ºÝºÝߣ

ºÝºÝߣShare a Scribd company logo

Spontaneous consecutive exotropia, 2022.pdf

•
•
Alvina Pauline Santiago, MD
Alvina Pauline Santiago, MD

Spontaneous consecutive exotropia was presented at the 5th Asean Ophthalmology Congress held online in 2022

1 of 20
Spontaneous Consecutive Exotropia Alvina Pauline Santiago, MD
Case 1: 3, Male Sc MET 4PD, 30PD LE(T)’ Atropine +2.50 OU With +2.50, small MXT noted Given Plano A +1.50 cc 0-2 PD MET, ortho at near
Case 1: 3, Male Managed with reduced plus with Adds till age 7 Short-acting cycloplegia: +2.00 OU Given +1.00 OU
Case 1: 3 now 9 Lost to follow-up for 2 years Wearing a +1.00 prescribed from 2 years prior 30PD X(T) Subjective Refraction •OD: -0.50 20/20 •OS: -0.75 20/40 Cyclorefraction: +0.50, OU •Conservative management •Myopic Rx •Convergence exercises •Patching
Case 1: 3 now 17 Findings • -1.00 OU • Orthotropia w correction • 14PD X(T) without Rx
Case 1: 3 now 17 Findings • -1.00 OU • Orthotropia w correction • 14PD X(T) without Rx Risk Factors • Amblyopia • Control of ET in 2 months • IOOA • Remote NPC • High AC/A • Lost to follow-up 2 years
Case 2: 9 mo, Male • +3.00 OU, still w 30PD ET • 40PD sc • Atropine: +4.25 OU • Age 1: Cycloplegic: +2.50 OU • Reduced plus +1.50 OU controlled
Case 2: 9 mos, now 5 •Cyclorefraction: +2.00 OU •Reduced plus: •+1.00 20/40 •+1.00 20/60
Case 2: 9mo, now 7 • Lost to follow-up for 2 years • Wearing last known Rx +1.00 • Monofixation Exotropia w/sc • Cycloplegic refraction: +1.00 OU • Patching • Overminus lenses: -0.50 OU • VA at least 20/40
Case 2: 9mo, now 9 Current Management • Tolerated overminus: -1.00 OU • 20/30 OU • X(T) = 14PD • Cycloplegic: plano OU • -1.50: 12PD X(T) Risk Factors • Amblyopia • DVD • Remote NPC • Wrong glasses • Lost to follow-up 2 years
Case 3: 1, Male Clinical Features • ET 35PD • Right preferred • Surgery advised • Membrane prisms • Cyclo: +1.50 OU Risk Factors • V pattern; IOOA • DVD
Case 3: 1 now 5 •18-25PD X(T) •Controlled w -1.50 OU •Remote NPC
Case 3: 1, now 12 • 12-16PD X(T) • Over minus lenses: 10-16 X(T) • Orthoptics Risk Factors • Remote NPC • Amblyopia • DVD • IOOA, V pattern • Preterm
Case 4: 4 mo, F • E(T) = 25PD • SAC: +2.00 OU • Controlled for 2 years • Then MX(T) • Between ages 5-8, sometime MET, sometimes MXT
Case 4: 4 mo, now 8 • 20PD X(T) w DVD • Best correction: • OD: -0.25 20/25 • OS: -1.00 -0.50 x 180 20/20 Risk Factors • Variable monofixation? • Amblyopia • DVD • E(T) recurrence
Take home message • Spontaneous consecutive exotropia can occur: • Accommodative esotropia • Infantile esotropia (managed with prisms) • Nonrefractive Accommodative ET with or without high AC/A • Intermittent esotropia • Recognize risk factors • Taper earlier than we were taught https://www.kindpng.com/picc/m/481-4819822_transparent-light- bulb-idea-clipart-take-home-message.png
Possible Risk Factors •Poor follow-up •Wrong prescription •High AC/A •Prematurity •Rapid control of deviation •Rapid drop in refraction •Amblyopia •DVD •IOOA •Remote NPC
Management Pearls • Full cycloplegic refraction • 2 cycles good control: consider reduce plus 1-1.5D from full cycloplegic refraction • Intermediate or Short acting cycloplegic refraction • If ET controlled, No need to run after latent hyperopia if ET controlled with Rx • Iff residual ET, proceed with atropine refraction • Closer follow-up than we were used to data:image/jpeg
References 1. Santiago AP (2022). Spontaneous Consecutive Exotropia After Accommodative Esotropia. Acta Medica Philippina (Online) https://doi.org/10.47895/amp.vi0.4540. 2. Lembo A, Serafino M, Strologo MD, Saunders RA, Trivedi RH, Villani E, et al. Accommodative esotropia: the state of the art. Int Ophthalmol. 2019 Feb; 39(2):497-505. doi: 10.1007/s10792-018-0821-6. PMID: 29332227. 3. Raab E. Accommodative Esotropia. Difficult Esotropia Entities: Principles of Management. In Clinical Strabismus Management Principles and Technique. Rosenbaum AL, Santiago AP (editors), Philadephia, WB Saunders, 1999, pp 140-143. 4. Shin DH, Choi CY, Han SY. Risk factors for spontaneous consecutive exotropia in children with refractive and nonrefractive accommodative esotropia. Jpn J Ophthalmol. 2020 May; 64(3):292-7. doi: 10.1007/s10384-020-00724-5. PMID: 32108919. 5. Senior JD, Chandna A, O'Connor AR. Spontaneous consecutive exotropia in childhood. Strabismus. 2009 Jan-Mar; 17(1):33-6. doi: 10.1080/09273970802678818. PMID: 19301191.
References 6. Weir CR, Cleary M, Dutton GN. Spontaneous consecutive exotropia in children with motor fusion. Br J Ophthalmol. 2001 Feb; 85(2):242-3. doi: 10.1136/bjo.85.2.238e. PMID: 11225577; PMCID: PMC1723827. 7. Beneish R, Williams F, Polomeno RC, Little JM. Consecutive exotropia after correction of hyperopia. Can J Ophthalmol. 1981 Jan; 16(1):16-8. PMID: 7470983. 8. Watanabe-Numata K, Hayasaka S, Watanabe K, Hayasaka Y, Kadoi C. Changes in deviation following correction of hyperopia in children with fully refractive accommodative esotropia. Ophthalmologica. 2000 Sep-Oct; 214(5):309-11. doi: 10.1159/000027511. PMID: 10965242. 9. Yurdakul NS, Ugurlu S. Analysis of risk factors for consecutive exotropia and review of the literature. J Pediatr Ophthalmol Strabismus. 2013 Sep-Oct; 50(5):268-73. doi: 10.3928/01913913-20130430-01. Epub 2013 May 7. PMID: 23641958. 10. Ha SG, Suh YW, Kim SH. Esodeviation without correction for tapering hyperopia in refractive accommodative esotropia. Can J Ophthalmol. 2018 Oct; 53(5):453-7. doi: 10.1016/j.jcjo.2018.01.019. Epub 2018 Mar 16. PMID: 30340709.

More Related Content

Spontaneous consecutive exotropia, 2022.pdf

  • 2. Case 1: 3, Male Sc MET 4PD, 30PD LE(T)’ Atropine +2.50 OU With +2.50, small MXT noted Given Plano A +1.50 cc 0-2 PD MET, ortho at near
  • 3. Case 1: 3, Male Managed with reduced plus with Adds till age 7 Short-acting cycloplegia: +2.00 OU Given +1.00 OU
  • 4. Case 1: 3 now 9 Lost to follow-up for 2 years Wearing a +1.00 prescribed from 2 years prior 30PD X(T) Subjective Refraction •OD: -0.50 20/20 •OS: -0.75 20/40 Cyclorefraction: +0.50, OU •Conservative management •Myopic Rx •Convergence exercises •Patching
  • 5. Case 1: 3 now 17 Findings • -1.00 OU • Orthotropia w correction • 14PD X(T) without Rx
  • 6. Case 1: 3 now 17 Findings • -1.00 OU • Orthotropia w correction • 14PD X(T) without Rx Risk Factors • Amblyopia • Control of ET in 2 months • IOOA • Remote NPC • High AC/A • Lost to follow-up 2 years
  • 7. Case 2: 9 mo, Male • +3.00 OU, still w 30PD ET • 40PD sc • Atropine: +4.25 OU • Age 1: Cycloplegic: +2.50 OU • Reduced plus +1.50 OU controlled
  • 8. Case 2: 9 mos, now 5 •Cyclorefraction: +2.00 OU •Reduced plus: •+1.00 20/40 •+1.00 20/60
  • 9. Case 2: 9mo, now 7 • Lost to follow-up for 2 years • Wearing last known Rx +1.00 • Monofixation Exotropia w/sc • Cycloplegic refraction: +1.00 OU • Patching • Overminus lenses: -0.50 OU • VA at least 20/40
  • 10. Case 2: 9mo, now 9 Current Management • Tolerated overminus: -1.00 OU • 20/30 OU • X(T) = 14PD • Cycloplegic: plano OU • -1.50: 12PD X(T) Risk Factors • Amblyopia • DVD • Remote NPC • Wrong glasses • Lost to follow-up 2 years
  • 11. Case 3: 1, Male Clinical Features • ET 35PD • Right preferred • Surgery advised • Membrane prisms • Cyclo: +1.50 OU Risk Factors • V pattern; IOOA • DVD
  • 12. Case 3: 1 now 5 •18-25PD X(T) •Controlled w -1.50 OU •Remote NPC
  • 13. Case 3: 1, now 12 • 12-16PD X(T) • Over minus lenses: 10-16 X(T) • Orthoptics Risk Factors • Remote NPC • Amblyopia • DVD • IOOA, V pattern • Preterm
  • 14. Case 4: 4 mo, F • E(T) = 25PD • SAC: +2.00 OU • Controlled for 2 years • Then MX(T) • Between ages 5-8, sometime MET, sometimes MXT
  • 15. Case 4: 4 mo, now 8 • 20PD X(T) w DVD • Best correction: • OD: -0.25 20/25 • OS: -1.00 -0.50 x 180 20/20 Risk Factors • Variable monofixation? • Amblyopia • DVD • E(T) recurrence
  • 16. Take home message • Spontaneous consecutive exotropia can occur: • Accommodative esotropia • Infantile esotropia (managed with prisms) • Nonrefractive Accommodative ET with or without high AC/A • Intermittent esotropia • Recognize risk factors • Taper earlier than we were taught https://www.kindpng.com/picc/m/481-4819822_transparent-light- bulb-idea-clipart-take-home-message.png
  • 17. Possible Risk Factors •Poor follow-up •Wrong prescription •High AC/A •Prematurity •Rapid control of deviation •Rapid drop in refraction •Amblyopia •DVD •IOOA •Remote NPC
  • 18. Management Pearls • Full cycloplegic refraction • 2 cycles good control: consider reduce plus 1-1.5D from full cycloplegic refraction • Intermediate or Short acting cycloplegic refraction • If ET controlled, No need to run after latent hyperopia if ET controlled with Rx • Iff residual ET, proceed with atropine refraction • Closer follow-up than we were used to data:image/jpeg
  • 19. References 1. Santiago AP (2022). Spontaneous Consecutive Exotropia After Accommodative Esotropia. Acta Medica Philippina (Online) https://doi.org/10.47895/amp.vi0.4540. 2. Lembo A, Serafino M, Strologo MD, Saunders RA, Trivedi RH, Villani E, et al. Accommodative esotropia: the state of the art. Int Ophthalmol. 2019 Feb; 39(2):497-505. doi: 10.1007/s10792-018-0821-6. PMID: 29332227. 3. Raab E. Accommodative Esotropia. Difficult Esotropia Entities: Principles of Management. In Clinical Strabismus Management Principles and Technique. Rosenbaum AL, Santiago AP (editors), Philadephia, WB Saunders, 1999, pp 140-143. 4. Shin DH, Choi CY, Han SY. Risk factors for spontaneous consecutive exotropia in children with refractive and nonrefractive accommodative esotropia. Jpn J Ophthalmol. 2020 May; 64(3):292-7. doi: 10.1007/s10384-020-00724-5. PMID: 32108919. 5. Senior JD, Chandna A, O'Connor AR. Spontaneous consecutive exotropia in childhood. Strabismus. 2009 Jan-Mar; 17(1):33-6. doi: 10.1080/09273970802678818. PMID: 19301191.
  • 20. References 6. Weir CR, Cleary M, Dutton GN. Spontaneous consecutive exotropia in children with motor fusion. Br J Ophthalmol. 2001 Feb; 85(2):242-3. doi: 10.1136/bjo.85.2.238e. PMID: 11225577; PMCID: PMC1723827. 7. Beneish R, Williams F, Polomeno RC, Little JM. Consecutive exotropia after correction of hyperopia. Can J Ophthalmol. 1981 Jan; 16(1):16-8. PMID: 7470983. 8. Watanabe-Numata K, Hayasaka S, Watanabe K, Hayasaka Y, Kadoi C. Changes in deviation following correction of hyperopia in children with fully refractive accommodative esotropia. Ophthalmologica. 2000 Sep-Oct; 214(5):309-11. doi: 10.1159/000027511. PMID: 10965242. 9. Yurdakul NS, Ugurlu S. Analysis of risk factors for consecutive exotropia and review of the literature. J Pediatr Ophthalmol Strabismus. 2013 Sep-Oct; 50(5):268-73. doi: 10.3928/01913913-20130430-01. Epub 2013 May 7. PMID: 23641958. 10. Ha SG, Suh YW, Kim SH. Esodeviation without correction for tapering hyperopia in refractive accommodative esotropia. Can J Ophthalmol. 2018 Oct; 53(5):453-7. doi: 10.1016/j.jcjo.2018.01.019. Epub 2018 Mar 16. PMID: 30340709.