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Pédiatrie > 8 - Esodeviations > Flashcards

8 - Esodeviations Flashcards

1
Q

Major types of esodeviation (Ddx)

A
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2
Q

Chez l’enfant, esodéviation ou exodéviation qui est le plus fréquent? Account pour combien En %?

A

Esodeviation
* The most common type of childhood strabismus
* Accounting for more than 50% of ocular deviations in the pediatric population

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3
Q

Chez l’adulte, esodéviation ou exodéviation qui est le plus fréquent?

A

In adults, esodeviations and exodeviations are equally prevalent.

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4
Q

Prévalence H versus F de l’ésodéviation

A

H : F

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5
Q

Prévalence selon ethnicité : African Americans versus White versus Asian?

A

More common in African Americans and White ethnic groups than in Asian ethnic groups in the United States.
* African Americans + White ethnic groups&raquo_space; Asian ethnic groups

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6
Q

FdR développement ésotropie (x8)

A
  • Anisometropia
  • Hyperopia
  • Neurodevelopmental impairment
  • Prematurity
  • Low birth weight
  • Craniofacial or chromosomal abnormalities
  • Maternal smoking during pregnancy
  • Family history of strabismus
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7
Q

Prévalence de l’ésotropie augmente avec … ? (x3)

A

The prevalence of esotropia increases with
* Age (higher prevalence at 48–72 months compared with 6–11 months)
* Moderate anisometropia
* Moderate hyperopia

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8
Q

% d’enfants qui développent une amblyopie 2nd ésotropie

A

Amblyopia develops in approximately 50% of children who have esotropia (lorsque non traité j’imagine…)

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9
Q

Causes d’ésodéviation

A

Esodeviations can result from innervational, anatomical, mechanical, refractive or accommodative factors

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10
Q

Définir Pseudotropie

A

Pseudoesotropia : appearance of esotropia when the visual axes are in fact aligned

  • Less than the expected amount of sclera is seen nasally → creating the impression that the eye is deviated inward
  • Especially noticeable when the child gazes to either side → because no real deviation exists
  • Results of corneal light reflex testing and cover testing are normal
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11
Q

Causes de Pseudotropie

A

The appearance may be caused by
* Flat and broad nasal bridge
* Prominent epicanthal folds
* Narrow interpupillary distance
* Negative angle kappa

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12
Q

(Ésotropie infantile)

Définir l’ésotropie infantile

A

Infantile esotropia is defined as an esotropia that is present by 6 months of age

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13
Q

(Ésotropie infantile)

V ou F, l’ésotropie infantile est congénitale

A

Faux.
Some ophthalmologists refer to this disorder as congenital esotropia, although the deviation is usually not manifest at birth.

Donc, parfois appelé ésotropie congénitale mais ce n’est pas manifeste à la naissance.

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14
Q

(Ésotropie infantile)

Qu’est-il fréquent de voir comme ésotropie à 2-3 mois de vie?

A

Variable, transient, intermittent strabismus is commonly noted in the first 2–3 months of life
Also, it is common to see both intermittent esotropia and exotropia in the same infant (termed ocular instability of infancy). This condition should resolve by 3 months of age but sometimes persists, especially in premature infants.

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15
Q

(Ésotropie infantile)

Chez quelles populations (x2) la prévalence de l’ésotropie infantile est plus élevée?

A

Infantile esotropia occurs more frequently
* in children born prematurely
* in up to 30% of children with neurologic and developmental problems, including cerebral palsy and hydrocephalus

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16
Q

(Ésotropie infantile)

V ou F, infantile esotropia has been associated with a decreased risk of development of mental illness by early adulthood.

A

Faux.
Infantile esotropia has been associated with an increased risk of development of mental illness by early adulthood (2.6 times higher in patients with infantile esotropia than in controls)

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17
Q

(Ésotropie infantile)

Si les yeux sont d’AV similaire, comment est la fixation?

A

The eyes may have equal vision → in which case alternate fixation or cross- fixation will be present

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18
Q

Qu’est-ce que le cross fixation?

A

Cross- fixation :
* The use of the adducted eye for fixation of objects in the contralateral visual field
* Associated with large- angle esotropias

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19
Q

(Ésotropie infantile)

Que se produit-il a/n de la fixation lorsque l’enfant a une amblyopie sur son ésotropie infantile?

A

A fixation preference can be observed (avec le meilleur oeil)

The better- seeing eye will fixate in all fields of gaze, making the amblyopic eye appear to have an abduction deficit

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20
Q

(Ésotropie infantile)

La déviation d’une ésotropie infantile :
* Est-elle davantage comitante ou incomitante?
* < 30 D ou > 30 D ?

A

The deviation is comitant and characteristically larger than 30D

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21
Q

(Ésotropie infantile)

% de patients développant une surrélévation en ADD chez patient avec ésotropie infantile

A

Overelevation in adduction and dissociated strabismus complex develop in more than 50% of patients, usually after 1–2 years of age

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22
Q

(Ésotropie infantile)

Comment distinguer un oeil fixateur d’un patient amblyope versus déficit de l’ABD (lors d’une ésotropie infantile)

A
  • The infant’s ability to abduct each eye can be demonstrated with the doll’s head maneuver or by observation after patching either of the patient’s eyes.
  • The clinician can also hold the infant and spin in a circle, which stimulates the vestibular- ocular reflex and helps demonstrate full abduction
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23
Q

(Ésotropie infantile)

Jusqu’à quel âge peut-on observer une asymétrie horizontale de la smooth pursuit? Et dans quelle direction est-il la plus développée?

A

Asymmetry of monocular horizontal smooth pursuit is normal in infants up to age 6 months, with the nasal- to- temporal direction less well developed than the temporal- to- nasal

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24
Q

(Ésotropie infantile)

V ou F : Patients with infantile esotropia have persistent smooth- pursuit asymmetry throughout their lives

A

Vrai. Patients with infantile esotropia have persistent smooth- pursuit asymmetry throughout their lives

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25
Q

(Ésotropie infantile)

Quel type de nystagmus est souvent associé aux éso infantiles ?

A

Fusion maldevelopment nystagmus syndrome (also known as latent and manifest latent nystagmus)

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26
Q

(Ésotropie infantile)

À quoi ressemble la réfraction cycloplégique (en dioptries) d’un enfant atteint d’ésotropie infantile?

A

Cycloplegic refraction characteristically reveals low hyperopia (+1.00 to +2.00 D)

Hyperopia greater than 2.00 D should prompt consideration of spectacle correction; reduction of the strabismic angle with glasses indicates the presence of an accommodative component

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27
Q

(Ésotropie infantile)

Définir le syndrome de Ciancia

A

A severe form of infantile esotropia, referred to as Ciancia syndrome, consists of
* Large angle esotropia (>50D)
* Abducting nystagmus
* Mild abduction deficits
* Children with this syndrome uniformly use cross- fixation

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28
Q

(Ésotropie infantile)

Laquelle des situations suivantes répond le mieux à un Tx avec correction de l’hypermétropie :
* A small- angle esotropia that is variable in degree or intermittent
* A large-angle or constant esotropia

A

A small- angle esotropia that is variable in degree or intermittent may be more likely to respond to hyperopic correction than would a large-angle or constant esotropia

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29
Q

(Ésotropie infantile)

V ou F : Concurrent amblyopia should be fully treated before surgery.

A

Faux.
Previously, it was thought that concurrent amblyopia should be fully treated before surgery. However, it has recently been shown that successful postoperative alignment is as likely to occur in patients with mild to moderate amblyopia at the time of surgery as it is in those whose amblyopia has been fully treated preoperatively

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30
Q

(Ésotropie infantile)

En plus de prévenir l’amblyopie, quels sont les avantages d’achieved earlier un ocular alignment?

A

When ocular alignment is achieved earlier, there may be the added benefits of better fusion, stereopsis, and long- term stability

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31
Q

(Ésotropie infantile)

Goal of surgical treatment of infantile esotropia?

A

The goal of surgical treatment of infantile esotropia is to reduce the deviation to orthotropia or as close to it as possible

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32
Q

(Ésotropie infantile)

Que peut-il se développer lorsque le Tx chirurgical de l’ésotropie infantile résulte en un alignement à 8-10 D de l’orthotropie?

A

Alignment within 8D–10D of orthotropia frequently results in the development of the monofixation syndrome, characterized by
* Peripheral fusion
* Central suppression
* Favorable appearance

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33
Q

(Ésotropie infantile)

Caractéristiques du monofixation syndrome (that results from alignement within 8-10D of orthotropia after surgery).

A

Alignment within 8D–10D of orthotropia frequently results in the development of the monofixation syndrome, characterized by
* Peripheral fusion
* Central suppression
* Favorable appearance

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34
Q

(Ésotropie infantile)

V ou F : The child’s psychological and motor development may not improve or even worsen after the eyes are straightened

A

Faux. The child’s psychological and motor development MAY improve and accelerate after the eyes are straightened

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35
Q

(Ésotropie infantile)

À quel âge (au plus tard) devrait-on opérer un enfant avec ésotropie infantile afin d’optimiser la coopération binoculaire?

A

The belief is that the eyes should be aligned by 2 years of age, preferably earlier, to optimize binocular cooperation

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36
Q

(Ésotropie infantile)

À partir de quel âge un enfant avec une ésotropie infantile peut-il être opéré?

A
  • The belief is that the eyes should be aligned by 2 years of age, preferably earlier, to optimize binocular cooperation
  • Surgery can be performed in healthy children as early as age 4 months
  • The Congenital Esotropia Observational Study showed that when patients present with constant esotropia of at least 40D after 10 weeks of age, the deviations are unlikely to resolve spontaneously
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37
Q

(Ésotropie infantile)

Résultat de l’étude The Congenital Esotropia Observational Study

A

The Congenital Esotropia Observational Study showed that when patients present with constant esotropia of at least 40D after 10 weeks of age, the deviations are unlikely to resolve spontaneously

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38
Q

(Ésotropie infantile)

V ou F : Ocular alignment is always achieved without surgery in early- onset esotropia.

A

Faux. Ocular alignment is rarely achieved without surgery in early- onset esotropia

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39
Q

(Ésotropie infantile)

Dans quel contexte l’ésotropie infantile peut-elle seulement être observée dans un premier temps vs opéré directement (étant donnée une possible résolution spontanée)? Basé sur quelle étude ?

A

Smalle angles (= < 40D après 10 semaines d’âge) can be monitored, as they may improve spontaneously

The Congenital Esotropia Observational Study

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40
Q

(Ésotropie infantile)

Types de chirurgie suggérés pour l’ésotropie infantile

A

Two-surgery muscle :
* The most commonly performed initial procedure is recession of both medial rectus muscles
* Recession of a medial rectus muscle combined with resection of the ipsilateral lateral rectus muscle is also effective

Two-muscle surgery spares the other horizontal rectus muscles for subsequent surgery should it be necessary, which is not uncommon.

For infants with large deviations (typically >60D), some surgeons operate on 3 or even 4 horizontal rectus muscles at the time of the initial surgery, or they add botulinum toxin injection to the medial rectus muscle recession.

Significant inferior oblique muscle overaction can be treated at the time of the initial surgery.

Injection of botulinum toxin to the medial rectus muscles has also been used as primary treatment of infantile esotropia.

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41
Q

(Ésotropie infantile)

À partir de quelle déviation on considère opéré plus de 2 muscles en même temps ?

A

For infants with large deviations (typically >60D), some surgeons operate on 3 or even 4 horizontal rectus muscles at the time of the initial surgery, or they add botulinum toxin injection to the medial rectus muscle recession.

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42
Q

(Ésotropie infantile)

Quelle autre chirurgie (concomitante aux muscles horizontaux) peut être faite dans l’ésotropie infantile?

A

Significant inferior oblique muscle overaction can be treated at the time of the initial surgery

43
Q

(Ésotropie infantile)

Pertinence de la toxine botulique dans le traitement de l’ésotropie infantile?

A

Injection of botulinum toxin to the medial rectus muscles has also been used as primary treatment of infantile esotropia
* In a recent study, botulinum toxin injection was associated with a substantially higher reoperation rate than was strabismus surgery, and children treated with botulinum toxin were found to have a higher rate of postoperative abnormal binocularity
* Botulinum toxin may be most useful for smaller deviations

44
Q

Définir l’ésotropie accomodative

A

Defined as a convergent deviation of the eyes associated with activation of the accommodative reflex

45
Q

Les ésodéviations accomodatives sont-elles innées ou acquises?

A

All accommodative esodeviations are acquired

46
Q

Caractéristiques de l’ésotropie accomodative :
* Onset?
* Constant ou intermittent?
* Concomitant ou inconcomitant?
* Hérédité?
* Facteurs précipitants?
* Association avec amblyopie?
* Diplopie?

A

All accommodative esodeviations are acquired and can be characterized as follows :
* Onset typically between 6 months and 7 years of age, averaging 2 years of age (can be as early as age 4 months
* Usually intermittent at onset, becoming constant
* Comitant
* Often hereditary
* Sometimes precipitated by trauma or illness
* Frequently associated with amblyopia
* Possibly occurring with diplopia (especially with onset at an older age), which usually disappears with development of a facultative suppression scotoma in the deviating eye

47
Q

Types d’ésotropie accomodative

A
  • Refractive accommodative esotropia
  • High AC/A ratio accommodative esotropia
  • Partially accommodative esotropia
48
Q

(Refractive accommodative esotropia)

3 facteurs impliqués dans la pathogénèse du Refractive accommodative esotropia.

A

The mechanism of refractive accommodative esotropia involves 3 factors:
* Uncorrected hyperopia
* Accommodative convergence
* Insufficient fusional divergence

49
Q

(Refractive accommodative esotropia)

Pourquoi le patient doit-il accomoder dans le Refractive accommodative esotropia?

A

Because of uncorrected hyperopia, the patient must accommodate to focus the retinal image

50
Q

(Refractive accommodative esotropia)

Autres éléments accompagnant l’accomodation (aka les autres composantes du near reflex)

A

Accommodation is accompanied by the other components of the near reflex, namely convergence and miosis

Near reflex :
* Accommodation
* Convergence
* Miosis

51
Q

(Refractive accommodative esotropia)

Comment l’enfant doit-il compenser pour l’augmentation tonique de la convergence (dans le contexte d’une hypermétropie non corrigée)

A

Via le fusional divergence mechanism.

  • If the patient’s fusional divergence mechanism is insufficient to compensate for the increased convergence tonus → esotropia results
52
Q

(Refractive accommodative esotropia)

Décrire l’angle de l’ésotropie lors de la fixation VL versus VP

A

The angle of esotropia is approximately the same at distance and near fixation
* Is generally between 20D and 30D

53
Q

(Refractive accommodative esotropia)

Average de l’erreur réfractive (en D) chez les patients avec un Refractive accommodative esotropia

A

Patients with refractive accommodative esotropia have an average of +4.00 D of hyperopia

54
Q

(Refractive accommodative esotropia)

Traitement #1 du Refractive accommodative esotropia

A
  • Treatment of refractive accommodative esotropia consists of correction of the full amount of hyperopia, as determined under cycloplegia
  • If binocular fusion is maintained, the refractive correction can later be decreased to 1.00–2.00 D less than the full cycloplegic refraction
55
Q

(Refractive accommodative esotropia)

Traitement de l’amblyopie dans un contexte de Refractive accommodative esotropia

A

Amblyopia, if present, may respond to spectacle correction alone, but treatment with occlusion or atropine may be necessary if the amblyopia persists after a period of spectacle wear

DONC :
1. Spectacle correction alone
2. Treatment with occlusion or atropine (if the amblyopia persists after a period of spectacle wear)

56
Q

(Refractive accommodative esotropia)

Est-ce que le port de lunettes correctrices peut guérir le Refractive accommodative esotropia?

A

Parents must understand not only that full- time wear of the glasses is important but also that the refractive correction can only help control the strabismus, not “cure” it.

57
Q

(Refractive accommodative esotropia)

Est-ce que le strabisme d’un Refractive accommodative esotropia peut augmenter avec le port de lunettes correctrices? Pourquoi?

A

Once full- time wear has begun, the esotropia may increase when the child is not wearing glasses, because the child makes a strong accommodative effort to produce an image that is as clear as the one experienced with refractive correction

58
Q

(Refractive accommodative esotropia)

Quand peut-on envisager un Tx chirurgical pour le Refractive accommodative esotropia (aka l’indication)?

A
  • Strabismus surgery may be required when a patient with presumed refractive accommodative esotropia does not achieve an ocular alignment within the fusion range (up to 8D–10D) with correction (partially accommodative esotropia)
  • Before proceeding with surgery, the ophthalmologist should recheck the cycloplegic refraction to rule out latent uncorrected hyperopia.
59
Q

(High AC/A ratio accommodative esotropia)

Que signifie avoir un high accommodative convergence/accommodation (AC/A) ratio?

A

Patients with a high accommodative convergence/accommodation (AC/A) ratio have an excessive convergence response for the amount of accommodation required to focus while wearing their full cycloplegic correction

60
Q

(High AC/A ratio accommodative esotropia)

Décrire l’angle de l’ésotropie lors de la fixation VL versus VP

A

The deviation is present only at near or is much larger at near

61
Q

(High AC/A ratio accommodative esotropia)

Average of refractive error (en D) in High AC/A ratio accommodative esotropia

A

The refractive error in high AC/A ratio accommodative esotropia (also called nonrefractive accommodative esotropia) averages +2.25D
* However, this esotropia can occur in patients with a normal level of hyperopia or high hyperopia, with emmetropia, or even with myopia

62
Q

(High AC/A ratio accommodative esotropia)

3 options de traitement dans le High AC/A ratio accommodative esotropia

A
  • Bifocals
  • Chirurgie
  • Observation
63
Q

(High AC/A ratio accommodative esotropia)

Caractéristiques des lentilles bifocales dans le traitement du High AC/A ratio accommodative esotropia
* Objectif du Tx
* Type recommandé de lunettes bifocales
* Lentilles positives ou négatives?

A
  • Plus lenses for hyperopia reduce accommodation and therefore accommodative convergence
  • Bifocal glasses further reduce or eliminate the need to accommodate for near fixation
  • If bifocals are used, the initial prescription should be for flat-top style bifocals with the lowest plus power needed (up to +3.00 D) to achieve ocular alignment at near fixation
    *
64
Q

(High AC/A ratio accommodative esotropia)

Que signifie « réponse idéale » et « réponse acceptable » pour le traitement avec lunettes bifocales?

A
  • An ideal response to bifocal glasses is restoration of normal binocular function (fusion and stereopsis) at both distance and near fixation
  • An acceptable response is fusion at distance and less than 10D of residual esotropia at near with bifocals (signifying the potential for fusion)
65
Q

(High AC/A ratio accommodative esotropia)

Évolution et management dans le temps des lunettes bifocales

A
  • While some children improve spontaneously with time, others need to be slowly weaned (sevrés) from bifocal glasses
  • The process of reducing the bifocal power in 0.50–1.00 D steps can be started at about age 7 or 8 years and should be completed by age 10–12 years
66
Q

(High AC/A ratio accommodative esotropia)

Type de churirgie proposé dans un High AC/A ratio accommodative esotropia? Qu’est-il suggéré de faire avant d’opérer?

A
  • Surgical management of high AC/A ratio accommodative esotropia is controversial
  • Some ophthalmologists advocate (favorisent) surgery (medial rectus muscle recessions with or without posterior or pulley fixation) to normalize the AC/A ratio, which may allow discontinuation of bifocals
  • The risk of overcorrection at distance is low (<10%)
  • Some ophthalmologists use prism adaptation, which entails using prisms preoperatively to neutralize a deviation for a certain length of time
  • The prism neutralization can then be used to predict the outcome of surgery and determine the maximum deviation
67
Q

(High AC/A ratio accommodative esotropia)

Pourquoi pouvons-nous seulement observer vs traité d’emblée un High AC/A ratio accommodative esotropia?

A
  • Many patients show a decrease in the near deviation with time, and binocular vision at both distance and near fixation ultimately develops
  • Some ophthalmologists observe the near deviation as long as the distance alignment allows for the development of peripheral fusion
68
Q

Jusqu’à quel âge l’hypertropie augmente-t-elle chez un enfant? Que se passe-t-il après? Et quel est l’impact sur le long-term management of both refractive and high AC/A ratio accommodative esotropiaT

A
  • For the long-term management of both refractive and high AC/A ratio accommodative esotropia, it is important to remember that hyperopia usually increases until age 5–7 years before it starts to decrease
  • Therefore, if the esotropia with correction increases, the cycloplegic refraction should be repeated and the full correction prescribed
  • If glasses correct all or nearly all the esotropia and if some degree of sensory binocular cooperation or fusion is present, the clinician may begin to reduce the hyperopic correction to create a small esophoria, which is thought to stimulate fusional divergence
  • An increase in the fusional divergence, combined with the natural decrease of both the hyperopia and the high AC/A ratio, may enable the patient to eventually maintain straight eyes without bifocals or glasses altogether
69
Q

(Partially accommodative esotropia)

Définir Partially accommodative esotropia

A

Patients with partially accommodative esotropia show reduction in the angle of esotropia when wearing glasses but have a residual esotropia despite provision of the full hyperopic correction

70
Q

(Partially accommodative esotropia)

When is more likely to occur the Partially accommodative esotropia?

A

This is more likely to occur if there is a long delay in refractive correction.
* In some cases, partially accommodative esotropia results from decompensation of a pure refractive accommodative esotropia
* In other instances, an initial nonaccommodative esotropia subsequently develops an accommodative component

71
Q

(Partially accommodative esotropia)

Traitement du Partially accommodative esotropia

A
  • Treatment of partially accommodative esotropia consists of strabismus surgery for the deviation that persists while the patient wears the full hyperopic correction
  • It is important that the patient and parents understand before surgery that its purpose is to produce straight eyes with spectacle wear— not to enable the child to discontinue wearing glasses altogether
  • In older patients, refractive surgery may be considered to both reduce the hyperopic refractive error and improve the ocular alignment
72
Q

Exemples de Acquired Nonaccomodative Esotropia

A

Several types of comitant esotropia not associated with activation of the accommodative reflex may develop in later infancy (>6 months), childhood or even adulthood. The causes of these acquired nonaccommodative esotropias are varied.
* Basic Acquired Nonaccommodative Esotropia
* Cyclic Esotropia
* Sensory Esotropia
* Divergence Insufficiency
* Spasm of the Near Reflex
* Consecutive Esotropia

73
Q

(Basic Acquired Nonaccommodative Esotropia)

Caractéristiques du Basic Acquired Nonaccommodative Esotropia
* Concomitant ou inconcomitant?
* Age at onset?
* Associated or not associated with an accommodative component?
* The amount of hyperopia?
* The angle of deviation at VL versus VP
* Diplopie?

A

Basic acquired nonaccommodative esotropia is a comitant esotropia that develops after age 6 months and is not associated with an accommodative component.
As in infantile esotropia
* The amount of hyperopia is not significant
* The angle of deviation is similar when measured at distance and near
Acquired esotropia may be acute in onset
* In such cases, the patient immediately becomes aware of the deviation and may have diplopia

74
Q

(Basic Acquired Nonaccommodative Esotropia)

FdR précipitants un Basic Acquired Nonaccommodative Esotropia.

A

Temporary but prolonged disruption of binocular vision— such as may result from a hyphema, preseptal cellulitis, mechanical ptosis or prolonged patching for amblyopia—is a known precipitating cause of acquired nonaccommodative esotropia
* Chez des patients dont la fusion binoculaire est précaire

75
Q

(Basic Acquired Nonaccommodative Esotropia)

Critères nécessitant des investigations supplémentaires dans un contexte de acquired nonaccommodative esotropia in an older children.

A

Because the onset of nonaccommodative esotropia in an older child may be a sign of an under lying neurologic disorder, neuroimaging and neurologic evaluation may be indicated, especially when other symptoms or signs of neurologic abnormality are present, such as
* Lateral incomitance
* Deviation greater at distance than near
* Abnormal head position
* Concomitant headache

76
Q

(Basic Acquired Nonaccommodative Esotropia)

V ou F : Many patients with acquired nonaccommodative esotropia have a history of normal binocular vision

A

Vrai

77
Q

Quel est le Px concernant la restauration de la vision binoculaire avec un Basic Acquired Nonaccommodative Esotropia

A

The prognosis for restoration of single binocular vision** with prisms and/or surgery is good**

Because many patients with acquired nonaccommodative esotropia have a history of normal binocular vision

78
Q

Traitement du Basic Acquired Nonaccommodative Esotropia

A

The prognosis for restoration of single binocular vision with prisms and/or surgery is good.
Therapy consists of
* Amblyopia treatment if necessary
* Surgical correction or botulinum toxin injection as soon as possible after the onset of the deviation
The Prism Adaptation Study showed a smaller undercorrection rate (approximately 10% less) when the amount of surgery was based on the prism-adapted angle

79
Q

(Cyclic esotropia)

Caractéristiques du Cyclic esotropia
* Onset?
* Concomitant ou inconcomitant?
* Durée d’un cycle?
* Fusion et vision binoculaire?

A
  • Cyclic esotropia is a rare form of strabismus
  • Onset of cyclic esotropia is typically during the preschool years.
  • The esotropia is comitant and intermittent
  • Usually occurring every other day (48- hour cycle).
  • Variable intervals and 24- hour cycles have also been documented
  • Fusion and binocular vision are usually absent or defective on the strabismic day, with marked improvement or normalization on the orthotropic day
80
Q

(Cyclic esotropia)

Que peut-il se produire si l’on fait un occlusion therapy avec le Cyclic esotropia?

A

Occlusion therapy may convert the cyclic deviation into a constant one

81
Q

(Cyclic esotropia)

Traitement du Cyclic esotropia

A
  • Occlusion therapy may convert the cyclic deviation into a constant one
  • Surgical treatment of cyclic esotropia is usually effective
  • The amount of surgery is based on the maximum angle of deviation present when the eyes are esotropic
82
Q

(Sensory Esotropia)

Définir le Sensory Esotropia. Phyiopathologie?

A
  • Monocular vision loss (due to cataract, corneal clouding, optic nerve or retinal disorders, or various other entities) may cause sensory (deprivation) esotropia
  • Conditions preventing clear and focused retinal images and symmetric visual stimulation must be identified and remedied promptly → to prevent irreversible amblyopia
83
Q

(Sensory Esotropia)

Est-ce que la chirurgie est indiquée dans le traitement du Sensory Esotropia?

A
  • Corriger la cause
  • If surgery or botulinum toxin injection is indicated for strabismus, it is generally performed only on the eye with a significant vision deficit
84
Q

(Divergence insufficiency)

Définir le Divergence insufficiency.
Concomitant ou inconcomitant?

A
  • In divergence insufficiency, the characteristic finding is an esodeviation that is greater at distance than at near
  • The deviation is horizontally comitant and fusional divergence is reduced
85
Q

(Divergence insufficiency)

2 formes de divergence insufficiency et étiologies

A

There are 2 forms of divergence insufficiency:

  • A primary, isolated form
  • A secondary form that is rare and associated with neurologic abnormalities, including pontine tumors, increased intracranial pressure, or severe head trauma

In these secondary cases, the divergence insufficiency is probably due to a mild sixth nerve paresis

86
Q

(Divergence insufficiency)

Investigation nécessaire dans contexte de secondary divergence insufficiency

A

Patients with secondary divergence insufficiency require neuroimaging to rule out treatable intracranial lesions

87
Q

(Divergence insufficiency)

Chez l’adulte :
* Synonyme de Divergence insufficiency?
* Prévalence?
* Age of onset?
* Acute or gradual onset?
* Diplopie?
* Signes à l’imagerie?

A
  • Primary divergence insufficiency is an increasingly diagnosed type of adult strabismus
  • More recently termed age- related distance esotropia
  • The entity is a slowly progressing, benign condition that occurs predominantly in patients older than 50 years
  • Affected individuals report a gradual onset of horizontal diplopia that is present at distance but not at near
  • Imaging may demonstrate thinning, elongation and rupture of the connective tissue between the lateral and superior rectus muscles and sagging and elongation of the lateral rectus muscles
88
Q

(Divergence insufficiency)

Traitement du Divergence insufficiency

A

Management consists of
* Base-out prisms
* Botulinum toxin injection of the medial rectus muscles
* Strabismus surgery

In patients with age related distance esotropia, reestablishment of binocular fusion generally occurs following treatment

89
Q

(Spasm of the near reflex)

Étiologie(s) du Spasm of the near reflex

A
  • Spasm of the near reflex (also known as ciliary spasm or convergence spasm) is a spectrum of abnormalities of the near response
  • The etiology is generally thought to be functional, related to psychological factors such as stress and anxiety
  • In rare cases, it can be associated with organic disease
90
Q

(Spasm of the near reflex)

Triade de signes associée au Spasm of the near reflex

A

Patients present with varying combinations of
* Excessive convergence,
* Increased accommodation
* Miosis

91
Q

(Spasm of the near reflex)

Concernant le Spasm of the near reflex, lesquels sont faux :
1. Patients may present with acute esotropia alternating with orthotropia
2. Substitution of a convergence movement for a gaze movement with horizontal versions is characteristic
3. Monocular abduction is always normal
4. Hypermetropia may occur

A

Réponse : 3 et 4 sont faux.
* Patients may present with acute esotropia alternating with orthotropia
* Substitution of a convergence movement for a gaze movement with horizontal versions is characteristic
* Monocular abduction is normal despite marked limitation of abduction on version testing
* Pseudomyopia may occur

92
Q

(Spasm of the near reflex)

Traitement du Spasm of the near reflex (1ère et 2e intentions)

A

Treatment consists of
* Cycloplegic agents such as atropine or homatropine
* Hyperopic correction
* Bifocal glasses

If the spasm cannot be broken, botulinum toxin injection of the medial rectus muscles and strabismus surgery may be considered with caution.

93
Q

(Consecutive Esotropia)

Définir le Consecutive esotropia

A

Consecutive esotropia refers to an esotropia that follows a history of exotropia

94
Q

(Consecutive Esotropia)

Étiologies du Consecutive esotropia (2)

A

It can arise spontaneously or it can develop after surgery for exotropia
Spontaneous consecutive esotropia is rare
* Almost always occurs in the setting of neurologic disorders or with very poor vision in 1 eye

Postsurgical consecutive esotropia, on the other hand, is not uncommon
* It often resolves over time without treatment
* In fact, an initial small overcorrection is desirable after surgery for exotropia, as it is associated with an improved long-term success rate

95
Q

(Consecutive Esotropia)

Traitement du Consecutive Esotropia

A

Treatment options for consecutive esotropia include
* Base-out prisms
* Hyperopic correction
* Alternating occlusion
* Botulinum toxin injection
* Strabismus surgery

In postsurgical consecutive esotropia, unless the deviation is very large or a slipped or “lost” muscle is suspected, surgery or botulinum toxin injection may be postponed for several months after onset because of the possibility of spontaneous improvement

96
Q

Causes of significant abduction deficit after a strabism surgery? Comment les différencier?

A
  • A slipped or lost lateral rectus muscle produces various amounts of esotropia and incomitance, depending on the amount of slippage
  • Should be suspected in consecutive esotropia following lateral rectus recession surgery if a significant abduction deficit is present.
  • If the ipsilateral medial rectus muscle was resected at the time of the lateral rectus recession, the consecutive esotropia could be due to a tight medial rectus muscle
  • Forced duction testing helps differentiate between these 2 causes
  • In cases of a slipped or lost lateral rectus muscle, surgical exploration is required

DONC causes :
* Slipped or lost lateral rectus muscle (2nd lateral rectus recession surgery)
* Tight medial rectus muscle (2nd medial rectus resection surgery)

97
Q

(Nystagmus and Esotropia)

Several types of nystagmus are associated with esotropia. Nommez 3 exemples de syndrome.

A
  • Several types of nystagmus are associated with esotropia
  • Fusion maldevelopment nystagmus syndrome (also known as latent and manifest latent nystagmus) is a common feature of infantile esotropia
  • Ciancia syndrome is a severe form of infantile esotropia associated with an abducting nystagmus
  • Nystagmus blockage syndrome occurs in children with congenital motor nystagmus, who use convergence to “damp” or decrease the amplitude or frequency of, their nystagmus → resulting in esotropia
98
Q

(Incomitant esotropia)

There are several positional, restrictive, and innervational abnormalities of the extraocular muscles that may result in incomitant esotropia. Nommez des exemples.

A
  • Sixth Nerve Palsy
  • Thyroid eye disease
  • Orbital myositis
  • Medial orbital wall fracture with medial rectus entrapment
  • Excessive medial rectus muscle resection
  • Congenital fibrosis of the extraocular muscles
  • Duane retraction syndrome
  • Möbius syndrome
  • In patients with high myopia, esotropia may develop because of prolapse of the posterior globe between displaced lateral and superior rectus muscles
99
Q

(Sixth Nerve Palsy)

Caractéristiques d’un Sixth Nerve Palsy
* Muscle impliqué?
* Concomitant ou inconcomitant?
* Prévalence?
* Permanent ou Transitoire?
* Comment différencier du Duane retraction syndrome?

A
  • Weakness of the lateral rectus muscle due to palsy of the abducens nerve results in incomitant esotropia
  • Sixth cranial nerve palsy occurring in the neonatal period is rare and usually transient
  • Most cases of suspected congenital sixth nerve palsy are actually infantile esotropia with cross-fixation
  • Congenital sixth nerve palsy may be difficult to differentiate from esotropic Duane retraction syndrome, which is more common in young infants, as the unique retraction feature of this syndrome may not yet be evident
  • A distinguishing characteristic is that for an equal amount of abduction deficit, the deviation in primary position is usually much larger in sixth nerve palsy than it is in esotropic Duane retraction syndrome
100
Q

(Sixth Nerve Palsy)

Causes d’un Sixth Nerve Palsy chez l’enfant

A

Congenital sixth nerve palsy is usually benign and transient
* May be caused by the increased intracranial pressure associated with the birth process

Sixth nerve palsy in older children is associated with
* Intracranial lesions in approximately one-third of cases, which may have additional neurologic findings
* Other cases may be related to infectious or immunologic processes involving cranial nerve VI

The most common cause of isolated, transient sixth nerve palsy
* In a child is thought to be a virus
* In an adult, a microvascular occlusive event

101
Q

(Sixth Nerve Palsy)

Signes et sx associés à un Sixth Nerve Palsy

A
  • Older children and adults may report diplopia
  • Often there is a compensatory head turn toward the side of the paralyzed lateral rectus muscle, adopted to place the eyes in a position where they are best aligned
  • If a child presents soon after onset of the deviation, vision in the eyes is usually equal
  • The esotropia increases in gaze toward the side of the paralyzed lateral rectus muscle
  • Versions show limited or no abduction of the affected eye
  • Results of the saccadic velocity test show slowing of the affected lateral rectus muscle
  • Active force generation tests document weakness of that muscle
102
Q

(Sixth Nerve Palsy)

Ix nécessaire lors d’un Sixth Nerve Palsy chez l’enfant?

A
  • Because of high prevalence of associated intracranial lesions in children with sixth nerve palsy, neurologic evaluation and magnetic resonance imaging of the head and orbit are usually indicated
  • Even in the absence of other focal neurologic findings
103
Q

(Sixth Nerve Palsy)

Management of Sixth Nerve Palsy

A
  • Patching may be necessary to prevent or treat amblyopia if the child is not using a compensatory head posture or if the child is very young
  • Press-on prisms are sometimes used to correct diplopia in primary position
  • Correction of a significant hyperopic refractive error may help prevent the development of an associated accommodative esotropia
  • Botulinum toxin injection of the ipsilateral medial rectus muscle is sometimes employed to temporarily decrease the esotropia

If the deviation does not resolve after 6 months of treatment, surgery may be indicated. Options include :
* Horizontal rectus muscle surgery if abduction is at least partially preserved
* Vertical rectus muscle transposition surgery if abduction is absent

104
Q

Avec quel alignement (en D) PO de chirurgie d’éso on pourrait s’attendre à développer un syndrome de monofixation ?

Est-ce un bon outcome chirurgical ?

A

8-10 D

Bon outcome car on atteint une fixation périphérique (moins bon que fixation centrale mais bon, quand même popire !)

Pédiatrie (17 decks)

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