatment - • Correction of refractive error • Part-time alternate patching • Base-out prisms • Botulinum toxin injection • Reoperation
- 41. CONTINUE…….. Under Correction : • Observation • Orthoptic exercise • Prism therapy • Reoperation
- 42. TAKE HOME MESSAGE • Intermittent Exotropia is difficult to diagnose. • Proper evaluation required. • Timely treatment necessary. • Follow-up must be done to record progression. • Goal - To restore alignment and preserve Binocular Single Vision (BSV).
- 43. REFERENCE… • Noorden GK von: Atlas of strabismus , ed 4. St Louis , Mosby- Year Book, 1983. • Noorden GK von : Exodeviation . In: Binocular Vision and Ocular Motality 5 th ed, 1996 Mosby pg. 343. • Manley DR. Classification of the exodeviations. In: ,Manley D ed.: Symposium on horizontal ocular deviation. St Louris. 1971. Mosby – Year Book Inc. pg 128.
Editor's Notes
- #16: Patients of intermittent exotropia rarely complain of the symptoms because of the well developed suppression mechanism. During Normal Retinal correspondence patient does not complain but only does when there is ARC with one eye deviated
- #19: They may be influenced by decreased tonic convergence with increasing age, the development of suppression, loss of accommodative power and increasing divergence of orbit with advancing age