CONGENITAL ESOTROPIA

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CONGENITAL ESOTROPIA
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CAUSE

• Subtle neurological developmental problem
• Usually in isolation
• selection bias

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CORE DEFECTS

• NOT ET! ALL CORTICAL
• Sensory N-T asymmetry
• Motor N-T asymmetry, LMLN TH

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Secondary effects

• Large angle ET with tight medial rectus
• Amblyopia ?30
• Cross fixation LE used for right gaze, RE for L
  gaze.
• X-fixation usually reflects the mechanical
  situation, and not vision

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Secondary effectsVERTICALS IN CET

• 2 types
• 1. DVD
• Non fixing eye drifts up
• 2. Oblique dysfunction
• Usu IO OA
• Can be SO OA
• ? Innervational ?orbital - prob both

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VERTICALS IN CET DVD
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VERTICALS IN CET DVD

• Common pattern
• Right fixation L?
• L fixation R ?
• End result of braking the torsional component
  of LMLN in the fixing eye to try and improve
  acuity

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ASSOCIATIONS 1 REFRACTION

• Usual range of infant refraction
• 25 caucasian neonates gt 4
• ? Higher more prone to CET

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ASSOCIATIONS 2 BRAIN

• Downs 30
• Severe neonatal course IVH / HC 100
• PVL
• delayed devpt 20

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ASSOCIATIONS 3 GENETIC

• Williams syndrome 100
• 25 incidence in many chromosomal disorders

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The clinical spectrum of early-onset esotropia

• If it looks like CET is it CET?

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PEDIG CET Observational Study

• ET with onset in early infancy frequently
  resolves in patients
• first examined lt 20 w of age
• ET lt 40 ?
• ET intermittent or variable.

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PEDIG CET Observational Study

• ET 40 ? presenting after 10 w of age low
  likelihood of spontaneous resolution.
• Surgery at 3-4 mo of age could reasonably be
  considered in some CETs

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TIMING OF TREATMENT

• Early
• Very early
• Late
• How late

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DOMDuration of misalignment

• lt 4 mo DOM
• Stereo, reduced need for 2nd surgery, reduced
  incidence DVD Birch
• lt12 mo DOM age
• Stereo better than gt12 mo Ing, 2002

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OVERVIEW OF MGMT

• Check vision - any obvious amblyopia
• Amblyopia Rx patch 1w/y of life then review eg
  age 10 mo patch for 50 of waking hours for 5
  days before the next visit
• Amblyopia may not respond with large ET
  mechanical barrier

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OVERVIEW 2

• Measure angle 2 times, consistent or increasing
• Check refraction
• gt3 try anti- accommodative Rx
• Gls / pilo / phospholine
• THEN alignment as soon as convenient

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OVERVIEW

• Bimedial recession - reliable to 50?
• Recess / resect prob BMR to 35?
• Augment for very large angles - botox, 1-2 extra
  muscles

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OVERVIEW

• Day surgery
• Check within 24-36 hours re slipped stitch
• Recurrent / residual ET often accommodative
• Consceutive XT with time 1 p.a.

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RESULTS

• Orthotropia for D and/ or N _at_ 2 mo 80
• Subsequent careful mngmt for recurrent ET,
  amblyopia

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LK RESULTS

• Selection bias
• Private pts
• Healthy infants
• Multiple visits gt than feasible in public
  setting
• other unrecognised bias
• 2nd surgery for BMR _at_ 12 mo
• LK 10 -15