Case Presentation on Post-Operative Intermittent Exotropic Consecutive Esotropia
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This patient presented with binocular horizontal diplopia that occurs frequently, especially when tired. She has a history of intermittent exotropia and underwent bilateral lateral rectus recession surgery at age 11. On examination, she displayed small esophoria and 10 prism diopters of base-out exotropia. She was diagnosed with postoperative intermittent exotropic consecutive esotropia. Her management plan includes undercorrection of her glasses prescription, use of Fresnel prisms to relieve diplopia, and titrated prism addition to monitor deviation and diplopia. Consecutive strabismus occurs when a patient develops a deviation in the opposite direction of their original pre-operative alignment.
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Case Presentation on Post-Operative Intermittent Exotropic Consecutive Esotropia
- 1. CASE PRESENTATION A story after another story….. Prepared by Anis Suzanna binti Mohamad Pegawai Optometri U41 Jabatan Oftalmologi, Hospital Sultanah Bahiyah
- 3. History taking • Miss NL, D.O.B: 18.04.1999 • 16/F/M • Chief complaint – Pt c/o binocular horizontal diplopia at distance occurs frequently – Onset are varies: morning/afternoon/evening – Frequency: most of the time especially when tired – Degree: almost the same all the time – She now in Form 5, will take SPM examination by the end of this year – She worried due to she cannot focus in the class – When diplopia occurred, she unable to see writing on the whitebord and troublesome for her in order to study
- 4. • Signs & symptoms – AHP: Slight face turn to the right • Previous treatment – H/o underwent squint surgery (bilateral LR recession) @ 11 years old – Previously she is intermittent exotrope – She has anisometropia, compliance to glasses – Start with visual therapy: 2 circles exercise 5 minutes daily, not comply
- 5. Assessment Right eye Left eye Distance VA (aided) 6/6 6/6 Near VA (aided) N5@33cm N5@33cm Current spectacles Rx -2.00/-1.50x175 -4.75/-1.75x167 K-reading 45.00 @ 92 47.37 @ 2 44.75 @ 170 47.12 @ 80 Refraction & VA -2.00/-1.50x175 (VA: 6/6) -4.75/-1.75x170 (VA: 6/6) 1) VA and refraction
- 6. Binocular vision assessment Hirschberg Central and symmetry Cover test (Distant) Small esophoria with LE hypophoria (Near) Small esophoria with LE hypophoria Prism cover test (∞) 10 pd BO, 2 pd BU over LE (Near) 10 pd BO, 2 pd BU over LE PFV (+ve) (∞) x/12/10 (Near) x/14/12 NFV (-ve) (∞) x/4/11 (Near) x/6/2 NPC See single until 8cm AC/A ratio 6.8 pd/D 2) Vergence component
- 7. Binocular vision assessment Right eye Left eye AA Pt’s expected AA: ±13.5 D 9.5 D, 10 D, 10 D 13D, 14D, 14D PRA (-ve) +2.00DS NRA (+ve) -3.50DS Facility 9.0 cpm 9.0 cpm BE: 5.0 cpm 3) Accommodation component
- 8. Binocular vision assessment Krimsky 14 BO EOM RMR o/a +1 RIO o/a +2 Worth-4-Dot test Identify 5 shapes, uncrossed diplopia Stereopsis 50 secs of arc using Random Dot Stereofly @ 33cm 4) Strabismus
- 9. Binocular vision assessment 5) Additional test (Hess screen test)
- 10. Diagnosis Post-operative Intermittent Exotropic Consecutive Esotropia
- 11. Prognosis • Good • Patient & parents cooperative and committed towards treatment • Goal:- – Obtain single vision
- 12. Management & Follow-up care Under correction of her gls Rx • (give minimum myopia on non-dominant eye with compromise vision) Fresnel prism • (to relieve diplopia in patient) TCA • (To check angle of deviation and diplopia after give fresnel prism)
- 13. Disscussion • Consecutive strabismus A deviation of the eye in the op posite direction to what it was previously. • This condition may follow surgery although it may occur spontaneously. • There are two types: – consecutive exotropia in a patientwho previously had esotropia or esophoria – consecutive esotropia in a patient who previously had exotropia or exophoria. Definition
- 14. Disscussion Eso Tropia Phoria 1° 2 ° Consec. i. Conv. Excess Constant ii. Div. Weakness i. withAccom. Elem. iii. Non-specific ii. without Accom. Elem. Intermittent i.Accom. ii. Distance - near eso - distance eso iii. Time - cyclic/alternate day squint iv. Non-specific Eso deviation
- 15. Guideline for consecutive esotropia management
- 16. Continue •An esotropia occurs commonly after surgery for intermittent exotropia. • If this consecutive deviation is relatively small (less than 10 diopters) and if abduction is full or nearly full, it should not be treated. • A slight overcorrection has been correlated with the most stable long term postoperative alignment of intermittent exotropia. •An overcorrection larger than 10 diopters should be monitored and if treated it should be done so at first conservatively including some or all of the following: full plus correction, alternate patching, and fully correcting base out prism. •Only if all conservative approaches have been exhausted is additional surgery indicated.
- 18. Conclusions • Good history taking – Esotropia in a patient who previously had an exotropia/exophoria. – Generally occur as a result of surgery- immediate or long term. • Post-Operative Consecutive Esotropia - may be deliberate - may be due to over-liberal surgery e.g LR recession or MR resection. • Management depend on whether the case is functional or cosmetic.
- 19. References • Books Essentials of Clinical Binocular Vision by Erik M. Weissberg; Butterworth Heinemann 2004 • Website http://www.cybersight.org/bins/volume _page.asp?cid=1-351-355-448 J Korean Ophthalmol Soc. 2006 Oct;47(10):1623-1629. Korean.
Notas do Editor
- (1) An esodeviation is called consecutive when it occurs after surgery for exotropia or when an exotropia changes spontaneously into esotropia. (2) When passive ductions are free in a patient with limited abduction, the lateral rectus muscle is not functioning properly. (3) Postoperative lateral rectus underaction in the presence of normal passive ductions is caused by excessive recession of the lateral rectus muscle. This muscle must be brought forward to its original insertion with or without resection to restore normal abduction. 24, p.448 (4) If no lateral rectus is found, a full tendon transfer shifting the superior and inferior rectus muscles to the insertion site of the lateral rectus is indicated. (5) When passive ductions are restricted, the first requirement is to free the restriction. Restriction is usually caused by excessive resection of the medial rectus muscle and/or extensive scarring of the nasal conjunctiva. (6) Recessing the medial rectus muscle and/or the nasal conjunctiva may be sufficient to release the restriction.24, p.284 (7) In larger consecutive esodeviations a resection or advancement of the lateral rectus muscle, or both is indicated in addition to medial rectus recession. If the esodeviation is greater at near and lateral rectus function is normal, bimedial rectus recession may be required. (8) An esotropia occurs commonly after surgery for intermittent exotropia. If this consecutive deviation is relatively small (less than 10 diopters) and if abduction is full or nearly full, it should not be treated. A slight overcorrection has been correlated with the most stable long term postoperative alignment of intermittent exotropia. (9) An overcorrection larger than 10 diopters should be monitored and if treated it should be done so at first conservatively including some or all of the following: full plus correction, alternate patching, and fully correcting base out prism. Only if all conservative approaches have been exhausted is additional surgery indicated. 24, p.441; 58, p.335 (10) A spontaneous change from exotropia is esotropia in the absence of an obvious cause such as fifth nerve palsy is rare and has been reported only once. 18