8 - Esodeviations Flashcards

Question

# (Ésotropie infantile) Quel type de nystagmus est souvent associé aux éso infantiles ?

Answer 1

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

Answer 2

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*

Answer 3

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**

Answer 4

**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

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

* 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

Answer 13

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**

Answer 14

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

Answer 15

**Smalle angles** (= < 40D après 10 semaines d'âge) can be monitored, as they may improve spontaneously The Congenital Esotropia Observational Study

Answer 16

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.

Answer 17

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.

Answer 18

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

Answer 19

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**

Answer 20

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

Answer 21

All accommodative esodeviations are **acquired**

Answer 22

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

Answer 23

* Refractive accommodative esotropia * High AC/A ratio accommodative esotropia * Partially accommodative esotropia

Answer 24

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

Answer 25

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

Answer 26

Accommodation is accompanied by the other components of the near reflex, namely convergence and miosis Near reflex : * Accommodation * Convergence * Miosis

Answer 27

Via le fusional divergence mechanism. * If the patient’s fusional divergence mechanism is insufficient to compensate for the increased convergence tonus → esotropia results

Answer 28

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

Answer 29

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

Answer 30

* 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

Answer 31

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)

Answer 32

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**.

Answer 33

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

Answer 34

* 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.

Answer 35

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

Answer 36

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

Answer 37

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

Answer 38

* Bifocals * Chirurgie * Observation

Answer 39

* **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** *

Answer 40

* 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)

Answer 41

* 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

Answer 42

* 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**

Answer 43

* 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**

Answer 44

* 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

Answer 45

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

Answer 46

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

Answer 47

* 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

Answer 48

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

Answer 49

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**

Answer 50

**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

Answer 51

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**

Answer 52

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

Answer 53

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**

Answer 54

* 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**

Answer 55

Occlusion therapy **may convert the cyclic deviation into a constant one**

Answer 56

* 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

Answer 57

* **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

Answer 58

* 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

Answer 59

* 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

Answer 60

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

Answer 61

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

Answer 62

* 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

Answer 63

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

Answer 64

* 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**

Answer 65

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

Answer 66

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

Answer 67

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.

Answer 68

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

Answer 69

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

Answer 70

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

Answer 71

* 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)

Answer 72

* 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

Answer 73

* 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

Answer 74

* 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

Answer 75

**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

Answer 76

* 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

Answer 77

* 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

Answer 78

* **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

Answer 79

8-10 D Bon outcome car on atteint une fixation périphérique (moins bon que fixation centrale mais bon, quand même popire !)

8 - Esodeviations Flashcards

(104 cards)